Talking about sex: sex can be hard to talk about with children. But with U.S. teen pregnancy rates the highest in the developed world, sex education can't be ignored.

Teaching children about sex and its consequences has never been simple. It's a challenge that Maryland Senator Paula C. Hollinger, a former school nurse, knows firsthand.

Assigned to help teach family life to a class of fifth graders, Hollinger hit upon the idea of putting a box in the classroom in which the 10- and 11-year-olds could leave anonymous questions and have them answered the next day without fear of embarrassment.

"And, boy, did they leave questions," sighs Hollinger, now the Senate's majority whip and vice chairman of its Education, Health and Environmental Affairs committee. "They wanted to know about condoms, birth control, the real meanings for various street terms," she recalls. "They were very frank and very open. We would read their questions as written and give them honest answers."

But that was in the 1970s--before AIDS began its deadly march, before teen childbearing rates began surging and before the youth market was saturated with sexual messages and images. Now, say Hollinger and other state legislators, the imperative to teach children and teens about the dangers of casual sex and the need for responsible behavior has never been greater. "If young people don't get the information they need," says Hollinger, "they will get into trouble."

For legislators, agreeing that children and teens need more education about sex is easy. Deciding just what lessons to teach and what messages to send is often the hard part.

Some state lawmakers, like Arizona Representative Mark Anderson, believe that abstinence from sex "is the best possible option for kids" and should be the overriding, if not sole, lesson that schools teach. "I think you do a great disservice by sending out conflicting messages," he says. Others, like Maine Representative Arthur F. Mayo, believe in combining a strong abstinence message with broader instruction covering contraception, avoiding disease, and personal responsibility. "Like it or not, today's high school students are facing tough decisions about sex and abstinence," he says. "It's been proved that the more students know, the less likely they are to have unwanted pregnancies. It seems to me that education rather than experimentation is the better approach."

TROUBLING HEALTH TRENDS

Despite their philosophical differences over what sex education should and should not cover, both Anderson and Mayo wholeheartedly agree that standing on the sidelines is not an option for legislators. Recent youth health statistics help explain why.

While there were welcome declines in teen sexual activity, pregnancy and in some sexually transmitted disease (STD) rates during the 1990s, the overall situation remains troubling. Dr. Laura Kann, an expert in adolescent health with the Centers for Disease Control and Prevention (CDC), says that in a typical class of 30 high school students, 15 have had sexual intercourse at least once. Five have had four or more sex partners, and 11 have had sex in the past three months. Of those latter 11, five did not use a condom the last time they had sex, nine did not use birth control pills, and two had been drinking or using drugs.

Every year nearly 1 million U.S. teenagers become pregnant, says Kann, which works out to a rate of almost 90 pregnancies per 1,000 girls, ages 15 to 19. It is the highest rate among all developed nations. The vast majority of U.S. teen pregnancies are unintended, and roughly half a million of these young women give birth. Teen mothers, Kann notes, are less likely to get adequate and timely prenatal care and are more likely to smoke. Their low-birthweight babies often require extensive medical care. And these girls also are less likely than others to finish high school or have steady jobs and more likely to be on welfare and have unstable marriages.

Sexually active adolescents also run the risk of contracting HIV and other sexually transmitted diseases. In fact, every year one out of four sexually active teens will get an STD. And most chilling of all: Young people under 25 now account for about half of all new HIV infections annually.

WHAT GETS TAUGHT?

According to a 2000 study by the Henry J. Kaiser Family Foundation, roughly 90 percent of the nation's students will take a course in sex education at least once between grades seven and 12. However, the report, "Sex Education in America: A View From Inside the Nation's Classrooms," found that what they are taught varies widely. States have enacted a patchwork of sex education laws, ranging from general mandates to more specific guidelines for course content. The HIV epidemic gave rise to a separate and equally diverse set of education mandates and sources of funding.

Welfare reform efforts aimed at deterring out-of-wedlock childbirth also brought additional money and directives into play. As part of its sweeping 1996 welfare reform law, Congress authorized $250 million in matching grants to states over five years for school- and community-based sex education programs focused strictly on abstinence.

President Bush has proposed extending this funding at the same level. His FY 2003 budget also requests $73 million in abstinence education funding through grants by the Department of Health and Human Services and an additional $12 million through the 1981 Adolescent Family Life Act. Congress is expected to reauthorize the welfare program this year. Meanwhile, the Bush administration's pledge to make the promotion of marriage a central thrust of welfare reform could influence sex education course content down the road. The same holds true for centrist Democratic and Republican demands for welfare to aggressively promote responsible fatherhood.

According to the Kaiser study, 57 percent of high school principals report that school boards and local governments have a "great deal" of influence over what gets taught in sex education. Twenty-seven percent say state governments have a great deal of influence, and 43 percent say they exert only "some influence." In addition, 58 percent of principals say their school's main message is that students should abstain, but if they do not they should practice safer sex, compared with 34 percent who say their school's main message is abstinence-only.

In practice, however, the line dividing "abstinence-only" sex education from comprehensive or "abstinence-plus" instruction is often quite blurry. Courses described as abstinence-only sometimes include instruction about condoms as a means of avoiding disease and pregnancy. Likewise, virtually all comprehensive programs stress abstinence, and many provide only basic information about birth control and STDs.

WHAT DO PARENTS WANT?

Parents are arguably the most important constituents legislators must heed when crafting education policy. So what do parents say they want schools to teach their children about sex? The answer is a wider range of topics than schools teach today, according to a national sex education study that interviewed parents, students and educators, released by the Kaiser Family Foundation in 2000.

Virtually all parents want sex education to cover core concepts such as abstinence (97 percent), HIV/AIDS and other STDs (98 percent), and the basics of reproduction (90 percent), according to the study. Large majorities also want schools to address politically sensitive topics such as birth control (90 percent), how to use condoms (85 percent) and homosexuality (76 percent). They also overwhelmingly want schools to teach their children practical lessons, such as how to deal with pressure to have sex (94 percent), how to talk with boyfriends and girlfriends about sex, and STDs (88 percent). The survey, however, found wide gaps between the percentages of parents who say they want sensitive and real-life topics covered and the percentages of students who say that their schools actually teach them.

Parents seem to know intuitively what works in sex education. In 2001, the National Campaign to Prevent Teen Pregnancy, a nonpartisan, nonprofit group based in Washington, D.C., released a comprehensive evaluation of more than 100 pregnancy and STD prevention programs. The study, "Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy," identified eight with high success rates, and all of them share characteristics that correspond with what parents say they want.

For example, the successful programs deliver and consistently reinforce clear messages about abstaining from sex or using contraception. "They don't simply say, 'Here are the facts and here are five steps to making a decision,"' says Douglas Kirby of ETR Associates, a California-based training and research firm that conducted the study. "Everything within the program was designed to convince the young person that having unprotected sex is not a good idea, to get them to internalize that. It wasn't pros and cons and you decide what's best for you. It was a clear message, most commonly, that you should always avoid unprotected sex, abstinence is the safest and best choice, and if you have sex you should use protection."

HOW TO SAY NO

Successful programs also provide accurate information about the risks of unprotected sex, Kirby says. And they cover the real-life lessons that parents say they want, most notably commonsense instruction about avoiding situations that can lead to sex as well as practice in communication skills. "They do a lot of role playing," Kirby notes. "They practice saying no. They practice insisting on the use of condoms or contraception. They go through all the decisions they would have to make and all the things they couldn't do in their life if they had a baby. This personalizes it so that they really understand the impact upon their own lives."

Five of the eight successful programs are traditional sex or STD education programs and two are intensive community service programs. The eighth, created by Michael Carerra of the Children's Aid Society of New York, was singled out for special praise. It combines sex and family life education with tutoring and other help with academics, sports and arts, help getting into college or finding a job, and comprehensive health care. Teenagers enter the program in the eighth or ninth grade and are encouraged to stay in it through graduation. It is also expensive, costing between $4,000 and $6,000 per student per year.

The overwhelming weight of evidence shows that sex education programs that discuss contraception do not increase teen sexual activity, as many critics have asserted, according to the teen pregnancy prevention study. "Some of them, but not all of them, delay the initiation of sex, reduce the frequency of sex, and reduce the number of sexual partners," Kirby says. "Some of them also increase the use of condoms and contraception. We also saw that dual emphases on abstinence and contraception aren't conflicting. This is not a mixed message for young people. It's a message that young people do, in fact, understand."

There are too few studies of abstinence-only programs to reach definitive conclusions about their effectiveness, Kirby says. Congress earmarked $6 million in the 1996 welfare reform law for a comprehensive national evaluation of such programs. The research got under way in 1998 and preliminary data are expected to be available in early 2003. The final report to Congress is due in 2005.

BIPARTISAN CONSENSUS IN MAINE

Finally, notes Kirby, it takes highly trained and motivated teachers "to do all of these things--to talk about sex in the classroom, to role play, to model communication skills."

"You need teachers who believe in the program, who can relate well with young people, who are comfortable talking about sex and who get training so that they can do all of these things well," he says. "The training component is very important."

That's a message that Maine lawmakers have heeded. This spring, the House and Senate voted overwhelmingly in favor of legislation to strengthen sex education teacher training and curriculum development.

The bill codifies the definition of family life education in Maine for the first time, describing it as a comprehensive course of study encompassing abstinence, contraception, STDs, responsible decision making, parental communication and community values.

"This isn't just about sex education," says Representative Elaine Fuller, the bill's main sponsor in the House. "It's about communication, conflict resolution, responsible decision making--it's about all of the things that go into healthy family life." The original bill would have tripled annual state aid for sex education from $250,000 to $750,000, but the extra funds were stripped from the measure in committee because of the state's revenue shortfall.

The bill's moderate Democratic and Republican sponsors say they eased the way for its final passage by strengthening its language on abstinence and adding an opt-out provision for parents. "We made a very deliberate point to get strong bipartisan co-sponsorship for this bill," says Democrat Fuller. "We worked really hard in committee to get Republicans involved. We made concessions to address their concerns without destroying the intent of the program. And we did so to the extent that we came out of committee with a unanimous report. That was crucial."

Representative Fuller "kept me abreast because she knows this is a topic I'm interested in," says Mayo, a Republican supporter of the bill. "I talked with others in my caucus and a lot of them came on board."

Opposition to sex education "has tended to come from good people who have a strong feeling that this isn't something the state should be legislating, that family life education should come from the family," Mayo says. "You have to accept from Day 1 that you will never get unanimous agreement on a divisive issue like this. All you can do is work with all of the various constituencies, let them know what you are doing, and listen to and be open to their suggestions. You try to bring as many on board as you can."

Fuller, a registered nurse and former director of the state's Medicaid program, says that informing fellow lawmakers about gains linked to sex education was crucial to the bill's success. Maine had one of the nation's highest teen pregnancy rates two decades ago, she explains. But due in part to the state's existing sex education efforts, by 1999 it had fallen to roughly 30 births per 1,000 teenagers, one of the nation's lowest rates.

"That was an important point to make," she says. "Legislators needed to know that there was something out there that was making the rate low and that we need to ramp up our efforts in the places in the state where the rates are still high and where these courses are not being taught."

Lawmakers in other states who want to address sex education should begin by "getting your facts together," Fuller advises. "You need hard data to move forward."

RELATED ARTICLE: RESOURCES FOR STATE LEGISLATORS

State lawmakers rely on objective, accurate information. And to help them get the national and state-specific data on sex education they need, NCSL has formed a partnership with the Henry J. Kaiser Family Foundation, an independent national philanthropy dedicated to informing policymakers, the media and the public about health issues.

As part of their partnership, NCSL and Kaiser have published A State Legislator's Guide to Sex Education, an up-to-date compendium of information on sex education. It includes:

* Fact sheets with the latest information on teen pregnancy and adolescent sexual health.

* Answers to frequently asked questions that parents and policy-makers often have about sex education.

* State profiles with examples of how three different states have handled sex education.

* A resource guide with links to health and public policy organizations, state-by-state data and recent studies.

The guide has been mailed to legislators who chair health, human services and education committees nationwide. It also is available online at NCSL's adolescent health Web page at www.ncsl.org/programs/health/adoles.htm

Carla Curran is NCSL's expert on adolescent and school health policy. Virginia Witt is a senior program officer at the Henry J. Kaiser Family Foundation.