Decision-making has been identified as one of the most important skillsets in sexual health. This exploratory qualitative study explored how US middle and high school textbooks integrate the recommended sexual health decision-making skills recommended by Future of Sex Education (FOSE), a collaboration of organisations in the USA supporting comprehensive sex education. Using content analysis, we assessed 13 U.S. middle and high school health education textbooks recommended by school districts, state boards of education, and publishers. While textbooks touched on the knowledge and content areas for each skill set, skills were not taught to the extent that the skill was achieved or using a scaffolded approach that showed significant growth from middle to high school textbooks. As a result, young people receive inadequate content to competently perform the skills recommended by current National Standards. Changing state and district level health and sex education policies and aligning the curriculum with these standards, can better promote youth sexual decision-making.