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Running Head: Ethical and Legal Issues in Adolescent Sex Education
Ethical and Legal Issues in Adolescent Sex Education
Casey Bland
University of Southern Mississippi
Spring 2010
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
Abstract
Adolescents continue to engage in risky sexual behaviors that have led to alarming statistics on
teenage pregnancy and sexually transmitted diseases. This has fueled an ongoing debate about
the best approach on sex education for this vulnerable group. Each method attempts to educate in
an attempt to decrease the negative consequences associated with the irresponsible sexual
behaviors. The abstinence-only approach focuses on education that promotes refraining from sex
as the best and only way to prevent teen pregnancies and the spread of sexually transmitted
diseases. The opposing argument is for comprehensive programs that promote healthy adolescent
behavior by teaching teens about the benefits of abstinence but goes further and educates the teen
on condom use and birth control methods, as well as information about HIV and other STDs.
Research on the efficacy of each method is not clear, and varies based on which study one reads.
This problem is relevant to the nurse because nursing is in a unique role that has the ability to
influence adolescent behavior thereby aiding in decreasing the amount of negative consequences.
When facing situations that involve adolescent sex education, legal and ethical dilemmas are
often inevitable. Ethical issues involving autonomy, veracity, beneficence and nonmaleficence
are often associated with adolescent sex education. Legal issues of confidentiality, competence,
and informed consent can also become nursing dilemmas. Nurses must ensure they are guided
by the code of ethics and within legal limits when they are in these difficult situations.
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
One of the ongoing concerns in healthcare involves the legal and ethical dilemmas
associated with the role of healthcare professionals in adolescent sexual education. Alarming
statistics of high teenage pregnancy rates, adolescent abortions, and sexually transmitted diseases
in the youth population indicate a national health concern in need of serious intervention. It is
noted to be a public problem and not simply an adolescent problem because the consequences of
risky adolescent sexual activity are far reaching. The outcomes associated with this issue have
health, social and economic consequences. The statistics are clear. Each year, over 800,000
teenagers become pregnant. Every year, approximately 19 million cases of sexually transmitted
diseases are reported in the United States. Over half of all new HIV infections occur among
people under 25 years old (Santelli, 2006). Teenagers that have babies are at greater risk for
complications. These children are more likely to be premature resulting in health problems that
may become chronic, and these problems are often costly and may result in an increased
prevalence of teenagers that are forced to enter the welfare system due to financial hardships.
Childcare for a healthy child is costly and even these mothers may not have the support system
in place to adequately provide for a newborn. These problems can ultimately lead to an increased
number of teen moms and dads that don’t finish high school or go on to pursue any advanced
education. As a result, their lifetime earning potential drastically decreases. The effects of risky
adolescent behaviors are widespread and extensive.
All would agree that there needs to be significant strides made to improve the health
behaviors of adolescents but there has been controversy surrounding proposed solutions. The
divide is over the best approach to educate teens about sexual issues. Generally the arguments
have been whether the best method is to advocate abstinence-only programs or whether
education should focus on preventive programs that teach condom use and responsible sexual
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
behavior. Those in favor of abstinence-only education believe that the best way to prevent the
negative outcomes of adolescent sex is to eliminate it. These programs promote completely
refraining from sex whether one is a virgin or has already been sexually active in the past. It is
noted that one problem with many abstinence-only programs is that the main teachings are
misleading. For example, abstinence is not a fool-proof way to eliminate STD’s because many of
these infections can be spread through other means, such as kissing or oral sex. (Santelli, 2006).
Studies done on the efficacy of abstinence-only education on delaying sexual activity in teens
indicate mixed results. Some research reveals that these programs had no real effect on stopping
teens from engaging in sex nor did it decrease pregnancy and STD rates (Kohler, 2008). On the
other hand some studies found that abstinence programs were the most effective at delaying
teens from initiating sex when compared to alternative methods of sex education.
Those that oppose the abstinence-only method believe that while abstinence is the ideal
choice for teenagers, it should not be taught as the only choice. These programs focus on ways to
avoid the negative outcomes associated with risky sex and are based on the belief that the best
way to promote healthy adolescent outcomes is to teach them safe and responsible sexual
behaviors. Correct condom use, birth control methods, and education on HIV and other sexually
transmitted diseases are some of the topics included in preventive teaching programs. Research
on the efficacy of this approach is mixed as well. Some studies note that these programs are
associated with decrease rates of teen pregnancy. However, the tendency of these programs to be
successful in decreasing or delaying teen’s first sexual encounter or decreasing STD’s is unclear
(Kohler, 2008).
Another issue that is problematic in this debate is how each of these programs defines
sexual activity. While some may view abstinence as only refraining from intercourse, others may
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
define it as abstaining from all forms of sexual activity including kissing, touching, and heavy
petting. Teenagers’ perspectives on sex may be very different from those in a teaching position.
A key point to consider is the importance of realizing how the teenager defines sex, and any
education should be adjusted accordingly in order to be effective.
It is clear that the health profession is in an ideal position to address the adolescent
health status through the teaching role. Healthy People 2010 is a federally funded, nationwide
health initiative put forth to promote healthy outcomes and focus on disease prevention for all
age groups (CDC/National Center for Health Statistics, 2009). A part of the adolescent portion
focuses on responsible sexual behavior. Nurses especially have the opportunity to influence
adolescent health outcomes because it is the nurse that spends the most time with patients. This
unique aspect of the nurse-patient relationship can serve as a vehicle to promoting healthy and
positive behavior, and nursing has an obligation to make definitive strides in reaching Healthy
People objectives.
Nurses are likely to face dilemmas when dealing with the teenage population on this
issue because of the ethical and legal ramifications it involves. These issues can result in a great
deal of moral uncertainty on the part of the nurse. It is noted that the health profession often
views the abstinence debate in terms of it being a health issue but many view it as a moral or
religious dispute. (Santelli, 2006). This is one reason the debate has become so divisive. Nursing
practice is guided by a code of ethics which is in place to serve as a guide for professional
decision making. Nurses actions are also guided my one or more ethical principles. The
adolescent sex education debate brings into question the ethical principles of autonomy, veracity,
and beneficence and nonmaleficence.
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
Guido (2010) notes that autonomy is defined as one’s personal right to choose what will
happen to one’s own person. This debate addresses autonomy because it questions whether the
adolescent is given or denied that right to choose what they want in regards to sexual behavior.
Abstinence programs are directed at a sole choice for the adolescent, and the nurse may be in an
institution that promotes this approach. This places the nurse in a position to deny the teen
autonomy in making these decisions by not giving them a choice, but teaching them that the only
option is abstinence. In this situation, the nurse will have to decide whether to abide by the
policies set forth in the facility or be truthful with the adolescent regarding all alternatives. An
argument against revealing all options is that adolescents do not have the capacity to know what
is best for them, and therefore should have limited autonomy when making decisions. It is this
view that allows parents to make decisions on behalf of their teenage children.
This leads to the ethical principle veracity. Simply put, veracity is telling the truth. As
nurses, we are obligated to be honest with our patients. Issues involving veracity can occur if
nurses are asked questions about sexual behavior or ‘safe sex’. If advocates of abstinence-only
education respond by saying that refraining from sexual activity is the only safe sex, then that
goes against veracity because they are not giving full disclosure. On the other hand,
comprehensive programs that answer that question with information about condoms and
contraceptives without listing abstinence as a legitimate option are also not being completely
truthful. This is another situation in which the nurse may likely experience moral distress over
the decision to disclose all information to the adolescent patient. Parents that are very vocal
about their beliefs concerning what information the patient should be privy to only add to the
already stressful situation because nurses must be careful to respect the parent’s views if they are
contrary to those promoted in the educational program.
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
Denying one’s autonomy or not being truthful to a patient are closely associated with
beneficence and nonmaleficence. Guido (2010) states that beneficence exists when one’s actions
promote good, whereas nonmaleficence states that one should cause no harm. One must question
whether denying one access to full information about sexual activity choices and refusing one the
personal freedom to make a choice about them promotes good or causes harm. It can be argued
that an adolescent that has been taught abstinence-only that goes on to practice unprotected
sexual activity has engaged unnecessarily in risky behavior. Has the abstinence-only program
placed this teen in harm’s way by not teaching safe sex practices as an alternative to abstinence?
Has the comprehensive program really promoted good or have they too placed the teen in harm’s
way by unknowingly implying that adolescent sex is acceptable by teaching responsible sexual
behavior? These are some of the questions that nurses in this dilemma must answer.
Legal issues that have been associated with this debate involve questions about informed
consent, competence, and confidentiality. Informed consent is based on the premise that the
practitioner gives the patient all needed information in an understandable way so that they can
make an informed decision. Informed consent could be a problematic situation for a nurse in the
case of an adolescent that is seeking an abortion. The United States Supreme Court has left it up
to the states whether parental consent or notification is required before an adolescent can get an
abortion. Some states allow teens a ‘bypass’ by the court in which they are able to bypass the
parents through a process of the courts. In the state of Mississippi, youth abortions must have
parental consent by both parents. Mississippi does have the option of the court bypass through
the court’s approval. In the case of an emergency, abortions may be allowed without parental
consent. Informed consent that involves education regarding ‘responsible sexual behavior’ is a
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
difficult situation for nurses to deal with. One must ponder whether teens should be informed
about abortion as part of the more comprehensive educational approaches.
Also, there is the question concerning consent for birth control. This part of the
preventive approach is based on the belief that teens must be given all necessary information in
order to make better choices about sex. It is believed that teens will be more sexually responsible
if they are knowledgeable about preventive measures. Nurses may be in this situation if
adolescent patients that they care for inquire about this information. Often this is a decision that
is guided by state law since it mandates how and when teens can obtain birth control. Guido
(2010) points out that 25 states and the District of Columbia allow those 12 and older to obtain
contraceptive devices, 21 states limit which minors can consent, and 4 states have no relevant
policies concerning this.
The argument over adolescent informed consent is usually associated with the debate
over the legality concerning adolescent competence. This brings up the question of whether
adolescents are deemed competent and thus able to give informed consent. Most states view all
those under age 18 as a minor and minors are unable to give consent unless the minor is deemed
emancipated or mature, the law views the minor as having the ability to consent, there is a court
order to proceed with therapy, or there is a medical emergency (Guido, 2010). In the matter of
abstinence and preventive teaching, in most cases parents must sign consent in order for their
teens to be a part of that education. This undermines the idea that adolescents are competent
individuals and are entitled to knowledge that will give them the opportunity to make healthier
decisions for themselves. It is important to keep in mind that despite whether the adolescent is
viewed as competent, most teenagers are having sex. The CDC reports that as of 2007, over 50%
of teens in the United States had engaged in sex and 15% of those had had four or more sexual
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
partners. These statistics indicate a great need for education and intervention, despite whether
one views the teen as competent or not.
Confidentiality is another legal issue that presents itself in the sex education debate. A
typical situation I have personally experienced is when a teenager is brought in to the hospital
with complaints of abdominal pain and after numerous tests, it is discovered that pelvic
inflammatory disease is the cause. This diagnosis leads to questions about the sexual practices of
the teenager. Maintaining the patient’s confidentiality is a crucial aspect of both the nursing and
physician’s code of ethical practice. Teenagers are no less entitled to being assured that their
privacy be maintained. Laws vary regarding when physicians have to disclose information on
teens that are having sex. All sexual activity that involves cases of statutory rape, abuse, or other
harm must be reported. However, if the sexual activity occurs between two teenagers in a
consensual, non exploitive manner that does not involve harm or injury, physicians are not
generally bound by law to inform the parents. It can be argued that any underage person involved
in sex is viewed as risky behavior that can potentially be harmful, thus informing the parents
could be justified.
I believe that the best approach takes aspects from each method. Fundamentally, I believe
that in a perfect world abstinence is the best approach because it not only would eliminate a great
deal of the health risks associated with teenage sex, but would also reduce the amount of
emotional and mental stresses that go along with it. However, I am a realist and I understand that
the numbers don’t lie, and that statistically most teenagers are engaging in some type of sexual
activity. Since this is the case, I believe we should be educating youth at different points in their
adolescence with age appropriate information. A comprehensive program that focuses on
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
abstinence as a best choice, but gives teens information on responsible safe sex practices would
be a program that I would endorse.
Each day, a nurse’s day is filled with countless patient interactions. Each interaction
should focus on promoting the best health outcomes for those patients. When that patient is an
adolescent, statistics show that there is great potential that that teen has already become sexually
active or will become sexually active during their adolescent years. These are facts that make it
clear that sexual education is necessary and nurses are in a prime position to provide this vital
information. In order for the education to be effective, trust must exist and be maintained in the
patient relationship. If teenagers don’t believe they can trust their nurses, it is likely that they will
not listen to any teaching the nurse is attempting. It is imperative that nurses maintain the teen’s
privacy and foster an environment of trust by being truthful about their care, showing genuine
concern, and being sure not to be condescending or talk down to these patients even though they
are young. When dealing with what is the ideal way to educate teens about sex, nurses will have
to make decisions that are tough because there is no clear cut answer. Research studies vary on
the best approach to sex education and so many ethical and legal issues are involved. Thus, it is
clear that these debates will continue, but as nurses encounter these situations one should keep in
mind that all decisions made should be based on the basic principle to do no harm and to
promote the best health outcome for all patients.
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Running Head: Ethical and Legal Issues in Adolescent Sex Education
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