Document Type


Publication Date

Spring 5-21-2012

Journal / Book Title

Health Education & Behavior


In many ways, the HIV epidemic changed the discourse about sex in the United States and worldwide (Ehrhardt, 1992; Everett, 1986) and continues to drive approaches to sex education. After a period of rapid growth in the late 1980s (approximately 150,000 new infections per year), by the late 1990s, HIV rates in the United States slowed to some 40,000 new infections annually (Centers for Disease Control and Prevention [CDC], 2001), and new HIV infections continue to hover around that number. The first successful examples of behavior change that resulted in decreased HIV transmission emerged from communities of men who have sex with men (MSM; Coates, Richter, & Caceres, 2008). However, although the past decade has been marked by longer survival rates, and significant reductions in new infections in some population groups, MSM remain the largest HIV transmission category in the United States and the only one associated with an increasing number of HIV/AIDS diagnoses (CDC, 2008). In 2010, some 61% of newly diagnosed HIV infections were attributed to male-to-male sexual contact (CDC, 2012).

Over this same period, school-based sex education programs have varied widely in focus and content (Kirby, 2007; Santelli et al., 2006). The political landscape from the 1990s through 2008 yielded the largest investment of federal funds in abstinence-only-until-marriage programs. In 2009, however, funds awarded in the Teen Pregnancy Prevention initiative were primarily for comprehensive sex education programs, with some funds for abstinence education programs appropriated in the 2010 health reform legislation (Boonstra, 2010), despite their limited effectiveness. Currently, state standards for school curricula vary widely, with 18 states requiring instruction on the importance of engaging in sexual activity only within marriage, whereas 19 others require instruction on condoms and contraception (Guttmacher Institute, 2011).

Within this highly politicized context, questions remain as to how to stem the tide of disease and teen pregnancy, while addressing the needs of both youth and adults, heterosexual and non-heterosexual, as they seek healthy sexual relationships and protection from harm over their life course. It may be that our very efforts to point lasers at disease, with abstinence (Guttmacher Institute, 2011) or condoms (Warner, Gallo, & Macaluso, 2012) as a central focus, rather than at the context in which sexual behavior occurs, has limited our vision to find messages that more effectively lead to the kinds of outcomes we seek.

This issue of Health Education & Behavior carries six articles focused on sexuality within the context of various types of relationships, providing important implications for sex educators and others addressing risks related to sexual activity. The articles highlight several specific population groups and the unique aspects of their sexual relationships and risk-taking. Together they suggest the limitations of prevention messages that focus solely on sexually transmitted infections and HIV, that promote either abstinence or condom use as their nearly universal emphasis, and that do not take relationships and other social contexts into account.


DOI: 10.1177/1090198112446337

Published Citation

Lieberman, Lisa D. "Relationships and context as a means for improving disease prevention and sexual health messages." (2012): 255-258.