II 118th CONGRESS 1st Session S. 1697 IN THE SENATE OF THE UNITED STATES May 18, 2023 Ms. Hirono (for herself, Mr. Booker , Mr. Blumenthal , Mr. Brown , Ms. Duckworth , Mr. Markey , Mr. Menendez , Mr. Merkley , Mr. Murphy , Mr. Padilla , Ms. Smith , Mr. Van Hollen , and Ms. Warren ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To provide for the overall health and well-being of young people, including the promotion and attainment of lifelong sexual health and healthy relationships, and for other purposes.

1. Short title This Act may be cited as the Real Education and Access for Healthy Youth Act of 2023 . 2. Purpose and findings (a) Purpose The purpose of this Act is to provide young people with sex education and sexual health services that— (1) promote and uphold the rights of young people to information and services that empower them to make decisions about their bodies, health, sexuality, families, and communities in all areas of life; (2) are evidence-informed, comprehensive in scope, confidential, equitable, accessible, medically accurate and complete, age and developmentally appropriate, culturally responsive, trauma-informed and resilience-oriented, and align with the National Sex Education Standards of the Future of Sex Ed Initiative; (3) provide information about the prevention, treatment, and care of pregnancy, sexually transmitted infections, and interpersonal violence; (4) provide information about the importance of consent as a basis for healthy relationships and for autonomy in healthcare; (5) provide information on gender identity and gender expression; (6) provide information on the historical and current condition in which education and health systems, policies, programs, services, and practices have uniquely and adversely impacted Black, Indigenous, Latine, Asian American, Native Hawaiian, Pacific Islander, and other People of Color; and (7) redress inequities in the delivery of sex education and sexual health services to marginalized young people. (b) Findings Congress finds the following: (1) Young people need and have the right to sex education and sexual health services that are evidence-informed, comprehensive in scope, confidential, equitable, accessible, medically accurate and complete, age and developmentally appropriate, culturally responsive, and trauma-informed and resilience-oriented. (2) Currently, there is a gap between the sex education that young people should be receiving based on expert standards and the sex education many actually receive. (3) Only 38 States and the District of Columbia mandate sex education or human immunodeficiency virus (HIV) education in schools. (4) When there is sex education or instruction regarding HIV or sexually transmitted infections (STI), 13 States do not require the content to be evidence-informed, medically accurate and complete, age and developmentally appropriate, or culturally responsive. (5) Many sex education programs and sexual health services currently available were not designed to and do not currently meet the needs of marginalized young people. Some such programs and services actually harm marginalized young people. (6) For marginalized young people, a lack of comprehensive in scope, confidential, equitable, and accessible sex education and sexual health services is not unfamiliar, but rather a longstanding manifestation of white supremacy, which has touched every aspect of our history, culture, and institutions, including the education and healthcare systems. (7) The development and delivery of sexual health education and sexual health services in the United States historically has been rooted in the oppression of Black, Indigenous, Latine, Asian American, Native Hawaiian, Pacific Islander, and other People of Color. (8) The United States has a long history of eugenics and forced sterilization. The sexual and reproductive rights and bodily autonomy of specific communities deemed undesirable or defective were targeted by our governments resulting in state-sanctioned violence and generations of trauma and oppression. These communities include— (A) people with low incomes; (B) immigrants; (C) people with disabilities; (D) people living with HIV; (E) survivors of interpersonal violence; (F) people who are incarcerated, detained, or who otherwise have encountered the criminal-legal system; (G) Black, Indigenous, Latine, Asian American, and other People of Color; (H) people who are lesbian, gay, bisexual, transgender, and queer; and (I) young people who are pregnant and parenting. (9) Black young people are more likely to receive abstinence-only instruction. Research shows that abstinence-only instruction, also known as sexual risk avoidance instruction, is ineffective in comparison to sex education. (10) Black, Indigenous, and Latine young people are disproportionately more likely to be diagnosed with an STI, have an unintended pregnancy, or experience sexual assault. (11) The framework of Reproductive Justice acknowledges and aims to address the legacy of white supremacy, systemic oppression, and the restrictions on sex education and sexual health services that disproportionately impact marginalized communities. Reproductive Justice will be achieved when all people regardless of actual or perceived race, color, ethnicity, national origin, religion, immigration status, sex (including gender identity and sexual orientation), disability status, pregnancy or parenting status, or age have the power to make decisions about their bodies, health, sexuality, families, and communities in all areas of life. (12) Increased resources are required for sex education and sexual health services to reach all young people, redress inequities and their impacts on marginalized young people, and achieve Reproductive Justice for young people. (13) Such sex education and sexual health services should— (A) promote and uphold the rights of young people to information and services in order to make and exercise informed and responsible decisions about their sexual health; (B) be evidence-informed, comprehensive in scope, confidential, equitable, accessible, age and developmentally appropriate, culturally responsive, and trauma-informed and resilience-oriented; (C) include instruction and materials that address— (i) puberty and adolescent development; (ii) sexual and reproductive anatomy and physiology; (iii) sexual orientation, gender identity, and gender expression; (iv) contraception, pregnancy, and reproduction; (v) HIV and other STIs; (vi) consent and healthy relationships; and (vii) interpersonal violence; (D) promote gender equity and be inclusive of young people with varying gender identities, gender expressions, and sexual orientations; (E) promote safe and healthy relationships; and (F) promote racial equity and be responsive to the needs of young people who are Black, Indigenous, and other People of Color. 3. Definitions In this Act: (1) Age and developmentally appropriate The term age and developmentally appropriate means topics, messages, and teaching methods suitable to particular ages, age groups, or developmental levels, based on cognitive, emotional, social, and behavioral capacity of most young people at that age level. (2) Consent The term consent means affirmative, conscious, and voluntary agreement to engage in interpersonal, physical, or sexual activity. (3) Culturally responsive The term culturally responsive means education and services that— (A) embrace and actively engage and adjust to young people and their various cultural identities; (B) recognize the ways in which many marginalized young people face unique barriers in our society that result in increased adverse health outcomes and associated stereotypes; and (C) may address the ways in which racism has shaped national health care policy, the lasting historical trauma associated with reproductive health experiments and forced sterilizations of Black, Latine, and Indigenous communities, or sexual stereotypes assigned to young People of Color or LGBTQ+ people. (4) Evidence-informed The term evidence-informed means incorporates characteristics, content, or skills that have been proven to be effective through evaluation in changing sexual behavior. (5) Gender expression The term gender expression means the expression of one's gender, such as through behavior, clothing, haircut, or voice, and which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine. (6) Gender identity The term gender identity means the gender-related identity, appearance, mannerisms, or other gender-related characteristics of an individual, regardless of the individual's designated sex at birth. (7) Inclusive The term inclusive means content and skills that ensure marginalized young people are valued, respected, centered, and supported in sex education instruction and materials. (8) Institution of higher education The term institution of higher education has the meaning given the term in section 101 of the Higher Education Act of 1965 ( 20 U.S.C. 1001 ). (9) Interpersonal violence The term interpersonal violence means abuse, assault, bullying, dating violence, domestic violence, harassment, intimate partner violence, or stalking. (10) Local educational agency The term local educational agency has the meaning given the term in section 8101 of the Elementary and Secondary Education Act of 1965 ( 20 U.S.C. 7801 ). (11) Marginalized young people The term marginalized young people means young people who are disadvantaged by underlying structural barriers and social inequities, including young people who are— (A) Black, Indigenous, Latine, Asian American, Native Hawaiian, Pacific Islander, and other People of Color; (B) immigrants; (C) in contact with the foster care system; (D) in contact with the juvenile justice system; (E) experiencing homelessness; (F) pregnant or parenting; (G) lesbian, gay, bisexual, transgender, or queer; (H) living with HIV; (I) living with disabilities; (J) from families with low-incomes; or (K) living in rural areas. (12) Medically accurate and complete The term medically accurate and complete means that— (A) the information provided through the education is verified or supported by the weight of research conducted in compliance with accepted scientific methods and is published in peer-reviewed journals, where applicable; or (B) the education contains information that leading professional organizations and agencies with relevant expertise in the field recognize as accurate, objective, and complete. (13) Resilience The term resilience means the ability to adapt to trauma and tragedy. (14) Secretary The term Secretary means the Secretary of Health and Human Services. (15) Sex education The term sex education means high quality teaching and learning that— (A) is delivered, to the maximum extent practicable, following the National Sexuality Education Standards of the Future of Sex Ed Initiative; (B) is about a broad variety of topics related to sex and sexuality, including— (i) puberty and adolescent development; (ii) sexual and reproductive anatomy and physiology; (iii) sexual orientation, gender identity, and gender expression; (iv) contraception, pregnancy, pregnancy options, and reproduction; (v) HIV and other STIs; (vi) consent and healthy relationships; and (vii) interpersonal violence; (C) explores values and beliefs about such topics; and (D) helps young people in gaining the skills that are needed to navigate relationships and manage one’s own sexual health. (16) Sexual health services The term sexual health services includes— (A) sexual health information, education, and counseling; (B) all methods of contraception approved by the Food and Drug Administration; (C) routine gynecological care, including human papillomavirus (HPV) vaccines and cancer screenings; (D) pre-exposure prophylaxis or post-exposure prophylaxis; (E) substance use and mental health services; (F) interpersonal violence survivor services; and (G) other pregnancy and STI prevention, care, or treatment services. (17) Sexual orientation The term sexual orientation means an individual's romantic, emotional, or sexual attraction to other people. (18) State educational agency The term State educational agency has the meaning given the term in section 8101 of the Elementary and Secondary Education Act of 1965 ( 20 U.S.C. 7801 ). (19) Trauma The term trauma means a response to an event, series of events, or set of circumstances that is experienced or witnessed by an individual or group of people as physically or emotionally harmful or life-threatening with lasting adverse effects on their functioning and mental, physical, social, emotional, or spiritual well-being. (20) Trauma-informed and resilience-oriented The term trauma-informed and resilience-oriented means an approach that realizes the prevalence of trauma, recognizes the various ways individuals, organizations, and communities may respond to trauma differently, recognizes that resilience can be built, and responds by putting this knowledge into practice. (21) Young people The term young people means individuals who are ages 10 through 29 at the time of commencement of participation in a project supported under this Act. (22) Youth-friendly sexual health services The term youth-friendly sexual health services means sexual health services that are provided in a confidential, equitable, and accessible manner that makes it easy and comfortable for young people to seek out and receive services. 4. Grants for sex education at elementary and secondary schools and youth-serving organizations (a) Program authorized The Secretary, in coordination with the Secretary of Education, shall award grants, on a competitive basis, to eligible entities to enable such eligible entities to carry out projects that provide young people with sex education. (b) Duration Grants awarded under this section shall be for a period of 5 years. (c) Eligible entity In this section, the term eligible entity means a public or private entity that delivers health education to young people. (d) Applications An eligible entity desiring a grant under this section shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require. (e) Priority In awarding grants under this section, the Secretary shall give priority to eligible entities that are— (1) State educational agencies or local educational agencies; or (2) Indian Tribes or Tribal organizations, as defined in section 4 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 5304 ). (f) Use of funds Each eligible entity that receives a grant under this section shall use the grant funds to carry out a project that provides young people with sex education. 5. Grants for sex education at institutions of higher education (a) Program authorized The Secretary, in coordination with the Secretary of Education, shall award grants, on a competitive basis, to institutions of higher education or consortia of such institutions to enable such institutions to provide students with age and developmentally appropriate sex education. (b) Duration Grants awarded under this section shall be for a period of 5 years. (c) Applications An institution of higher education or consortium of such institutions desiring a grant under this section shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require. (d) Priority In awarding grants under this section, the Secretary shall give priority to an institution of higher education that— (1) has an enrollment of needy students, as defined in section 318(b) of the Higher Education Act of 1965 ( 20 U.S.C. 1059e(b) ); (2) is a Hispanic-serving institution, as defined in section 502(a) of such Act ( 20 U.S.C. 1101a(a) ); (3) is a Tribal College or University, as defined in section 316(b) of such Act ( 20 U.S.C. 1059c(b) ); (4) is an Alaska Native-serving institution, as defined in section 317(b) of such Act ( 20 U.S.C. 1059d(b) ); (5) is a Native Hawaiian-serving institution, as defined in section 317(b) of such Act ( 20 U.S.C. 1059d(b) ); (6) is a Predominantly Black Institution, as defined in section 318(b) of such Act ( 20 U.S.C. 1059e(b) ); (7) is a Native American-serving, nontribal institution, as defined in section 319(b) of such Act ( 20 U.S.C. 1059f(b) ); (8) is an Asian American and Native American Pacific Islander-serving institution, as defined in section 320(b) of such Act ( 20 U.S.C. 1059g(b) ); or (9) is a minority institution, as defined in section 365 of such Act ( 20 U.S.C. 1067k ), with an enrollment of needy students, as defined in section 312 of such Act ( 20 U.S.C. 1058 ). (e) Uses of funds An institution of higher education or consortium of such institutions receiving a grant under this section shall use grant funds to develop and implement a project to integrate sex education into the institution of higher education in order to reach a large number of students, by carrying out 1 or more of the following activities: (1) Adopting and incorporating age and developmentally appropriate sex education into student orientation, general education, or courses. (2) Developing or adopting and implementing educational programming outside of class that delivers age and developmentally appropriate sex education to students. (3) Developing or adopting and implementing innovative technology-based approaches to deliver age and developmentally appropriate sex education to students. (4) Developing or adopting and implementing peer-led activities to generate discussion, educate, and raise awareness among students about age and developmentally appropriate sex education. (5) Developing or adopting and implementing policies and practices to link students to sexual health services. 6. Grants for educator training (a) Program authorized The Secretary, in coordination with the Secretary of Education, shall award grants, on a competitive basis, to eligible entities to enable such eligible entities to carry out the activities described in subsection (e). (b) Duration Grants awarded under this section shall be for a period of 5 years. (c) Eligible entity In this section, the term eligible entity means— (1) a State educational agency or local educational agency; (2) an Indian Tribe or Tribal organization, as defined in section 4 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 5304 ); (3) a State or local department of health; (4) an educational service agency, as defined in section 8101 of the Elementary and Secondary Education Act of 1965 ( 20 U.S.C. 7801 ); (5) a nonprofit institution of higher education or a consortium of such institutions; or (6) a national or statewide nonprofit organization or consortium of nonprofit organizations that has as its primary purpose the improvement of provision of sex education through training and effective teaching of sex education. (d) Application An eligible entity desiring a grant under this section shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require. (e) Authorized activities (1) Required activity Each eligible entity receiving a grant under this section shall use grant funds for professional development and training of relevant teachers, health educators, faculty, administrators, and staff, in order to increase effective teaching of sex education to young people. (2) Permissible activities Each eligible entity receiving a grant under this section may use grant funds to— (A) provide training and support for educators about the content, skills, and professional disposition needed to implement sex education effectively; (B) develop and provide training and support to educators on incorporating anti-racist and gender inclusive policies and practices in sex education; (C) support the dissemination of information on effective practices and research findings concerning the teaching of sex education; (D) support research on— (i) effective sex education teaching practices; and (ii) the development of assessment instruments and strategies to document— (I) young people’s understanding of sex education; and (II) the effects of sex education; (E) convene conferences on sex education, in order to effectively train educators in the provision of sex education; and (F) develop and disseminate appropriate research-based materials to foster sex education. (3) Subgrants Each eligible entity receiving a grant under this section may award subgrants to nonprofit organizations that possess a demonstrated record of providing training to teachers, health educators, faculty, administrators, and staff on sex education to— (A) train educators in sex education; (B) support internet or distance learning related to sex education; (C) promote rigorous academic standards and assessment techniques to guide and measure student performance in sex education; (D) encourage replication of best practices and model programs to promote sex education; (E) develop and disseminate effective, research-based sex education learning materials; or (F) develop academic courses on the pedagogy of sex education at institutions of higher education. 7. Authorization of grants to support the delivery of sexual health services to marginalized young people (a) Program authorized The Secretary shall award grants, on a competitive basis, to eligible entities to enable such entities to provide youth-friendly sexual health services to marginalized young people. (b) Duration Grants awarded under this section shall be for a period of 5 years. (c) Eligible entity In this section, the term eligible entity means— (1) a public or private youth-serving organization; or (2) a covered entity, as defined in section 340B of the Public Health Service Act ( 42 U.S.C. 256b ). (d) Applications An eligible entity desiring a grant under this section shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require. (e) Uses of funds Each eligible entity that receives a grant under this section may use the grant funds to— (1) develop and implement an evidence-informed project to deliver sexual health services to marginalized young people; (2) establish, alter, or modify staff positions, service delivery policies and practices, service delivery locations, service delivery environments, service delivery schedules, or other services components in order to increase youth-friendly sexual health services to marginalized young people; (3) conduct outreach to marginalized young people to invite them to participate in the eligible entity’s sexual health services and to provide feedback to inform improvements in the delivery of such services; (4) establish and refine systems of referral to connect marginalized young people to other sexual health services and supportive services; (5) establish partnerships and collaborations with entities providing services to marginalized young people to link such young people to sexual health services, such as by delivering health services at locations where they congregate, providing transportation to locations where sexual health services are provided, or other linkages to services approaches; (6) provide evidence-informed, comprehensive in scope, confidential, equitable, accessible, medically accurate and complete, age and developmentally appropriate, culturally responsive, and trauma-informed and resilience-oriented sexual health information to marginalized young people in the languages and cultural contexts that are most appropriate for the marginalized young people to be served by the eligible entity; (7) promote effective communication regarding sexual health among marginalized young people; and (8) provide training and support for eligible entity personnel and community members who work with marginalized young people about the content, skills, and professional disposition needed to provide youth-friendly sex education and youth-friendly sexual health services. 8. Reporting and impact evaluation (a) Grantee report to secretary For each year a grantee receives grant funds under section 4, 5, 6, or 7, the grantee shall submit to the Secretary a report that includes— (1) the use of grant funds by the grantee; (2) how the use of grant funds has increased the access of young people to sex education or sexual health services; and (3) such other information as the Secretary may require. (b) Secretary’s report to Congress Not later than 1 year after the date of the enactment of this Act, and annually thereafter for a period of 5 years, the Secretary shall prepare and submit to Congress a report on the activities funded under this Act. The Secretary's report to Congress shall include— (1) a statement of how grants awarded by the Secretary meet the purpose described in section 2(a); and (2) information about— (A) the number of grantees that are receiving grant funds under sections 4, 5, 6, and 7; (B) the specific activities supported by grant funds awarded under sections 4, 5, 6, and 7; (C) the number of young people served by projects funded under sections 4, 5, and 7, in the aggregate and disaggregated and cross-tabulated by grant program, race and ethnicity, sex, sexual orientation, gender identity, and other characteristics determined by the Secretary (except that such disaggregation or cross-tabulation shall not be required in a case in which the results would reveal personally identifiable information about an individual young person); (D) the number of teachers, health educators, faculty, school administrators, and staff trained under section 6; and (E) the status of the evaluation required under subsection (c). (c) Multi-Year evaluation (1) In general Not later than 6 months after the date of the enactment of this Act, the Secretary shall enter into a contract with a nonprofit organization with experience in conducting impact evaluations to conduct a multi-year evaluation on the impact of the projects funded under sections 4, 5, 6, and 7 and to report to Congress and the Secretary on the findings of such evaluation. (2) Evaluation The evaluation conducted under this subsection shall— (A) be conducted in a manner consistent with relevant, nationally recognized professional and technical evaluation standards; (B) use sound statistical methods and techniques relating to the behavioral sciences, including quasi-experimental designs, inferential statistics, and other methodologies and techniques that allow for conclusions to be reached; (C) be carried out by an independent organization that has not received a grant under section 4, 5, 6, or 7; and (D) be designed to provide information on output measures and outcome measures to be determined by the Secretary. (3) Report Not later than 6 years after the date of enactment of this Act, the organization conducting the evaluation under this subsection shall prepare and submit to the appropriate committees of Congress and the Secretary an evaluation report. Such report shall be made publicly available, including on the website of the Department of Health and Human Services. 9. Nondiscrimination Activities funded under this Act shall not discriminate on the basis of actual or perceived sex (including sexual orientation and gender identity), age, parental status, race, color, ethnicity, national origin, disability, or religion. Nothing in this Act shall be construed to invalidate or limit rights, remedies, procedures, or legal standards available under any other Federal law or any law of a State or a political subdivision of a State, including the Civil Rights Act of 1964 ( 42 U.S.C. 2000a et seq. ), title IX of the Education Amendments of 1972 ( 20 U.S.C. 1681 et seq. ), section 504 of the Rehabilitation Act of 1973 ( 29 U.S.C. 794 ), the Americans with Disabilities Act of 1990 ( 42 U.S.C. 12101 et seq. ), and section 1557 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18116 ). 10. Limitation No Federal funds provided under this Act may be used for sex education or sexual health services that— (1) withhold health-promoting or life-saving information about sexuality-related topics, including HIV; (2) are medically inaccurate or incomplete; (3) promote gender or racial stereotypes or are unresponsive to gender or racial inequities; (4) fail to address the needs of sexually active young people; (5) fail to address the needs of pregnant or parenting young people; (6) fail to address the needs of survivors of interpersonal violence; (7) fail to address the needs of young people of all physical, developmental, or mental abilities; (8) fail to be inclusive of individuals with varying gender identities, gender expressions, and sexual orientations; or (9) are inconsistent with the ethical imperatives of medicine and public health. 11. Amendments to other laws (a) Amendment to the Public Health Service Act Section 2500 of the Public Health Service Act ( 42 U.S.C. 300ee ) is amended by striking subsections (b) through (d) and inserting the following: (b) Contents of programs All programs of education and information receiving funds under this subchapter shall include information about the potential effects of intravenous substance use. . (b) Amendments to the Elementary and Secondary Education Act of 1965 Section 8526 of the Elementary and Secondary Education Act of 1965 ( 20 U.S.C. 7906 ) is amended— (1) by striking paragraphs (3), (5), and (6); (2) by redesignating paragraph (4) as paragraph (3); (3) in paragraph (3), as redesignated by paragraph (2), by inserting or after the semicolon; and (4) by redesignating paragraph (7) as paragraph (4). 12. Funding (a) Authorization For the purpose of carrying out this Act, there is authorized to be appropriated $100,000,000 for each of fiscal years 2024 through 2029. Amounts appropriated under this subsection shall remain available until expended. (b) Reservations of funds (1) In general The Secretary— (A) shall reserve not more than 30 percent of the amount authorized under subsection (a) for the purposes of awarding grants for sex education at elementary and secondary schools and youth-serving organizations under section 4; (B) shall reserve not more than 10 percent of the amount authorized under subsection (a) for the purpose of awarding grants for sex education at institutions of higher education under section 5; (C) shall reserve not more than 15 percent of the amount authorized under subsection (a) for the purpose of awarding grants for educator training under section 6; (D) shall reserve not more than 30 percent of the amount authorized under subsection (a) for the purpose of awarding grants for sexual health services for marginalized youth under section 7; and (E) shall reserve not less than 5 percent of the amount authorized under subsection (a) for the purpose of carrying out the reporting and impact evaluation required under section 8. (2) Research, training, and technical assistance The Secretary shall reserve not less than 10 percent of the amount authorized under subsection (a) for expenditures by the Secretary to provide, directly or through a competitive grant process, research, training, and technical assistance, including dissemination of research and information regarding effective and promising practices, providing consultation and resources, and developing resources and materials to support the activities of recipients of grants. In carrying out such functions, the Secretary shall collaborate with a variety of entities that have expertise in sex education and sexual health services standards setting, design, development, delivery, research, monitoring, and evaluation. (c) Reprogramming of abstinence only until marriage program funding The unobligated balance of funds made available to carry out section 510 of the Social Security Act ( 42 U.S.C. 710 ) (as in effect on the day before the date of enactment of this Act) are hereby transferred and shall be used by the Secretary to carry out this Act. The amounts transferred and made available to carry out this Act shall remain available until expended. (d) Repeal of abstinence only until marriage program Section 510 of the Social Security Act ( 42 U.S.C. 710 et seq. ) is repealed.