MICHIGAN ASSOCIATION OF SCHOOL NURSES SEX EDUCATION IN MICHIGAN

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Sex Education in Michigan Schools MICHIGAN SCHOOL NURSE GUIDELINES AND RESOURCES

Original Date of Issue: 2016

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Foreword These guidelines contain current best practice recommendations for the health service topic addressed. The guidelines have been reviewed by the School Nurse Practice Subcommittee of the Michigan Statewide School Nurse Task Force as a means to provide consistent and safe care to students. Specific laws and regulations that direct school nursing practice or other health services are identified in the guidelines. There is no guarantee that the use of guidance in this document will lead to any particular result or outcome. The information in this document was researched in March, 2016.

Purpose This document will provide guidelines and resources for implementing sex education programs in schools.

Overview

Teenage pregnancy and sexually transmitted infections (STI) or sexually transmitted diseases (STD), including human immunodeficiency virus (HIV), are often an unintended health outcome for youth. A high quality sex education program can help eliminate some health disparities while reducing sexual risk behaviors and promoting positive child-parent communication. The Community Preventive Services Task Force from the Centers for Disease Control and Prevention (CDC) (2012) recommends group-based comprehensive risk-reduction interventions delivered to adolescents, in schools or communities, to promote behaviors that prevent or reduce the risk for HIV, other STDs, and pregnancy in grades 6-12. Vivancos, Abubakar, Phillips-Howard, and Hunter (2013) found that addressing multiple risk behaviors and promoting protective factors by enhancing family interaction and the school environment were the most effective interventions. Kirby’s (2008) study demonstrated that comprehensive sexual health education programs show strong evidence for positively affecting young people’s sexual behavior, including both delaying initiation of sex and increasing condom and contraceptive use among youth. Improvements in public health, including sexual health, can contribute to a reduction in health care costs (National Sexuality Standards, 2012). Teen pregnancy and childbearing bring substantial social and economic costs through immediate and long-term impacts on teen parents and their children and strains the public sector. Having a child during the teen years carries high costs—health, economic, and social—to the mother, father, child, and community. In 2010, teen pregnancy and childbirth accounted for at least $9.4 billion in costs to U.S. taxpayers for increased health care, foster care, incarceration rates among children of teen parents, and lost tax revenue because of lower educational attainment and income among teen mothers (CDC, 2016a). The cost of teen pregnancy in Michigan during the same year was $283 million (National Campaign to Prevent Teen and Unplanned Pregnancy, 2016). The children of teenage mothers are more likely to have added health problems, give birth as a teenager themselves, and face unemployment as a young adult (CDC, 2013a). Parents play a key role in the development of their child’s health behavior. Kao and Manczak (2013) concluded that positive family function significantly protects adolescents from STIs overtime. Not only do parents influence their children’s health decisions but studies have also shown that parents want to see sex education in the schools. Barr, Moore, Johnson, Forrest, and Jordan (2014) discovered public support for age-appropriate sexuality education in their study of 1715 parents in Florida with 80% of

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parents stating they would allow their children to participate in sex education. This group of parents supported sex education at the elementary level. More than half of the parents supported teaching HIV and gender and sexual orientation issues. In Michigan, 78% of parents indicated sex education should be taught in schools (Michigan Department of Education [MDE], 2016a). The 2004 survey results can be retrieved at http://www.michigan.gov/documents/mde/Sex-Ed-Survey_258531_7.pdf . Smart, Parker, Lampert, and Sulo (2012) completed a study to assess adolescents’ health information needs. Students identified the need for accessible, high quality, and relevant information. Preferences ranged from two-way communication with individuals in a personalized way to one-way communication such as static web pages, television, lectures and print. Brewin, Koren, Morgan, Shipley, and Hardy, (2014) recommended including youth in program planning to facilitate a strong sex education program. Michigan and National Data The 2013 Michigan Youth Risk Behavior Survey (YRBS) (MDE,2013a) trend data showed the following risk behaviors for Michigan students compared to the national 2013 YRBS data from the CDC (2015a):

38.1% of Michigan high school students have ever had sexual intercourse (47% nationally).

26.9% of Michigan high school students who have ever had sexual intercourse with one or more people during the past three months (34% nationally).

Among students who had sexual intercourse, 61% used a condom (59% nationally). Although the rates of HIV diagnoses remained stable in 2009-2013, teens likely to be diagnosed were black males who have sex with males (Michigan Department of Health and Human Services [MDHHS], 2015). The CDC (2013b) reported that nationally 1 in 4 new HIV infections occur in youth ages 13 to 24 years. Furthermore, about 60% of all youth with HIV do not know they are infected, are not getting treated, and can unknowingly pass the virus on to others. The CDC (2016b) reported that only 10% of sexually experienced students have ever been tested for human immunodeficiency virus (HIV). In Michigan, the number of chlamydia, gonorrhea, and syphilis cases in 2010 – 2014 for youth less than 15 was 3290 (MDHHS, 2016a). For youth between the ages of 15 – 19 the number was 85,602. Chlamydia is the most commonly reported STD, gonorrhea was the second, followed by syphilis. Retrieved from http://www.mdch.state.mi.us/pha/osr/STD/STDCasesByAgeSexObject.asp. The CDC (2015b) indicated that youth ages 15-24 make up just over one quarter of the sexually active population, but account for half of the 20 million new sexually transmitted infections that occur in the United States each year. The pregnancy rate in 2014 for females in Michigan age 15-19 was 34.8 per 1000 (MDHHS, 2016b) (retrieved from http://www.mdch.state.mi.us/pha/osr/abortion/PregTrdTeen15-19.asp). For white females, the pregnancy rate was 25.3 per 1000 in this age group (MDHHS, 2016c) (retrieved from http://www.mdch.state.mi.us/pha/osr/abortion/WhitePregTrd15-19.asp) and for black females the pregnancy rate was 73.5 per 1000 (MDHHS, 2016d) (retrieved from http://www.mdch.state.mi.us/pha/osr/abortion/BlackPregTrd15-19.asp). The MDHHS (2016e) reports pregnancy rates by county at http://www.mdch.state.mi.us/pha/osr/abortion/pregbycoteen.asp . In Michigan, 8.7% of students identify as lesbian, gay, or bisexual and/or have engaged in same sex sexual behavior. These students are 3 times more likely to be threatened or injured

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with a weapon on school property (18% versus 6%); 2.7 times more likely to not go to school because they felt unsafe (16% versus 6%); and 4.6 times more likely than other students to actually attempt suicide (32% versus 7%). Sexual minority youth often face harassment, abuse, and violence in school settings that put them at greater risk for serious problems, such as substance abuse, HIV, suicide, as well as school failure and dropout (MDE, 2016b). Retrieved from http://www.michigan.gov/mde/0,4615,7-140-74638_74639_29233_59543-367599--,00.html .

Legal Framework for Sex Education in Schools

Federal Law

Protection of Pupil Rights Amendment

http://familypolicy.ed.gov/ppra

Surveys may be subject to the Protection of Pupil

Rights Amendment.

Michigan Law

The MDE (MDE, 2013b) provides a summary of the laws regarding HIV/STI and sex education retrieved

at

http://www.michigan.gov/documents/mde/HIV_and_Sex_Ed_Laws_Chart_Rev_4_2010_345047_7.pdf

The unabridged version of the Michigan laws pertaining to HIV and sex education can be retrieved at

http://www.michigan.gov/documents/mde/4_Unabridged_Sex_Ed_Laws_249443_7.pdf

MCL 380.1169

http://www.michiganlegislature.org/mil

eg.asp?page=getObject&objName=mcl-

380-1169

Dangerous communicable diseases; human

immunodeficiency virus infection and acquired

immunodeficiency virus infection; teacher training;

teaching materials; curricula; teaching of abstinence from

sex.

MCL 380.1506

http://www.michiganlegislature.org/mil

eg.asp?page=getObject&objName=mcl-

380-1506

Program of instruction in reproductive health; supervision;

request to excuse pupil from attendance; “reproductive

health” defined.

MCL 380.1507

http://www.michiganlegislature.org/mil

eg.asp?page=getObject&objName=mcl-

380-1507

Instruction in sex education; instructors, facilities, and

equipment; stressing abstinence from sex; elective class;

notice to parent or guardian; request to excuse pupil from

attendance; qualifications of teacher; sex education

advisory board; public hearing; distribution of family

planning drug or device prohibited; “family planning,”

“class, and “course” defined.

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School Nurse’s Role

The National Association of School Nurses (NASN) (2012) believes the school nurse plays a vital role in the development and implementation of instructional programs that utilize evidence-based strategies to prevent unintended pregnancies and sexually transmitted infections including HIV. School nurses can utilize the principal of Public Health in the NASN Framework for 21st Century School Nursing Practice to develop and implement sex education programs (Maughan, Bobo, Butler, Schantz, & Schoessler, 2015; NASN, 2016).

Recommendations for Practice

Surveillance

1. Utilize state and local data to plan, implement and evaluate sex education programming. The MDE provides information on how to obtain the latest data pertaining to sexual risk behaviors and health outcomes such as HIV, other STDs, teen pregnancy and births that can be retrieved at http://www.michigan.gov/documents/mde/Data_on_Adolescent_Sexual_Risk_Behaviors_373267_7.pdf .

School nurses can find STD rankings by county and local health department at http://www.mdch.state.mi.us/pha/osr/index.asp?Id=12 .

MCL 380.1507a

http://www.michiganlegislature.org/mil

eg.asp?page=getObject&objName=mcl-

380-1507a

Notice of excuse from class; enrollment.

MCL 380.1507b

http://www.michiganlegislature.org/mil

eg.asp?page=getObject&objName=mcl-

380-1507b

Sex education and instruction; curriculum requirements.

MCL 388.1766

http://www.michiganlegislature.org/mil

eg.asp?page=getObject&objName=mcl-

388-1766

Dispensing or distributing family planning drug or device,

dispensing prescriptions for family planning drug, or

making referrals for abortion; forfeiture.

MCL 388.1766a

http://www.michiganlegislature.org/mil

eg.asp?page=getObject&objName=mcl-

388-1766a

Instruction in reproductive health or other sex education;

complaint process.

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2. Advocate for the implementation of the Michigan Profile for Healthy Youth (MiPHY) (MDE, 2015) to gather specific local data about the health risks (including sexual behavior) and needs of their students. The MiPHY is administered to grades 7, 9 and 11. Schools and districts register and survey via an on-line system. More information about the MiPHY can be retrieved at http://www.michigan.gov/mde/0,4615,7-140-74638_74639_29233_44681---,00.html.

Outreach

Consider a parent survey to assess parents view about sex education in their child’s school, specific topics to be taught and when they should be introduced (Michigan State Board of Education, 2003). The MDE (2016) provides a sample parent survey that can be retrieved at http://www.michigan.gov/mde/0,4615,7-140-74638_74639_29233_29803---,00.html .

Once a sex education advisory board is established, fact sheets developed for the community can be a helpful tool to share the progress of the advisory board as well as student growth in the area of reproductive health.

School nurses may also want to establish partnerships with adolescent-friendly providers of sexual health services (e.g., testing for HIV, other STDs and pregnancy; contraception; HPV vaccinations) in the community to facilitate access for students. Collaboration with the local health department and community-based organizations can help identify providers and resources in the community. The Health Teen Network provides a sample lesson on linking students to sexual health care at http://www.healthyteennetwork.org/keep-it-simple-lesson-linking-teens-sexual-health-care-lesson-plan.

School-Based Health Centers provide a model of a system of health care delivery that provides a health care “safety net” for students who are uninsured or underinsured or represent special populations who do not regularly access health care (American Academy of Pediatrics [AAP] Council on School Health, 2012). Information about the MDHHS (2016f, Child and Adolescent Health Center Program (CAHC) can be found at http://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_4912_44686---,00.html.

Population-Based Care

School policies provide critical support for implementation of comprehensive HIV, other STD, and pregnancy prevention education. In Michigan, school districts choose if they will provide sex education. School nurses can advocate for sex education based upon local and state data, MiPHY data, and parent surveys. The State of Michigan State Board of Education (2003) Policy to Promote Health and Prevent Disease and Pregnancy recommends that school boards support their school administrators and faculty to select, adopt, and implement comprehensive sexuality education programs. The policy further states that local school districts should use multiple sources of data to plan programs that meet the prevention needs of all students. The NASN (2012) position statement indicates that age-appropriate health education about human sexuality should be included as part of a comprehensive school health education program and be accessible to all students in schools.

Additional rationale for school districts to provide sex education can be found at http://www.cdc.gov/healthyyouth/fundedpartners/1308/strategies/index.htm.

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Levels of Prevention

Primary Prevention – Steps for Implementing a Sex Education Program of Instruction in Your School District

Intervention Resource

Collaborate with school administrators, school staff and other community members to develop and/or sustain a sex education advisory board. The MDE provides specific guidance to help school districts develop and sustain a sex education advisory board.

http://www.michigan.gov/mde/0,4615,7-140-74638_74639_29233_29803---,00.html

and http://www.michigan.gov/mde/0,4615,7-140-

74638_74639_29233_29803-204637--,00.html

School nurses can consider one or both of the leadership roles for sex education instruction. Michigan School Code identified the sex education advisory board co-chair and the sex education supervisor as leadership roles for sex education instruction. MCL 380.1506 specifies that a program of instruction in reproductive health shall be supervised by a registered physician, registered nurse, or other person certified by the state as qualified. The MDE has a request for approval form for the Sex Education Supervisor.

http://www.michigan.gov/mde/0,4615,7-140-74638_74639_29233_29803-204637--,00.html

School nurses may want to consider professional development regarding sex education in Michigan schools. The Michigan School Health Coordinators are a resource for continuing education in sex education. The regional health coordinators can also provide technical assistance to school nurses as well as school board.

https://mishca.org/

and https://mishca.org/who/

When determining curriculum, sex education advisory boards need to ensure that the required content is covered and that abstinence is emphasized.

The National Sexuality Education Standards (2012) provide guidance on the minimum core content for sexuality education that is developmentally and age appropriate for K-12 students (National Sexuality Standards, 2012).

School districts are encouraged to align the content with the Grade Level Content Expectation for Grades K-8 and the Michigan Model Curriculum Credit Guidelines for high school.

MCL 380.1507b

http://www.michiganlegislature.org/mileg.asp?page=getObject&objName=mcl-380-1507b

http://www.futureofsexed.org/documents/jos

h-fose-standards-web.pdf

http://www.michigan.gov/documents/mde/1_G

LCEs_and_Michigan_Merit_Curriculum_Credit_

Guidelines_250290_7.pd

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School nurses need to follow state laws regarding implementing sex education in Michigan schools. In addition to the legal framework for state laws, planning needs to include funding for teacher training, curriculum, media, and possibly copy costs for the chosen curriculum.

Planning considerations also include class schedules and the number of days needed to implement a curriculum with fidelity.

http://www.michigan.gov/documents/mde/HIV

_and_Sex_Ed_Laws_Chart_Rev_4_2010_345047

_7.pdf

School nurses need to have a clear understanding about the role of the sex education advisory board according to Michigan law: 1. Establishing program goals and objectives. 2. Reviewing and recommending materials and methods. 3. Evaluating, measuring and reporting attainment of program goals and objectives and making the report available to parents at least every two years. The Michigan Department of Education provides a sample two-year report. Note: Sex education curricula often have imbedded pre and post-tests that can be used to assess student knowledge and skills. The MiPHY also provides data for sex education evaluation. Parent surveys and focus groups can also be a source of evaluation data.

http://www.michigan.gov/mde/0,4615,7-140-

74638_74639_29233_29803---,00.html

Michigan law provides clear guidance for sex

education advisory board membership. Students,

teachers and parent members are an essential

component of the sex education advisory board.

MCL 380.1507

http://www.michiganlegislature.org/mileg.asp?

page=getObject&objName=mcl-380-1507

School nurses may be a guest presenter in the

classroom to teach sex education. MDE provides

information about the guest presenter policy.

http://www.michigan.gov/documents/mde/OPP

S_Health_Guest_Presenter_Policy_2011_05121

2_352793_7_362824_7.pdf

and

http://www.michigan.gov/mde/0,4615,7-140-74638_74639_29233_29803---,00.html

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Social Determinants of Health and Health Equity

1. Ensure health equity for all youth by addressing the needs of youth who are at higher risk for targeted problems through education and youth development strategies. School nurses need to analyze state and local data to help determine who are the youth with the greatest risk for teen pregnancy and STIs/HIV:

Sexually transmitted diseases in Michigan show a disproportionate burden within minority communities: http://www.mdch.state.mi.us/pha/osr/std/STDbyRace.asp

Of all Michigan teens (age 13-19) diagnosed with HIV in the last five years, 83% are black compared to 61% of persons diagnosed at ages 20 + (Retrieved from http://www.michigan.gov/documents/mdch/MIReport15_487766_7.pdf.

Michigan teen pregnancy rates are higher for black females when compared to white females: http://www.mdch.state.mi.us/pha/osr/index.asp?id=2 .

Lesbian, gay, bisexual, transgender and questioning youth are of disproportionate risk for HIV and other STIs. Retrieved from http://www.michigan.gov/mde/0,4615,7-140-74638_74639_29233_29803-367152--,00.html

2. Consider using translators for public hearings regarding the sex education advisory boards’ curriculum recommendations when the school community has diverse languages and cultures. Translation of parent letters and exclusion information is also helpful to non-English speaking parents and caregivers.

3. Advocate for programs that are inclusive of and sensitive to LGBTQ youth by using inclusive language and a “zero tolerance” for discriminatory words. The Welcoming Schools Guide provides guidance to school staff for using inclusive language: file:///C:/Users/patbe/Documents/LSD/lsdwork2015/sex%20ed%202011/LGBT/Welcoming-Schools-What-Do-You-Say-to-Thats-So-Gay.pdf

4. Help students access community health care or school-based health services. Information about the MDHHS Child and Adolescent Health Center Program (CAHC) (MDHHHS, 2016f) can be found at http://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_4912_44686---,00.html and http://www.michigan.gov/mde/0,4615,7-140-74638_74639_29233_29803-367152--,00.html.

School nurses need to be aware that Michigan’s

model health education curriculum, the Michigan

Model for Health® is used by a majority of school

districts in Michigan. It includes model curricula on

HIV/STI prevention for Grades 4 and 5, 7-8, and 9-

12. Districts can choose to adopt, adapt, or

disregard the model curriculum and implement

commercially or locally developed curricula.

Once curriculum is determined, the school district

may consider placing the curriculum outline on

the district web site along with other parent

resource material.

http://www.michigan.gov/mmh

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5. Students with intellectual disabilities are at greater risk for sexual abuse and is essential that sex education be provided in a concrete way (Blom, Crawford and Whitehead, 2013).

Red Flags for Implementing Sex Education in the School Setting Based Upon Michigan Law

1. School districts are required to teach about dangerous communicable diseases, including, but not limited to, HIV/AIDS. Instruction must be offered at least once a year at every building level (elementary, middle/junior, and senior high). 2. Every district that chooses to provide sex education must have a sex education advisory board that includes required membership. 3. Each person who teaches K-12 pupils about HIV/AIDS shall have training in HIV/AIDS education for young people. 4. Teachers must be qualified to teach sex education (MDE, 2007). Specific teacher qualifications can be retrieved at http://www.michigan.gov/documents/mde/Qualifications_of_Sex_Ed_Tchr_3.07_Districts_191454_7.pdf 5. Clinical abortion cannot be considered a method of family planning, nor can abortion be taught as a method of reproductive health. Family planning drugs or devices cannot be dispensed or distributed in the public school or public school property. School districts may want to consider developing guidelines for teachers about answering student questions as well as guidelines for referrals for health services (i.e. Child and Adolescent Health Centers) not including abortion. 6. Parents and legal guardians must be notified of HIV and sex education instruction and their right to exclude their child without penalty. 7. Curricula, materials, and methods used as a part of HIV/STI or sex education instruction offered by a school district must go through the formal approval process, including two public hearings and school board approval. 8. Public Acts 165 and 166 of 2004 require school districts that offer reproductive health or sex education to include information informing students about underage sex and the sex offender registry. 9. Clearly identify school district referral procedures for students seeking sexual health services in the community. Identify who can make the referrals, when can referrals be made, what steps are involved in making the referral and where can students go in the community for services.

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