Key Findings from “Comprehensive Sexuality Education as a Primary Prevention Strategy for Sexual Violence Perpetration” © 2021 National Sexual Violence Resource Center. All rights reserved. This publication was supported by the Grant or Cooperative Agreement Number 6 NUF2CE002510-02-01, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. The content of this publication may be reprinted with the following acknowledgment: This material was reprinted, with permission, from the National Sexual Violence Resource Center’s publication entitled Key findings from “Comprehensive Sexuality Education as a Primary Prevention Strategy for Sexual Violence Perpetration.” This guide is available by visiting www.nsvrc.org. Key Findings From “Comprehensive Sexuality Education as a Primary Prevention Strategy for Sexual Violence Perpetration” Research translation by NSVRC Can school-based sex education programs become an important strategy in preventing harm? An analysis has been published that suggests school-based programs centering the learning objectives and skill building contained in the National Sexuality Education Standards (Future of Sex Education Initiative, 2020) can elevate programs into effective tools for sexual violence prevention. By examining prevention programming and perpetration research, the authors conclude that such programs can meet both traditional sex education goals as well as address risk factors for perpetrating sexual violence. Traditional school-based sexuality education programs have been used to provide education on sexual health issues including teen pregnancy, sexually transmitted infections such as HIV, and other adverse outcomes of sexual activity. In the recent past, most school-based sexual violence prevention programs have been independent from sexuality education programs and have provided education to raise awareness about sexual violence. Recognizing the ubiquitous nature and long-term ramifications of sexual violence, schools have begun redirecting program efforts toward primary prevention. By definition, primary prevention addresses the root causes of violence and the risk factors including attitudes, beliefs, and behaviors that lead to perpetrating sexual violence. This approach differs considerably from an education and awareness focus, and research continues to emerge on the most effective ways to address risk factors. What is comprehensive sexuality education? Sexuality education programs that build a foundation of knowledge and skills relating to human development, relationships, decision-making, abstinence, contraception, and disease prevention. Ideally, comprehensive sexuality education should start in kindergarten and continue through 12th grade. At each developmental stage, these programs teach age-appropriate, medically accurate information that builds on the knowledge and skills that were taught in the previous stage. Future of Sex Education Initiative, 2012, p. 39 In Comprehensive Sexuality Education as a Primary Prevention Strategy for Sexual Violence Perpetration (Schneider, & Hirsh, 2020), the authors suggest that using the National Sexuality Standards (NSES) program components within a school-based program is an effective strategy to modify many risk factors for perpetration. Further, the authors state that a K-12 program begins reaching children early in the lifespan, providing the opportunity to modify and develop behavioral skills that will lower perpetration. A good starting place to make the most of this analysis is with a brief overview of the NSES. The Standards, first published in 2012, were developed from a broad span of disciplines and designed to guide a more consistent implementation of sexuality education in public schools while accounting for limited time and resources dedicated to health education generally. More specifically, the new framework that was developed includes content and skills the panel deemed to be minimum, essential knowledge for K-12 students, delivered in planned, age-appropriate, and evidence-informed ways. Sexual development is seen as a normal, natural, healthy part of human development and addresses a content area that is highly relevant to students and important to academic achievement (Future of Sex Education Initiative, 2012). The Standards are a set of foundational guidelines that can be used in developing and evaluating sexuality education programs developed for K-12 students (Future of Sex Education Initiative, 2012, p. 11). Standard 1: Core Concepts. Students will comprehend concepts related to health promotion and disease prevention to enhance health. Standard 2: Analyzing Influences. Students will analyze the influence of family, peers, culture, media, technology, and other factors on health behaviors. Standard 3: Accessing Information. Students will demonstrate the ability to access valid information, products, and services to enhance health. Standard 4: Interpersonal Communication. Students will demonstrate the ability to use interpersonal communication skills to enhance health and avoid or reduce health risks. Standard 5: Decision-Making. Students will demonstrate the ability to use decision-making skills to enhance health. Standard 6: Goal–Setting. Students will demonstrate the ability to use goal-setting skills to enhance health. Standard 7: Self-Management. Students will demonstrate the ability to practice health-enhancing behaviors and avoid or reduce health risks. Standard 8: Advocacy. Students will demonstrate the ability to advocate for personal, family, and community health. The Standards are applied to each of the seven topic areas below and further developed based on student grade completion to include age-appropriate performance indicators (Future of Sex Education Initiative, 2012, pp. 12–36). The topics include: Anatomy and Physiology, Puberty and Adolescent Development, Identity, Pregnancy and Reproduction, Sexually Transmitted Diseases and HIV, Personal Safety, and Healthy Relationships (Future of Sex Education Initiative, 2012, p. 10). The second edition was released in 2020 and builds on the initial guidelines including additional topics and newer research on issues such as sexual orientation, gender identity, reproductive healthcare, and sexual agency and consent as well as digital technologies, social media, and the growing impact of social and sexually explicit media on relationships (Future of Sex Education Initiative, 2020). For example: Personal Safety (PS) was changed to: Interpersonal Violence (IV) and “better reflects all types of violence (e.g., bullying, sexual harassment, sexual abuse, sexual assault, dating violence, domestic violence) that may occur in a variety of relationships, e.g., peer-to-peer, family, romantic, sexual” (Future of Sex Education Initiative, 2020, pp. 8–9). Comprehensive Sexuality Education as a Primary Prevention Strategy for Sexual Violence Perpetration (Schneider, & Hirsh, 2020) presents a case that centering and incorporating NSES into school-based sex education programs can be a successful primary prevention strategy for sexual violence. Since there is no evaluation data, the authors present their argument conceptually. First they examine effective prevention programming against NSES, and secondly they examine how NSES programming can mitigate known risk factors for sexual violence. The following is an example of applying the Standards within the topic area of Healthy Relationships. Using age-appropriate content, students who have completed grade five should be able to: Core Concepts: Describe the characteristics of healthy relationships. Analyzing Influences: Compare positive and negative ways friends and peers can influence relationships. Assessing Information: Identify parents and other trusted adults they can talk to about relationships. Interpersonal Communication: Demonstrate positive ways to communicate differences of opinion while maintaining relationships. Self-Management: Demonstrate ways to treat others with dignity and respect. (Future of Sex Education Initiative, 2012, p. 15) Effective prevention programming Beginning with the seminal work of Nation et al. (2003), the nine characteristics of effective prevention programs were measured against the NSES guidelines. The nine characteristics are: Comprehensive Sufficient dosage Positive relationships Socioculturally relevant Well-trained staff Varied teaching methods Theory driven Appropriate timing Outcome evaluations Schneider and Hirsch (2020) suggest that a program incorporating NSES meets each of these characteristics. They note the standards are comprehensive based on the range of topics that are covered (earlier); positive relationships are taught as a key component throughout. The Standards are age appropriate, use different learning objectives for different grade levels, and recommend varying teaching methods. Further, they are theory-driven and were developed using social learning/social cognitive theory (LaMorte, 2019) and the social ecological model (Centers for Disease Control and Prevention [CDC], 2020). They also include teacher training, development, and ongoing support to ensure that those delivering comprehensive sexuality education are well trained (Schneider & Hirsch, 2020, p. 443). Known risk factors for perpetration Addressing the second component of their thesis — incorporating the guidelines of the NSES may prevent sexual violence perpetration behaviors — next the authors use the work of Tharp and colleagues (2012) who examined 191 published empirical studies looking at perpetration by and against adolescents and adults to examine whether the NSES guidelines may prevent sexual violence perpetration. Multiple risk factors were identified that exist across the social-ecological spectrum — individual, interpersonal/relationship, community, and societal-level risk factors. Effective prevention strategies work at many levels and go beyond individual efforts to change attitudes. Effective strategies recognize that individuals interact in the world at multiple levels (individual, relationship, community, and societal). See the social-ecological model (CDC, 2020) for more information. The Social-Ecological Model Individual Relationship Community Societal The many risk factors identified through these studies were grouped into four primary categories: sex, gender, and violence-related risk factors; child abuse–related risk factors; sexual behavior–related risk factors; and social and emotional intelligence–related risk factors. Considerable discussion is devoted to examining the learning objectives and skills achieved in an NSES-centered program as paths to mitigate many of these risk factors. For example, the authors define the gender transformative programming of NSES as “those that aim to reconfigure gender roles in the direction of more gender equitable relationships” (Schneider & Hirsch, 2020, p. 446). Gender transformative components, they argue, have the potential to counter sexual behavior-related risk behaviors such as early initiation of sex and multiple sexual partners. They note that sex education programs that address gender and power are more successful at reducing pregnancy and sexually transmitted infections than programs that don’t (p. 447). Additionally, NSES-centered programs teach children age-appropriate skills designed to impact child sexual abuse risk factors. These include such things as naming body parts, recognizing signs of abuse, and telling a trusted adult. The authors acknowledge, however, as do other experts in child sexual abuse, that the burden of prevention should never be placed on a child. Educating children does not provide protection against other forces outside of school, including the home and community environments where other strategies are necessary (p. 448). That said, the authors suggest these may be important to helping a child out of some abusive situations. Finally, social–emotional learning skills are addressed in NSES learning objectives throughout the K-12 span. Skills including respectful communication, conflict negotiation, effective decision-making strategies, and respectful and dignified treatment of others have shown to be effective in impacting risk factors for perpetration (p. 449). Skills such as respectful communication, conflict negotiation, effective decision-making strategies, and respectful and dignified treatment of others have shown to be effective in impacting risk factors for perpetration. Findings Based on their evaluation of the NSES guidelines, both meeting the standards for effective prevention programming as well as addressing risk factors for sexual violence perpetration, the authors conclude: Research shows that the majority of causal risk factors for SV (sexual violence) perpetration fall into four categories: (1) sex, gender, and violence-related risk factors; (2) child abuse-related risk factors; (3) sexual behavior-related risk factors; and (4) social–emotional intelligence-related risk factors. Current primary prevention strategies: (1) fail to address the majority of SV perpetration risk factors and (2) do not use pedagogical approaches that characterize effective prevention programs. (Ed. Note: the research reviewed to arrive at this assertion was published by DeGue, et al., in 2014.) Evidence suggests that all four categories of risk factors can be modified through educational programming that employs characteristics of effective prevention. Comprehensive Sexuality Education, using the National Sexuality Education Standards (NSES), addresses the majority of SV perpetration risk factors, adheres to the qualities of effective prevention programs, and reaches youth at a developmentally appropriate age, thus making it a potentially effective strategy at reducing SV perpetration (p. 451). Limitations The authors acknowledge a number of limitations with using an NSES–guided program to address sexual violence prevention by preventing perpetration. Such a program will not address all of the known risk factors associated with perpetration. They note, for example, a school-based program cannot address emotional or physical abuse of children as it cannot alter events and interactions that happen inside a home. They acknowledge the importance of additional strategies focused on caregivers such as behavioral parent training. Additionally, a comprehensive sexuality education program cannot undo the gendered structure of popular culture that drive to problematic stereotypes and behaviors (p. 450). The study suggests, however, that helping students develop critical thinking skills toward “beliefs, attitudes and behaviors about gender” can provide a path to altering the gender-related risk factors that can lead to perpetration (p. 450). A further limitation is the focus on cisgender, heterosexual men and women. The authors suggest that evaluation research is needed to examine the impact of comprehensive sexuality education on rates of sexual assault among LGBTQ populations. The authors also note that primary prevention strategies should be complemented by strategies that include secondary and tertiary prevention, such as perpetration recidivism, and providing trauma-informed support to victims in the aftermath of abuse. Schneider and Hirsh conclude that traditional sex education programs initially intended to reduce unplanned teenage pregnancies, HIV/STI acquisition, and other health risk behaviors hold the potential to evolve into a vehicle to prevent sexual violence by incorporating and centering the National Sexuality Education Standards into a comprehensive sexuality education program. What can this mean for the future of sexual violence prevention? Review current practices. Use this article to review current K-12 prevention strategies. Explore curricula that have been designed around the standards. Advocates for Youth, a nonprofit advocacy group working to empower youth in their sexual and reproductive rights, developed a program called Rights, Respect, Responsibility (3Rs). The 3Rs is a comprehensive sexuality education curriculum that fully meets the National Sexuality Education Standards as well as the 16 topics outlined by CDC as essential for sexual health education. The curriculum is LGBTQ inclusive as outlined in the recent Call to Action endorsed by more than 50 health, rights, and justice organizations. Build support for policies that support prevention and comprehensive sexuality education. This article can be shared and used to build support for using NSES to build a comprehensive sexuality program. Also see the National Sexual Violence Resource Center (NSVRC) Talking Points (2016) on Comprehensive Sexual Misconduct Policy for Grades K-12. Develop messaging. A key to wider acceptance within schools and communities may be the messaging that precedes implementing a program. The Minnesota Coalition Against Sexual Assault developed and tested a variety of messages directed to both general audiences as well as specific target audiences that included parents, school administrators, and staff. Specific messages were ranked by their ability to encourage, support, and promote healthy relationship and sexual violence prevention through school-based education. The report suggests messaging should focus on: the health and safety of children and families, the limitations of the current healthy relationship and sexual violence prevention education curriculums used in schools and community settings, the inclusion of parents in the process, stressing that the teachings would reinforce, not replace, what parents do at home (Minnesota Coalition Against Sexual Assault, 2019, p. 12). While the study results are specific to the state of Minnesota, there is likely wider applicability to other states as well. The National Coalition for Sexual Health (n.d.) has also developed a set of resources to help effectively communicate with the public about the importance of sexual health. Also see 10 Principles for Effective Prevention Messaging from NSVRC (2015). Help build the evidence base. Partner with universities or evaluation consultants to evaluate programs that center on the NSES. Build and support culturally specific comprehensive sexuality programs (to address gaps in curricula for youth with disabilities and youth who are Black, Indigenous, and people of color). Further reading and additional Resources: Advocates for Youth. (2018). Rights, respect, responsibility: A K-12 sex education curriculum. https://advocatesforyouth.org/resources/health-information/rights-respect-responsibility-a-k- 12-sex-education-curriculum Minnesota Coalition Against Sexual Assault. (2019). Messaging report summary: Support for healthy relationships and sexual violence prevention education for children and youth. https://www.mncasa.org/wp-content/uploads/2019/09/One-Page-Messaging-Report-Final-1.pdf National Coalition for Sexual Health. (n.d.). National Coalition for Sexual Health [Website]. https://nationalcoalitionforsexualhealth.org/ National Sexual Violence Resource Center. (2015). 10 principles for effective prevention messaging. https://www.nsvrc.org/sites/default/files/2015-05/publications_bulletin_10- principles-for-effective-prevention-messaging.pdf National Sexual Violence Resource Center. (2016, December 6). Talking points: Considerations for school district sexual misconduct policies. https://www.nsvrc.org/sites/default/files/2016-12/considerations_for_school_district_ sexual_misconduct_policies.pdf National Sexual Violence Resource Center. (2020, September 15). Sex ed: Curricula, critical thinking, and using technology to teach sexuality education [Podcast]. https://www.nsvrc.org/resource/2500/sex-ed-curricula-critical-thinking-and-using- technology-teach-sexuality-education Seattle & King County (WA) Public Health. (n.d.). FLASH curriculum [Website]. ETR. https://www.etr.org/flash/flash-curriculum/ Sexuality Information and Education Council of the United States. (2018). On our side: Public support for sex education. https://siecus.org/resources/public-support-sex-education/ Women of Color Sexual Health Network. (n.d.). Women of Color Sexual Health Network [Website]. http://www.wocshn.org/ References Assini-Meytin, L., Fix, R. L., & Letourneau, E. J. (2019). Child sexual abuse: The need for a perpetration prevention focus. Journal of Child Sexual Abuse, 29(1), 22–40. https://doi.org/10.1080/10538712.2019.1703232 Centers for Disease Control and Prevention. (2020). The Socio-Ecological Model: A framework for prevention. U.S. Department of Health & Human Services. https://www.cdc.gov/violenceprevention/publichealthissue/social-ecologicalmodel.html DeGue, S., Valle, L. A., Holt, M. K., Massetti, G. M., Matjasko, J. L., & Tharp, A. T. (2014). A systematic review of primary prevention strategies for sexual violence perpetration. Aggression and Violent Behavior, 19(4), 346–362. https://doi.org/10.1016/j.avb.2014.05.004 Future of Sex Education Initiative. (2012). National Sexuality Education Standards: Core content and skills, K–12. Rutgers University. http://answer.rutgers.edu/file/national- sexuality-education-standards.pdf Future of Sex Education Initiative. (2016). Building a foundation for sexual health is a K–12 endeavor: Evidence underpinning the National Sexuality Education Standards. Advocates for Youth. https://advocatesforyouth.org/wp-content/uploads/2019/09/Building-a-foundation-for-Sexual-Health.pdf Future of Sex Education Initiative. (2020). National Sexuality Education Standards: Core content and skills, K–12 (2nd ed.). Advocates for Youth. https://advocatesforyouth.org/wp-content/uploads/2020/03/NSES-2020-web.pdf LaMorte, W. W. (2019). The Social Cognitive Theory. Boston University School of Public Health. https://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories5.html Minnesota Coalition Against Sexual Assault. (2019). Messaging report: Support for healthy relationships and sexual violence prevention education for children and youth. Minnesota Coalition Against Sexual Assault. https://www.mncasa.org/wp-content/ uploads/2019/09/MNCASA-Messaging-Report-Update.pdf National Coalition for Sexual Health. (n.d.). Talking with the public about sexual health: Message frameworks [Webpage]. https://nationalcoalitionforsexualhealth.org/tools/for-healthcare-providers/ talking-with-the-public-about-sexual-health-message-frameworks National Sexual Violence Resource Center. (2014). Key findings from a systematic review of primary prevention strategies for sexual violence perpetration. https://www.nsvrc.org/publications/nsvrc-publications-guides-research-briefs/key-findings- systematic-review-primary Nation, M., Crusto, C.,Wandersman, A., Kumpfer, K. L., Seybolt, D., Morrissey-Kane, E., & Davino, K. (2003). What works in prevention: Principles of effective prevention programs. American Psychologist, 58(6–7), 449–456. https://doi.org/10.1037/0003-066X.58.6-7.449 Schneider, M., & Hirsh, J. S. (2020). Comprehensive sexuality education as a primary prevention strategy for sexual violence perpetration. Trauma, Violence, & Abuse, 21(3), 439–455. https://doi.org/10.1177/1524838018772855 Tharp, A. T., DeGue, S., Valle, L. A., Brookmeyer, K. A., Massetti, G.M., & Matjasko, J. L. (2012). A systematic qualitative review of risk and protective factors for sexual violence perpetration. Trauma, Violence, & Abuse, 14(2), 133–167. https://doi.org/10.1177/1524838012470031 National Sexual Violence Resource Center | (877)739-3895 | resources@nsvrc.org | www.nsvrc.org