Sex Education Inclusivityand Sexual Minority Health The Perceived Inclusivityof Sex Education Scale

American Journal of Sexuality Education
ISSN: 1554-6128 (Print) 1554-6136 (Online) Journal homepage: https://www.tandfonline.com/loi/wajs20
Sex Education Inclusivity and Sexual Minority

Health: The Perceived Inclusivity of Sex Education
Scale
Gregory H. Keiser, Paul Kwon & Steven Hobaica
To cite this article: Gregory H. Keiser, Paul Kwon & Steven Hobaica (2019): Sex Education
Inclusivity and Sexual Minority Health: The Perceived Inclusivity of Sex Education Scale, American
Journal of Sexuality Education, DOI: 10.1080/15546128.2019.1600448
To link to this article: https://doi.org/10.1080/15546128.2019.1600448
Published online: 23 Apr 2019.
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AMERICAN JOURNAL OF SEXUALITY EDUCATION
https://doi.org/10.1080/15546128.2019.1600448
Sex Education Inclusivity and Sexual Minority Health:

The Perceived Inclusivity of Sex Education Scale
Gregory H. Keiser , Paul Kwon, and Steven Hobaica
Department of Psychology, Washington State University, Pullman, WA, USA
ABSTRACT KEYWORDS
Minority stress research has demonstrated negative health Sex education; inclusivity;
outcomes in sexual minority populations. However, the influ- health outcomes; LGB
ence of sex education on these outcomes remains unclear. In
the current study, the Perceived Inclusivity of Sex Education
Scale (PISES) was developed and administered to sexual
minorities (N ¼ 263) to assess the associations between sex
education climate and health outcomes. Greater perceived
inclusivity was associated with lower anxiety, depression, and
suicidality, but was not associated with sexual risk-taking and
substance use. We hypothesized that a number of resilience
factors would moderate these relationships, but no interac-
tions were found. These findings may help guide further
research on sex education among sexual minorities.
The growing interest in the effects of discrimination against sexual minor-

ities (i.e., individuals reporting nonheterosexual orientations, such as les-
bian, gay, and bisexual individuals), has underemphasized specific areas of
policy and treatment that may help alleviate the stresses faced by victims of
sexual prejudice. Among the facets of sexual minority experiences that has
been relatively underexamined is the influence of sex education in terms of
climate and the inclusion or exclusion of relevant content: the authors are
aware of only two quantitative studies that explicitly address these issues
(i.e., Blake et al., 2001; Snapp, McGuire, Sinclair, Gabrion, & Russell, 2015).
The current study aimed to explore the aspects most associated with per-
ception of inclusion in sex education among sexual minorities, to develop a
measure to assess these aspects of sex education perceptions, and to investi-
gate the mental and sexual health outcomes associated with perceived
inclusivity and exclusivity in sex education curricula. Establishing a better
understanding of these associations may help provide guidance for future
research and public policy.
Sex education may represent a potentially significant period of learning,
both in terms of sexual identity formation as well as instruction on safe
CONTACT Gregory H. Keiser gregory.keiser@wsu.edu Department of Psychology, Washington State

University, Pullman, WA, 99164–4820, USA.
ß 2019 Taylor & Francis Group, LLC
2 G. H. KEISER ET AL.
sexual practices (see discussion of Floyd & Stein, 2002, and Hobaica &
Kwon, 2018, below). Sex education has been suggested to be an especially
salient and often exclusive experience among sexual minorities as well as
gender minorities (i.e., transgender and gender nonconforming individuals;
see Gowen & Winges-Yanez, 2014; Hobaica & Kwon, 2018). Few examples
of published research exist that specifically investigate the impacts of inclu-
sive sex education on mental and sexual health outcomes among sexual
and gender minority groups. The empirical literature that does exist sug-
gests that inclusive general curricula may be beneficial to minority students:
lesbian, gay, bisexual, and transgender (LGBT)-inclusive general curricula
were associated with greater perceived safety and lower rates of bullying in
California middle- and high-schools (Snapp, McGuire, et al., 2015). In add-
ition, Blake et al. (2001) studied the effects of a “Safe Schools” program in
Massachusetts, which was developed to encourage improved education,
greater inclusivity, and additional resources for sexual minority students.
The study also assessed teachers’ levels of confidence in their ability to
meet LGB students’ needs, aggregated these scores for each school involved
in the research, and ranked schools from minimal to high sensitivity. LGB
students reported higher levels of substance use, sexual risk behaviors, and
suicide attempts than heterosexual students, but risk behaviors in LGB stu-
dents at highly inclusive schools were significantly lower than those in less
inclusive schools. The study also found higher rates of confidence among
teachers in their ability to meet the needs of LGB students (87%) compared
to previous findings (24–37%; Kerr, Allensworth, & Gayle, 1989;
Telljohann, Price, Poureslami, & Easton, 1995).
Though research into the clinical outcomes regarding inclusive curricula
is scarce, work in the education literature has painted a fairly clear picture
of the scholastic benefits of including diverse populations and issues rele-
vant to them in academic settings. Hallinan (1998) found that desegrega-
tion of schools, wherein minority students begin to attend majority-white
schools in greater proportions, tends to lead to better academic outcomes
for minority students. Additionally, institutions of higher education that
promote multiculturalism and inclusion in curricular and cocurricular
opportunities demonstrated lower perceived discrimination, greater satisfac-
tion with college, and higher graduation rates among minority students.
Hurtado (2001) reported that greater interaction between members of dif-
ferent ethnic and cultural groups in higher education was associated with
greater acceptance of different races and cultures, better cultural under-
standing, higher scores on measures of leadership ability, and greater crit-
ical thinking ability. Similarly, Gurin, Dey, Hurtado, and Gurin (2002)
reported a positive relationship between a more diverse makeup of class
members and educational outcomes, as well as between diverse course
AMERICAN JOURNAL OF SEXUALITY EDUCATION 3
material and outcomes. Additionally, a positive relationship was found

between exposure to diversity in education and measures of civic engage-
ment. In addition to the described benefits of more inclusive curricula and
climates, curricular and cocurricular activities associated with diversity
were found to reduce racial bias in a meta-analysis of bias reduction studies
(Denson, 2009).
Although most of the education research on diversity and inclusion
focuses on ethnic minorities, sexual and gender minorities have also
received some research interest. Kosciw, Palmer, Kull, and Greytak (2013)
investigated the associations between school climate and the academic out-
comes of lesbian, gay, bisexual, and transgender (LGBT) students. Higher
levels of victimization among LGBT students led to worse achievement out-
comes and lower self-esteem, but school-based support resources reduced
victimization and correlated with better academic outcomes. Despite ample
research on the effects of inclusive and diverse curricula on academic per-
formance, little investigation of the associations between inclusive curricula
and health outcomes has been undertaken. Given the purpose of sex educa-
tion in promoting sexual health, and the influence of an inclusive or exclu-
sive climate on mental health in sexual and gender minorities, the potential
health outcomes associated with perceived inclusivity of sex education rep-
resent important unanswered questions in this field.
Unfortunately, extensive problems continue to exist in meeting the
needs of sexual minority students. Public policy with regards to sex edu-
cation varies across states, but as of 2016 only 24 states and the District
of Columbia require sex education, and only 20 states require sex educa-
tion, if provided, to be factually accurate (National Conference of State
Legislators, 2015). A report from the Gay, Lesbian, and Straight
Education Network (GLSEN) indicated that eight states (Alabama,
Arizona, Louisiana, Mississippi, Oklahoma, South Carolina, Texas, and
Utah) explicitly prohibit sex education curricula that include sexual
minorities by law (Kosciw, 2012). Even in states promoting inclusion, sex
education does not appear to meet students’ needs: although Blake et al.
(2001) found relatively high rates of instructor confidence, much of the
literature presents a less optimistic view of educators’ abilities. Elia and
Eliason (2010) explored historical trends in sex education, reporting that
a majority of programs fail to rise above abstinence-only or simplistic,
heteronormative education that treats heterosexuality as normal and
ignores or marginalizes sexual minority identities. Even in regional pro-
grams deemed successful in implementing inclusivity, such as the
Massachusetts “Safe Schools” program, sexual minority students reported
far lower satisfaction with the climate of diversity than their heterosexual
peers (Szalacha, 2003).
School-based exclusion and heteronormative curriculum and school poli-

cies may contribute to myriad negative outcomes in sexual minority stu-
dents: disproportionate disciplinary action affecting sexual minority
students and related hostile school climate may contribute to higher rates
of criminal sanctions among these students (Snapp, Hoenig, Fields, &
Russell, 2015). Conversely, curriculum focused on sexual orientation and
gender identity was associated with fewer teacher reports of bullying in
schools assessed by teachers as less safe (Russell, Day, Ioverno, & Toomey,
2016). However, curricula designed to be more inclusive of sexual minority
students are not necessarily perceived by these students as sufficient:
although students reported receiving positive lessons regarding sexual
minority orientations and gaining opportunities to discuss systemic oppres-
sion, they expressed dissatisfaction in coverage of social justice education
and intervention in bullying targeted towards sexual minority students
(Snapp, Burdge, Licona, Moody, & Russell, 2015).
Whereas inclusive sex education could possibly protect minority students
from risky sexual practices and negative health outcomes, more exclusive
and heteronormative sex education may be a contributing factor in poorer
behaviors and health. Many sexual health outcomes are poorer in sexual
minority populations than in their heterosexual counterparts. For example,
Blake et al. (2001) reported an earlier average age of first intercourse, a
higher number of sexual partners, a greater rate of substance use before
last intercourse, and increased pregnancy rates among LGB students than
heterosexual students. LGB individuals report greater rates of childhood
and adult physical and sexual abuse compared to heterosexual peers, with
the largest differences in sexual victimization between sexual minority men
and heterosexual men (Balsam, Rothblum, & Beauchaine, 2005).
Additionally, male adolescents with both-sex sexual partners, and female
adolescents with both-sex and only same-sex partners, reported greater sex-
ual risk behaviors compared to other groups (Pathela & Schillinger, 2010).
Further, sexual minority girls have a higher risk of contracting a sexually
transmitted infection (STI) despite being more likely to believe they are at
lower risk for contracting them (Kaestle & Waller, 2011). Additionally, sex-
ual minority individuals may be at greater risk of nonconsensual sexual
experiences, dating abuse, and victimization. Gay men report higher levels
of victimization than do heterosexual men, though lower than heterosexual
women (Krahe, Sch€ utze, Fritsche, & Waizenh€ ofer, 2000). Thus, sexual
minority populations appear to be at broadly greater risk for risky sexual
behaviors, nonconsensual sex, and associated negative health outcomes.
The extent to which inclusive and applicable sex education regarding safe
sex practices and consent may influence this risk is not pres-
ently understood.
In addition to higher rates of sexual risk taking and negative sexual

health consequences, sexual minority students exposed to heteronormative,
exclusive sex education may face worse mental health outcomes. According
to the minority stress model (Meyer, 1995), sexual minority individuals
experience several unique stressors including internalized homophobia,
stigma, discrimination, and violence that contribute to poorer mental
health outcomes. Many of these stressors may be amplified during the pro-
cess of sexual identity formation, during which an individual questions,
determines, and discloses their sexual orientation. The major milestones of
sexual identity formation appear to occur primarily during middle school
and high school (Floyd & Stein, 2002), with median ages ranging from 11
at the first milestone (recognizing same-gender attraction) to 18 at the last
milestone (disclosing orientation to a nonimmediate family member).
Although substantial variation exists in the process of sexual identity for-
mation, these median ages correspond with exposure to sex education and
it is therefore possible that heteronormative, exclusive sex education may
strongly influence minority stress during this period when orientation is
so salient.
Research on minority stress more broadly has consistently found elevated
rates of depression, anxiety, suicidality, and substance abuse among sexual
minorities compared to heterosexual samples (Atkinson et al., 1988;
Cochran & Mays, 2000a, 2000b; Fergusson, Horwood, & Beautrais, 1999;
Gilman et al., 2001; Mays & Cochran, 2001; Pillard, 1988; Saghir, Robins,
Walbran, & Gentry, 1970a, 1970b; Sandfort, de Graaf, Bijl, & Schnabel,
2001; Wilcox et al., 2012). In a review and meta-analysis, Meyer (2003)
demonstrated higher rates of mood and anxiety disorders as well as suici-
dality among LGB populations compared to heterosexual populations, espe-
cially among LGB youth. Subsequent reviews and meta-analyses support
these findings regarding sexual minority populations (see Herek & Garnets,
2007; King et al., 2008; Marshal et al., 2011; Pl€ oderl & Tremblay, 2015),
though some conflicting evidence is found for increased substance use and
in particular alcohol use among sexual minorities. These categories appear
to represent the most relevant mental health outcomes in at-risk sexual
minority populations. However, little research has associated sex education
and its perceived inclusivity or exclusivity with the mental health outcomes
related to minority stress.
In the face of minority stress, sexual minority populations have been
demonstrated to benefit from a number of resilience factors, including
hope, social support, and emotional processing (see Kwon, 2013). Hope is
theorized to promote resilience in sexual minority populations and has
been shown to bolster resilience to chronic stressors in sexual minorities
(Kwon & Hugelshofer, 2010) as well as other populations such as college
students (Visser, Loess, Jeglic, & Hirsch, 2013), caretakers (Horton &
Wallander, 2001), and older adults (Ong, Edwards, & Bergeman, 2006).
Social support has also been identified as an important protective factor in
the face of minority stress, and sexuality-specific social support has been
associated with decreased distress and greater self-esteem in the face of
sexuality stress (Doty, Willoughby, Lindahl, & Malik, 2010; Snapp, Watson,
Russell, Diaz, & Ryan, 2015; Wright & Perry, 2006). Finally, research has
demonstrated a role of emotional processing in preventing relapse of
depression (Teasdale, 1999), in promoting healthy adjustment in the face of
a cancer diagnosis (Stanton et al., 2000), and in improving adjustment and
self-compassion following academic failures (Neff, Hsieh, & Dejitterat,
2005). These resilience factors may interact with influences on minority
health, potentially including the influences of sex education. Similar experi-
ences in terms of minority stress and resilience have been suggested across
sexual and gender minority groups (Meyer, 2015); both groups should
therefore be considered in assessing the influences of sex education.
An important theoretical foundation has been developed to begin to
address the lack of investigation regarding the influences of inclusive sex
education. Hobaica and Kwon (2018) reported on qualitative findings
regarding the perceptions of sex education curricula among sexual minority
students. Participants reported highly heteronormative, exclusive environ-
ments within their sex education, noting a lack of visibility of sexual
minority orientations, feelings of shame associated with their orientations,
and a dearth of relevant information regarding safe sexual practices. As a
result, many participants reported feeling unprepared for sexual activity
during adolescence and early adulthood. Participants connected their heter-
onormative, exclusive sex education with other negative experiences,
including vulnerability to sexual violence, risky sexual behaviors, and gen-
eral sexual hesitancy. Due to the lack of representation in sex education,
participants also reported using other resources for self-education. Based
on these responses, Hobaica and Kwon formulated a theoretical model that
posits a relationship between sex education exclusivity, insufficient sexual
knowledge, internalized stigma, and poor health outcomes, as well as a
model outlining the potential relationship between inclusive sex education
and more positive outcomes (see Hobaica and Kwon’s original paper for
figures). However, no quantitative study to date has examined these pro-
posed relationships between perceived inclusivity of sex education and out-
comes among sexual minority populations.
To address this apparent gap in the literature, we developed a new ques-
tionnaire titled the Perceived Inclusivity of Sex Education Scale (PISES;
Table 1) to evaluate LGB persons’ opinions of how well their sex education
included information relevant to them and their sexual orientation. The
Table 1. Perceived inclusivity of sex education scale.

Directions: Read each item carefully. Using the scale shown below, please select the number that best describes
your experience.
1. My sex education included language relevant to my sexual orientation.
Strongly disagree Strongly agree
1 2 3 4 5 6 7
2. My sex education included content relevant to my sexual orientation.
1 2 3 4 5 6 7
3. My sex education instructor(s) affirmed my orientation as normal and acceptable, and equal to other
orientations.
1 2 3 4 5 6 7
4. My sex education instructor(s) encouraged my classmates to support and accept those who identify
with my sexual orientation.
1 2 3 4 5 6 7
5. My sex education addressed contraception and safe sex practices for a variety of sexual activities
relevant to those who identify with my sexual orientation.
1 2 3 4 5 6 7
6. My sex education instructor(s) encouraged questions from individuals of my sexual orientation when
clarification was needed.
1 2 3 4 5 6 7
7. My sex education made me feel prepared and comfortable for future sexual experiences.
1 2 3 4 5 6 7
8. My sex education made me feel visible in the curriculum and in the classroom.
1 2 3 4 5 6 7
9. My sex education made me feel comfortable with my sexual orientation.
1 2 3 4 5 6 7
10. My sex education provided sufficient information, so that I did not have to seek out sexual information
through other sources.
1 2 3 4 5 6 7
items included in the PISES were founded upon the theoretical model and
qualitative information presented by Hobaica and Kwon (2018). The
themes of visibility and normalization of sexual minority orientations, as
well as the inclusion of sex education curricula regarding sexual behaviors
relevant to sexual minority students, were revealed by the coded qualitative
data in Hobaica and Kwon (2018). In part, the present study aimed to pro-
vide initial validation of this measure. The authors hypothesized that
greater sex education inclusivity would be associated with better sexual and
mental health outcomes on the measures outlined above. Finally, a number
of moderating resilience factors were included in the analysis, including
hope, social support, and emotional processing. It was hypothesized that
each of the above resilience factors would moderate the impact of perceived
inclusivity such that greater levels of each would buffer the negative
impacts of highly exclusive and heteronormative sex education.
Method
Participants
Adults ages 18–26 were solicited online to participate in an online survey.
The sample was recruited from this age cohort in order to capture sexual
minority populations more fully, as younger cohorts identifying as sexual
minorities may exclude those whose sexual identity formation has not been
completed. Additionally, the authors were interested in whether associa-
tions between sex education inclusivity and health outcomes persisted after
the completion of formal sex education. Recruitment was completed
through two primary routes: solicitations through LGTBQ-affiliated groups
at university campuses across the United States and advertisements on
social media platforms displayed to individuals who indicated same-sex
attraction on their profiles. A total of 661 responses were collected,
although many of these responses were incomplete. After removing incom-
plete data and data from those who failed attention check items, a total of
263 valid responses of participants who completed the survey and passed
all attention checks were included in analyses.
Participants indicated their assigned sex at birth: 38% of participants were
assigned male at birth (n ¼ 101) and 62% were assigned female (n ¼ 162).
Participants explicitly self-reported their gender through a free response
item. In terms of gender, 40% reported male gender (n ¼ 106), 46% reported
female gender (n ¼ 121), 5% explicitly self-reported transgender identity
(n ¼ 14), and 8% reported nonbinary gender identity (n ¼ 22).
Approximately 21% of participants were considered to report gender minor-
ity status, indicating a gender identity that differed in some way from their
sex assigned at birth (n ¼ 56), a number which includes those who self-
reported transgender or nonbinary gender identity as reported above. The
vast majority of participants (79%) self-identified as White (n ¼ 205); other
participants self-identified as Asian (5%, n ¼ 12), Black (2%, n ¼ 5), Hispanic
or Latinx (5%, n ¼ 14), Native American or Indigenous (2%, n ¼ 4), and
multiracial (7%, n ¼ 18). Five participants declined to report their ethnicity.
All participants self-identified as sexual minority individuals (i.e., did not
identify as solely heterosexual). In terms of sexual orientation, 49% (n ¼ 129)
self-identified as gay or lesbian, 27% (n ¼ 72) as bisexual, 12% (n ¼ 31) as
pansexual, 8% (n ¼ 20) as queer, and 3% (n ¼ 9) as asexual. Two participants
declined to report their sexual orientation.
Measures
Perceived inclusivity of sex education
A ten-item Perceived Inclusivity of Sex Education Scale (PISES; Table 1)
was developed by the authors including items based on a theoretical
foundation and qualitative analysis from Hobaica and Kwon (2018). These
items included questions regarding the visibility of sexual minority orienta-
tions in sex education, acceptance from instructors and peers during sex
education courses, and depth and breadth of applicable sex education infor-
mation as perceived by participants. Item response options included a
range from 1 (Strongly disagree) to 7 (Strongly agree). The scale demon-
strated excellent internal consistency, a ¼ .93. The scale’s hypothesized rela-
tionship with outcome variables were anticipated to provide initial
construct validity.
Resilience factors
Hope was assessed using the Adult Hope Scale (Snyder et al., 1991), a 12-
item measure. Item responses on the Hope Scale range from Definitely false
to Definitely true, with eight anchors. The Hope Scale yields high conver-
gent validity with similar measures and is associated with less severe psy-
chological problems on the Minnesota Multiphasic Personality Inventory.
The scale also has demonstrated test-retest reliability of .85 at 3 weeks and
.73 at 8 weeks. In the present study, the scale demonstrated good internal
consistency, a ¼ .88. Emotional processing was measured using the process-
ing subscale of the Emotional Approaches Coping Scale (Stanton et al.,
2000); this subscale has demonstrated test-retest reliability of .73 and con-
vergent validity with measures of hope, self-esteem, and life satisfaction.
This measure uses a 7-point Likert-type scale ranging from Never to
Always. The scale demonstrated a good internal consistency, a ¼ .82, in the
present study. Social support was measured using an adjusted version of the
Multidimensional Scale of Perceived Social Support (MSPSS; Zimet,
Dahlem, Zimet, & Farley, 1988) to assess social support received during the
time participants received sex education. The MSPSS demonstrated an
internal consistency of .87 in the present study, and its subscales have been
shown to predict familial and romantic relationship behaviors (Zimet,
Powell, Farley, Werkman, & Berkoff, 1990). This measure uses a 7-point
scale with responses ranging from Very strongly disagree to Very
strongly agree.
Mental health and behavioral outcomes

Anxiety was measured using the Generalized Anxiety Disorder-7 (GAD-7;
Spitzer, Kroenke, Williams, & L€ owe, 2006), an anxiety scale with high test-
retest reliability and convergent, procedural, and predictive validity. For the
present study, this measure demonstrated good to excellent internal con-
sistency, a ¼ .88–.91. Anxiety was measured retrospectively, with partici-
pants completing a GAD-7 for the symptoms they experienced during high
school and another for symptoms they had experienced between graduating
high school and when they completed the survey. To evaluate levels of anx-
iety across these time periods, the language of items and responses were
adjusted. Specifically, participants were asked to consider each item for the
period of their high school years or between graduating high school and
when they completed the survey. Responses included Never or very rarely,
Occasionally but not usually, Usually but not always, and Always or nearly
always. Thus, a cautious interpretation of scores on this measure should be
used as typical cutoff values are inappropriate to evaluate levels of anxiety.
Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9;
Kroenke, Spitzer, & Williams, 2001). The PHQ-9 demonstrates good pre-
dictive validity for functional impairment and poor quality of life. The
internal consistency of this measure for the present sample was excellent,
a ¼ 90. As with anxiety, depression was assessed for two time points: dur-
ing high school and between high school and completion of the survey.
Additionally, similar adjustments were made to this scale to accommodate
the time periods being evaluated, and similar caveats must be made for the
interpretation of scores.
Suicidality was measured using three items assessing suicidality in the
Composite International Diagnostic Interview (CIDI; Robins et al., 1988),
an assessment used by nonprofessional interviewers for epidemiological
studies and measuring suicidal ideation, suicide plan formation, and suicide
attempts. Each item included “yes/no” response options.
Substance use was measured using four items corresponding to partici-
pants’ estimations of their average number of drinks consumed in a week,
average frequency of drinking until intoxicated per month, cigarette use
per week, and drug use per month. These items were repeated to assess
participants’ substance use during the typical week or month in high school
as well as between graduating high school and completing the survey. Risky
sexual behaviors were assessed using three items: number of participants’
sexual relationships, number of sexual experiences with a partner they had
just met for the first time, and number of times participants engaged in
sexual activity without use of STI and/or pregnancy protection. Again,
these items were asked twice to correspond to participants’ experiences
during and after high school.
Procedure
Participants responding to online solicitations were directed to a survey
through the Qualtrics website (Version February, 2018; Qualtrics).
Solicitations included information regarding a lottery that would award five
randomly selected participants with a $50.00 gift card to Amazon.com at
Table 2. Descriptive statistics for independent and dependent variables.

Variable Mean (standard deviation) Observed minimum/maximum
PISES 21.62 (11.79) 10/70
Hope 46.68 (9.83) 12/64
Social Support 64.01 (11.38) 12/84
Emotion Processing 19.68 (4.72) 4/28
HS Anxiety 13.40 (5.39) 8/28
HS Depression 15.79 (6.93) 9/36
Post-HS Anxiety 11.88 (5.66) 7/28
Post-HS Depression 13.92 (6.54) 9/36
Number of relationships HS 2.00 (3.02) 0/20
Recent acquaintance sex HS 0.89 (3.17) 0/30
Sex without protection HS 1.11 (2.99) 0/30
Number of relationships Post-HS 4.73 (6.89) 0/50
Recent acquaintance sex Post-HS 3.54 (7.59) 0/60
Sex without protection Post-HS 2.86 (5.80) 0/50
Number of drinks HS 1.81 (14.20) 0/50
Frequency of intoxication HS .72 (2.29) 0/20
Cigarette use HS 2.66 (13.73) 0/140
Drug use HS 1.75 (5.22) 0/30
Number of drinks Post-HS 2.54 (3.72) 0/25
Frequency of intoxication Post-HS 2.09 (3.21) 0/25
Cigarette use Post-HS 3.51 (15.23) 0/140
Drug use Post-HS 2.87 (6.83) 0/35
Note. PISES: Perceived Inclusivity of Sex Education Scale; HS: high school.
the end of data collection. Participants were asked to read and agree to an
informed consent document before completing the survey, consisting of the
measures outlined above as well as demographic information. The informed
consent statement included information regarding the highly sensitive
nature of some of the questions. A debriefing statement was included at
the end of the survey explaining the purpose of the study and providing
contact information for the authors as well as crisis intervention and sui-
cide prevention resources. Recruitment of participants took place over 9
months. Data security was maintained through deidentification, password
protection, and encryption of electronic data stored securely behind a fire-
wall and on a computer physically accessible only by lab personnel. All
data will be destroyed by January 2021. All procedures were approved by
the Washington State University Institutional Review Board.
Results
All analyses were conducted using Statistical Package for the Social
Sciences (SPSS) software (Version 21; IBM Corporation, 2012). Descriptive
statistics for the entire sample (N ¼ 263) for each of the study variables are
reported in Table 2. For the overall sample, on average high rates of poor
mental health outcomes were reported. Specifically, approximately 70% of
the sample reported suicidal ideation, 42% reported making a suicide plan,
and 28% reported attempting suicide in high school. Post-high school suici-
dality rates were lower but remained substantial: 61% reported suicidal
ideation, 31% reported making a suicide plan, and 10% reported a suicide
attempt following high school. Additionally, substantial average levels of
anxiety and depression in high school were reported, as were anxiety symp-
toms and depressive symptoms post-high school. Average scores indicated
that perceptions of sex education inclusivity were towards the low end of
this scale, as the average response to a given item was close to 2 on a 1–7
Likert scale. For each of the resilience factors, mean scores fell at the high
end of the scales for hope (average response of approximately 6 on a 1–8
Likert scale), social support (average response of approximately 5 on a 1–7
Likert scale), and emotion processing (average response of approximately 5
on a 1–7 Likert scale).
An analysis of the Pearson correlation coefficients among risk/resilience
factors demonstrated a significant correlation between perceived inclusivity
and hope. In addition, the resilience factors were all significantly correlated
with one another. The PISES was significantly and negatively correlated
with depression (p < .001) and anxiety (p < .001) in high school and post-
high school (depression, p ¼ .002; anxiety, p ¼ .001), as well as with making
a suicide plan (p ¼ .001) and attempt (p ¼ .002) during high school, and
making a suicide plan post-high school (p ¼ .004). The other resilience fac-
tors included in the analysis each correlated significantly with several of the
mental health outcomes (Table 3). Following a Bonferroni’s correction to
account for the family-wise error rate of the hypotheses regarding perceived
inclusivity (i.e., 24 correlations), all but the correlation between PISES and
making a suicide plan post-high school remained significant given the
adjusted alpha level (a ¼ .002). Perceived inclusivity of sex education did not
correlate significantly with any of the substance use or sexual risk-taking out-
comes. These outcomes included count variables and were highly positively
skewed. After transforming these data through a logarithmic transformation,
analyses were conducted again correlating perceived inclusivity of sex educa-
tion with these measures, with no changes in results.
Hierarchical regression analyses were conducted to test the effect of per-
ceived inclusivity in sex education on the mental health outcomes, control-
ling for demographic variables. Control variables, including age and
dummy-coded variables for gender, ethnicity, and sexual orientation were
included in the first step of the regression model; the PISES was included
alone in the second step. Perceived inclusivity of sex education accounted
for significant variance in high school anxiety and depression as well as
suicidal ideation, suicide plan, and suicide attempt in high school
(Table 4). In several of the regression models, certain demographic varia-
bles were significantly associated with the outcome variables. Specifically,
age was associated with lower scores on high school anxiety, lower depres-
sion scores, lower probability of suicidal ideation in high school, and lower
Table 3. Zero-order correlations between study variables.

PISES Hope Social Support Emotion Processing
PISES .14 .10 .08
Emotion Processing .40 .32
Social Support .40
High School Anxiety .24 .25 .23 .26
High School Depression .26 .35 .26 .25
Post-HS Anxiety .20 .36 .23 .29
Post-HS Depression .19 .51 .35 .32
High School Suicidal Ideation .12 .22 .25 .11
High School Suicide Plan .21 .22 .19 .06
High School Suicide Attempt .20 .23 .13 .05
Post-HS Suicidal Ideation .11 .29 .28 .07
Post-HS Suicide Plan .18 .37 .25 .17
Post-HS Suicide Attempt .07 .24 .09 .03
Number of drinks HS .00 .04 .02 .05
Frequency of intoxication HS .09 .06 .07 .04
Cigarette use HS .03 .01 .08 .01
Drug use HS .10 .15 .09 .00
Number of drinks Post-HS .01 .04 .02 .06
Frequency of intoxication Post-HS .03 .00 .03 .04
Cigarette use Post-HS .01 .13 .09 .10
Drug use Post-HS .10 .16 .07 .01
Number of relationships HS .03 .17 .06 .06
Recent acquaintance sex HS .01 .02 .06 .05
Sex without protection HS .08 .04 .04 .02
Number of relationships Post-HS .07 .01 .02 .06
Recent acquaintance sex Post-HS .07 .05 .02 .01
Sex without protection Post-HS .01 .01 .10 .00
Note. PISES: Perceived Inclusivity of Sex Education Scale; HS: high school.
p < .05, p < .01.
risk of suicide attempt. Explicit identification of transgender identity was

significantly associated with higher scores on high school depression.
Explicit identification of transgender female identity was also significantly
associated with greater risk for suicide plan in high school. For post-high
school symptoms, adding the PISES yielded significantly greater model
power for anxiety, depression, and developing a suicide plan (Table 5).
Identifying as pansexual was associated with a significant increase in post-
high school depression.
For each of the results in high school, except suicidal ideation, the overall
model accounted for a significant proportion of variability in the outcomes
including anxiety, depression, suicide plan, and suicide attempt. The overall
regression model accounted for a significant proportion of variability in
post-high school anxiety and depression, but did not significantly account
for the suicidality measures for post-high school.
To determine if symptoms differed significantly between high school and
post-high school, paired-samples t-tests were conducted. For each of the
mental health outcomes, including anxiety (t (259) ¼ 5.62, p < .001) and
depression (t (254) ¼ 4.92, p < .001) as well as suicidal ideation
(t (256) ¼ 3.21, p ¼ .002), suicide plan (t (255) ¼ 3.67, p < .001), and suicide
attempt (t (258) ¼ 6.14, p < .001), symptoms were significantly higher in
Table 4. Regression of high school symptoms on perceived inclusivity of sex education, con-
trolling for age, ethnicity, gender, and sexual orientation.
HS HS HS HS HS
Anxiety Depression Suicidal Ideation Suicide Plan Suicide Attempt
Step 1 F/R2 F/R2 F/R2 F/R2 F/R2
All covariates 2.21/.12 2.40/.13 1.10/.07 .98/.06 1.37/.08
PISES 13.96/.05 19.46/.07 5.37/.02 15.46/.06 10.58 .04
Independent variables b/B b/B b/B b/B b/B
Covariates:
White – .06/.99 – – –
Asian .02/.51 .003/.11 .01/.03 .09/.21 .11/.22
Black .10/3.68 .08/4.47 .02/.08 .11/.49 .03/.10
Hispanic .001/.02 .07/2.17 .06/.12 .02/.04 .04/.08
Native American .02/.63 .05/2.52 .05/.19 .05/.18 .004/.01
Multiracial .06/1.14 – .00/.00 .02/.03 .03/.05
Cis Male .06/.63 .00/.00 .01/.01 .01/.01 .03/.02
Trans Male .09/2.69 .13/4.95 .08/.21 .08/.22 .17/.44
Trans Female .01/.60 .13/9.87 .11/.54 .14/.79 .10/.49
Trans Nonbinary .03/1.61 .05/3.15 .01/.05 .04/.19 .07/.28
Nonbinary .07/1.23 .06/1.56 .05/.09 .00/.00 .01/.01
Gay/Lesbian .04/.44 – – 0.06/.06 .13/.12
Bisexual – .05/.76 .04/.04 – –
Pansexual .07/1.19 .12/2.61 .08/.11 .02/.03 .06/.08
Queer .02/.36 .11/2.75 .10/.18 .06/.12 .02/.03
Asexual .09/2.80 .04/1.32 .02/.06 .04/.10 .07/.18
Age .24/.45 .24/.59 .17/.03 .08/.01 .13/.02
Main variable of interest:
PISES .24/.11 .27/.16 .15/.01 .26/.01 .21/.01
Note. – Indicates a variable that was excluded from a model due to collinearity problems. HS: high school;
PISES: Perceived Inclusivity of Sex Education Scale.
p < .05, p < .01.
high school compared to post-high school symptoms. Conversely, when

comparing substance use and sexual risk-taking behaviors, high school
results were significantly lower for number of sexual relationships
(t (257) ¼ 6.53, p < .001), sexual behaviors with new acquaintances
(t (260) ¼ 6.57, p < .001), sexual intercourse without a form of protection
(t (251) ¼ 4.92, p < .001), frequency of intoxication (t (258) ¼ 6.85,
p < .001), and illicit drug use (t (255) ¼ 2.93, p ¼ .004).
Further analyses were conducted to determine whether gender minority
status (reporting a gender identity, including nonbinary or gender noncon-
forming, that differs from one’s sex assigned at birth) was associated with
outcomes. Independent samples t-tests revealed that gender minority par-
ticipants (n ¼ 56) reported significantly lower perceived inclusivity in sex
education, t(259) ¼ 2.19, p ¼ .03, and significantly lower hope, t(257) ¼ 2.96,
p ¼ .01, compared to cisgender sexual minority participants. Using gender
minority status as an independent variable in simple regression revealed
significantly higher anxiety, depression, and suicidal ideation in high
school, as well as significantly higher depression, suicidal ideation, and sui-
cide plan post-high school (Table 6).
Moderation analyses were conducted to determine if the effect of perceived
inclusivity on the dependent variables differed as a function of any of the
Table 5. Regression of post-high school symptoms on perceived inclusivity of sex education,

controlling for age, ethnicity, gender, and sexual orientation.
Post-HS Post-HS Post-HS
Post-HS Post-HS Suicidal Suicide Suicide
Anxiety Depression Ideation Plan Attempt
All covariates 1.89/.11 1.95/.11 1.22/.07 0.95/.06 0.58/.04
Step 2 DF/DR2 DF/DR2 DF/DR2 DF/DR2 DF/DR2
PISES 5.78/.02 7.11/.03 1.93/.01 6.40/.03 1.77/.01
Independent variables ß/B ß/B ß/B ß/B ß/B
Covariates:
White – .04/.65 .07/.08 .19/.22 –
Asian .11/2.83 .03/.93 .08/.19 .05/.10 .04/.05
Black .08/3.33 .12/5.46 .01/.04 .05/.18 .06/.13
Hispanic .03/.68 .07/2.15 .05/.10 .09/.19 .02/.03
Native American .001/.03 .02/.77 .12/.47 .11/.41 .01/.01
Multiracial .06/1.38 – – – .05/.06
Cis Male .10/1.19 .02/.26 .03/.03 .01/.01 .02/.01
Trans Male .10/3.32 .08/3.03 .06/.16 .05/.13 .02/.04
Trans Female .10/6.59 .03/2.29 .08/.42 .03/.15 .001/.004
Trans Nonbinary .03/1.33 .002/.15 .07/.30 .03/.13 .06/.16
Nonbinary .02/.32 .04/1.00 .04/.07 .06/.10 .14/.15
Gay/Lesbian .86/.05 – – – .01/.01
Bisexual – .01/.13 .06/.07 .03/.03 –
Pansexual .13/2.23 .18/3.57 .17/.26 .11/.15 .03/.03
Queer .04/.84 .05/1.32 .04/.07 .10/.18 .06/.07
Asexual .02/.60 .12/4.29 .01/.03 .05/.12 .08/.13
Age .09/.17 .12/.27 .01/.001 .04/.01 .01/.001
Main variable of interest:
PISES .16/.08 .17/.10 .09/.004 .17/.01 .09/.002
Note. – Indicates a variable that was excluded from a model due to collinearity problems. HS: high school;
PISES: Perceived Inclusivity of Sex Education Scale.
p < .05, p < .01.
Table 6. Gender minority status as a predictor of mental health outcomes.

R2 F ß/b SE t p
HS Anxiety .03 7.839 .172/2.26 .17 2.80 .01
HS Depression .06 17.23 .25/4.27 1.03 4.151 <.001
Post-HS Anxiety .01 2.94 .11/1.47 .86 1.72 .09
Post-HS Depression .02 6.36 .16/2.48 .98 2.52 .01
HS Suicidal Ideation .02 4.70 .13/.15 .07 2.17 .03
HS Suicide Plan .01 2.54 .10/.12 .08 1.60 .11
HS Suicide Attempt .01 3.15 .11/.12 .07 1.78 .08
Post-HS Suicidal Ideation .02 6.29 .16/.18 .07 2.51 .01
Post-HS Suicide Plan .02 4.66 .13/.15 .07 2.16 .03
Post-HS Suicide Attempt .00 0.77 .05/.04 .05 .88 .38
p < .05, p < .01.
other resilience variables included in the analysis. None of these models

yielded a significant interaction term for any of the included outcomes.
Discussion
The purpose of the present study was to develop a measure of sexual
minority students’ perceptions of inclusivity in sex education and to assess
relationships between inclusion in sex education and sexual and mental

health outcomes, including depression, anxiety, and suicidality, among sex-
ual minority populations. The results indicate that sexual minority students
receive highly heteronormative and exclusive sex education on average and
that greater levels of exclusion were associated with higher rates of anxiety
and depression as well as greater risk for suicide. Many of these associa-
tions persisted among the sample even after graduating high school:
although poor mental health outcomes generally lessened over time, those
reporting greater levels of exclusion endorsed lingering mental health con-
sequences. Notably high rates of suicidality were reported by the overall
sample, and exclusion in sex education appeared to be associated with this
risk. The results also provide insight into the unique challenges faced by
transgender and gender nonconforming populations, with poorer mental
health outcomes reported by gender minorities in the sample, as well as
even less perceived inclusivity in sex education curricula.
The results also suggest that, given its high internal consistency and the
association of the scale with several of the hypothesized mental health out-
comes, the Perceived Inclusivity of Sex Education Scale (PISES) may be an
important and useful tool for future research in this field. The correlations
between PISES and the outcome variables provide initial establishment of
the scale’s construct validity. Further work is needed to provide greater val-
idation of this scale, including assessment of test-retest reliability, potential
factor structure, and invariance across different groups. The present study
provides initial evidence for the scale’s validity and utility, but this support
should be considered preliminary.
Average scores on the PISES demonstrated that participants on average
perceived their sex education as highly exclusive. Although many individu-
als reported perceiving inclusive sex education curricula, the modal experi-
ence of sex education among the sample was perceived as exclusive and
heteronormative. These results are unsurprising given Hobaica and Kwon’s
(2018) qualitative work, the legal status of inclusive sex education (Kosciw,
2012), the lack of information relevant to sexual minority students in texts
and curricula, and the urgent calls for inclusive sex education from advo-
cacy groups like GLSEN (Gay, Lesbian, and Straight Education Network).
Perhaps also unsurprisingly, participants on average scored at the high end
of the measures for each resilience factor including hope, social support,
and emotion processing. Although average scores on these items did not
appear to substantially differ from typical mean scores in general samples,
it is encouraging to demonstrate typical levels of these resilience factors
among a population that is likely to benefit strongly from them. As sug-
gested by Kwon (2013), these factors are likely powerful forces among sex-
ual minority individuals. In the face of discrimination and minority stress,
individuals may find these elements to be valuable in mitigating poor men-

tal health outcomes.
Consistent with the primary hypotheses, the main effects of perceived
inclusivity on mental health outcomes were found to be statistically signifi-
cant. Namely, greater perceived inclusivity was significantly associated with
lower levels of depression and anxiety during and after high school, and
lower rates of suicidality in high school. Taken from the opposite perspec-
tive, exclusion in sex education was associated with a higher degree of
mental health difficulties and suicidality. This result was anticipated given
Meyer’s (1995) minority stress model as well as preliminary empirical
research done in this field (e.g., Blake et al., 2001; Snapp, McGuire, et al.,
2015). Contrary to the hypotheses regarding sexual risk-taking and sub-
stance use, perceived inclusivity did not significantly account for these out-
comes. Perceptions of heteronormative, exclusive sex education did not
appear to yield poorer sexual health behaviors or substance use for the
items measured in the present study. These results do not provide support
for the hypothesis that the visibility and acceptance of sexual minority ori-
entations in sex education directly influences the applicability of practical
knowledge conveyed in sex education curricula. It is possible that the sin-
gle-item measurement of these constructs resulted in unreliable measure-
ment. More consistent and reliable evaluation of substance use and sexual
risk-taking may have provided a better opportunity to find effects of per-
ceived inclusivity, if they exist. Further investigation of these relationships
is required to more clearly delineate the influence of inclusive sex educa-
tion on sexual health and related behaviors.
The moderation analyses conducted did not support the authors’ hypoth-
eses regarding interactions between perceived inclusivity and the resilience
factors of hope, social support, and emotional processing. Each of the fac-
tors hypothesized to bolster psychological resilience, including perceived
inclusivity of sex education, were significantly and substantially related to
mental health outcomes. The interactions between these variables may not
be significant because each is likely equally powerful in the presence or
absence of the others among sexual minorities, who face a wide array of
sources of prejudice, stigma, and discrimination.
The relationships between gender and outcomes in the study provide
some understanding of these more complex dynamics. Gender minority
participants reported poorer mental health outcomes on several measures
compared to cisgender sexual minority participants. This finding is consist-
ent with the expectation in Meyer’s (1995) minority stress model that mul-
tiple minority stress, or minority stress experienced by individuals from
more than one stigmatized minority group, may lead to stronger negative
impacts on mental health. Some empirical support has been established
identifying the magnifying effects of multiple minority stress (e.g., Balsam,

Molina, Beadnell, Simoni, & Walters, 2011; Bowleg, Huang, Brooks, Black,
& Burkholder, 2003). It is possible that greater perceived inclusivity of sex
education promotes resilience to multiple minority stress such that dual-
minority individuals benefit more strongly from inclusive curricula, and are
at risk for greater exclusion from heteronormative curricula.
The associations between perceptions of sex education and mental health
demonstrate that exclusion and stigma from an institution (i.e., one’s high
school) relate to one’s mental health both during high school and follow-
ing. The immediacy of sex education during the process of sexual identity
formation (Floyd & Stein, 2002) may help to explain these associations.
Minority stress and internalized homophobia (Newcomb & Mustanski,
2010) appear to be powerful negative influences on sexual minority youth,
and exclusion in education and particularly sex education may contribute
to these forces. As students develop a sense of social and sexual identity,
they receive messaging from their education about the acceptability and
normality of their experiences. The connection between perceived inclusiv-
ity of sex education and mental health outcomes is unsurprising given these
dynamic and powerful influences. The finding that mental health outcomes
improved over time within this sample may speak to the benefits of leaving
discriminatory institutions for more accepting ones: most of the sample
were attending or had attended universities, which tend to be relatively
inclusive of sexual minority populations and often take steps to promote
inclusion, despite obstacles (Rankin, 2005).
The primary results of the present study provide provisional support for
the theoretical models outlined by Hobaica and Kwon (2018). The connec-
tion between perceived inclusivity of sex education and mental health out-
comes had not yet been established prior to the present investigation.
However, the mechanisms by which perceived inclusivity of sex education
influence health outcomes remain unclear. To provide fuller support for
this theoretical model, or to adjust the model to better reflect empirical
observations, more research must be conducted on the bridges between
perceptions of heteronormative, exclusive sex education and poorer mental
health. Specifically, this model posits that heteronormative sex education
leads first to an insufficient or stigmatizing knowledge base, which in turn
promotes negative cognitive and behavioral consequences (e.g., risky sexual
behaviors, exposure to sexual violence, internalized homophobia, etc.).
These consequences are suggested to subsequently influence poor mental
health. The present study aimed to establish the connection between the
first and final steps of this model, and cannot provide evidence for the
details regarding intermediary, mediating steps in the model. However,
empirically documenting the relationship between perceived inclusivity of
sex education and mental health is an important first step in evaluating

this model and providing insight into the dynamic influences of inclusive
sex education curricula.
The tentative conclusions drawn from these results help to clarify more
fully the nature of sex education experiences among sexual minorities.
Although some empirical support has demonstrated relationships between
inclusion of sexual minorities in sex education curricula and health out-
comes, the present study appears to be the first to evaluate the correlates of
perceptions of inclusive sex education from the perspective of the students
themselves. These findings also suggest that mental health outcomes related
to the level of inclusion in sex education persist after high school. More
broadly, the present study provides insight into the experiences of sexual
minority students, with average ratings of sex education indicating a modal
experience of perceiving heteronormative, exclusive curricula. Additionally,
the results indicate that sexual minority students possess high levels of the
resilience factors included. It is interesting to note that the sample reported
relatively high levels of resilience factors, yet much of the research literature
has demonstrated substantially poorer mental health outcomes among sex-
ual minority populations compared to heterosexual populations (e.g., Herek
& Garnets, 2007; King et al., 2008; Marshal et al., 2011; Meyer, 2003;
Pl€
oderl & Tremblay, 2015). Sexual minority populations suffer from several
sources of prejudice and minority stress, including perceived exclusive sex
education, which result in poorer health outcomes even in the presence of
resilience factors.
Limitations
The present study included several limitations that restrict the conclusions
that can be drawn. One major limitation is the retrospective nature of sev-
eral items. Specifically, participants were asked to evaluate the inclusivity of
their sex education curricula in high school. These items required partici-
pants to recall and evaluate inclusivity in curricula received after a period
of time that varied depending on the age of the participant and when they
received sex education. Several factors may contribute to making these esti-
mations inaccurate or biased, including biased recall based on new infor-
mation (e.g., recalling relatively more heteronormative and exclusive sex
education after moving to a new community or college campus that is
more inclusive), inaccurate recall due to normal forgetting or other influen-
ces on memory, and under- or over-estimation of normalization or visibil-
ity of sexual minority orientations in sex education, among others.
Additionally, although analyses were made using retrospective measures to
determine changes over time, all data were collected at one time point. The
cross-sectional design of the present study precludes full confidence in the

results regarding change over time and may limit generalizability by pre-
senting data collected only at one time point.
Similarly, measures for many outcome variables included recall of past
experiences. Assessment of anxiety, depression, suicidality, sexual risk-tak-
ing, and substance use in high school required participants to recall each of
these symptoms as they broadly experienced them in high school. The
same limitations regarding retrospective measures outlined above apply to
the measures for many of the outcome variables included in the present
study. To gather a more holistic sense of participants’ experiences, some of
these items were adapted to fit a different timeline than originally designed
to measure. For example, the PHQ-9 and GAD-7 were altered to estimate
depressive and anxiety symptoms, respectively, for participants’ overall
experience during high school and following high school. These periods
ranged from 1 to 8 years, depending on participants’ current age and age
when completing high school, and may include wider gaps depending on
which years of high school students received sex education. These altera-
tions preclude conclusions about absolute levels of depression and anxiety
using the traditional cutoff scores for the measures used. Instead, only rela-
tive differences between subjects in the present study, as well as changes
within subjects between time points, can be confidently assessed. We are
not aware of other research studies that have modified the PHQ-9 and
GAD-7 in this manner, which is a limitation of our study. However, this
approach in asking for retrospective recall of symptomatology has been
taken with other questionnaires, such as the Depression Proneness Rating
Scale (Zemore, Fischer, Garratt, & Miller, 1990).
Another important limitation regarding the present study is the lack of
control for environmental factors besides exclusivity of sex education.
Namely, the perceived inclusivity measure may explain a nonunique pro-
portion of variability in the outcomes measured when controlling for other
elements of participants’ social environment during their sexual identity
formation. For example, inclusivity of sex education is likely to covary with
inclusivity of one’s community, laws affecting sexual minority populations
within specific states, and other sources of minority stress in general. Thus,
it is unclear from the present study whether inclusive sex education would
demonstrate similar associations with mental health outcomes when other
sources of inclusion or exclusion are included in an analysis. Although the
measure developed to assess sex education inclusivity was founded on pre-
vious theoretical work, held adequate face validity, and demonstrated excel-
lent internal consistency, it is possible that inclusive sex education
functions as one part of a broader inclusive and protective environment.
Due to a lack of statistical control for these covariates, the present study
does not on its own provide sufficient empirical evaluation of the theoret-
ical model explaining the unique contribution of sex education on out-
comes in sexual minority populations (Hobaica & Kwon, 2018).
One environmental factor in particular, privilege and access to further
education and sexual health resources, limits the generalizability of the pre-
sent findings. Most of the participants in the sample were attending a col-
lege or university. As noted above, these settings tend to be more inclusive
than other settings. Additionally, university attendance is often limited to
individuals who can afford costs of tuition and who had previously had
access to stable academic and social environments. University students may
also be more likely to find additional information about sexual health and
sexuality through higher education coursework, as well as outside their for-
mal sex education curricula through resources available to them that are
less accessible to other groups. Further, this study did not gather informa-
tion regarding other forms of outside education used, such as media, inter-
net, and conversations with others, which all would likely affect the results
described. Thus, the relationships between perceived inclusivity of sex edu-
cation and health outcomes may differ between those included in the sam-
ple and sexual minority individuals with less access to resources
and education.
The nature of the survey data analyzed for the present study limits inter-
pretation of the results. Causal effects cannot be inferred, particularly due
to the cross-sectional and correlational nature of the study design.
Additionally, fewer than half of responses collected were included in the
analyses after those ineligible for the study and those who failed attention
checks were removed from the dataset. Many participants initiated a
response to the survey but did not complete it. This attrition may be due
to several factors, some of which may be relevant to the analyses used in
the present study. Therefore, it is unclear how generalizable the above
results are to a broader population of sexual minority individuals.
Additionally, the effect of self-selection of potential participants receiving
information about the study into the study is unclear and may similarly
bias the data.
Future directions
Given the limitations as well as the exploratory nature of the present study,
future research is needed to more fully describe the associations suggested
by the above findings. Although there appears to be a connection between
the inclusivity of sex education and mental health outcomes among sexual
minority populations, details remain unclear regarding the complexities of
this relationship. In order to develop a clearer understanding of these
dynamics, future research may investigate these relationships across time

with longitudinal study designs. Because the present study relied on retro-
spective measures of sex education inclusivity and health outcomes during
high school, a longitudinal study may provide more insight into these asso-
ciations by measuring students’ perceptions while receiving sex education
and measuring outcomes over time following sex education. This design
would also allow for the statistical control of covariates that would likely be
related to the outcomes measured, including geographic location, inclusivity
within a broader community, general levels of minority stress, and local
laws affecting sexual minority populations. With greater research support
for the potential influence of sex education inclusivity on outcomes in sex-
ual minority populations, future research programs may also develop inter-
ventions to increase the normalization and visibility of sexual minority
orientations in sex education curricula. Assessing the outcomes related to
such interventions may bolster the empirical support for the associations
between sex education inclusivity and health outcomes.
Future studies may also include mediating and moderating variables to
more clearly delineate the connections between sex education inclusivity
and health outcomes. Hobaica and Kwon’s (2018) theoretical model of the
effects of inclusive or heteronormative sex education includes a number of
mediators that may or may not be important mechanisms facilitating the
influence of sex education on mental health outcomes. These mediators
include the applicability of information conveyed in sex education, access
and utilization of relevant resources, and the experience of sexual or phys-
ical violence, among others. Future education regarding sexual health and
sexuality may be an important factor to consider when evaluating these
relationships. These variables were outside the scope of the present study,
but represent important questions for future empirical study. The PISES
may also be especially useful in evaluating the outcomes of intervention
studies to assess the effects of sex education interventions among sexual
minority populations. Finally, our lab is planning on replicating the current
study with a gender minority sample, as well as updating the language
included in PISES, to better represent gender minority experiences in sex
education curricula.
Conclusions
The generalizability of these results should be considered regarding the
above limitations, however, the present study contributes to a growing
body of research on the experiences of sexual minority populations in sex
education and provides an important first quantitative evaluation of these
experiences. From these results it is clear that many of the important facets
of inclusive sex education as described by Hobaica and Kwon (2018) are

absent in the sex education among many sexual minority students.
Heteronormative, exclusive sex education was the standard among this
sample, which was expected given the current status of sex education. The
present study not only demonstrates the typical heteronormative and exclu-
sive climate of sex education as perceived by sexual minority students, but
also provides initial empirical support for the relationship between per-
ceived inclusivity and mental health outcomes.
In a population facing extraordinary minority stress, heteronormative
sex education appears to contribute to poor health outcomes including
depression, anxiety, and suicidality. More inclusive sex education may ful-
fill a protective role, providing normalization and visibility of sexual
minority orientations in curriculum. These results highlight the potential
power of sex education policies and laws at the national, state, and local
level on sexual minority youth. Despite the possible harm of heteronor-
mative sex education on this population, regulations prohibiting or dis-
couraging the discussion of sexual minority orientations in sex education
commonly persist. An extreme example is presented by the stipulation
under current Alabama law that “an emphasis, in a factual manner and
from a public health perspective, that homosexuality is not a lifestyle
acceptable to the general public and that homosexual conduct is a crim-
inal offense under the laws of the state” (Alabama Code Title 16.
Education § 16–40A-2). Sexual minority students often receive such inva-
lidating and exclusionary messages from sex education, and the present
study offers a preliminary understanding of how these messages may
relate to health outcomes. Further research is necessary to more fully
comprehend the influences of sex education on the health and well-being
of sexual minority students. However, these results represent a crucial
first examination of these relationships and provide an empirical under-
pinning bolstering the calls for inclusion within sex education and in
communities more broadly.
Author note
Gregory H. Keiser, Department of Psychology, Washington State
University; Paul Kwon, Department of Psychology, Washington State
University; Steven Hobaica, Department of Psychology, Washington
State University.
ORCID
Gregory H. Keiser http://orcid.org/0000-0001-8860-8368
Steven Hobaica http://orcid.org/0000-0001-7760-277X
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ISSN: 1554-6128 (Print) 1554-6136 (Online) Journal homepage: https://www.tandfonline.com/loi/wajs20

Sex Education Inclusivity and Sexual Minority

Gregory H. Keiser, Paul Kwon & Steven Hobaica

To link to this article: https://doi.org/10.1080/15546128.2019.1600448

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Sex Education Inclusivity and Sexual Minority Health:

The growing interest in the effects of discrimination against sexual minor-

CONTACT Gregory H. Keiser gregory.keiser@wsu.edu Department of Psychology, Washington State

material and outcomes. Additionally, a positive relationship was found

School-based exclusion and heteronormative curriculum and school poli-

In addition to higher rates of sexual risk taking and negative sexual

Table 1. Perceived inclusivity of sex education scale.

Mental health and behavioral outcomes

Table 2. Descriptive statistics for independent and dependent variables.

Table 3. Zero-order correlations between study variables.

risk of suicide attempt. Explicit identification of transgender identity was

high school compared to post-high school symptoms. Conversely, when

Table 5. Regression of post-high school symptoms on perceived inclusivity of sex education,

Table 6. Gender minority status as a predictor of mental health outcomes.

other resilience variables included in the analysis. None of these models

relationships between inclusion in sex education and sexual and mental

individuals may find these elements to be valuable in mitigating poor men-

identifying the magnifying effects of multiple minority stress (e.g., Balsam,

sex education and mental health is an important first step in evaluating

cross-sectional design of the present study precludes full confidence in the

dynamics, future research may investigate these relationships across time

of inclusive sex education as described by Hobaica and Kwon (2018) are

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