Overall, 18.8% of students were currently sexually active (Table 1), 54.0% of whom reported condom use at last sex. Among currently sexually active students who ever had sex with an opposite-sex partner, 40.8% used condoms; 27.8% used a shot, patch, or ring or BCP; 13.4% used no method; 9.3% used withdrawal or some other method; and 5.8% used an IUD or implant at last sex with a member of the opposite sex to prevent pregnancy. Current sexual activity differed significantly by age, race and ethnicity, sexual identity, sex of sexual contact, experiences of racism at school, and English proficiency. It was lowest among Hispanic students (14.7%) and highest among Non-Hispanic White (20.9%) students. Prevalence of current sexual activity was higher in students who reported opposite-sex only sexual contacts (48.2%) than those who reported same-sex or both-sex sexual contacts (34.1%), higher among students who experienced racism at school than those who did not (21.5% versus 17.3%), and higher among students who reported they did not speak English well than those who reported speaking English well (31.8% versus 18.3%).

This study provides insight into adolescent SRH behaviors in early 2021 during the COVID-19 pandemic and associations with demographic variables, experiences of racism in school, and self-rated English proficiency. We found higher prevalence of current sexual activity among students who ever reported experiencing racism at school, but not among students belonging to racial and ethnic groups who experience the greatest levels of racism, such as Black and Hispanic/Latino students.¹⁴ Data from the 2021 national Youth Risk Behavior Survey (YRBS) also indicate no significant differences by race/ethnicity for current sexual activity, except among Asian students, who were least likely to be currently sexually active.²³ More research is needed to contextualize these findings relating to racism, race, and ethnicity; including examining associations between racism and sexual behaviors by race and ethnicity subgroups, which this study was not sufficiently powered to do. Investigating how racism and socioecological factors affect sexual behaviors is critical to understanding how risk factors may interplay with each other or further contribute to negative influences on SRH, which has been highlighted in other studies.²⁴ Our findings expand this evidence, contributing to other literature on the negative impacts of discrimination and experiences of racism on adolescent SRH outcomes.^25,26 Further, English proficiency self-reported as “not well” was also linked with current sexual activity. English language proficiency may be capturing different underlying constructs, including experiences of discrimination, a potential barrier to access to health care, and a proxy for acculturation. In one 2005 study with 7th–12th grade Hispanic and White youth, less acculturated Hispanic youth (using English language use as a proxy for acculturation with primary language spoken) were less likely to report ever having sex than White youth.²⁷ However, the transportability of these findings to different time periods and contexts is unclear. Prior literature suggests that acculturation may be associated with a number of HIV-related sexual behaviors,²⁸ and also illustrates how language barriers may limit access to and delivery of health services and contribute to health-related disparities among populations.^29,30 More research is needed to examine the role of language acquisition and proficiency, particularly among adolescents self-identifying as having low English proficiency, and impacts on sexual health behaviors.³¹ Furthermore, 1.2% of adolescents (n = 87) in our study reported both poor English proficiency and ever experiencing racism. Future studies should consider how these two experiences might relate to and interact with adolescent sexual behaviors.

While LGB students had similar prevalence of current sexual activity to heterosexual peers, they reported lower prevalence of condom use at last sex and use of condom as a primary method to prevent pregnancy with a member of the opposite sex. This might be due to differences of perceived pregnancy risk and motivation to use condoms, as well as the types of sexual behaviors considered when answering the survey question.^32,33 Nonetheless, the finding is concerning considering persistent and disproportionate increases in STI infection rates³⁴ and HIV³⁵ among adolescents and young adults, and among those with sexual minority identities. Robust evidence describes effective interventions and strategies in school, clinic, and community settings to help reduce risk behaviors and experiences contributing to STI/HIV and unintended pregnancy among adolescents.^36,37

Less than one-fifth of currently sexually active students reported STI testing in the past 12 months, and we found that it was also higher among those who reported same-sex and both-sex sexual contacts. Taken together, these findings underscore the need for access to high-quality, inclusive SRH health care, counseling, and education.^34,35 Differences in STI testing by sex are likely due to differing STI screening recommendations for males and females.^20,21 Studies document practices such as incorporating testing into routine clinic visits, offering universal STI/HIV screening during health care visits, and improving provider skills for delivering youth-friendly and culturally responsive care as effective in increasing STI testing among youth.^38,39

Schools are critical venues that provide adolescent SRH services through referrals, direct service provision, and comprehensive education. School-based health clinics are shown to improve uptake of contraceptives among adolescents,⁴⁰ and STI screening events^{41, 42} and staff referrals to SRH providers⁴³ can also increase student’s receipt of STI testing. School nurses, SBHC staff, and other health care providers are essential for improving students’ access to youth-friendly, culturally-sensitive, and inclusive services.⁴⁴ For example, schools could provide resources in different languages. Moreover, given the overall low levels of condom use and STI testing, which may be exacerbated by disruptions to sexual health clinics caused by the COVID-19 pandemic,⁴⁵ schools and SBHCs become increasingly important in bridging the gap in health care, especially in under-resourced settings. Coupling school-based or school-linked SRH services with skills-based SRH education⁴⁶ to promote student’s knowledge and skills for accessing and using SRH services may improve testing and contraceptive behaviors among currently sexually active adolescents.

Findings from this study are subject to limitations. General limitations for ABES are explained elsewhere;¹⁹ notably, ABES is a one-time cross-sectional survey. Causality or directionality of the findings cannot be determined and changes in behaviors or experiences are not assessed. Further, small sample sizes, led to some imprecise estimates and the suppression of cells, and prevented us from conducting further analyses. English proficiency was self-reported and obtained from a survey only offered in English and Spanish, which may result in a less reliable measure of English proficiency compared with a formal language assessment. Further, those who report low proficiency in English-based surveys may differ from those who were not able to take the survey in the first place. The item measuring primary contraceptive method used at last sex with an opposite-sex partner to prevent pregnancy was restricted to a single response choice, so we cannot determine if respondents (or their partners) used more than one method at last sex or contraceptive use among same-sex partners. Lastly, data were collected during the COVID-19 pandemic and are not directly comparable to other public health surveillance data (e.g., Youth Risk Behavior Survey), so we are unsure how the context of the pandemic may have influenced these associations, if at all.

This study investigated adolescent SRH behaviors during the COVID-19 pandemic and found differences by demographic characteristics. Pre-pandemic disparities in adolescent SRH behaviors and outcomes, in conjunction with the difference we observed in data from the pandemic period, suggest ongoing efforts to enhance access to and quality of SRH services and education are essential for all youth. Experiences of racism in school and a potential indicator of discrimination, self-rated ability to speak English proficiently, were also associated with an increase in current sexual activity. Coupling such efforts with structural interventions that address racism and discrimination in school settings is needed. Future studies should explore the impacts of discriminatory experiences and language-related barriers to SRH care on adolescent STI/HIV and pregnancy outcomes, and consider effective and inclusive school, clinic, and community interventions.