A 2019 study revealed same-sex sexual behavior is not genetically predetermined. ^[4] This is important since LGBTQ-identified youth are at greater risk of experiencing all negative consequences of sexual activity. These health disparities also exist in LGBTQ-affirming countries where minority stress is minimal; even higher rates of attempted suicide are not explained by discrimination. ^[5],[6] Adverse childhood events and high-risk behaviors may be larger contributors to these health disparities than minority stress.

Anal intercourse is high-risk for trauma and infection. The large intestine, in contrast to the vagina, is not a receptive organ; it is structured to excrete feces. Semen has immune-suppressant activity which promotes fertilization during vaginal intercourse, but increases infection and cancer risk during anal intercourse. Consequently, the risk of contracting HIV from a single act of receptive anal intercourse is 20 times greater than for receptive vaginal intercourse.^[7] Anal sex is also more likely to facilitate HPV infection resulting in anal and rectal cancer.^[8],[9]  Women who have sex with women are also at higher risk for STDs and other health problems than are heterosexual women.^[10]  As lesbian-identified scholar Camille Paglia states, “[I]n nature, procreation is the single relentless rule. That is the norm… Our sexual bodies were designed for reproduction.”^[11]

Due to how humans are innately structured for reproduction, human sex is binary and immutable.  According to the DSM-5, sex is the “Biological indication of male and female (understood in the context of reproductive capacity), such as sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia.”^[12]  Two sexes exist because only two gametes exist: sperm and ova. The colloquialism “intersex” refers to rare disorders of sex development (DSD) in male or female patients. DSD are deficiencies and malformations of the reproductive system associated with impaired fertility. Sex is determined at fertilization and registered in every nucleated cell of the body.^[13]

CSE programs, created by the Sexuality Education Information Council of the United States (SEICUS) and Planned Parenthood have proliferated in schools for over three decades. Based on the secondary public health principle of risk reduction, they are touted as “effective” at reducing teen risk behavior, pregnancy and STDs.^[14] Yet, U.S. teen pregnancy and STD rates are still among the highest of industrialized countries. Why?^[15],[16]

In 2024, the Institute for Research and Evaluation (IRE) analyzed seven systematic literature reviews of school-based CSE applying public health standards of effectiveness. IRE found no long-term evidence of improvements in abstinence, consistent condom use, or reduced rates of pregnancies and STDs in the same program.^[17] One of the systematic reviews identified 6 CSE programs with significant negative effects: increases in sexual initiation, higher rates of oral sex without condoms, lower levels of contraceptive use, and increases in teen pregnancy.^[18] Given Planned Parenthood’s financial conflict of interest, these findings are not surprising.

A promising alternative exists: sexual risk avoidance education (SRAE). When the IRE analyzed SRAE in schools the evidence—though limited—was more positive:

• [E]vidence of effectiveness … appeared somewhat greater than for CSE in U.S. schools (seven AE studies vs. three CSE studies) and the overall success rate … at 47%, [was] higher than that of school-based CSE in the U.S., at 15%. Moreover, the prevalence of negative effects appeared somewhat lower for AE (6%) than for CSE in U.S. schools (12%).^[19]

SRAE is based on the primary public health principle of risk avoidance which the CDC has long acknowledged:

• Abstinence from vaginal, anal, and oral intercourse is the only 100% effective way to prevent HIV, other STDs, and pregnancy. The correct and consistent use of male latex condoms can reduce the risk of STD transmission, including HIV infection. However, no protective method is 100% effective. And condom use cannot guarantee absolute protection against any STD or pregnancy.^[20]

SRAE teaches six universally transferrable principles:

1. Sexual delay is a protective factor for sexual health.
2. The fewer lifetime partners a person has, the healthier the sexual outcomes.
3. Teen sex is high-risk but certain behaviors are especially risky, even with a condom.
4. Healthy relationships have a greater opportunity to develop when they are not complicated with sexual activity.
5. Setting boundaries, learning refusal skills, and acquiring date-rape prevention strategies help to prevent victimization.
6. Reserving sex for a lifetime, sexually faithful, monogamous relationship with an uninfected partner is the best protection against contracting STDs or sexually transmitted HIV.^[21]

Contrary to critics’ claims, effective SRAE is medically accurate, discusses condoms and contraceptives, and has helped students commit to abstinence without decreasing condom or contraceptive use.^[22]

Sharma writes through the narrow lens of minority stress theory, which overlooks important realities.  Sharma advises “those in places of influence” to “mobilize … public health education towards positive sexual health outcomes for LGBTQ individuals.” However, inclusive CSE already fails to provide positive outcomes for LGBTQ-identified students, let alone all students. More of the same is not the answer. Adolescent sexual activity is harmful. Long-standing evidence indicates failure of CSE programs. But promising early evidence for SRAE, alongside CDC data, indicate adolescents are capable of sexual abstinence. This is good news upon which to collaborate.