1. Developing Inclusive Health Education Materials for LGBTQ Youth and Allies
Sarah Roush, California Family Health Council
Nico Storrow, Vista Community Clinic
Introduction to topic
Set ground rules

2. Introductions Name Organization/Affiliation
Personal Gender Pronoun (PGPs)

3. Project Background
Identified a lack of resources related to LGBTQ-inclusive sex education
Received requests from project partners for inclusive education tools…we decided to create our own!
The primary project of my field placement was originally to design and implement an assessment of HIV prevention education in County school districts. After researching the Education Code, previous assessments in California, and conducting key informant interviews.
Project partner: Nico of chatNCSD (curbing HIV/AIDS transmission in north county san diego)
169 San Diego youth surveyed to identify preferred topics for events and workshops:
“LGBTQ friendly sex education” selected 85 times
“Communicating with your partner” selected 77 times
Nico- talk about survey process in GSA Clubs, visited clubs to survey students ask what kind of support they were looking for interests etc, other selected items- mental health (offered through other orgs), meditation/stress management. While working in discussion group, a common topic that came up was body image, which is how we selected our third topic.

4. Project Background Under California law:
HIV prevention education is required for all students.
Comprehensive sex education is allowed but not mandated.
Abstinence-only education is prohibited.
Lessons must be appropriate for students of any gender, race, sexual orientation, religious or cultural background.
*Nico: talk briefly about youth experiences
California Department of Education. (2014). Comprehensive Sexual Health & HIV/AIDS Instruction. Retrieved from:

5. Project Background
San Diego Unified School District Youth Risk Behavior Survey (YRBS), 2013:
60% of surveyed GLB students report having ever had sex, compared with 35% of heterosexual peers.
Nearly 15% report having had sex before the age of 13, compared with 4% of heterosexual peers.
CDC. (2013) Youth Risk Behavior Survey Results: San Diego Unified School District High School Survey, Risk Behaviors and Sexual Identity Report.

6. Project Background
San Diego Unified School District Youth Risk Behavior Survey (YRBS) Data, 2013:
16% of GLB students report having been threatened by or feeling unsafe because of someone they dated, compared to 5% of heterosexual students.
22% of GLB students report having ever experienced being physically forced to have sex against their will, compared to 6% of heterosexual students.
Dating violence is also a significant topic for this community; as one adult GSA advisor told us, she was thrilled to see discussions of healthy relationships and consent in a lesson for LGBTQ youth, because as a young woman she was told to never let a man treat her badly…but never the message that a relationship with a woman could be abusive, and that she could ask for help.
CDC. (2013) Youth Risk Behavior Survey Results: San Diego Unified School District High School Survey, Risk Behaviors and Sexual Identity Report.

7. Project Background
San Diego Unified School District Youth Risk Behavior Survey (YRBS) Data, 2013:
GLB students were 3x more likely than heterosexual students to report disordered eating behaviors (30% vs. 10%) and other unsafe practices in order to lose weight.
Why did we select these topics? We know there are unique pressures faced by the LGBTQ community, and sub communities
Multiple identities impact body image: race, age, ability, sexuality, gender, etc
What does it mean to be gender non-conforming in our society?
Looking at what is reported in the SDUSD YRBS, we see that although GLB students are on the whole not significantly different from heterosexual peers, they engage in much higher levels of disordered eating behaviors and unhealthy behaviors related to weight. This doesn’t capture the many issues related to body image and self esteem, but is one relevant statistic looking at SD youth.
Although limited, studies have found that gay and bisexual men experience the highest rates of disordered eating, and LGBTQ adolescents experience higher levels of disordered eating and negative body image than their heterosexual peers.
CDC. (2013) Youth Risk Behavior Survey Results: San Diego Unified School District High School Survey, Risk Behaviors and Sexual Identity Report.

8. Project Background
Goal: develop an effective, inclusive, culturally- and age-appropriate education tool
Channel: Gay-Straight Alliances (GSAs) in local schools, community-based LGBTQ youth groups
Format: 3 Lessons
Love Your Body, Healthy Relationships, and Safer Sex
Lessons include facilitator instructions, handouts, associated materials and references
-there are many resources targeting MSM (not necessarily free), but for the most part these are look at high risk adult populations. We wanted to develop a material that was inclusive and appropriate for use with diverse youth – we may be presenting in a room representing the entire rainbow, we might be presenting to a room full of straight allies. Some participants may be sexually active, some may not start dating for years. We aren’t making any assumptions about who is in the room, and we want everyone to feel represented. To make materials as effective as possible, we primarily adapted existing evidence-based materials that were freely available on sites like sexedlibrary.org
-LGBTQ youth in schools congregate, along with non-LGBTQ youth who identify as allies, in GSA clubs, which are designated safe spaces. Therefore, club meetings are one of the only spaces in schools where LGBTQ-identified youth come together and can be addressed as a group. Additionally, while LGBTQ youth may be hesitant to ask questions related to their sexuality in a general health or sex education class, the GSA club is a space where they can openly identify as LGBTQ and comfortably discuss issues related to their sexuality or gender identity. As noted by Kirby, et al., creating “a safe social environment for youth to participate” in sexual risk reduction lessons is a critical characteristic of an effective program (2011, p. 5). By delivering health lessons through established GSAs, the time and effort necessary to develop a safe space for participants has already taken place.
-Addressing students in GSA clubs has the additional benefit of circumventing potential barriers to providing sex education in conservative school districts. GSA clubs are typically student-led extracurricular groups, which gives them greater latitude in the topics they are allowed to discuss, despite being held on school grounds

9. Development Process Curriculum development process
Review of available resources (using sites like
Selected evidence based, free curricula/activities
Adapted activities to be relevant and broadly inclusive of diverse LGBTQ youth
Community review process Dec. 2013–Feb. 2014
Permission was received to use all included materials; citations included
We will talk more about adapting and this process of tweaking existing materials in “best practices”

10. Activity! Worksheet: Using Inclusive Language
Please take 3 minutes to fill in the worksheet.
Is the language in the statement on the left inclusive of LGBTQ individuals?
If not, how could it be improved?
Adapted from: Pamela Wilson, MSW / Darcy Allder, Girls Incorporated, Alameda, CA Examples of how to make Sex Education More Inclusive

11. Activity! Women get pregnant from vaginal sex.
If semen/sperm gets into the vagina there is a chance or pregnancy.
Puberty is a time when many people start feeling attracted to the opposite sex.
Puberty is a time when many people start having crushes and romantic attractions.
Gender identity refers to a person’s internal sense of being either male or female.
Gender identity refers to a person’s internal sense of their gender –girl/woman, boy/man, transgender, some of each, or something else (genderqueer, gender non-conforming).
A blow job is when a woman uses her mouth to stimulate a man’s penis.
A blow job refers to oral sex - mouth on penis.
Women should get pap smears every 3 years, beginning at age 21.
Cervical cancer screening (“pap smear”) is important for anyone with a cervix – this should be done every 3 years, beginning at age 21.
Are you sexually active?
Are you sexually active with males, females, or both? / What kinds of sex do you and your partner have?
Condoms help prevent pregnancy and STD's by keeping the semen inside the condom and vaginal fluids outside.
Anything going inside a person’s genitals is safer with a condom or glove on it, for example: penis, dildo, or hand
Women can use female condoms which can be inserted in the vagina before having sex.
Internal condoms can be inserted into the vagina or the anus prior to sex.
When a baby is born, it is either male or female.
Babies can be born male, female, or intersex.
We’ll also give an example later of how we adapted a specific scenario within our lessons, and describe the review process we went through the reach the final product.
Notes: Add a couple examples, sex and kinds of sex, anyone with a cervix should get a pap smear, preferred terminology
Are you sexually active?
Adapted from: Pamela Wilson, MSW / Darcy Allder, Girls Incorporated, Alameda, CA Examples of how to make Sex Education More Inclusive

12. Development Process
Public Health Seattle & King County. (2011). Family Life and Sexual Health, Talking With Partners about Prevention, Grades 9-12, Lesson 13. Retrieved from:

13. Development Process
Discuss process Also mention examples of adapting scenarios about trans characters

14. Review Process AT Furuya Volunteer, Hillcrest Youth Center
Christopher White, PhD Director, Safe and Healthy LGBT Youth Project, GSA Network
Giovan Hernandez Community Health Representative, UCSD Mother-Child-Adolescent HIV Program
Indie Landrum Community Organizer, Critical Voice: A Queer Youth Coalition
Jennifer Lewis, PhD Clinical Social Work Supervisor, UCSD Mother-Child-Adolescent HIV Program
Kelly Jean Gainor, MEd Community Health Educator, Planned Parenthood Keystone
Kelly Hutton, MA Director, South Bay Youth Organizing
Kenyatta Parker Coordinator, CSU San Marcos Gender Equity Center
Nicole Kent, PhD Marriage & Family Therapist / Lecturer, San Diego State University
Pamela Wilson, MSW Program Consultant and Trainer
Rachel Miller, MEd HIV/Sex Ed Resource Teacher, San Diego Unified School District
Sophia Arredondo Coordinator, Hillcrest Youth Center, San Diego LGBT Community Center
Tara Beeston, MPH HIV, STD and Hepatitis Branch of Public Health Services, County of San Diego
These are the primary individuals we requested feedback from. These individuals include teachers, health educators, individuals working on different aspects of STI/HIV prevention, sexual & reproductive health, and LGBTQ youth programs. They also represent diverse personal backgrounds – we tried to ensure that we had broad representative of LGBTQ individuals as reviewers to receive varied perspectives on the materials.
As a result, we changed some of the language and representation of trans individuals in the scenarios, worked to improve our discussions of STDs/HIV to ensure that they aren’t stigmatizing for youth who are or may become positive, and increased our focus on discussions of healthy relationships and issues around consent.

15. The Lessons: Content (briefly describe the content of the lessons)
Each has Goals, Objectives, Lessons Outlines, and the Materials & Preparation needed to implement

16. The Lessons: Content
Each lesson also includes key lessons – because we know that in many settings (such as short GSA meetings) time is an issue, we’ve pulled out the key messages for facilitators to highlight, and emphasize the correct delivery of important content.

17. The Lessons: Content
Public Health Seattle & King County. (2011). Family Life and Sexual Health, Abstinence, Grades 9-12, Lesson 9. Assertiveness Handout. Retrieved from:

18. The Lessons: Content

19. Limitations Lack of more extensive formative research
Time (length of GSA meetings)
Limitations related to school setting (choice to not include condom demonstration, etc)
-Our process would have been strengthened through surveys or key informant interviews of school administrators, teachers that provide classroom-based sexual health education, and students; we were unable to conduct this activity due to the non-approval of the HIV education survey by the County. We had hoped to gain more insight into the specific barriers and quality improvement needs of school districts, including around the issue of LGBTQ inclusion in HIV prevention and comprehensive sexual health education.
-GSA clubs are an excellent setting for the lessons for other reasons - including that they are a congregation point for LGBTQ youth in schools, they are a safe space where youth feel comfortable discussing issues related to their sexuality and gender identity, and they are student-led clubs, which allow them greater autonomy to invite guest speakers – the brevity of meetings makes the implementation of health education lessons difficult. To meet the need for a one hour lesson, we compensated by including instructions for each lesson to be scheduled over the course of two consecutive GSA meetings. While this is not ideal, it will allow time for interactive sessions and group discussions. Additionally, when the lessons are implemented after school or at community centers, they can be scheduled to take place during a 60 minute (or longer) session.
-A final potential limitation in the project was our decision to not include a condom demonstration in the Safer Sex lesson. Although we felt this was important content, it was left out for two reasons. First, as mentioned, GSA meetings are extremely brief, often taking place over a 30 minute lunch session. Additionally, we felt that bringing condoms into schools might cross a line with conservative administrations, resulting in the lessons being banned and receiving a negative reputation in the education community. For these reasons, we opted to exclude a condom demonstration. However, the educational brochure included in the Safer Sex lesson, which discusses STIs and risk reduction, does include illustrations on proper condom use.

20. Lessons Learned
There is a desire for this information from youth and educators, and a need for resources
When surveying participants for desired topics, offer those that you are able to provide
Delivering lessons through GSAs and community centers is an acceptable way to reach LGBTQ youth with inclusive messages
Collaborating with diverse community partners is critical for ensuring that materials are inclusive and relevant to LGBTQ youth

21. Best Practices
Follow best practices for medically accurate, age-appropriate health information
Be as broadly inclusive and representative of the youth you work with as possible
Use gender neutral language
Involve diverse stakeholders as reviewers
Be prepared to revise after review & pilot
Don’t let perfect be the enemy of good

22. Pilot & Implementation Phase
Initially piloted with several school-based GSAs in San Diego and 2 community-based LGBTQ youth groups; received feedback from participants and adult facilitators.
CHATncsd (Vista Community Clinic) staff have implemented lessons in 18 GSAs over the last year.
NICO: We started piloting these workshops in the beginning of 2014 after we had completed the review process. We started with GSAs that we had already developed strong relationships with such as Carlsbad High (one of the largest GSA Clubs in North County- currently has about 70 members, but at that time closer to 40). We also piloted at the Hillcrest Youth Center since it was harder to get the “Safe Sex” workshops in to schools due to conservative political climate. In the beginning it was challenging just getting into schools, but the more we continued to show up at communiyt events, and build relationships the easier it became.

23. Evaluations: Initial Findings
Evaluations include a simplified pre-post format, given limited time for lessons balanced against wanting to measure our impact

24. Evaluations: Initial Findings
Table 1. Percentage of Respondents Who Reported “High” Content Knowledge Before and After the Lesson by Content Areas and Lesson
Before
Lesson
After
Love Your Body Lesson (N=120)
I can identify and analyze factors in society that affect body image and self-esteem.
53%
96%
I know at least one technique that I can use to improve my body image and self-esteem.
30%
84%
I can explain the connections between body image, self-esteem, and sexual health.
40%
Healthy Relationships Lesson (N=45)
I can explain what a healthy relationship is.
28%
98%
I can describe why communication is an important part of an emotionally and physically healthy relationship.
63%
100%
I can use assertive communication with a partner (now or in the future) to discuss our relationship and safer sex.
93%
I know what sexual consent means and why it’s important.
81%
Safer Sex Lesson (n=22)
I can describe how STDs and HIV are spread between partners.
45%
95%
I can identify the most common symptoms of a sexually transmitted infection.
32%
82%
I know the risks of STDs of different sexual acts (like protected vs. unprotected oral, vaginal and anal sex).
50%
I can describe what “safer sex” means.
73%
Analysis of evaluations provided by EvalCorp
To date, 100 evaluations have been completed by participants in San Diego County high schools
Across all participants, 98% indicated learning something from the lesson.
78% increased their knowledge after the lesson.
The workshops were well recieved. Students seemed to really appreciate the opportunity to speak and ask questions and share their experiences in comfortable spaces. One challenge we came across was completing the workshop in the limited GSA meeting (usually 30 min, bell to bell). Love your body- a lot of positive feedback and better for shorter sessions. We were surprised to hear that many students were recieving little if any sex education and it certainly was not LGBTQ inclusive.

25. Evaluations: Initial Findings
Participants expressed approval of activities, particularly the open environment for sharing
96% felt included
82% responded that they wouldn’t change anything
Other requested topics: mental health, sexual health, race
Those that did make suggested changes frequently requested longer time periods to have more discussion, along with suggestions like providing lunch and having more videos.
Felt included: aggregate: 161/167
Wouldn’t change anything: aggregate: 128/156

26. Facilitator Training September 18-19th, 2014
Day 1: LGBTQ sensitivity workshop, with co-facilitators from:
Critical Voice: a queer youth coalition
UndocuQueer San Diego
Hillcrest Youth Center
Day 2: Introduction to the lessons & facilitation
Participants included staff from local school districts, GSA Advisors, and a variety of youth-serving agencies
Day 1: overview of summary from chatNCSD’s youth surveys (LGBTQ student’s experiences in SD schools, how educators and service providers can create more welcoming and supportive environments); Critical Voice is presenting on LGBTQ competency: terminology, trans 101, how to be an ally; UndocuQueer is discussing working with queer undocumented youth; LGBTQ youth panel from the Hillcrest Youth Center.
we recieved feedback that the trainings and some of the suggestions from the facilitator training were being implemented in various settings, including a juvenile detention center in San Diego County.

27. Best Practices
Setting up the Space: Ground Rules & Introductions (PGPs)
Intersectional Identities
Popular Education Model
Encouraging critical engagement
Mental Health/Triggers
Handling Difficult situations
Do’s and Don’ts
Setting up the space: Circles, Keep it interesting and engaging, Multi-directional learning, We are all experts in our own experiences, YOUTH CENTERED!
Popular Education Model: “An approach to education where participants are active contributors to the learning process… emphasizes the personal experiences and strives to connect these experiences to societal problems and concerns. The goal is to achieve positive community change through collective consciousness-raising and problem solving.”
Critical Engagement: What if some of the materials we have recreate dynamics we are critiquing, lacks representation, enforces a gender binary?

28. Best Practices: Utilizing Community Agreements
Respect
Don’t Yuck My Yum
One Diva, One Mic
Step Up, Step Back
Confidentiality
Use “I” Statements
Oops and Ouch
Don’t call anyone out in front of the group
Importance of ground rules and setting up space:
culture of accountability and respect, Expectations/tone, agreements to come back to, Give students opportunity create and agree upon common rules, Gives value to all voices

29. Best Practices
What advice would you give to someone hoping to make their organization more welcoming for LGBTQ students?
“Be willing to learn.”
"Let the LGBTQ students speak up. Listen to any concerns and take them seriously. Use the name and pronouns the students want”
“Actively hire trans people”
“Ask questions when you’re unsure of something to ensure safety and respect”
Because we think it is important to include direct youth feedback whenever possible. These were responses from some of our youth in North County San Diego.

30. Best Practices: Critical Engagement
What if some of the materials we have recreate dynamics we are critiquing, lacks representation, enforces a gender binary?
Sonya Renee clip and discuss adaptations
and crticial engagement
NICO: Sonya Renee- body is not an apology – 1 min. clip, adapting for trans friendly, working with text to make inclusive, working with existing resources, nothing is perfect, handout
handout that talks about “men” and “women” only, aknowledging and critiquing resources and engaging students in this process.

31. Best Practices: Critical Engagement
Sonya Renee: "The Body Is Not An Apology"

32. Best Practices: Mental Health & Triggers
Mandated reporters
Potential trigger topics: body image, abusive relationships, consent/rape culture, STD’s
Check in with students afterwards
Let students know if you can be a resource
Know about local mental health resources (see resources in manual pages 55-56)

33. Best Practices - Do Use inclusive language and eye contact
Respect pronouns, ask when unsure
Listen and validate individuals’ experiences
Get comfortable with “the terms”
Recognize multiple cultures, races, abilities, genders etc
Use “go rounds” to give everyone the chance to speak
Ask youth to sit in circle, but allow them to pass
Put students’ thoughts and concerns at the center of the conversation

34. Best Practices - Don’t Use heterosexist assumptions or stereotypes
Call anyone out or ask them to speak for their community
Use broad generalizations about individuals or communities
Delegitimize someone’s experience
Ask personal questions about someone’s body
Force anyone to speak
Answer a question you don’t know
Allow a few students to dominate
Expect to get through everything

35. Resources for Developing Inclusive Education Materials
Centers for Disease Control & Prevention (CDC):
Youth Risk Behavior Surveillance System
Lesbian, Gay, Bisexual and Transgender Health
GLSEN:
National School Climate Survey
ETR Associates:
Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-based Programs
SIECUS:
Sex Ed Library
Public Health - Seattle & King County:
Family Life and Sexual Health (FLASH) Curriculum
Population Council:
It’s All One Curriculum

36. Thank you for attending!
Questions?
Thank you for attending!
Please contact Nico or Sarah if you’re interested in further information regarding the lessons. Sarah Roush
Nico Storrow