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Want to Improve Sexual Health Education for Girls? Include Body Image

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Title: Want to Improve Sexual Health Education for Girls? Include Body Image
Language: English
Authors: Ramseyer Winter, Virginia, Ward, Michaella, Pilgrim, Sarah, Cook, Mackenzie, Summers, Alison
Source: American Journal of Sexuality Education. 2019 14(2):152-164.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 13
Publication Date: 2019
Document Type: Journal Articles
Reports - Evaluative
Descriptors: Sexuality, Sex Education, Females, Health Education, Self Concept, Adolescents, Health Promotion, Curriculum Development
DOI: 10.1080/15546128.2018.1531362
ISSN: 1554-6128
Abstract: Research suggests body image is related to sexual behaviors, which can impact sexual health across the lifespan. This paper aims to explain the necessity for including body image content in sexuality education to improve outcomes among girls. Our recommendations, supported by theory and empirical research include (a) an assessment of existing curricula; (b) designing new, theoretically-informed curricula; (c) using innovative technology in sex education; (d) rigorous evaluation of existing and new curricula; and (e) revising the National Sexuality Education Standards. These recommendations are discussed after providing the necessary background and rationale.
Abstractor: As Provided
Entry Date: 2019
Accession Number: EJ1214340
Database: ERIC
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  Value: <anid>AN0136149625;[1h2p]01apr.19;2019May02.05:00;v2.2.500</anid> <title id="AN0136149625-1">Want to improve sexual health education for girls? Include body image </title> <p>Research suggests body image is related to sexual behaviors, which can impact sexual health across the lifespan. This paper aims to explain the necessity for including body image content in sexuality education to improve outcomes among girls. Our recommendations, supported by theory and empirical research include (a) an assessment of existing curricula; (b) designing new, theoretically-informed curricula; (c) using innovative technology in sex education; (d) rigorous evaluation of existing and new curricula; and (e) revising the National Sexuality Education Standards. These recommendations are discussed after providing the necessary background and rationale.</p> <p>Keywords: Body image; sex education; curricula</p> <hd id="AN0136149625-2">Introduction</hd> <p>Body image is a multidimensional construct that includes the following: (a) the ways in which an individual subjectively views their body (evaluation or self-perceived discrepancies from an ideal), (b) the significance they place on their appearance (investment or the resulting behaviors involving management of one's appearance), and (c) the feelings and experiences they associate with their view of their body (affect or the emotions associated with one's experiences related to external evaluations of their appearance) (Cash & Pruzinsky, [<reflink idref="bib4" id="ref1">4</reflink>]). Unfortunately, girls and women experience disparities in negative body image when compared to boys and men (Fiske, Fallon, Blissmer, & Redding, [<reflink idref="bib9" id="ref2">9</reflink>]), which has significant implications for their sexual health. When referring to girls and women, we are specifically referring to cisgender girls and women as the research on body image and sexual health among transwomen and nonbinary individuals is severely lacking. Without this baseline research, we cannot make well-informed recommendations. As such, this paper focuses on sexual health education for cisgender girls (referred to as girls and women throughout).</p> <p>Body image is related to overall sexual health and well-being among girls and women. According to the National Commission on Adolescent Sexual Health, sexual health and well-being includes the ability "...(a) to develop and maintain meaningful interpersonal relationships; (b) to appreciate one's body; (c) to interact with both genders in respectful and appropriate ways..." (as cited in Tolman, Striepe, & Harmon, [<reflink idref="bib32" id="ref3">32</reflink>], p. 4). The association between body image and sexual health has historically been reflected in theory, though more recent research has found significant correlation between appropriate health behavior and positive body image (Liberska & Boniecka, [<reflink idref="bib16" id="ref4">16</reflink>]), which includes body appreciation, body acceptance, a broad conceptualization of beauty, and more (Tylka & Wood-Barcalow, [<reflink idref="bib33" id="ref5">33</reflink>],[<reflink idref="bib34" id="ref6">34</reflink>]). However, body image is only briefly mentioned in the National Sexuality Education Standards (NSES; Future of Sex Education [FOSE], 2011) and is not often included in sexuality or sexual health education based on comprehensive comparison and evaluation of numerous sexuality education curricula (Alford, Bridges, Gonzalez, Davis, & Hauser, [<reflink idref="bib1" id="ref7">1</reflink>]; Haberland, [<reflink idref="bib14" id="ref8">14</reflink>]).</p> <hd id="AN0136149625-3">Background</hd> <p></p> <hd id="AN0136149625-4">National Sexuality Education Standards (NSES)</hd> <p>The NSES was developed to address the inconsistency in K–12 sexual education across the 50 states. The standards are an ongoing initiative called the Future of Sex Education and provide guidelines on the "essential minimum, core content" (FOSE, [<reflink idref="bib12" id="ref9">12</reflink>], p. 6). Importantly, the NSES is not mandated. As such, school districts are welcome to follow the standards, or not. The NSES contains seven topics for all sexuality education curricula. These include (a) anatomy and physiology, (b) puberty and adolescent development, (c) identity, (d) pregnancy and reproduction, (e) sexually transmitted diseases and HIV, (f) healthy relationships, and (g) personal safety. Each topic is accompanied by sets of learning and developmental goals for students at each level or year of education.</p> <p>Body image is not explicitly included in the required seven topics but is included under the Puberty and Development topic. For example, body image is first mentioned as an educational expectation or target under the Puberty and Development topic for grades 3 through 5, indicating students should be able to "describe how friends, family, media, society, and culture can influence ideas about body image" (Future of Sex Education Initiative, [<reflink idref="bib12" id="ref10">12</reflink>], p. 14). For grades 6 through 8, students are expected to be able to not only describe but also "analyze how friends, family, media, society, and culture can influence self-concept and body image" by the end of grade 8 (FOSE, [<reflink idref="bib12" id="ref11">12</reflink>], p. 16). In total, body image is only listed as an outcome that students should have achieved in the sexuality education received. The body image educational expectations for students to accomplish by grades 2, 5, 8, and 12 vary only slightly. In 5th grade, students are expected to be able to "describe" body image influences, while by the end of the 12th grade, students are expected to be able to "analyze" body image influences (Future of Sex Education Initiative, [<reflink idref="bib12" id="ref12">12</reflink>]).</p> <p>Sexuality education curricula is expected to be based on evidence-based practice, but the curricula are not required to be based in a specific theory. The most common theories used to inform sexuality education curricula include Theory of Planned Behavior, Theory of Reasoned Action, Social Cognitive Theory, Cognitive Behavior Theory, and, less frequently, the Health Belief Model (Alford et al., [<reflink idref="bib1" id="ref13">1</reflink>]). These theories have been proven to be effective short term for promoting behavioral changes among adolescents; however, sexuality education curricula based solely in theories of behavioral change have not produced lasting change in sexual health behaviors among adolescents as they become young adults (e.g., Coyle, Glassman, Franks, Campe, Denner, & Lepore, [<reflink idref="bib6" id="ref14">6</reflink>]; Haberland, [<reflink idref="bib14" id="ref15">14</reflink>]). Recent evaluations of sexuality education curricula suggest using theories of behavioral change alone is not effective due to expanding knowledge of the dynamics of sexual behavior among adolescents (Haberland, [<reflink idref="bib14" id="ref16">14</reflink>]). Theories pertaining directly to sexual health, inclusive of body image, will be explored in the following subsections followed by an overview of literature expanding on sexual health models by further explaining the associations between body image and sexual health among girls.</p> <hd id="AN0136149625-5">Theoretical underpinnings</hd> <p></p> <hd id="AN0136149625-6">Objectification theory</hd> <p>Objectification theory provides a theoretical link between body image and sexual behavior, providing the theoretical foundation for including body image in sexuality education. Objectification theory "[describes] the tendency for most women sometimes, and some women much of the time, to adopt the outsiders' gaze as their own—that is, to see themselves as others see them (or as they think others do)" (Chrisler, [<reflink idref="bib5" id="ref17">5</reflink>], p. 652). In other words, women's views regarding their own body are greatly influenced by the stereotypes and roles formed by cultural constructs. Originally, Fredrickson and Roberts ([<reflink idref="bib10" id="ref18">10</reflink>]) theorized depression, eating disorders, and sexual dysfunction as outcomes of their model. Recently, Ramseyer Winter ([<reflink idref="bib22" id="ref19">22</reflink>]) provided cross-sectional evidence to suggest an extension to include sexual behavior as an outcome of self-objectification, mediated by body image.</p> <hd id="AN0136149625-7">Sexual health model</hd> <p>According to Robinson, Bockting, Rosser, Miner, and Coleman ([<reflink idref="bib26" id="ref20">26</reflink>]), the Sexual Health Model aims to describe how sexuality and sexual health should positively impact all aspects of life. Depicted as a wheel, each spoke on the wheel of the Sexual Health Model is assigned a factor contributing to sexual health and viewed as equally important to all factors. For example, body image is pictured equally alongside all aspects of sexual health because positive body image is essential to healthy sexual functioning (Robinson et al., [<reflink idref="bib26" id="ref21">26</reflink>]). The Sexual Health Model wheel also describes an order or progression by which to address the individual aspects of sexual health. For example, "talking about sex" is necessary before effectually discussing "safer sex" or "positive sexuality" (Robinson et al., [<reflink idref="bib26" id="ref22">26</reflink>]). With progressive topics, the Sexual Health Model demonstrates how to encourage open dialogue about sex to engage in complete and educational conversations about sexual health.</p> <hd id="AN0136149625-8">Adolescent sexual health model</hd> <p>While the Sexual Health Model can be applied to people of all ages, a model specific to adolescents is beneficial for examining the objectives and goals of the NSES (FOSE, [<reflink idref="bib12" id="ref23">12</reflink>]) because the educational standards target children and adolescents through each level of K–12 education. Tolman et al. ([<reflink idref="bib32" id="ref24">32</reflink>]) have begun developing an Adolescent Sexual Health Model to better encapsulate the role adolescence plays in sexual health. For example, gender identity is included in the Adolescent Sexual Health Model because gender identity is developed during childhood and adolescence and plays a critical role in sexual health (Tolman et al., [<reflink idref="bib32" id="ref25">32</reflink>]). Using a social constructionist perspective to include gender in the Adolescent Sexual Health Model demonstrates the impact social narratives of binary gender can have on adolescents' perception of their bodies. Essentially, the Adolescent Sexual Health Model includes gender and gender identity in the model to reflect the pressure adolescents experience to conform to conventional masculinity or femininity in behavior and appearance (Tolman, Spencer, Rosen-Reynoso, Harmon, & Striepe, [<reflink idref="bib31" id="ref26">31</reflink>]). Pressure to conform to conventional feminine appearance among adolescent girls may be a form of self-objectification, a concept closely related to body image.</p> <hd id="AN0136149625-9">Body image and sexual health: A snapshot of empirical research</hd> <p>The importance of framing sexuality education with sexual health theories in addition to using Theory of Planned Behavior, Theory of Reasoned Action, or Social Cognitive Theory, for example, is evident by the relationship between body image and sexual behavior. While theoretical models of sexual health are more holistic and include body image concepts, literature detailing the impact body image can have on sexual health is compelling. Empirical evidence of the relationship between body image and sexual behavior demonstrates the importance of providing body image inclusive sexuality education for adolescents.</p> <hd id="AN0136149625-10">Body image and sexual behavior</hd> <p>As mentioned previously, self-objectification involves the tendency for young girls, adolescent girls, and women to internalize what they hear about their body from peers, family, and strangers as well as what they see in the media (Schooler, [<reflink idref="bib28" id="ref27">28</reflink>]) and view their bodies as intended to be consumed by others (Fredrickson & Roberts, [<reflink idref="bib10" id="ref28">10</reflink>]). Having experienced sexual harassment and unwanted physical touching is identified as a predictor of self-objectification in young women (Ricciardelli & McCabe, [<reflink idref="bib25" id="ref29">25</reflink>]). Studies have identified that approximately 50% of preadolescent girls are identified as having poor body image (Ricciardelli & McCabe, [<reflink idref="bib25" id="ref30">25</reflink>]). In addition, as young women move through adolescence, it is reported that upwards of 80% of them identify as having poor body image (Eisenberg, Neumark-Sztainer, & Paxton, [<reflink idref="bib8" id="ref31">8</reflink>]). This is congruent with the developmental theory of embodiment (Piran, [<reflink idref="bib20" id="ref32">20</reflink>]), which suggests that preadolescent girls have "restricted access to sites of physical engagement" (p. 75), which forces them to contend with a gender hierarchy present at places such as the school yard and elsewhere that extends the majority of the site to physical activities that preadolescent males engage in, thus, restricting preadolescent girls to the margins of the physical location, excluded from the larger community activities. In addition, they experience more restrictive clothing, making their pubertal bodies "open to commentary and violation" (p. 81). As such, girls at this age have an increased risk of internalizing negative feelings and feedback leading to self-objectification. These statistics are important as self-objectification and poor body image may interfere with a young woman's ability to advocate or negotiate on her behalf regarding her sexual health (Schooler, [<reflink idref="bib28" id="ref33">28</reflink>]).</p> <p>Numerous studies focusing attention on body image and sexual behaviors have found that negative body image is in fact related to an increase in risky sexual behaviors among girls and women (Gillen, Lefkowitz, & Shearer, [<reflink idref="bib13" id="ref34">13</reflink>]; Merianos, King, & Vidourek, [<reflink idref="bib17" id="ref35">17</reflink>]; Ricciardelli & McCabe, [<reflink idref="bib25" id="ref36">25</reflink>]; Satinsky, Dennis, Reece, Sanders, & Bardzelle, [<reflink idref="bib27" id="ref37">27</reflink>]; Schooler, [<reflink idref="bib28" id="ref38">28</reflink>]). Specifically, Gillen et al. ([<reflink idref="bib13" id="ref39">13</reflink>]) found that women and young girls who report having a negative body image often report engaging in sexual behaviors that could increase their risk of sexually transmitted infections (STIs), including HIV, and unplanned and/or unwanted pregnancy. This occurs through increased occurrences of unprotected sex with casual partners, being intoxicated directly prior to sexual contact, and not using condoms or contraceptives during said sexual encounter. Unlike their peers who reported low body satisfaction, women with higher levels of body satisfaction were more likely to use condoms and less likely to engage in unprotected sexual behaviors following intoxication. Increased body image satisfaction acted as a protective factor for this population (Gillen et al., [<reflink idref="bib13" id="ref40">13</reflink>]).</p> <p>Two additional studies focused attention on poor body image in women and its correlation with risky sexual behaviors. In the first study conducted by Schooler ([<reflink idref="bib28" id="ref41">28</reflink>]), adolescent females were assessed in the 8th, 10th, and 12th grades for associations between body satisfaction and condom use while controlling for ethnicity and early initiation of sexual activity. Schooler ([<reflink idref="bib28" id="ref42">28</reflink>]) found that, overall, adolescents females experienced decreasing body satisfaction throughout adolescence; however, this finding was moderated by ethnicity. For Caucasian and Multiracial adolescent females, the decrease in body satisfaction from 8th grade to 12th grade was not as significant as it was for adolescent females who identified as Latina (Schooler, [<reflink idref="bib28" id="ref43">28</reflink>]). Latina participants identified decreased body satisfaction at a level three times greater than those who identified as Caucasian or Multiracial. With that said, Schooler ([<reflink idref="bib28" id="ref44">28</reflink>]) did find that body satisfaction and early initiation of sexual activity did associate with condom use among females who initiated sexual activity at a later age regardless of ethnicity: "...girls who first had sex before 10th grade were not using condoms consistently, regardless of how they felt about their bodies" (p. 58). Schooler ([<reflink idref="bib28" id="ref45">28</reflink>]) concluded that establishing educational programming for young girls focused on positive body image prior to the onset of sexual activity could be promising for increasing confidence during negotiations about sexual activity later in life.</p> <p>In a related study, Wingood, Diclemente, Harrington, and Davies et al. ([<reflink idref="bib35" id="ref46">35</reflink>]) examined the association between body image and sexual health in a sample of African American adolescent females. With a sample of 522 adolescent females aged 14–18 years, Wingood et al. ([<reflink idref="bib35" id="ref47">35</reflink>]) found that in fact there was an association between increased body dissatisfaction and sexual attitudes, beliefs, behaviors, and sexual health concerns. Through bivariate analysis, Wingood et al. ([<reflink idref="bib35" id="ref48">35</reflink>]) discovered that adolescents in the study who identified as having lower satisfaction with their body image in fact were more likely to have riskier sexual attitudes (HIV anxiety; perceived control over sexuality; confidence to refuse an unsafe sexual encounter), behaviors (never used condoms––30 days; never used condoms––6 months; unprotected vaginal sex; being less than 14 years old at initiation of sexual activity), and beliefs (fear of abandonment when negotiating condom use; few options for sex partners; less control in relationship; greater HIV/AIDS anxiety). In addition, having lower body positivity was associated with "...less positive ethnic identity, a lower self-esteem, depression, and exposure to sexual stereotypical images of women on television" (p. 436). Wingood et al. ([<reflink idref="bib35" id="ref49">35</reflink>]) concludes with recommendations for interventions that emphasize conversations about healthy sexual relationships as well as positive self-talk to increase body positivity and reduce sexual health risk.</p> <p>Throughout the research focusing on the topic of body image and sexual behavior, a common theme emerged: education around body image and methods to increase body satisfaction should be introduced to young people as it could serve as a protective factor against engaging in risky sexual behaviors. In fact, Schooler ([<reflink idref="bib28" id="ref50">28</reflink>]) and other scholars present findings supporting the protective factor of positive body image as related to subsequent condom use in young women. Ramseyer Winter ([<reflink idref="bib22" id="ref51">22</reflink>]) found that body appreciation was significantly related to preventive sexual health behaviors among a sample of emerging adults, and Ramseyer Winter, Gillen, and Kennedy ([<reflink idref="bib24" id="ref52">24</reflink>]) found that young women with higher levels of body appreciation had higher levels of comfort communicating about sex. In another study, a higher level of body appreciation was related to being more likely to use condoms and use dual methods (condoms and a hormonal contraceptive) (Ramseyer Winter & Ruhr, [<reflink idref="bib22" id="ref53">22</reflink>]). "The better people feel, the better decisions they make. Body image and sexual health fit clearly into that equation...With sexual literacy as a goal, youth require honest, open conversations about sexual health and body image" (Kelly, n.d.).</p> <hd id="AN0136149625-11">Discussion</hd> <p>Instead of considering overall improved sexual health of the individual, sexuality education curricula tend to focus most heavily on reducing unplanned or teen pregnancy and sexually transmitted infections, including HIV/AIDS, through emphasizing abstinence, delayed sexual debut, and consistent condom use. While results from curricula with the aforementioned focuses provide significant immediate results showing improved condom use or abstinence, the results are not significant over time. To work toward a model of sexual health that is more than the absence of negative sexual health-related outcomes, we must approach sex education from a theoretical perspective that is congruent with this definition.</p> <hd id="AN0136149625-12">Recommendations</hd> <p></p> <hd id="AN0136149625-13">Existing curricula</hd> <p>There are many existing efficacious sex education curricula that improve sexual health among children and adolescents. These include Becoming a Responsible Teen, Making Proud Choices, and Reducing the Risk (see www.recapp.etr.org), among others. There are also many sex education curricula being used without rigorous evaluation to establish efficacy. As such, our recommendations begin with existing curricula. We recommend adding body image content that is congruent with theoretical frameworks to existing sexual health education and utilizing rigorous methods to test the efficacy of these curricula with the new content included. Body image content could, with permission, be derived from existing evidence-based body image interventions, such as The Body Project (e.g., Stice, Butryn, Rohde, Shaw, & Marti, [<reflink idref="bib30" id="ref54">30</reflink>]) or Expand Your Horizon (Alleva, Martijn, Van Breukelen, Jansen, & Karos, [<reflink idref="bib2" id="ref55">2</reflink>]). We recommend reviewing and revising the NSES to include body image as indicated by the findings of these evaluations.</p> <hd id="AN0136149625-14">New curricula</hd> <p>Although there are many existing curricula, there is room for the addition of new sexuality education curricula built on the foundation of the Sexual Health Model (Robinson et al., [<reflink idref="bib26" id="ref56">26</reflink>]), Tolman's et al. ([<reflink idref="bib32" id="ref57">32</reflink>]) gendered Adolescent Sexual Health Model, and Piran's ([<reflink idref="bib20" id="ref58">20</reflink>]) developmental theory of embodiment. New curricula should begin prior to puberty, as girls experience intense negative shifts in their body image during puberty (Piran, [<reflink idref="bib20" id="ref59">20</reflink>]) and should be delivered in all settings (e.g., churches, schools, community centers). In new curricula, we can truly make sexuality education <emph>comprehensive</emph> and reflective of theoretical constructs relevant to girls. New curricula will incorporate topics beyond the traditional birth control and STI prevention messages, such as body image, race, gender, relationships, and more. By challenging gender norms and stereotypes in sex education as the Adolescent Sexual Health Model (Tolman et al., [<reflink idref="bib32" id="ref60">32</reflink>]) suggests and approaching sexual health education through an intersectional lens, sexual health education will be congruent with best practices for sex education (Pound et al., [<reflink idref="bib21" id="ref61">21</reflink>]).</p> <p>Further, these comprehensive curricula should incorporate the use of innovative technology. As always, sexuality education should aim to meet participants where they are (Pedlow & Carey, [<reflink idref="bib19" id="ref62">19</reflink>]) and traditional sex education methods delivered by teachers are no longer as relevant as they once were (Pound et al., [<reflink idref="bib21" id="ref63">21</reflink>]). Adolescents today are captivated by virtual reality, mobile applications, social media, and gaming (Dondlinger, [<reflink idref="bib7" id="ref64">7</reflink>]; Olson, [<reflink idref="bib18" id="ref65">18</reflink>]). By utilizing innovative technology for information transmission and skills development, we can engage students in new and exciting ways with the aim of improving sexual health behaviors and outcomes. Further, technology can offer a sense of privacy. For example, youth can "practice" putting on a condom using virtual reality technology, which requires them to wear goggles. When all youth in the classroom are wearing virtual reality goggles, they are engaging in sexual health education in privacy. This allows a safer environment for skills practice than doing so in front of peers, something that youth desire in their sexual health education (Pound et al., [<reflink idref="bib21" id="ref66">21</reflink>]).</p> <hd id="AN0136149625-15">Evaluation</hd> <p>Finally, we cannot justify our previous recommendations without a recommendation to conduct rigorous evaluation of sexuality education interventions to establish efficacy and effectiveness for various populations. These evaluations should include process/implementation, outcome, and impact evaluations using standardized tools and rigorous design (e.g., randomized control trial, experimental). With these findings, we can recommend further revisions to NSES and sex education policy.</p> <hd id="AN0136149625-16">NSES revisions</hd> <p>Although evaluation is needed prior to extensive revisions to NSES, there is room for some changes preceding this research. With so few body image outcomes expected throughout primary and secondary sexuality education, it is easy for body image topics to be minimized in sex education curricula or overlooked in favor of other very important topics focused on harm reduction (i.e., reducing teen pregnancy and sexually transmitted illness). However, research indicates a significant relationship between body image and sexual behaviors among girls, which suggests that if body image were more thoroughly integrated into sexuality education, girls' sexual health outcomes may improve (Gillen et al., [<reflink idref="bib13" id="ref67">13</reflink>]). Research on adolescent sexual health insists the development of self-esteem, including self-worth and body image, is critical to understanding and improving sexual health (Tolman et al., [<reflink idref="bib32" id="ref68">32</reflink>]). As such, though the NSES demonstrates that accumulation of knowledge grows as youth age and develop, the NSES currently does not adequately address all aspects of developing identity and self-perception, including self-esteem, embodiment, and body image. The body image outcomes found within the Puberty and Development section of the NSES could be more heavily emphasized and additional outcomes related to improving body image (rather than simply describing and analyzing) should be added.</p> <hd id="AN0136149625-17">What does this mean for boys?</hd> <p>We would be remiss if we did not make recommendations regarding boys. This paper focuses on girls, as the theoretical and empirical research is enough for such claims. However, we know that boys experience pressure to obtain a muscular ideal body type and suffer from negative body image (Boyd & Murnen, [<reflink idref="bib3" id="ref69">3</reflink>]) and experience negative sexual health outcomes such as unintended pregnancy and STIs. In addition, research suggests that emerging males, those ages 16–24 years, have an elevated risk of sexual victimization (French, Tilgman, & Malebranche, [<reflink idref="bib11" id="ref70">11</reflink>]). Even more so, young males who identify as sexual minorities experience sexual violence at a staggering rate (Smith, Cunningham, & Freyd, [<reflink idref="bib29" id="ref71">29</reflink>]). Most commonly, boys are the victims of forcible rape and verbal coercion resulting in negative outcomes like their female counterparts. When compared to their nonvictimized peers, male victims of sexual assault and coercion experience increased risk behaviors such as alcohol abuse, and risky sexual behaviors, as well as decreased psychological functioning (French et al., [<reflink idref="bib11" id="ref72">11</reflink>]). In addition, young males who identify as sexual minorities suffer increased mental distress following an incident of sexual violence due to institutional failure to address their needs (Smith et al., [<reflink idref="bib29" id="ref73">29</reflink>]).</p> <p>Unfortunately, the body of research on body image and sexual health among boys is, currently, conflicting and lacks the depth necessary to make recommendations related to body image in sexual health education among boys. We are not suggesting that sexual health education should be conducted separately for boys and girls. Instead, research on body image and sexual health among boys is warranted. In addition, special attention should be made to the evaluation of curricula recommended above in terms of boys' outcomes to be sure that sexual health education infused with body image education designed to improve sexual health education for girls is helpful and not harmful to boys.</p> <hd id="AN0136149625-18">Conclusion</hd> <p>Body image can have an impact on girls' sexual behaviors and sexual health. Having a curriculum that enhances body image and reflects theory could potentially lead to longer-lasting positive sexual behaviors and outcomes for adolescent girls and young women. Current sexual health education guidelines do not focus on body image as a core topic. This paper recommends that body image be included as a core topic and that research and evaluations be performed to understand if there is an impact on girls' sexual health and well-being from these new curricula.</p> <hd id="AN0136149625-19">Disclosure statement</hd> <p>No potential conflict of interest was reported by the authors.</p> <ref id="AN0136149625-20"> <title> References </title> <blist> <bibl id="bib1" idref="ref7" type="bt">1</bibl> <bibtext> Alford, S., Bridges, E., Gonzalez, T., Davis, L., & Hauser, D. (2012). Science and success: Sex education and other programs that work to prevent teen pregnancy, HIV, and sexually transmitted infections. Advocates for Youth: 2012 Executive Summary. Washington, DC : Advocates for Youth. 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  Data: Want to Improve Sexual Health Education for Girls? Include Body Image
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  Data: <searchLink fieldCode="AR" term="%22Ramseyer+Winter%2C+Virginia%22">Ramseyer Winter, Virginia</searchLink><br /><searchLink fieldCode="AR" term="%22Ward%2C+Michaella%22">Ward, Michaella</searchLink><br /><searchLink fieldCode="AR" term="%22Pilgrim%2C+Sarah%22">Pilgrim, Sarah</searchLink><br /><searchLink fieldCode="AR" term="%22Cook%2C+Mackenzie%22">Cook, Mackenzie</searchLink><br /><searchLink fieldCode="AR" term="%22Summers%2C+Alison%22">Summers, Alison</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22American+Journal+of+Sexuality+Education%22"><i>American Journal of Sexuality Education</i></searchLink>. 2019 14(2):152-164.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Data: 13
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  Data: Journal Articles<br />Reports - Evaluative
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  Data: <searchLink fieldCode="DE" term="%22Sexuality%22">Sexuality</searchLink><br /><searchLink fieldCode="DE" term="%22Sex+Education%22">Sex Education</searchLink><br /><searchLink fieldCode="DE" term="%22Females%22">Females</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Education%22">Health Education</searchLink><br /><searchLink fieldCode="DE" term="%22Self+Concept%22">Self Concept</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Promotion%22">Health Promotion</searchLink><br /><searchLink fieldCode="DE" term="%22Curriculum+Development%22">Curriculum Development</searchLink>
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  Data: 10.1080/15546128.2018.1531362
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  Data: Research suggests body image is related to sexual behaviors, which can impact sexual health across the lifespan. This paper aims to explain the necessity for including body image content in sexuality education to improve outcomes among girls. Our recommendations, supported by theory and empirical research include (a) an assessment of existing curricula; (b) designing new, theoretically-informed curricula; (c) using innovative technology in sex education; (d) rigorous evaluation of existing and new curricula; and (e) revising the National Sexuality Education Standards. These recommendations are discussed after providing the necessary background and rationale.
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