YES! Program: Adolescent Lessons Learned during a Virtual Sexual Health Program

Abstract

Effective sexual health education provides individuals medically accurate knowledge and promotes the skills necessary for positive behaviors related to sexual health. This qualitative study employs focus groups to examine learning experiences of nine participating adolescents from a comprehensive youth empowerment and sexual health virtual summer program (The YES! Program). Focus group interviews were coded using inductive analysis to compute student learning themes (safety and prevention, preparation, and communication) and utterance coverage. Narrative inquiry highlighted the experiences of the participants. The results highlight students’ learning experiences through participation in the YES! Program and the skill outcomes of comprehensive sexual health education.

1. Introduction

With political polarization affecting the ideologies of individuals in the U.S. context about sexual health issues (e.g., abortion, gender/sexual identity) [1,2], there is greater need to research the content of sexual health programs and skills individuals use to navigate life and make adaptive decisions related to sexual health. Political polarization and ideology also impact education standards. The passage of the ‘Don’t Say Gay Bill’ in Florida [3], which limits instruction about sexual identity in public institutions, exemplifies current sociocultural phenomena impacting sexual health education, particularly in relation to educational standards. Formal educational settings have been proven to be effective, safe contexts in which adolescents may be engaged in learning and equipped with skills to make decisions impacting their futures [4]. Despite the need for effective sexual health education that impartially provides both knowledge and skills, allowing students to critically gauge the knowledge they receive, the standards for sexual health education greatly differ across the U.S.

Human sexuality education is valued by American parents, despite political ideology. Kantor and Levitz [5] found that close to 90% of parents who identified as either Republicans or Democrats supported topics within sexual health education such as puberty, healthy relationships, abstinence, sexually transmitted diseases, and birth control for their high schoolers, and nearly 80% also supported inclusion of those topics in sexual health education for middle schoolers. Parents generally wish for students to receive human sexuality education during middle and high school and support sexuality education occurring in public schools [5,6]. It should be noted that political influence, including legislation and funding mandates, have also likely influenced parental opinion of sexual health education and local educational implementation of sexual health programs within schools [7].

Regardless of parent support of sexual health education within schools, health education standards vary across the nation. Currently, 30 states and the District of Columbia have requirements for schools to teach sex education, and 28 states specify the inclusion of HIV education [8]. In total, 39 states and the District of Columbia require public school instruction relating to HIV. Shockingly, only 22 states require that sex and/or HIV education, if provided, be medically, factually, or technically accurate, with definitions of ‘medically accurate’ varying from state to state [8]. Only 13 states require sex education or HIV/STI instruction to include information related to consent [9]. Additionally, only 12 states mandate inclusivity practices within sexual health education for all participants, and only 9 states have educational policies regarding the inclusion or affirmation of sexual orientation instruction or sexual health related specifically to the LGBTQ+ community [9]. Unfortunately, six states have mandates for explicit, discriminatory sexual health education toward members of the LGBTQ+ community [9].

1.1. Effective Sexual Health Education

Traditionally, sexual health education can be broken down into three types: abstinence-only, abstinence-plus, and comprehensive. Abstinence-only sex education generally promotes abstinence from sexual activity until marriage to prevent harmful physical/psychological effects occurring from participating in premarital sexual activity [8]. Abstinence-plus sex education includes promoting abstinence while usually teaching about contraceptives and STIs [10]. Comprehensive sex education promotes medically accurate sexual and age-appropriate education regarding human sexuality and practices such as abstinence, contraceptive use, and other topics [10]. It has been defined as education that focuses on the knowledge, beliefs, and attitudes/values/behaviors of individuals, rooting itself in biology, biochemistry, and the psychology of interpersonal and intrapersonal phenomena related to sexual health [11,12]. Abstinence-only sex education is often associated with limited or no discussion about contraceptives or sexually transmitted infections (STIs) [10,11,13]. However, abstinence-only and abstinence-plus sex education can include teachings about contraceptives and STIs [14,15,16]. Comprehensive sex education typically focuses on contraceptives and discussion of STIs [10,11,13]. The discussion of contraceptives and STDs/STIs is not required in comprehensive sex education for some states [17]; however, 19 states in the U.S. do mandate that contraceptives and STIs be discussed during comprehensive sex education [17,18].

To promote healthy decision making, knowledge, and skills, sexual health education should be based on medically accurate information; it should also be research-based, developmentally appropriate, and culturally inclusive [19,20,21]. Effective sexual health education is also most successful when taught by trained, professional health teachers who value the content they teach [22,23]. Additionally, research shows that comprehensive sexual health education is more effective than abstinence-only and abstinence-plus education in delaying adolescent sexual activity and reducing risky adolescent sexual behaviors leading to unintended pregnancy or the contraction of various STIs [24,25], particularly within group-based sexual health education learning environments [24]. Those who oppose comprehensive sexual health education often argue that teaching teenagers about contraception, sexual identity, and inter/intrapersonal sexual health phenomena from a comprehensive, multifaceted perspective rather than stressing direction in decision making (like abstinence-only or -plus models) will lead to early/increased adolescent sexual activity [14,26], but research suggests teaching about safe sexual behavior practices is not associated with increased risk of unsafe sexual behavior among teens [26]. Within the last 30 years, research regarding the effectiveness of comprehensive sexual health education has indicated that individuals who receive comprehensive sex education report greater appreciation for sexual diversity, increased awareness of intimate partner violence and violence prevention, and develop healthier relationships than their counterparts who receive abstinence-based or abstinence-only sexual health education [14]. Other outcomes associated with receiving comprehensive sexual health education include increased prevention of child sex abuse, improved social and emotional learning, and increased media literacy [14].

This study examines the experiences of adolescents specifically within central Ohio, receiving an in-depth comprehensive human sexuality program. Ohio law does not allow the State Board of Education to adopt health education standards [27]. Ohio is the only state in the U.S. without health education standards [28]. The only requirement for health class is one-half unit in order to graduate from high school—merely 60 h of instruction (note: an equivalent one-half unit of physical education is defined as 120 h of instruction) [27,29]. If sexual health education is taught, emphasis on abstinence is required when instructing about sexually transmitted infections. Additionally, guidelines instruct teaching about side effects of sexual activity before marriage, providing instruction that having children prior to marriage is harmful, and pushing adoption as an option for unintended pregnancies [30].

In Ohio, each school is generally allowed to decide what to teach in health class, and the Ohio Department of Education (ODE) provides only topic recommendations of what health education should include, not set standards. Topic descriptions are limited and broad. Given the lack of health education standards in Ohio, and limited sexual health education topic recommendations within state legislation, there is a need to understand the experiences of Ohio adolescents during health education courses or programs. This is true for all topics within health education, including sexual health education.

1.2. Purpose

This study examines Ohio adolescents’ thoughts and experiences about an innovative, in-depth, comprehensive sexual health education virtual summer program based in youth empowerment skills (The YES! Program), such as sexual health, and workforce development. We focus on the insights of students interviewed in two focus groups on sexual health. While there have been efforts to test the behavioral and cognitive outcomes arising from comprehensive sexual health education [31], it is equally important to understand the perceptions students have about such programs by asking them about their learning experiences. Thus, this study focuses on insights and perceptions of students participating in the YES! Program, specifically those related to sexual health and sexual health education. The following research questions guided this study:

• After participating in the YES! Program, what thoughts do students have relating to their personal sexual health?
• What experiences in the YES! Program were beneficial to students?
• What thoughts and experiences from the YES! Program participants might prove useful in future sexual health education programs?

2. Materials and Methods

2.1. The YES! Program

The YES! Program, YES standing for ‘Youth Empowerment Skills’, was a virtual fellowship program offered to students in central Ohio, specifically designed during the COVID-19 pandemic for online delivery. It was marketed as a fellowship program for youth ages 14–19 to learn life and employment skills alongside professionals in the healthcare field and become positive sexual health messengers within their community, and occurred during the summer of 2021. Informational flyers were used in local schools as recruitment tools, as was word of mouth by professional healthcare staff participating in other school programs. Students attended three 2-h meetings per week for 8 weeks with the opportunity to receive up to USD 1100 for complete program participation. As a fellowship program, participation was meant to mimic a part-time summer job. There were two facets to the program: workforce development and sexual health education. Both facets were given equal time for coverage over the eight weeks, and several collaborative and individual online activities were used in the program to discuss sexual-health-related issues covered in programmatic lectures.

Workforce development topics included resume preparation, interviewing skills, work permits, tax issues, customer service skills, and information on local higher education opportunities. Sexual health topics included anatomy, physiology, gender, communication, STIs, teen pregnancy prevention, healthy relationships, consent, and more. Healthcare professionals and reproductive health specialists delivered the content, with additional community members invited as guest speakers/mentors discussing their careers and professional journeys.

2.2. Data and Participants

Data collection occurred at the end of the 8-week virtual instruction. In total, 54 students ages 14–19 from central Ohio participated in the YES! Program. At the end of the YES! Program, all participants were invited to participate in focus groups discussing one of three topics: academic success, career motivation, sexual health. Students who wished to participate in focus groups selected one topic to discuss. Nine volunteers participated in two separate focus groups discussing sexual health. The study was approved by the appropriate hospital partner’s Institutional Review Board. Participants from the program were asked to volunteer for focus group interviews after its completion; consent forms were distributed and properly obtained. For participants below the age of 18, parents were also asked to sign a consent form to permit their child’s participation in the study. Consenting participants agreed that their deidentified quotes from the focus group interviews would be used for research purposes and were free to withdraw from the focus groups at any time.

2.3. Focus Group Interviews

Two focus groups were conducted by the research team. The goal was to better understand students’ thoughts and experiences about sexual health education after having completed the YES! Program course. Each focus group was carried out by two researchers as accompanying facilitators; each focus group lasted 30–45 min. One focus group had 5 student participants (3 male, 2 female), and the other had 4 (2 male, 2 female). One example focus group questions is: ‘Which parts of the YES! Program were most beneficial to you as you learned about sexual health?’ Focus groups were conducted virtually and were recorded using Zoom. Zoom recordings were transcribed and prepared as interview transcripts for each of the separate focus groups.

2.4. Analytic Approach

To analyze transcripts, we used a post-positivist qualitative framework to understand how researchers’ perceptions of data may create emergent themes in an inductive manner. The authors of this study relied on an inductive coding approach to create themes or labels from the data collected [32], followed by narrative inquiry [33] of transcript excerpts to describe student experiences in detail. Both authors separately examined each of the focus group interviews thoroughly and began to highlight student reported experiences that covered perceptions related to sexual health. We made sure that ideas were being expressed by more than one student across the two groups, thus constituting a category or theme; as only 4–5 students participated in each focus group, it seemed appropriate that thematic categories emerging in the thinking and speech of at least two participants would constitute as a theme. After introductory categorization and thematic highlight, we then grouped responses into final categories and themes. Authors discussed any differences in initial categorization and theme development prior to final theme selection, discussing differing perceptions. At first, several category-based themes emerged (contraception, STIs), but these were clustered into more general ideas related to human learning in sexual health at the intra- and interpersonal levels (e.g., contraception and STI-related speech would be broadly classified under a theme related to prevention or safety). Three final themes emerged: safety and prevention, preparation, and communication.

After theme development, authors conducted an agreement exercise on the longer of the two focus group interviews after importing the entirety of the transcribed interviews into Nvivo12 (Lumivero, Denver, CO, USA). They separately coded student speech using the software to ascertain that their thinking about the developed themes matched and merged their interview files to understand the level of co-occurrence of their thematic codes. Inter-rater reliability was calculated for each of the three themes. The Kappa values produced lay between 0.69 and 0.80, indicating substantial agreement [34]. Values for each theme are provided in

Table 1. Kappa values for coded variables.

Theme	Kappa Value
Safety and Prevention	0.80
Communication	0.69
Preparation	0.77

.

After this agreement exercise, one of the researchers coded the second focus group interview and shared their insights with the second author, who provided feedback on the codes and discussed any disagreements to integrate differing perspectives. Facilitator speech was removed from the transcripts, and percentage of utterance coverages in student speech were computed for each theme, e.g., [35]. Researchers then examined each focus group interview to find narratives providing a rich picture of students’ learning, adhering to a narrative inquiry design [33]. Both the safety and prevention and preparation themes co-occurred with the communication theme, interpersonal aspects of the former two themes could be categorized as related to communication skills. While the number of words in the interviews remained constant, the quotes covering multiple categories (or displaying a crossover between communication and one of the two other themes) were added to the numerator of the utterance percentage computation.

3. Results

Student speech expressed three themes: safety and prevention, preparation, and communication; all themes contributed to an understanding of the skills they acquired through participation in the program. All five students in the first group and three of four students in the second group contributed a substantial amount of feedback related to aspects of sexual health covered by the YES! Program. The first theme focused on students’ perceived competence with safety and prevention in situations pertaining to sexual health (refusal, consent, protection, etc.). The second theme focused on students’ perceptions of learning preparing them for adulthood and future decisions made related to their sexual health. The third theme focused on students’ perceptions about their ability to communicate about sexual health with others in an assertive and objective way. A brief explanation of each theme is provided below:

• Safety and Prevention: This theme indicates the occurrence of student speech talking about engaging in safe sexual health practices, asserting issues such as the prevention of sexually transmitted infections (STIs), the use of contraceptives, and protection methods.
• Preparation: This theme indicates the occurrence of student speech talking about being ready and feeling confident about dealing with complex issues of sexual health (e.g., gender identity, sexuality) by applying medically accurate, skills-based knowledge.
• Communication: This theme relates to the occurrence of student speech talking about effectively communicating with peers and trusted adults, informing them about issues of sexual health, and communicating with one’s partner about personal boundaries.

Generally, students reported benefiting from YES! Program participation and becoming equipped to effectively deal with sexual health issues in their daily lives. They suggested traditional sexual health education programs in their schools often focused only on providing content, without much discussion of how this may be applied to real life experiences and situations. When asked about the effectiveness of the curriculum, one of the students responded:

‘I just wanted to say it was really nice to have the actual like comprehensive stuff about…sex...that school just absolutely teaches you nothing about. Which is very like, vital information. Which that was really, really nice to get kind of an insight on.’

Students also alluded indirectly to the lack of concrete sexual health standards in Ohio, where the intervention was conducted. They suggested the nature of the content covered in traditional sexual health programs offered as a part of the regular school curriculum was often influenced by the views and opinions of teachers. They appreciated that the YES! Program was value-neutral, providing information using a skills-based approach, and encouraging open-ended questioning from students about sensitive topics such as gender and sexual identity. One of the participants explained comparisons they drew between the YES! Program and the school’s traditional sexual health curriculum as follows:

‘For me, last school year I took health at my school, and so I had something to compare it to and my school definitely was, um like the way he taught it, it was with his opinion and with his, like input into what he was talking about. And I didn’t necessarily agree with some of the things he was saying. And the way he was talking about stuff never really, like wasn’t a very nice way of thinking about things. So, I was glad that this program was not—didn’t have anybody’s opinion who was teaching us. And it was more of just the information and there was no judgement on if you had questions or something. And also, this program taught us about gender identity and sexuality which is a big deal because I don’t think any school really does that.’

These reflections on the nature of the YES! Program allowed us to understand student perceptions of whether the program was beneficial. Students’ accounts of their key learnings from the YES! Program tended to focus specifically on the three aforementioned themes. In

Table 2. Utterance coverages of the three themes across two focus groups.

Theme	Focus Group 1	Focus Group 2
Safety and Prevention	16.05%	26.73%
Communication	27.65%	43.56%
Preparation	19.75%	35.37%

, we provide utterance coverages of student learnings using focus group interview excerpts for each of the themes. In the next sections, we provide an elaboration of the expression of each theme.

3.1. Safety and Prevention

The first identified theme, safety and prevention, emerged from student speech indicating the content they received about sexual health, protection methods, sexually transmitted infections, and consent/boundaries enabled them to gain a higher level of knowledge related to sexual health issues. Overall, student perceptions suggest that participation in the YES! Program imparted skills to students that enabled them to better understand how to engage in safe sexual health practices.

Varied topics related to safety and prevention emerged in student speech. One such topic was students’ perception that the program educated them about the various risks that could emerge from sexual encounters, as was exemplified by this quote:

‘Learning about different risks that come with sexual encounters and stuff with sexual health.’

Students’ perceptions also suggested that program participation enabled them to gain knowledge about contraception methods and how protection can safeguard individuals engaging in consensual sexual activity from pregnancy and sexually transmitted infections (STIs). One individual suggested:

‘For me, personally, I learned a lot about the uh, just the contraceptive methods and then how to stay safe. Like, just generally with sex and you know wearing protection. All that, all that sort of stuff that was very good in my opinion.’

With regards to STI’s, students suggested that they not only learned about diagnosing STIs and the tell-tale signs of such infections, but also about how to prevent transmission. They also commented on how such problems are especially salient to the everyday lives of adolescents:

‘I think something that was uh pretty useful was when we learned about STIs, and how to properly protect ourselves from getting them. Because, because they’re pretty common.’

It was also shared that the program provided information about treating STIs in case of infection, rather than stigmatizing such afflictions:

‘STDs or STIs are becoming a big part of young people’s lives. So, it’s good to know about them and how to prevent them. Or to treat them if you do get one and can’t get rid of it.’

The importance of getting tested and preventing STI transmission through responsible practices also emerged. YES! Program participants were also appreciative of the inclusive language used in the program, covering content about protection against pregnancy in heterosexual relationships, protection methods for heterosexual and LGBTQ relationships, and measures to be taken against sexually transmitted infections across this spectrum of identities and relationships. One student said that their previous classes took a heteronormative lens on such topics. When asked about what could be improved about the program, one student responded:

‘With gender identity and sexuality, in my health class they only talked about male and female sexual intercourse. And this program did the same thing, but they did preface like ‘oh this can be with a woman and a woman and man and a man or people in general.’ Um, so maybe diving into more protection for those type of people and how that what would happen with them. Something like that.’

Another topic related to safety and prevention that was discussed within the focus group interviews was consent. Several students outlined how the information provided in the program enabled them to respect personal boundaries and seek consent from their partners before engaging in any sexual activity. Consent is outlined in greater detail in the section discussing the crossover between safety and prevention and communication.

3.2. Preparation

The second theme, preparation, was identified from students’ discussion relating to feelings of being better equipped to handle future interactions with others, sexual situations related to consent, and the establishment of boundaries. Examples of students’ feelings of preparation to navigate sexual health issues include perceiving greater sexual health knowledge from participating in the program and increased openness and normalcy surrounding sexual health topics.

In discussing their knowledge of sexual health after YES! Program participation, students generally indicated they had increased knowledge after program participation and felt better prepared for future situations:

‘I would say that I also do feel better about it. The way that we learn about sexual health in schools isn’t as, I guess um like multi-faceted as how we learned about it here. And so, I feel like I have a more well-rounded understanding than anything that I learned [from] a teacher in school who may have been more biased or been pushing a certain sort of state requirement or something like that.’

Increased knowledge was one of the shared outcome experiences among students. In addition to feeling better about the sexual health information knowledge they gained as a result of program participation, one student shared why they felt this knowledge was important:

‘Because I know what I’m talking about so just the knowledge. That’s uh, yeah that’s a big thing.’

Another shared how the organization of the program itself helped solidify their own sexual health knowledge:

‘I would just say how comprehensive it was. Just having, having [it] organized. Even if it was some stuff I’d heard of before, just having it in like an organized setting learning about it makes it a lot more solidified knowledge.’

Other students shared how program structure and organization, including the clarity of the information shared with them and receiving trusted knowledge, differed from their prior experiences of sexual health education and preparation in school classrooms:

‘It [the YES! Program] just gave such good information. It was very clear and direct and it wasn’t like school sex ed which was just like very, like very like ‘oh here’s this, this, this, and that’s it.’ Like it was more in depth, and it gave a lot of the necessary information that I feel like I was lacking. So it was pretty good.’

In discussing sexual health in general, one individual shared:

‘I think the course covered a lot of things that you just don’t learn in school that are very important. Definitely makes me feel a little bit more confident as I get older.’

Increased confidence was another shared experience among program participants. In discussing their own increased confidence with sexual health topics after participating in the YES! Program, one student said:

‘...it helped me a lot with confidence. So, so it wasn’t just like, I mean knowledge, and like learning that new information. Like...like just how easy everything was presented, you know, how normalized it was to talk about all this stuff. Yeah.’

Additionally, students were asked to describe their confidence level in taking control of their personal sexual health after participation in the YES! Program. All students responded saying their confidence level was either ‘very high’ or an 8 or 9 out of 10.

In discussing parts of the program students thought would be most influential, one student described program takeaways, putting emphasis on the usefulness of information in the future, saying:

‘I feel like the uh just the entire program actually, like all the information provided is useful stuff which will probably stay with all of us for a long time and be useful for a long time.’

Another discussed feeling empowered after participating in the program:

‘I don’t think there’s like any one fact um or lesson that really stood out I guess, but I just think that having an overall education um feels really empowering, just having that understanding.’

Additionally, another student described how they found open discussions about sexual health topics useful, saying:

‘Um, I think just the openness about it all. Like not shying away from the topic at all and not being like it’s something to be ashamed of or something to be embarrassed about it’s a genuine like hey this is normal, this is something you need to learn, and here it is and it’s not embarrassing or anything. It’s just normal. The way they treated the topic was very good.’

The focus group interviews revealed knowledge accrued from YES! Program participation made students feel more confident and better prepared to navigate issues of sexual health in their real lives. They appreciated how the program did not shy away from topics related to sexual health. Participants also suggested that the participation granted them more agency to take control of the decisions they make related to their own sexual health and to talk openly with others about these issues.

3.3. Communication

The third identified theme was communication, indicating students felt more comfortable discussing sexual-health-related issues with others after having participated in the program. Examples include discussing sexual health topics with parents and friends, as well as participating in discussion and communication about boundaries and being an active bystander. Participation in this program led students to experience greater comfort in communicating with others (namely peers and parents) about sexual health topics. One student, who had prior experience as a peer educator discussing sexual health topics with others mentioned specifically how they experienced increased comfort in communication with others after participating in this program, saying:

‘Just being more comfortable talking about like um sex education like stuff around that topic because prior when I was a peer educator I was like talking about it because I had to but I wasn’t as comfortable and I feel like with you guys, this program gave it more of a calmer feeling to go about it then I knew before. If that makes sense.’

When discussing talking to friends about sex before versus after program participation, most students agreed that they developed greater confidence in talking with their friends about sex, and even greater confidence in providing advice or answering friends’ questions:

‘I would say yes I was confident talking with my friends about it beforehand. Um and this has definitely increased that confidence just because I’m able to give them like um advice, or not advice I guess, but um like give them proper terminology or I guess give them advice but not in the way that you would typically think with like sex advice. Like advice about safety and advice about advocating for yourself and about um what you’re comfortable with, boundaries, and stuff like that. I do think I am more confident giving that sort of advice with my friends.’

Speaking specifically about the comparison of talking with their parents about sex before and after program participation, one student shared:

‘Before I was talking about it but it was awkward and now I’m more comfortable.’

Similarly, another student shared how they feel more comfortable talking to their parents about sex after program completion, suggesting that increased knowledge leads to less worry or anxiety in communication:

‘Just now knowing more about it [sex], feels like less of a thing to worry about talking about.’

Although confidence increased, some students discussed how talking with their parents about sex may still be somewhat awkward:

‘I feel more confident about talking to them, but I don’t think I will be talking to my parents about sex because it would just feel weird and awkward.’

However, when this student was asked what made them feel more confident in talking to their parents about sex, they responded by saying they now have the knowledge to know what they are talking about.

Some of the influential ideas students reported learning during their participation in the YES! Program were (1) boundaries and (2) communication. Most discussion of boundaries directly connected to conversation about consent (discussed in greater detail in the Communication x Safety and Prevention section). However, in relation to boundaries and communication, one student said the most influential thing learned to help them in their personal sexual health journey, now and in the future, was:

‘To be observant and ask my future partner questions before sexual encounters.’

Asking questions of a sexual partner relates to skills associated with feeling equipped to prevent sexual violence, but it also relates to communication, particularly in relation to bystander intervention. When asked what they would do differently in the coming months as a result of participation in the YES! Program, one student said:

‘One thing that I’m going to do is be more of an active bystander because I hadn’t heard a lot about that before and I think I could do better at that.’

Additionally, another student shared:

‘I personally will probably approach uh hostile situations differently because of what I’ve learned about like communication and stuff.’

The fact that students related communication and associated skills to preventing violence indicates students found concepts directly taught within the program, such as bystander intervention, valuable in relation to their own and others’ sexual health and futures. Focus group interviews suggested that students were able to learn how to augment their own interpersonal interactions related to sexual health topics by participating in the YES! Program. A large proportion of participants shared that they felt an increased sense of confidence talking about sexual health issues with trusted adults and peers, suggesting the program removed the stigma associated with open discussions about these topics. They also felt more equipped to advocate and stand up for others in incidences of violence, become active bystanders, and also express their own boundaries in issues related to consent.

3.4. Communication Crossover

As a theme, communication was directly related to the other themes of safety and prevention and preparation. This is because safety and prevention and preparation have both intra- and interpersonal facets; the interpersonal facets may generally constitute as communication skills in the context of sexual health. The following sections will discuss how communication was seen occurring within the themes of safety and prevention and preparation.

3.4.1. Communication x Safety and Prevention

When discussing the most useful thing learned during program participation, student conversations tended to focus on communication related to safety, particularly regarding personal advocacy:

‘The um most useful thing that we learned was about um like communication and how to advocate for yourself. Um not only so that you can advocate for yourself, and your own safety, but so that you can teach others um how they can advocate for themselves. Of course, in sexual situations and just like in general, in the workplace.’

And:

‘For me I think like learning about communication and um how to talk to someone and properly stand up for yourself um is a really good thing to have um. So, for me that was the most useful thing that I learned.’

Additionally, student conversations also focused on consent as one of the more important topics they learned. Consent generally refers to an agreement between participants. In a sexual context, consent refers to partners agreeing to participate in sexual behaviors. According to the RAINN (Rape, Abuse & Incest National Network), the country’s largest anti-sexual violence organization, consent directly relates to personal safety and prevention of sexual violence [36]. Understanding this allows for greater understanding of the connection between the themes of communication and safety and prevention. Here is how one student discussed consent as the most useful thing they learned after participating in the YES! Program:

‘I guess consent, using consent. Um because uh I don’t know I guess it prevents people from crossing other people’s boundaries and stuff. And consent also helped me learn more about my boundaries. If that makes sense.’

Another said:

‘I would say probably a lot about the communication elements and consent. Just knowing more about how people go about that stuff makes it a lot less of a burden to talk about you know.’

A third student suggested that greater depth of focus on consent within the YES! Program compared to school settings was useful:

‘Yeah and I also wanted to add like more communication side of things like not just the technical stuff like anatomy because we pretty much learned that in school but getting more into the communication stuff that was important. Like consent, those things that are really important for relationships.’

These student quotes make it clear that discussing consent can sometimes be difficult to do, yet understanding consent helps adolescents understand the boundaries of others and themselves and engage in safe sexual health practices.

3.4.2. Communication x Preparation

When asked about what they would do differently as a result of their participation in the YES! Program, students talked about some of the differences in their own school health education experiences and the YES! Program, saying that the implemented curriculum enabled them to feel ready to navigate real-life situations in the present cultural context. One student shared the sex education they had received before participation in the YES! Program, was not inclusive, saying:

‘I think that I knew a good amount but definitely from a very uh like cis het [cisgender, heterosexual] sort of um lens. It wasn’t fully inclusive [their prior sex education experiences]. So, I didn’t know like that much, I guess.’

This sentiment was shared by others, and another student pointed out the importance of preparedness in communication with others in order to promote inclusivity. Discussing discrepancies in sexual health education in their personal school experience and in the YES! Program, one student shared:

‘Gender identity and sexuality—um which is something like I don’t think I would ever hear or will ever hear in my school for a while. So I’m just glad that this program had that and actually taught other kids. Even if none of us, let’s just say none of us were part of the LGBTQ+ community or were all cisgender, it’s still good to know because you will come across somebody who is and it’s good to know what labels to use or how to talk to someone who is and be respectful of them and their identity.’

This idea of preparedness in knowing how to properly address someone by appropriate labels and show respect for their identity indicated an increase in preparedness of how to communicate with others:

‘I think that I probably am going to make sure that I use inclusive language all the time. We talked about that a good amount in with the Planned Parenthood educator. So just like I guess like not necessarily always saying like man and woman when you’re talking about health, like saying like a person with vagina-related parts and that kind of thing just to be more inclusive I think stood out to me.’

In addition, other students talked about their increased confidence in communicating with others because they now knew correct information and terms, leading to feelings of preparation in future communication:

‘I would say for me I’m more confident um because obviously we’ve learned like all of the names of things and not like not just like what do they call them? I’m trying to think. Like slang words. Like not those type of words. We also learned about other the other genders. Like we learned about all genders’ different body types. So, we all know—like, and can be more confident in how we talk about ourselves and other people.’

In summary, the views expressed by students about the communication skills they gained through YES! Program participation also suggested that accruing these skills to assertively talk about issues of sexual health prepared them for future real-life situations they may have to navigate in their future experiences.

4. Discussion

Students’ experiences during the YES! Program demonstrate that their perception of the program was, on the whole, positive. Additionally, they display potential focuses and areas of improvement in skills-based learning. The identified themes of safety and prevention, preparation, and communication cover three areas of concentration and skill development for comprehensive sexual health education. Our analysis shows that students gained considerable knowledge about safe sexual health practices, improved preparation to navigate complex sexual health issues in their real lives, and even learned to assertively communicate with their peers, partners, and other individuals in their communities about sensitive topics. Our study presents implications for sexual health education in terms of improving decision making related to personal health and instituting effective policy changes to promote the implementation of comprehensive, skills-based sexual health curricula across the U.S.

4.1. Implications for Personal Health

Our first research question focused on the thoughts that students had in relation to their personal sexual health after participation in the online YES! Program. The results show that students reported feeling better prepared to stay safe and became more aware of contraception, protection against STIs, and the importance of regularly getting tested for STIs. They felt increased preparation to navigate issues related to sexual health in their own lives, and they developed a sense of normalcy in discussing issues related to their own sexual health and that of others. Students felt more comfortable and confident in communicating with peers and trusted adults about sexual health and in preparing them to advocate for their own views and safety (e.g., establishing boundaries and exercising assertive decision making related to mutual consent in sexual activity).

These student reports contribute to the growing body of literature elaborating on possible benefits reaped from comprehensive, skills-based sexual health education. Because students felt better prepared to navigate issues related to sexual health in their own lives and advocate for their views and preferences, the curriculum may have had a protective effect in reducing the frequency of risky sexual behaviors in participants [24]. By prompting students to develop awareness about boundaries and mutual consent, the YES! Program curriculum fostered the development of healthy relationships with others [14] and encouraged navigating issues such as partner violence in an assertive manner. The results indicate teaching sexual health using a skills-based approach may foster greater awareness about risky behavior, the use of preventative strategies to ensure personal health and safety, and how to stand up for the rights of self and others.

4.2. Beneficial Student Experiences

Our second research question focused on beneficial experiences students had during YES! Program participation. One of the most beneficial outcomes experienced by participants was increased knowledge. Students found that being able to spend more time on various topics resulted in greater in-depth learning experience with the content. This is notable as often throughout the U.S., health class is a required course taken only once during the high school years. It is generally only one semester in duration when taken in person, and shorter online/virtual programs are often available. Although topics covered within health class vary, there is often a long list of topics that may be required or included, such as mental and emotional health, disease prevention, injury and accident prevention, basic first aid, nutrition, physical activity, illicit drug use/substance use prevention, reproduction and sexual health, and others [37,38]. Given the briefness of health class, in-depth learning about each of the important topics taught is difficult to achieve. Limited time devoted to each subject may also decrease opportunities for teachers to answer student questions and concerns or properly express the value associated with various skills related to each topic. Time constraints may also take away from efforts required to create a supportive classroom culture to discuss sensitive sexual health issues. Research indicates that the impact of students understanding how their teachers value the content they are teaching can be important for students in increasing their self-efficacy in skill development [22]. This is true for sexual health education, as students who feel their teachers value the content they teach experience higher adaptive self-efficacy beliefs, such as condom negotiation efficacy and refusal self-efficacy, than their peers [22,23].

Students also found benefit in the clarity and directness of the content covered in the YES! Program. This is in stark contrast to the experiences they had previously in typical school programs. State education requirements, state laws, or cultural influence may impact how direct teachers feel they may be when teaching about human sexuality. Effective sexual health education programs are taught using medically accurate information that is developmentally appropriate, culturally inclusive, and comprehensive [14,19,20,21]. Yet only 22 states require that sex and/or HIV education, if provided, be medically or factually accurate [8]. The lack of required health education standards focusing on medically accurate information leaves health teachers to teach content in ways they best see fit. Although most health teachers want to provide students with accurate information, the lack of a requirement for medically and factually accurate information [39], and the scarcity of teacher training programs, results in increased opinions shared by teachers with students rather than facts.

Another benefit of YES! Program participation was students’ own awareness of increased need for inclusion—particularly in relation to gender and sexuality—and the increased need for inclusion related to properly using pronouns and appropriately named biological terms, such as ‘a person with vagina-related parts’, or ‘an individual with a penis’ rather than typical cisgender terms such as ‘male’ and ‘female’ when discussing biology or reproductive anatomy. Research shows that younger generations tend to be more service-oriented than older generations and generally more open to change [40]. Increased awareness of the need for inclusion may result in greater emotional connection, respect for others, and an understanding of how the experiences of others may differ from one’s own.

4.3. Implications for Sexual Health Education Programs: Teaching and Policy Practices

Our third research question focused on YES! Program participants’ thoughts and experiences that might prove influential and useful in future sexual health education programs. The study findings offer evidence that increased in-depth comprehensive sexuality education in schools may result in young people experiencing an increase in skills and knowledge regarding safety and prevention, preparation, and communication related to human sexuality. Teaching and policy practices should place greater emphasis on personal safety and prevention surrounding sexual health education topics, particularly those related to pregnancy prevention, STI prevention, consent, and consensual sexual activity. When teaching about STIs, it is crucial to make sure students report an understanding of signs, symptoms, and treatment of STIs, and also of preventative measures protecting oneself from contracting an STI. Young people are disproportionately burdened by new cases of STIs when compared to the general population [21]. Teaching strategies focused on preventing the transmission of disease may prove useful for adolescents in allowing them to better understand the proactive steps they may adopt in taking charge of their own sexual health and well-being. Utilizing digital and social media platforms in teaching sexual health education and designing policy aimed at promoting protection of youth against STIs may prove successful if high-quality, evidence-based content is presented in a way that allows students to actively engage and evaluate their own personal safety related to sexual health [41].

Consent and consensual sexual activity relate to communication as well as safety and prevention. Of the fifty states and District of Columbia (DC), only eleven require that consent be covered during sexual health education [17]. Healthy relationships are often discussed during sexual health education units, and 35 states and Washington DC require that information related to healthy relationships be shared with students [17]. However, characteristics of healthy relationships do not necessarily include the idea of consent, and many teaching and policy practices may be lacking in correctly defining and explaining the concept of consent to students and in addressing student questions or concerns surrounding consent. Consent is not only a ‘Yes’ or ‘No’ but a concept which involves learning and understanding between individuals that necessitates transparent and rational communication [42]. Sexual consent may be nuanced, and unfortunately, facial expressions or body language may be misinterpreted or used as the only marker of consent, sometimes disregarding verbal or open and honest communication. However, increased instruction of affirmative sexual consent involving both body language and verbal communication, which relates to communication skills, decision making, personal space, and interpersonal relationships is needed [43,44]. Consent should be the focus of future teaching programs and policies made surrounding sexual health education for adolescents.

Young people desire to have a greater knowledge of honest, comprehensive sexual health education topics that are based in science, medically accurate, and free from opinion—and they want to be taught by well-educated, knowledgeable individuals who are comfortable teaching about human sexuality [45,46]. YES! Program participants directly related increased knowledge to feeling more prepared and confident in their navigation of personal concerns related to sexual health in their own lives. Whenever possible, professional health educators with a vast knowledge of sexual health education topics and experience teaching adolescents should be utilized in the delivery of sexual health education programs. Teaching and policy practices should not stray from increased educational opportunities for those delivering sexual health education curricula, as increased experience and knowledge for educators improves the delivery of content within sexual health education programs via increased teacher self-efficacy [47]. Increased support for teachers may also lead to increased value, skill-development, and preparation related to sexual health education for students as they learn from a trusted adult who they feel values the material they are teaching [22,23].

Additionally, teaching and policy practices for sexual health education programs should implement more inclusivity. Through participation in the YES! Program, participants realized their own need to practice more inclusion, especially in relation to gender and sexuality. Policy makers and teachers should also evaluate their own practices and influences relative to inclusivity and openness to all genders and sexualities, particularly when teaching about human sexuality. Increasing inclusive practices within the classroom, particularly in discussions on puberty, protection methods, and other sexual health topics, is an example of practicing open and honest communication. Conversations which diverge from majority-only experience lead to increased psychological well-being among all children and adolescents, including individuals of diverse ages, sexualities, and genders [48].

5. Conclusions

5.1. Limitations

This study has limitations. The first is a small sample size. Focus group volunteers represented only a small portion of those who participated in the YES! Program. Having more focus group participants may have had an impact on the direction of the course of conversation throughout focus group interviews. Second, focus groups were relatively short in length. This is due to the sensitive nature of the topic, the small sample size, and the virtual time constraints. Third, we acknowledge that thoughts and experiences expressed by volunteer adolescent participants may be different than those expressed by other adolescents, even other YES! Program participants. It is also possible that student participants may not have expressed their true feelings given the sensitive nature of the topic or embarrassment. Nevertheless, we did our best to minimize participant discomfort by informing volunteers that we would not use identifying information, that the group setting was a safe space to openly share thoughts and opinions, and that any views expressed would not negatively impact any outcomes of the course. Fourth, due in part to necessity from complications of the COVID-19 pandemic, the YES! Program was designed specifically for a virtual learning environment. This might have affected the learning trajectories of students who may have preferred to discuss sensitive sexual health topics in person; further implementations of the program in an in-person setting would be required to understand these differences.

5.2. Future Study

We suggest that future studies continue to showcase how in-depth, comprehensive sexual health education programs based in youth empowerment skills impact adolescents’ thoughts and experiences related to their personal sexual health. In addition, future studies of greater depth regarding safety and prevention, preparation, and communication resulting from youth participant in sexual health education programs may prove beneficial. Additionally, studies with larger sample sizes and diverse populations may provide greater insight into adolescent voices surrounding sexual health and sexual health education, thus enabling health educators and researchers to better meet adolescents’ needs. Future studies may also wish to examine adolescent thoughts about sexual health after participation in both online and in-person sexual health educational settings.

5.3. Conclusions

Given the many adult voices making choices related to sexual health education programs for adolescents, there is a need to understand the experiences of youth participants in said sexual health education programs. Student perceptions after participation in the YES! Program highlight the benefits of implementing comprehensive, skills-based sexual health education, particularly in relation to enabling adolescents to utilize skills related to various sexual health education topics. Our participants discussed lessons learned from program participation, namely the importance of safety and prevention, preparation, and communication related to their personal sexual health and openness of communication with others, particularly in relation to navigating challenges in life. The study’s results highlight the importance of listening to adolescent voices in sharing and understanding why knowledge and skills gained from participation in a comprehensive sexual health education program are important. The results also show that researchers and practitioners can benefit from listening to students’ voices about personal safety, consent within sexual relationships, open and honest communication about human sexuality, and increased inclusivity practices related to respecting others.