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New research: quality sex education has broad, long-term benefits for young people’s’ physical and mental health.

An extensive review finds that in addition to helping to prevent teen pregnancy and STIs, sex education can help prevent child sexual abuse, create safer school spaces for LGBTQ young people, and reduce relationship violence

Washington, DC – New research published in the Journal of Adolescent Health has identified a wide variety of benefits of comprehensive, quality sex education. 

For Three Decades of Research: The Case for Comprehensive Sex Education , Eva S. Goldfarb, Ph.D. and Lisa D. Lieberman, Ph.D. examined studies from over three decades of research on sex education and found “evidence for the effectiveness of approaches that address a broad definition of sexual health and take positive, affirming, inclusive approaches to human sexuality.”

From the authors: 

“We undertook this research because of the glaring lack of work that examines the impact  of sex education on all aspects of sexual health, rather than limiting the scope to pregnancy and STI prevention. Our research found that sex education has the potential do so much more. The impact of quality sex education that addresses the broad range of sexual health topics extends beyond pregnancy and STIs and can improve school success, mental health, and safety. As with all other areas of the curriculum, building an early foundation and scaffolding learning with developmentally appropriate content and teaching are key to long-term development of knowledge, attitudes, and skills that support healthy sexuality.

Further, if students are able to avoid early pregnancy, STIs, sexual abuse and interpersonal violence and harassment, while feeling safe and supported within their school environment, they are more likely to experience academic success, a foundation for future stability.”

The paper found that sex education efforts can also succeed in classrooms outside of  the health education curriculum. Given that most schools have limited time allotted to health or sex education, a coordinated and concerted effort to teach and reinforce important sexual health concepts throughout other areas of the curriculum is a promising strategy.

Members of the Future of Sex Education Initiative, a coalition of organizations working to ensure all students in grades K–12 receive comprehensive, quality sex education which developed the National Sex Education Standards, welcomed the research: 

Debra Hauser, President, Advocates for Youth:

“This paper confirms what educators and young people see every day in classrooms and school communities: sex education helps young people have healthier, safer lives and more affirming environments. We owe it to every young person to make sure they not only have the information and skills they need to protect their health, but that they are safe in their schools and their homes.”

Chris Harley, President & CEO, SIECUS:

“At SIECUS: Sex Ed for Social Change, we have been asserting that individual and social benefits of sex education extend far beyond simply decreasing rates of unintended pregnancies and sexually transmitted infections among young people. This new wealth of research is just the start of illuminating that the power and importance of comprehensive, inclusive sex education is in it’s ability to do so much more. The findings are clear: sex education helps all of our young people lead happier, healthier, safer lives—no matter who they are or how they identify. ”

Dan Rice, Executive Director, Answer:

“When it comes to most topics taught in school, the motto is often “ Knowledge is Power ;” but there’s often a double standard when it comes to sex education. This paper provides the evidence that access to comprehensive sex education is not only empowering to all students, but can also help to improve their emotional and social development.”

Eva S. Goldfarb, Ph.D. , and Lisa D. Lieberman, Ph.D. are available for comment; please reach out to [email protected] .

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Comprehensive sexuality education

Comprehensive sexuality education (CSE) gives young people accurate, age-appropriate information about sexuality and their sexual and reproductive health, which is critical for their health and survival.

While CSE programmes will be different everywhere, the United Nations’ technical guidance – which was developed together by UNESCO, UNFPA, UNICEF, UN Women, UNAIDS and WHO – recommends that these programmes should be based on an established curriculum; scientifically accurate; tailored for different ages; and comprehensive, meaning they cover a range of topics on sexuality and sexual and reproductive health, throughout childhood and adolescence.

Topics covered by CSE, which can also be called life skills, family life education and a variety of other names, include, but are not limited to, families and relationships; respect, consent and bodily autonomy; anatomy, puberty and menstruation; contraception and pregnancy; and sexually transmitted infections, including HIV.

Sexuality education equips children and young people with the knowledge, skills, attitudes and values that help them to protect their health, develop respectful social and sexual relationships, make responsible choices and understand and protect the rights of others. 

Evidence consistently shows that high-quality sexuality education delivers positive health outcomes, with lifelong impacts. Young people are more likely to delay the onset of sexual activity – and when they do have sex, to practice safer sex – when they are better informed about their sexuality, sexual health and their rights.

Sexuality education also helps them prepare for and manage physical and emotional changes as they grow up, including during puberty and adolescence, while teaching them about respect, consent and where to go if they need help. This in turn reduces risks from violence, exploitation and abuse.

Children and adolescents have the right to be educated about themselves and the world around them in an age- and developmentally appropriate manner – and they need this learning for their health and well-being.

Intended to support school-based curricula, the UN’s global guidance indicates starting CSE at the age of 5 when formal education typically begins. However, sexuality education is a lifelong process, sometimes beginning earlier, at home, with trusted caregivers. Learning is incremental; what is taught at the earliest ages is very different from what is taught during puberty and adolescence.

With younger learners, teaching about sexuality does not necessarily mean teaching about sex. For instance, for younger age groups, CSE may help children learn about their bodies and to recognize their feelings and emotions, while discussing family life and different types of relationships, decision-making, the basic principles of consent and what to do if violence, bullying or abuse occur. This type of learning establishes the foundation for healthy relationships throughout life.

Many people have a role to play in teaching young people about their sexuality and sexual and reproductive health, whether in formal education, at home or in other informal settings. Ideally, sound and consistent education on these topics should be provided from multiple sources. This includes parents and family members but also teachers, who can help ensure young people have access to scientific, accurate information and support them in building critical skills. In addition, sexuality education can be provided outside of school, such as through trained social workers and counsellors who work with young people. 

Well-designed and well-delivered sexuality education programmes support positive decision-making around sexual health. Evidence shows that young people are more likely to initiate sexual activity later – and when they do have sex, to practice safer sex – when they are better informed about sexuality, sexual relations and their rights.

CSE does not promote masturbation. However, in our documents, WHO recognizes that children start to explore their bodies through sight and touch at a relatively early age. This is an observation, not a recommendation. 

The UN’s guidance on sexuality education aims to help countries, practitioners and families provide accurate, up-to-date information related to young people’s sexuality, which is appropriate to their stage of development. This may include correcting misperceptions relating to masturbation such as that it is harmful to health, and – without shaming children – teaching them about their bodies, boundaries and privacy in an age-appropriate way.

There is sound evidence that unequal gender norms begin early in life, with harmful impacts on both males and females. It is estimated that 18%, or almost 1 in 5 girls worldwide, have experienced child sexual abuse.

Research shows, however, that education in small and large groups can contribute to challenging and changing unequal gender norms. Based on this, the UN’s international guidance on sexuality education recommends teaching young people about gender relations, gender equality and inequality, and gender-based violence. 

By providing children and young people with adequate knowledge about their rights, and what is and is not acceptable behaviour, sexuality education makes them less vulnerable to abuse. The UN’s international guidance calls for children between the age of 5 and 8 years to recognize bullying and violence, and understand that these are wrong. It calls for children aged 12–15 years to be made aware that sexual abuse, sexual assault, intimate partner violence and bullying are a violation of human rights and are never the victim’s fault. Finally, it calls for older adolescents – those aged 15–18 – to be taught that consent is critical for a positive sexual relationship with a partner. Children and young people should also be taught what to do and where to go if problems like violence and abuse occur.

Through such an approach, sexuality education improves children’s and young people’s ability to react to abuse, to stop abuse and, finally, to find help when they need it. 

There is clear evidence that abstinence-only programmes – which instruct young people to not have sex outside of marriage – are ineffective in preventing early sexual activity and risk-taking behaviour, and potentially harmful to young people’s sexual and reproductive health.

CSE therefore addresses safer sex, preparing young people – after careful decision-making – for intimate relationships that may include sexual intercourse or other sexual activity. Evidence shows that such an approach is associated with later onset of sexual activity, reduced practice of risky sexual behaviours (which also helps reduce the incidence of sexually transmitted infections), and increased contraception use.

On sexuality education, as with all other issues, WHO provides guidance for policies and programmes based on extensive research evidence and programmatic experience.

The UN global guidance on sexuality education outlines a set of learning objectives beginning at the age of 5. These are intended to be adapted to a country’s local context and curriculum. The document itself details how this process of adaptation should occur, including through consultation with experts, parents and young people, alongside research to ensure programmes meet young people’s needs.

Comprehensive sexuality education: For healthy, informed and empowered learners

Did you know that only 37% of young people in sub-Saharan Africa can demonstrate comprehensive knowledge about HIV prevention and transmission? And two out of three girls in many countries lack the knowledge they need as they enter puberty and begin menstruating? Early marriage and early and unintended pregnancy are global concerns for girls’ health and education: in East and Southern Africa pregnancy rates range 15-25%, some of the highest in the world. These are some of the reasons why quality comprehensive sexuality education (CSE) is essential for learners’ health, knowledge and empowerment. 

What is comprehensive sexuality education or CSE?

Comprehensive sexuality education - or the many other ways this may be referred to - is a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. It aims to equip children and young people with knowledge, skills, attitudes and values that empowers them to realize their health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and understand and ensure the protection of their rights throughout their lives.

CSE presents sexuality with a positive approach, emphasizing values such as respect, inclusion, non-discrimination, equality, empathy, responsibility and reciprocity. It reinforces healthy and positive values about bodies, puberty, relationships, sex and family life.

How can CSE transform young people’s lives?

Too many young people receive confusing and conflicting information about puberty, relationships, love and sex, as they make the transition from childhood to adulthood. A growing number of studies show that young people are turning to the digital environment as a key source of information about sexuality.

Applying a learner-centered approach, CSE is adapted to the age and developmental stage of the learner. Learners in lower grades are introduced to simple concepts such as family, respect and kindness, while older learners get to tackle more complex concepts such as gender-based violence, sexual consent, HIV testing, and pregnancy.

When delivered well and combined with access to necessary sexual and reproductive health services, CSE empowers young people to make informed decisions about relationships and sexuality and navigate a world where gender-based violence, gender inequality, early and unintended pregnancies, HIV and other sexually transmitted infections still pose serious risks to their health and well-being. It also helps to keep children safe from abuse by teaching them about their bodies and how to change practices that lead girls to become pregnant before they are ready.

Equally, a lack of high-quality, age-appropriate sexuality and relationship education may leave children and young people vulnerable to harmful sexual behaviours and sexual exploitation.

What does the evidence say about CSE?

The evidence on the impact of CSE is clear:

• Sexuality education has positive effects, including increasing young people’s knowledge and improving their attitudes related to sexual and reproductive health and behaviors.
• Sexuality education leads to learners delaying the age of sexual initiation, increasing the use of condoms and other contraceptives when they are sexually active, increasing their knowledge about their bodies and relationships, decreasing their risk-taking, and decreasing the frequency of unprotected sex.
• Programmes that promote abstinence as the only option have been found to be ineffective in delaying sexual initiation, reducing the frequency of sex or reducing the number of sexual partners. To achieve positive change and reduce early or unintended pregnancies, education about sexuality, reproductive health and contraception must be wide-ranging.
• CSE is five times more likely to be successful in preventing unintended pregnancy and sexually transmitted infections when it pays explicit attention to the topics of gender and power
• Parents and family members are a primary source of information, values formation, care and support for children. Sexuality education has the most impact when school-based programmes are complemented with the involvement of parents and teachers, training institutes and youth-friendly services .

How does UNESCO work to advance learners' health and education?

Countries have increasingly acknowledged the importance of equipping young people with the knowledge, skills and attitudes to develop and sustain positive, healthy relationships and protect themselves from unsafe situations.

UNESCO believes that with CSE, young people learn to treat each other with respect and dignity from an early age and gain skills for better decision making, communications, and critical analysis. They learn they can talk to an adult they trust when they are confused about their bodies, relationships and values. They learn to think about what is right and safe for them and how to avoid coercion, sexually transmitted infections including HIV, and early and unintended pregnancy, and where to go for help. They learn to identify what violence against children and women looks like, including sexual violence, and to understand injustice based on gender. They learn to uphold universal values of equality, love and kindness.

In its International Technical Guidance on Sexuality Education , UNESCO and other UN partners have laid out pathways for quality CSE to promote health and well-being, respect for human rights and gender equality, and empower children and young people to lead healthy, safe and productive lives. An online toolkit was developed by UNESCO to facilitate the design and implementation of CSE programmes at national level, as well as at local and school level. A tool for the review and assessment of national sexuality education programmes is also available. Governments, development partners or civil society organizations will find this useful. Guidance for delivering CSE in out-of-school settings is also available.

Through its flagship programme, Our rights, Our lives, Our future (O3) , UNESCO has reached over 30 million learners in 33 countries across sub-Saharan Africa with life skills and sexuality education, in safer learning environments. O3 Plus is now also reaching and supporting learners in higher education institutions.

To strengthen coordination among the UN community, development partners and civil society, UNESCO is co-convening the Global partnership forum on CSE together with UNFPA. With over 65 organizations in its fold, the partnership forum provides a structured platform for intensified collaboration, exchange of information and good practices, research, youth advocacy and leadership, and evidence-based policies and programmes.

Good quality CSE delivery demands up to date research and evidence to inform policy and implementation . UNESCO regularly conducts reviews of national policies and programmes – a report found that while 85% of countries have policies that are supportive of sexuality education, significant gaps remain between policy and curricula reviewed. Research on the quality of sexuality education has also been undertaken, including on CSE and persons with disabilities in Asia and East and Southern Africa .

How are young people and CSE faring in the digital space?

More young people than ever before are turning to digital spaces for information on bodies, relationships and sexuality, interested in the privacy and anonymity the online world can offer. UNESCO found that, in a year, 71% of youth aged 15-24 sought sexuality education and information online.

With the rapid expansion in digital information and education, the sexuality education landscape is changing . Children and young people are increasingly exposed to a broad range of content online some of which may be incomplete, poorly informed or harmful.

UNESCO and its Institute of Information Technologies in Education (IITE) work with young people and content creators to develop digital sexuality education tools that are of good quality, relevant and include appropriate content. More research and investment are needed to understand the effectiveness and impact of digital sexuality education, and how it can complement curriculum-based initiatives. Part of the solution is enabling young people themselves to take the lead on this, as they are no longer passive consumers and are thinking in sophisticated ways about digital technology.

A foundation for life and love

• Safe, seen and included: report on school-based sexuality education
• International Technical Guidance on Sexuality Education
• Safe, seen and included: inclusion and diversity within sexuality education; briefing note
• Comprehensive sexuality education (CSE) country profiles
• Evidence gaps and research needs in comprehensive sexuality education: technical brief
• The journey towards comprehensive sexuality education: global status report
• Definition of Sustainable Development Goal (SDG) thematic indicator 4.7.2: Percentage of schools that provided life skills-based HIV and sexuality education within the previous academic year
• From ideas to action: addressing barriers to comprehensive sexuality education in the classroom
• Facing the facts: the case for comprehensive sexuality education
• UNESCO strategy on education for health and well-being
• UNESCO Health and education resource centre
• Campaign: A foundation for life and love
• UNESCO’s work on health and education

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Comprehensive Sex Education Addressing Gender and Power: A Systematic Review to Investigate Implementation and Mechanisms of Impact

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• Published: 16 December 2021
• Volume 20 , pages 58–74, ( 2023 )

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• Kerstin Sell   ORCID: orcid.org/0000-0003-2481-7237 1 , 2 , 3 ,
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Delivered globally to promote adolescents’ sexual and reproductive health, comprehensive sex education (CSE) is rights-based, holistic, and seeks to enhance young people’s skills to foster respectful and healthy relationships. Previous research has demonstrated that CSE programmes that incorporate critical content on gender and power in relationships are more effective in achieving positive sexual and reproductive health outcomes than programmes without this content. However, it is not well understood how these programmes ultimately affect behavioural and biological outcomes. We therefore sought to investigate underlying mechanisms of impact and factors affecting implementation and undertook a systematic review of process evaluation studies reporting on school-based sex education programmes with a gender and power component.

We searched six scientific databases in June 2019 and screened 9375 titles and abstracts and 261 full-text articles. Two distinct analyses and syntheses were conducted: a narrative review of implementation studies and a thematic synthesis of qualitative studies that examined programme characteristics and mechanisms of impact.

Nineteen articles met the inclusion criteria of which eleven were implementation studies. These studies highlighted the critical role of the skill and training of the facilitator, flexibility to adapt programmes to students’ needs, and a supportive school/community environment in which to deliver CSE to aid successful implementation. In the second set of studies ( n  = 8), student participation, student-facilitator relationship-building, and open discussions integrating student reflection and experience-sharing with critical content on gender and power were identified as important programme characteristics. These were linked to empowerment, transformation of gender norms, and meaningful contextualisation of students’ experiences as underlying mechanisms of impact.

Conclusion and policy implications

Our findings emphasise the need for CSE programming addressing gender and power that engages students in a meaningful, relatable manner. Our findings can inform theories of change and intervention development for such programmes.

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Introduction

School-based comprehensive sexuality education (CSE) constitutes a public health intervention, promoted globally, to improve young people’s sexual and reproductive health and well-being. CSE, described by UNESCO as ‘a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality’ (UNESCO, 2018a , p. 16), seeks to equip children and young people with a set of skills, attitudes, and scientifically accurate knowledge to nourish respectful social and sexual relationships (UNESCO, 2018a ). It commonly incorporates a positive notion of sexuality, a holistic understanding of sexual health, and emphasises the sexual rights of young people as a human right (Berglas, 2016 ; Haberland & Rogow, 2015 ; UNFPA, 2015 ). CSE is therefore increasingly considered best practice in sexuality education (Vanwesenbeeck, 2020 ). Footnote 1

CSE is recognised to impact positively on a range of adolescent sexual and reproductive health (SRH) outcomes, including but not limited to the following: knowledge of SRH and human rights, communication skills, sexual and emotional well-being, and attitudes supporting gender equity (Goldfarb & Lieberman, 2021 ; Ketting et al., 2016 ; UNFPA, 2015 ). Systematic reviews have demonstrated that CSE programmes also tend to have positive impacts on knowledge, attitudes, and skills although they often demonstrate weak or inconsistent effects on behavioural outcomes such as sexual risk-taking, number of partners, age at initiation of sex, and condom use (Denford et al., 2017 ; Kirby, Laris, & Rolleri, 2007 ; UNESCO, 2018b ).

CSE is also considered an important tool in efforts to promote gender equality, reduce gender-based violence (GBV) (Miller, 2018 ; UNESCO, 2018a ), including intimate partner violence (Kantor et al., 2021 ; Makleff et al., 2019 ), and in achieving the Sustainable Development Goals (Starrs et al., 2018 ). These efforts are rooted in an understanding that gender inequality, gender norms, and SRH are closely intertwined, with gender inequality and restrictive gender norms contributing substantially to adverse health outcomes, including in the area of SRH (Heise et al., 2019 ). Conceptualising gender as a hierarchical social system differentiating between women and men and commonly ascribing higher power, resources, and status to men and things masculine, Heise et al. argue that gender norms uphold this social system via unwritten rules that define acceptable behaviour for women, men, and gender minorities (Heise et al., 2019 ). These norms act as a powerful determinant of adolescent SRH (Pulerwitz et al., 2019 ). Gender inequality places girls and women at higher risk of gender-based violence, STIs, biological, social and behavioural vulnerability to HIV, and unintended pregnancy (Dellar et al., 2015 ; Heise et al., 2019 ; Park et al., 2018 ; Wingood & DiClemente, 2000 ). Traditional gender norms place adolescents at higher risk of unsafe sex as it affects their ability to negotiate safe sex (Wood et al., 2015 ), whilst masculinity norms can drive risky sexual behaviour in men, including avoiding condom use and contraception (Heise et al., 2019 ).

As adolescence is considered a key developmental phase during which gender norms and attitudes intensify, this period presents a window of opportunity for intervention (Amin et al., 2018 ; Buller & Schulte, 2018 ; Kågesten et al., 2016 ). Therefore, schools and school-based CSE have been argued to constitute key sites to promote healthier gender norms and gender equality at scale (Jamal et al., 2015 ). Whilst the focus of our work is on adolescents, it is increasingly recognised that school-based interventions geared towards younger children and continued through the school trajectory may be very effective in addressing gender norms and roles (Goldfarb & Lieberman, 2021 ).

A systematic review of randomised controlled trials of sexuality education programmes that were not abstinence-only and focused on the prevention of HIV, other STIs, and unintended pregnancies as primary outcomes showed that interventions were more likely to have a positive effect on these three biological outcomes if they explicitly addressed ‘gender and power’ in relationships as compared to interventions that did not include this component Footnote 2 (Haberland, 2015 ). In the review, the gender and power content constituted ‘at least one explicit lesson, topic or activity covering an aspect of gender or power in sexual relationships, for example, how harmful notions of masculinity and femininity affect behaviors, are perpetuated and can be transformed; rights and coercion; gender inequality in society; unequal power in intimate relationships; fostering young women’s empowerment; or gender and power dynamics of condom use’ (Haberland, 2015 , p. 3). In addition to demonstrating the effectiveness of the programmes with gender and power content, Haberland identified four common characteristics of effective programmes: ‘Fostering critical thinking’, ‘explicit attention to gender or power in relationships’, ‘fostering personal reflection’, and ‘valuing oneself and recognising one’s own power’ (ibid, pages 6–7).

As a result of the work of Haberland and others, explicit attention to gender and gender-related power has been incorporated into many CSE programmes, e.g. by incorporating gender norms and power dynamics into the theory of change in CSE programmes (Berglas, 2016 ). Such ‘gender-transformative’ programming considers the roots of gender-based health inequities, incorporates strategies to address these, and ultimately seeks to shift gender relations and norms that contribute to these inequities (Ruane-McAteer et al., 2019 ; World Health Organization, 2011 ). However, whilst there is both a strong rationale and great emphasis on incorporating gender and power content in CSE (UNESCO, 2018a ) and evaluating gender- and power-related outcomes (Haberland & Rogow, 2015 ; UNFPA, 2015 ), these programmes’ pathways of change remain under-researched (Ketting et al., 2016 ; Kippax & Stephenson, 2005 ; Ruane-McAteer et al., 2019 ). In complex public health interventions such as CSE, gender and power components are likely to interact with context and impact on intervention effects in a non-linear manner (Petticrew et al., 2013 ; Rutter et al., 2017 ). Evaluation studies exploring these processes can therefore contribute to understanding how interventions work by elucidating mechanisms of impact, effective implementation strategies, and contextual factors shaping programme outcomes (MRC, 2015 ).

Building on Haberland’s work, we undertook a systematic review of process evaluations of school-based CSE and other sex education programmes with gender and power components targeting adolescents. By sex education, we mean interventions which seek to promote healthy sexual and relationship behaviours, excluding abstinence-only interventions. We sought to gain an in-depth understanding of how inclusion of gender and power content shapes programme implementation and outcomes with the ultimate goal of informing CSE programming by delineating effective implementation strategies and programme characteristics, as well as mechanisms of impact. We synthesised evidence on (i) implementation, (ii) programme characteristics, and (iii) mechanisms of impact.

Search Strategy

Searches for this review were conducted in six scientific databases: Medline, EMBASE, PsycINFO, Web of Science, ERIC, and the Cochrane Library of Systematic Reviews. The search strategy was developed iteratively based on repeated scoping searches and employed the following four concepts: programmes and interventions; sexuality education/schools; gender; power and rights (full search strategy available in online supplementary material ). Synonyms and proximity operators were used to enable identification of studies that were not explicitly labelled as addressing gender and power or as evaluation studies. Additionally, we screened articles referencing the seminal Haberland review ( 2015 ) and its sibling publication (Haberland & Rogow, 2015 ).

Inclusion and Exclusion Criteria

The following inclusion criteria were applied for screening:

Publication date : Studies published from 2013 onwards, as this was the cut-off date for the searches of the seminal review that informed our work.

Population: Adolescents aged 10 to 18.

Intervention: Employing a broad definition of sexuality education, studies were included when reporting on CSE or other programmes with sex education content that included a relevant ‘gender and power’ component according to three criteria: Programmes (a) were labelled as gender-transformative programmes, (b) addressed the social construction of gender, and/or (c) highlighted problems related to gender inequality as structural and not as individual problems.

Setting: Interventions based in schools. Activities set in middle or high schools or reporting on a school curriculum, including after-school programmes.

Study design : Process evaluations and other primary studies that reported data on implementation, context, or mechanisms of impact but were not labelled process evaluations. Thus, we included all kinds of quantitative, qualitative, and mixed methods empirical studies reporting on process.

Programme outcomes : Studies on interventions that were designed to improve biological outcomes (e.g. reduction in unwanted pregnancy, reduction of STIs and HIV), behavioural outcomes (e.g. condom use, age at sexual debut, number of sexual partners, self-efficacy), social outcomes (e.g. equitable attitudes and norms with respect to gender, gender and sexual diversity; communication skills and emotional skills), or knowledge-related outcomes related to SRH were included. This included GBV-related outcomes (e.g. bystander intentions and behaviour, GBV victimisation and perpetration).

Previous work identified ‘gender and power’ content as an important working component in sex education (Haberland, 2015 ). Thus, even if our ultimate aim was to inform CSE programming, we included studies about sex education programmes that were not explicitly labelled as ‘CSE’, as well as other school-based interventions, as long as they included gender and power content meeting the above definition. As it has been demonstrated that a wider range of interventions in the school environment may affect (sexual) health (Shackleton et al., 2016 ), we expected to improve our understanding of the wider social context of the intervention by including a broader set of studies.

The following exclusion criteria were applied:

Publication date : Studies published before 2013 were excluded.

Population: Studies reporting primarily on children in primary school, young adults, and adults were excluded.

Intervention: Studies were excluded when they reported on interventions which did not seek to challenge traditional gender roles and norms and when they demonstrated an understanding of gender as a biological determinant or as a marker of sexual reproductive categories, as opposed to a social construct amenable to change.

Setting: Interventions based outside of schools such as community-based interventions without a school component were excluded.

Study design : Non-peer-reviewed reports, editorials, conference abstracts, study protocols, baseline surveys, opinion papers, dissertations, book chapters, and reviews were excluded. Outcome evaluations were initially included but a decision to exclude these studies was made post hoc in order to focus the scope of this review.

Programme outcomes : Studies reporting on interventions that were targeting educational attainment outcomes or socio-emotional skills only were excluded.

Screening Process

The systematic review software EPPI-reviewer was used for screening (University College London, 2017 ). After piloting and refinement of the screening criteria including double screening of a subset of studies, the first author conducted title and abstract and then full text screening. Items coded as ambiguous were discussed with a second author to reach a consensus.

A cluster-search was performed for evaluation studies of five programmes that were referred to multiple times in screened full-texts but were not represented among included records. Additionally, reference lists of articles included in our review were cluster-searched for sibling publications reporting on the same programmes and a Google and Google Scholar search for the programmes and lead authors of all included articles was performed to identify further relevant process-focused articles (Booth et al., 2013 ).

Assessment of Study Quality

For assessment of study quality, the Critical Appraisal Skills Programme (CASP) checklist for qualitative research was used (Critical Appraisal Skills Programme, 2018 ). It comprises 10 questions that prompt the user to consider potential for bias, along with methodological and ethical issues. We derived scores from these questions to indicate study quality, with a 10 out of 10 indicating high quality. As we were primarily interested in qualitative results, mixed-methods implementation studies were assessed with the CASP checklist for qualitative research as well.

Data Extraction

Data from included studies was extracted into a Microsoft Excel–based data extraction sheet. Study and intervention details, qualitative outcomes, and large sections of text covering process-related aspects (mechanisms of change, context, and implementation (MRC, 2015 )) were extracted comprehensively. Data on process was extracted from the introduction, methods, results, and discussion sections of included studies and it was noted which of these sections the respective data originated from.

Data Analysis and Synthesis

Based on the respective research question asked, the study design, and methods, the included studies were categorised into two mutually exclusive types. One group of studies examined programme implementation, employing quantitative and/or qualitative methods. These studies were reporting data explicitly about intervention implementation, which was defined as ‘the structures, resources and processes through which delivery is achieved, and the quantity and quality of what is delivered’ (MRC, 2015 , p. 10), including contextual factors (Pfadenhauer et al., 2017 ). The second set of studies investigated the impacts on social and behavioural outcomes and underlying processes, employing qualitative methods. These studies had a focus on exploring the links between programme outcomes, programme characteristics, and/or mechanisms of impact. We subsequently refer to the first group of studies as ‘implementation studies’ and to the second group of studies as ‘studies exploring mechanisms of impact’. We conducted two distinct syntheses, one of each of these study types.

Synthesis 1: Data Analysis and Narrative Synthesis of Implementation Studies

The synthesis of implementation studies was informed by the Context and Implementation of Complex interventions (CICI) framework (Pfadenhauer et al., 2017 ). Categories within this framework comprise the implementation agents (individuals concerned with running or receiving an intervention), implementation process, implementation strategies, and context (Pfadenhauer et al., 2017 ). Results from implementation studies were organised into the distinct implementation categories and summarised narratively.

Synthesis 2: Data Analysis and Thematic Synthesis of Studies Exploring Mechanisms of Impact

We conducted a thematic synthesis of qualitative studies exploring programme outcomes, characteristics, and mechanisms of impact (Thomas & Harden, 2008 ). We conceptualised mechanisms of impact as the link between intervention activities and outcomes including ‘[p]articipant responses to, and interactions with, the intervention’ as well as mediators (MRC, 2015 , p. 24).

Data analysis was undertaken at the level of the extracted data: the sections of the data extraction sheet containing data on qualitative outcomes and process from the results and discussion sections of included qualitative studies were analysed thematically. Data excerpts served as the unit of analysis for coding. Codes were developed inductively and subsequently compared across studies and grouped and regrouped together in an iterative process to develop themes, resulting in the development of an initial mindmap. This process was informed by key findings from the preceding synthesis of implementation studies and by the four programme characteristics previously identified by Haberland ( 2015 , textbox 1 ), which shaped our initial understanding of relevant programme aspects of sex education with gender and power content.

Programme Characteristics of Effective Sex Education Programmes Addressing Gender and Power as Identified and Defined By Haberland ( 2015 )

These four previously identified characteristics were compared, contrasted, and linked with the newly developed themes to facilitate differentiation of the new themes as programme characteristics or potential mechanisms of impact. The themes and respective links are visualised in Fig.  2 .

Where we encountered data that was not sufficiently rich to describe mechanisms of impact, we made inferences about potential mechanisms, which are identified as hypothesised mechanisms in the results section.

Searches were run on June 22–23, 2019. Database searches yielded 14,571 records and citation searches yielded 127 records, resulting in a total of 14,698 records (Fig.  1 ). After deletion of duplicates, 9375 records were screened on title and abstract and one additional record was added via intervention-specific searches, yielding 261 records which were screened on full-text. Nineteen reports on 18 studies were included in this review, with two implementation reports addressing the same study.

PRISMA flowchart

Characteristics of Included Studies and Programmes

Eleven studies were process evaluations that focused on programme implementation and employed qualitative or mixed methods. Eight studies were qualitative studies exploring qualitative intervention outcomes, programme characteristics, and mechanisms of impact. Only four of these eight studies were explicitly referred to as evaluation studies. For the majority of included studies ( n  = 17), there was very little concern with study quality (Table 1 ).

The 19 included primary studies were conducted in 15 countries (Table 1 ). Most evidence was from Europe ( n  = 6 countries, 3 studies) and Africa ( n  = 6 studies from six countries), followed by North America ( n  = 4 studies) and Australia ( n  = 4). Most articles reported evaluations of locally implemented programmes targeting boys and girls.

Only five programmes were labelled by the authors as CSE or holistic sex education programmes (Boonmongkon et al., 2019 ; Browes, 2015 ; Chandra-Mouli et al., 2018 ; Rijsdijk et al., 2014 ; Wood et al., 2015 ). Other programmes exhibited key CSE characteristics but were not labelled as such: five articles reported on school-based interventions labelled violence prevention programmes (including dating, domestic, and gender-based violence) (Jaime et al., 2016 ; Joyce et al., 2019 ; Kearney et al., 2016 ; Ollis, 2017 ; Williams & Neville, 2017 ). Four programmes were explicitly called gender-transformative (Jaime et al., 2016 ; Sánchez-Hernández et al.,, 2018 ) or ‘healthy’ or ‘positive masculinities’ programmes (Claussen, 2019 ; Namy et al., 2015 ). Three programmes were sports- or PE-based (Jaime et al., 2016 ; Merrill et al., 2018 ; Sánchez-Hernández et al., 2018 ) and three were focused on critical media literacy or critical thinking related to gender (Berman & White, 2013 ; Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ). In three of these programmes, the gender and power content constituted the only sex education component of the programme (Berman & White, 2013 ; Jacobs, 2016 ; Sánchez-Hernández et al., 2018 ).

Programmers incorporated creative, non-conventional, and innovative teaching methods: participatory methods like role-plays and discussions were utilised in most included studies. Further methods included the following: artwork, dance, drama, film and media production (Berman & White, 2013 ; Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ). Beyond classroom-based intervention components, six studies included activities at the school (Joyce et al., 2019 ; Kearney et al., 2016 ; Namy et al., 2015 ; Williams & Neville, 2017 ) and/or community level (Chandra-Mouli et al., 2018 ; Robertson-James et al., 2017 ).

The gender and power content was delivered across a range of different school subjects, i.e. social studies, PE, home economics, health, science, language, and religious education classes (Boonmongkon et al., 2019 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ; Wood et al., 2015 ). In addition to teacher or facilitator-led programmes, some included peer mentors and student-led initiatives outside of the classroom (Berman & White, 2013 ; Namy et al., 2015 ; Williams & Neville, 2017 ).

Gender and Power Content

Gender and power content was covered at different degrees of depth in included interventions. Whilst addressing gender stereotypes was a common curricular topic, notably fewer interventions included in-depth discussions of gendered relationship power: two addressed the links between gender inequality, relationship power, and GBV (Ollis, 2017 ; Williams & Neville, 2017 ). In addition to discussing gendered power, some programmes included the exploration of other dimensions of power, such as power relationships between students and teachers (Claussen, 2019 ), power in the family context (Chandra-Mouli et al., 2018 ), power in an intersectional framework (Jacobs, 2016 ), and how gender-related power is apparent in the media (Jacobs, 2016 ; Ollis, 2017 ). In most programmes, gender and power content was linked with exercises to encourage personal reflection and critical discussions.

Synthesis 1: Narrative Synthesis of Implementation Studies

Included implementation studies stressed the critical role of the implementation agent and their skill set in delivering sex education. Programmes reported in the implementation studies were delivered by teachers (Boonmongkon et al., 2019 ; Browes, 2015 ; Rijsdijk et al., 2014 ; Wood et al., 2015 ), sports coaches (Jaime et al., 2016 ; Merrill et al., 2018 ), and external facilitators (Claussen, 2019 ). Whole-school approaches were further supported by an external project implementer (Joyce et al., 2019 ; Kearney et al., 2016 ; Robertson-James et al., 2017 ). Whilst reports suggest that teacher-delivered CSE was implemented as intended when teachers participated in high-quality training focused on gender and human rights (Wood et al., 2015 ), teachers who were unprepared to deliver CSE were found to omit relevant programme topics and frame adolescent sexuality as a risk or problem (Boonmongkon et al., 2019 ), reflecting teachers’ values (Browes, 2015 ; Rijsdijk et al., 2014 ). Teacher training for CSE was thus recommended to address both teachers’ knowledge and teachers’ gender attitudes (Browes, 2015 ; Wood et al., 2015 ).

Implementation support from an external change agent was described as instrumental in mainstreaming programme content beyond the classroom, e.g. by addressing gender in school policies, providing gender training to teachers, and undertaking a gender-focused audit and staff surveys (Joyce et al., 2019 ; Kearney et al., 2016 ; Robertson-James et al., 2017 ). The latter were fed back to schools as part of the intervention in one study, thus serving as feedback loops enhancing an overall change process (Kearney et al., 2016 ).

Implementation strategies : In programmes delivered by sports coaches and other external facilitators, non-hierarchical participatory teaching strategies promoted student engagement with intervention content and supported implementation. Engagement was reportedly fostered by creating a safe space and building student-facilitator relationships, with facilitators acting in a non-authoritative, non-judgemental, approachable manner and sharing personal experiences whilst addressing real-life issues (Claussen, 2019 ; Jaime et al., 2016 ; Merrill et al., 2018 ). Programmes facilitated by these ‘adult allies’ (Jaime et al., 2016 ) were often delivered in same-sex groups by same-sex facilitators acting as role-models that encouraged student engagement (Claussen, 2019 ; Jaime et al., 2016 ; Merrill et al., 2018 ). Other implementation strategies included a strong focus on interaction, reflection, and discussion (Claussen, 2019 ; Jaime et al., 2016 ; Merrill et al., 2018 ; Wood et al., 2015 ) and allowing for curricular flexibility to adapt programmes to students’ needs and knowledge (Claussen, 2019 ; Rijsdijk et al., 2014 ). One report suggested that the ‘dose delivered’ in process evaluations of these programmes should consider the degree of student engagement and their relating of programme content to their experiences (Jaime et al., 2016 ).

In terms of implementation context , included studies suggest that CSE programming is likely to be met with contradictory messages from schools, families, and communities (Browes, 2015 ) and sometimes with resistance from diverse actors in these settings (Chandra-Mouli et al., 2018 ), especially in conservative contexts, which could impact on programme implementation. While this may restrain programme effectiveness or may lead to programme adaptations (Browes, 2015 ; Chandra-Mouli et al., 2018 ; Wood et al., 2015 ), studies suggested that the implementation process can be tailored to build support for these programmes: successful approaches included framing the programmes around healthy skills instead of sexuality (Chandra-Mouli et al., 2018 ; Wood et al., 2015 ), getting stakeholder and community buy-in during the programme development phase (Chandra-Mouli et al., 2018 ), and building support networks or enhancing pre-existing networks for the programmes in schools and communities (Joyce et al., 2019 ; Kearney et al., 2016 ; Rijsdijk et al., 2014 ; Robertson-James et al., 2017 ), including with other initiatives that promote gender equality, such as non-governmental organisations providing teacher training (Wood et al., 2015 ).

Synthesis 2: Thematic Synthesis of Studies Exploring Mechanisms of Impact

The qualitative studies reporting on programme outcomes, characteristics, and/or mechanisms of impact primarily reported what happened in the classroom during delivery of eligible sex education interventions, focusing on the learning methods employed, the role of facilitators, and students’ reactions to the sessions. The reported outcomes predominantly constituted observations of students’ classroom behaviour and their comments about the programme and content whilst data on programme impact on SRH outcomes beyond the classroom were limited due to the nature of the included studies. However, our findings identify likely mechanisms of impact on SRH outcomes.

Six themes emerged in our analysis. Three constitute key programme characteristics: (i) student-facilitator relationship-building, (ii) student participation, and (iii) open discussions or ‘dialogues’ integrating student reflection and experience-sharing with critical content on gender and power. Three additional themes represented potential mechanisms of impact: empowerment , meaningful contextualisation of students’ experiences, and transformation of gender norms . Figure  2 depicts the themes and crosslinks, including further relevant programme characteristics identified in a previous review (Haberland, 2015 ).

Overview of programme characteristics (blue boxes) and potential mechanisms of impact (green boxes); light blue boxes represent programme characteristics that were identified in Haberland’s review ( 2015 ); dark blue boxes represent characteristics that were identified in our review

Programme Characteristics

Student-facilitator relationship-building.

Evidence from our thematic synthesis highlighted the importance of the facilitator’s role in building (egalitarian) relationships with students and enabling a teaching atmosphere where open discussions could take place, with codes echoing the factors that facilitated implementation described in the narrative synthesis above, in particular the relevance of safe spaces and facilitators as potential ‘allies’ (Jacobs, 2016 ; Namy et al., 2015 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ). Other important facilitator skills included emotional awareness and a ‘strong awareness of the socially constructed nature of gender’ (Jearey-Graham & Macleod, 2017 ). Across studies, a trusting atmosphere in the class and a confidential, safe space were highlighted as both a result of facilitators’ efforts to build relationships with students and as a prerequisite to successful programming and to the open discussions that emerged as another key theme (Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ; Sánchez-Hernández et al., 2018 ).

Student Participation

Our findings suggest there was a high degree of student participation in included interventions. This included students co-creating the curriculum (Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ) or taking on leadership roles in student initiatives that were linked to the programme, e.g. mentoring of younger students or participation in after-school clubs (Namy et al., 2015 ; Williams & Neville, 2017 ). Programmers noted students’ sense of shared responsibility and their ownership of programme messages (Berman & White, 2013 ; Jacobs, 2016 ; Williams & Neville, 2017 ), whilst students appreciated the opportunity to practice leadership and transferable skills and benefitted from supportive peer networks (Berman & White, 2013 ; Jacobs, 2016 ; Namy et al., 2015 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ).

Open Discussions to Discuss Gender and Power

All programmes but one (Ngabaza et al., 2016 ) were characterised by use of participatory methods, in particular open discussions where gender and power content was discussed critically and where students shared their experiences. The open discussions or ‘dialogues’ (Jearey-Graham & Macleod, 2017 ) served as a venue for students to exercise their curiosity and ask questions about sensitive topics, to be heard and share personal stories, to feel that their experience was validated, and to take on others’ perspectives (Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ). In one sports-based programme, ‘boys listening to girls’ enabled participants to recognise gender stereotypes (Sánchez-Hernández et al., 2018 ). Topics invoking emotional responses such as pornography or cheating on a partner were observed as instrumental in fostering students’ critical thinking about gender and power and creating awareness of gender norms and stereotypes (Jearey-Graham & Macleod, 2017 ; Ollis, 2017 ). The use of these open discussions thus went along with course content paying ‘explicit attention to gender and power in relationships’ and content ‘fostering critical thinking’, alongside ‘personal reflection’, the programme characteristics Haberland ( 2015 ) had previously described and which informed our analysis. In addition to critical examination of the status quo, some programmes explored alternative discourses to dominant gender narratives (Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ), including from an intersectional perspective (Jacobs, 2016 ).

Themes Representing Potential Mechanisms of Impact

Empowerment.

Empowerment emerged as a theme that was linked to the three programme characteristics described above, all of which contributed to a shift of power in the classroom: Facilitators’ emphasis on building egalitarian relationships with students, student leadership, enhanced peer support, and open discussions where students make their voices heard are empowering and rebalance otherwise hierarchical relations between students and teachers, representing a disruption of ‘traditional power dynamics’ (Jacobs, 2016 ). In three programmes, students who were involved as student mentors or participated in optional programme retreats displayed the strongest ownership of programme messages and experienced the greatest programme effects (Berman & White, 2013 ; Namy et al., 2015 ; Williams & Neville, 2017 ), demonstrating the link between enhanced student participation, empowerment, and outcomes. This resonates with the synthesis of implementation studies, which demonstrated that intervention activities taking place outside of the classroom, such as whole-school approaches, and interventions including the wider community, were found to enhance implementation. These interventions may lead to a change of hierarchies and relationships at a broader contextual level and further strengthening of student empowerment.

The empowerment theme corresponds with what Haberland coined ‘valuing oneself and one’s own power’, the acknowledgement of students’ own power as change agents (Haberland, 2015 ). We therefore hypothesise that student empowerment constitutes one mechanism of impact: sex education taught in an egalitarian, participatory manner may empower students to adapt attitudes and norms, enhance self-efficacy, and ultimately influence behaviour and SRH outcomes beyond the classroom.

Meaningful Contextualisation of Students’ Experiences and Transformation of Gender Norms

Across most included studies, open discussions and other participatory methods were utilised by facilitators to connect students’ reports of their own experiences with broader societal topics, including gender and power. Authors report that these participatory methods increased critical thinking and critical awareness of harmful gender norms, gender inequality, and GBV (Berman & White, 2013 ; Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ; Ollis, 2017 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ). Enhanced non-violent attitudes, willingness to change (Namy et al., 2015 ), and improved class climate (Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ) were described as further outcomes of the programmes.

In addition to reporting positive outcomes attributed to the participatory methods and critical discussions of gender and power content, authors also reported that the personalisation of programme content resonated strongly with students (Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ; Ollis, 2017 ) and that students identified the questioning of dominant beliefs as a crucial step towards behaviour change (Namy et al., 2015 ).

The open discussions thus served as a forum in which personal reflection and sharing of personal experiences made the sex education content more relevant and relatable for students, while programmes’ explicit focus on gender and power enabled critical examination of the patriarchal societal context of those experiences, especially unequal power in relationships, rigid gender norms, and gender stereotypes. Thus, evidence from our review points towards two interlinking mechanisms of impact: The first is meaningful contextualisation of students’ experiences, which highlights the importance of personalisation of programme messages to support students in developing an understanding of the societal context of their sexual and romantic relationships. This is closely linked with the second mechanism, transformation of gender norms. As Namy et al. ( 2015 ) observed, intervention participants showed an increased appreciation of ‘multiple masculinities’ and demonstrated willingness to change when they recognised personal identification with harmful masculinities. This shows an initial shift in gender norms and illustrates its link with the contextualisation of students’ experiences, as well as empowerment. It further suggests that discussing alternatives to dominant norms may expand the range of possible behaviours beyond traditionally gendered behaviours (Jearey-Graham & Macleod, 2017 ), enabling behaviour change that ultimately affects SRH outcomes.

Interaction of Mechanisms of Impact

At the same time, the use of participatory learning methods, in particular open discussions, encouragement of student participation, and egalitarian relationships of students and facilitators lead to a palpable shift in power in hierarchical school environments, complementing students’ theoretical discussions and reflections with a lived and embodied experience of empowerment. Based on this link and other connections between mechanisms as outlined above, we hypothesise that the mechanisms empowerment, meaningful contextualisation of students’ experiences, and transformation of gender norms act synergistically, build upon each other, and influence one another in affecting students’ behaviours and ultimately SRH outcomes (Fig.  2 ).

Unintended Effects

Included studies also highlighted that sex education with gender and power content may leave entrenched norms unchanged, in particular when student exposure to the programme was limited to only a few classroom sessions (Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ), and that teachers at times reinforced gender stereotypes (Ngabaza et al., 2016 ), resonating with similar findings from the implementation studies.

Nineteen studies met the inclusion criteria of this process-focused systematic review of school-based sex education programmes addressing gender and power. The review found that gender and power content was incorporated and operationalised differently in a diverse range of programmes. Implementation studies highlighted the importance of high-quality facilitator training, flexibility to adapt programmes to students’ needs, and building support for sex education programmes among school and local communities. We found that (i) student participation, (ii) student-facilitator relationship-building, and (iii) open discussions integrating student reflection and experience-sharing with critical content on gender and power constituted important programme characteristics that data suggest contribute to programme effectiveness. Evidence from our thematic synthesis suggests that linked to these intervention characteristics meaningful contextualisation of students’ experiences, empowerment, and transformation of gender norms may constitute mechanisms of impact that ultimately affect SRH outcomes.

Results in Context

Focusing on both CSE and other sex education interventions that include critical content on gender and power enabled comparisons across studies to enhance our understanding of how sex education with this component works. To place these results in context, we draw on the broader literature of CSE evaluation and the theoretical literature on sex education theory, empowerment, and critical pedagogy.

• Implementation

Our narrative synthesis of findings from implementation studies largely corresponds with other summaries of aspects that facilitate intervention implementation and engagement with CSE, e.g. regarding the importance of educator training and skill, support from external facilitators, non-hierarchical participatory teaching methods to engage students in intervention activities, and a supportive school and community context (Kirby et al., 2007 ; UNESCO, 2018a ; Vanwesenbeeck, 2020 ). These other reviews have further emphasised the critical role of an enabling school environment and multicomponent approaches for CSE implementation (UNESCO, 2018a ; Vanwesenbeeck, 2020 ).

Whether teachers or external facilitators are best placed to deliver CSE is an area of active debate. For example, in a UK-focused overview of best-practices in sex and relationships education (SRE), students deemed teachers unsuitable to deliver SRE whilst teachers and SRE professionals considered teacher-led SRE to be the most sustainable model long-term (Pound et al., 2017 ). This is reflected in our review where studies involving outside facilitators appeared to be pilot or one-off projects, or required substantial resources (e.g. Jaime et al., 2016 ; Joyce et al., 2019 ; Kearney et al., 2016 ; Williams & Neville, 2017 ). However, our results suggest that programmes were generally more successful in empowering students and engaging them in a meaningful way when implemented by an outside facilitator. Pound et al. argue that one of the challenges of teachers implementing SRE is the breeching of boundaries between teachers and students, which may be less of a problem when outside facilitators are involved (Pound et al., 2016 ). Given that the overall importance of the skill level of the teacher or facilitator for achieving positive programme effects has been strongly emphasised, it remains somewhat unclear to which extent programme ‘success’ can be attributed to the programme content as opposed to the skill level of the implementing agent, in particular with respect to addressing gender and power and facilitating participatory sessions. Whilst this may present an avenue for further research work, it is promising that authors in one implementation study included in our review argued that high-quality teacher training would enable teachers with previously limited CSE teaching skills to implement progressive sex education programmes as intended (Wood et al., 2015 ).

Hypothesised Mechanisms of Impact

In our thematic synthesis, empowerment of students emerged as a likely mechanism of impact on SRH outcomes. This is not unexpected, as empowerment is central to many CSE programmes (UNFPA, 2015 ; Vanwesenbeeck, 2020 ) and constitutes a key strategy in health promotion more generally (Laverack, 2004 ). In sex education, student empowerment is theorised to expand the range of ‘sexual or gendered subject positions’ (Jearey-Graham & Macleod, 2017 ), thus enabling health-promoting attitudes, practices, and behaviours, including sexual agency (Fields, 2008 ; Jearey-Graham & Macleod, 2017 ). Our findings suggest that fostering student engagement and egalitarian relationships in the classroom, as well as open discussions allowing students to share experiences and feel validated, led to a shift of power in classrooms and contributed to this mechanism. However, empowerment may be easier envisioned than enacted. Jessica Fields argues that even staunch CSE advocates tend to fall short of embracing the transformative and empowering potential of CSE. By resorting to narratives of danger, they eschew positive messaging that builds on students’ existing sexual knowledge, encourages sexual agency, and equips them to deal with the social challenges that are intertwined with sexuality (Fields, 2008 ). This is echoed by other authors who observe that even in the most progressive contexts sex education teachers fail to achieve a shift in power hierarchies that would enable student empowerment (Naezer et al., 2017 ; Sanjakdar, 2019 ). Thus, while our findings suggest student empowerment is a mechanism of impact that may ultimately affect adolescent SRH, this mechanism likely requires a very facilitative context and skilled implementer.

The second potential mechanism of impact we identified was meaningful contextualisation of students’ experiences, facilitated by open discussions that provided a forum for critical thinking on gender and power and personal reflection. Open discussions as interactive learner-centred approaches are emphasised in CSE guidance (UNESCO, 2018a ), desired by students (Pound et al., 2017 ), and theorised to make CSE relevant for the diverse and heterogeneous SRH needs of adolescents (Engel et al., 2019 ). Similarly, our analyses highlight their central role in CSE programming with gender and power content. Beyond ensuring that programmes are relevant for individual students, open discussions that include critical content on gender and power also address the societal dimensions of sex and relationships, enabling meaningful contextualisation of students’ experiences in particular in relation to gender inequality, and harmful gender norms. As Jessica Fields powerfully states, ‘Sex education offers students an opportunity to grasp sexuality’s place in the context of gender, racial and class inequalities […]’ (Fields, 2008 ). Ensuring that programmes are linked to the social environment of participants’ lived realities is understood to make SRH interventions more effective (Wingood & DiClemente, 2000 ).

The power of the interactive discussions led one group of authors in our review to conclude that students needed these open ‘sexuality dialogues’ more than what’s conventionally understood as sexuality education (Jearey-Graham & Macleod, 2017 ). The term ‘dialogues’ originates from critical pedagogy (Sanjakdar et al., 2015 ). In this framework, schools are understood as sites that reinforce existing social systems and power structures—which critical pedagogy seeks to counter (Sanjakdar et al., 2015 ). This approach is a democratic, joint process of knowledge creation that drives on student voice and curiosity, with teachers encouraging questioning and critical thinking via ‘dialogic teaching’ (Sanjakdar, 2019 ; Sanjakdar et al., 2015 ). The critical pedagogy framework thus incorporates the programme characteristics and mechanisms we identified, including the disruption of traditional power dynamics which was linked to our empowerment mechanism. A critical pedagogy approach in CSE may therefore facilitate a better understanding of the operationalisation of these mechanisms in educational systems and improve programme implementation.

Systematic review evidence suggests that gender-transformative programmes seeking to improve diverse SRH outcomes impact behaviour more effectively than programmes without this approach (Barker et al., 2010 ). Interventions addressing gender norms were identified as most promising in addressing a multitude of risk factors to reduce violence against women and girls (VAWG) (Jewkes et al., 2015 ). In our review, whilst transformation of gender norms emerged as a potential mechanism in our thematic analysis, only few included studies reported using an explicit gender transformative approach, defined as approaches including ‘strategies to foster progressive changes in power relationships between women and men’ by WHO ( 2011 ). This reflects findings from a systematic review of reviews on engaging boys and men in SRH programming that reported an overall dearth of gender transformative programmes (Ruane-McAteer et al., 2019 ). Programmes to prevent VAWG and those set in low- and middle-income countries were most likely to be gender transformative compared to programmes targeting other SRH outcomes (Ruane-McAteer et al., 2019 ), suggesting that the potential of a gender transformative approach has not yet been harnessed across the educational programming seeking to improve adolescent SRH. Our findings also highlight a barrier to implementation of gender transformative programming: programme implementation is highly dependent on implementation agents whose values and skills influence implementation and may reproduce gender stereotypes, thus maintaining gender relations (Boonmongkon et al., 2019 ; Browes, 2015 ; Ngabaza et al., 2016 ; Rijsdijk et al., 2014 ).

Strengths and Limitations

This review employed a broad and comprehensive search strategy across six databases and supplemental searches to include a wide range of studies. Inclusion of studies from 15 countries across diverse world regions may support transferability of our findings across contexts. Whilst we were interested in understanding how gender and power content would work in CSE, which is considered best practice in sexuality education, we included other sex education and school-based programmes with relevant gender and power components to broaden our understanding, in particular on potential mechanisms of impact. Since all included studies still contained relevant CSE content, we are confident that our conclusions are applicable for CSE programming. Similarly, we included studies that reported relevant data on the intervention process but were not strictly process evaluations in order to draw on a larger body of evidence. These decisions led to some ambiguity at the screening stage and heterogeneity among included studies but ultimately enhanced the findings in this work, especially the thematic synthesis.

This review also has limitations. Additional cluster-searching, repeated iterative searches, snowballing, inclusion of grey literature (Booth et al., 2013 ), and inclusion of studies published in languages other than English may have identified additional eligible studies but were beyond the scope of this review. Relevant studies may have been excluded based on programme descriptions, which were often limited in screened reports (Ruane-McAteer et al., 2019 ). Nevertheless, included studies reported a wide range of observations and reinforced key findings across studies, suggesting that included studies provide reliable insights to support implementation of CSE programmes with gender and power content among adolescents.

Implications for Policy, Practice, and Research

Whilst our synthesis does not allow for causal inference on mechanisms of impact that describe how school-based CSE interventions with a gender and power component ultimately impact adolescents’ SRH outcomes, the evidence suggesting empowerment, meaningful contextualisation of students’ experiences, and transformation of gender norms as relevant mechanisms correspond with the theoretical literature and existing empirical evidence. These mechanisms are facilitated by student participation, open discussions, and student-facilitator relationship-building and rely on skills of facilitators and a supportive context for effective intervention delivery.

This research can thus contribute to the growing body of literature to inform programme design, adaptation, transferability, and the evaluation of interventions to improve adolescent SRH. The mechanisms identified in this review can inform future research in which they are empirically tested and refined, for example through linked, rigorous outcome and process evaluations investigating the pathways to change of how sex education programme content impacts on the multiplicity of SRH outcomes, which constitutes a gap in the current literature. Furthermore, as it is considered best practice to guide intervention design, implementation, and the evaluation of complex interventions such as CSE by a relevant theory of change (De Silva et al., 2014 ; Moore & Evans, 2017 ), our results can inform the evaluation of ongoing programmes and inform the theory of change of future programmes—which is currently not often made explicit in interventions to improve SRH (Ruane-McAteer et al., 2019 ). Our review identified only one study which incorporated an explicit focus on complexity into the evaluation of school-based CSE (Joyce et al., 2019 ; Kearney et al., 2016 ). Their results suggest that feedback loops and the evaluation itself may have an important effect on programme implementation and outcomes and should be considered in future intervention planning and theories of change (Kearney et al., 2016 ).

In the field of knowledge co-production in public health research, co-produced (research) knowledge has long been argued to be more relevant to research users, empower communities, increase the chance of research uptake, and to ultimately affect health outcomes, but evidence supporting this has been scarce (Oliver et al., 2019 ). Whilst preliminary, our findings elucidate how the non-hierarchical, discussion-based co-production of knowledge on gender, sex, and relationships in sex education interventions makes this knowledge more relevant to participants, which may inform other interventions employing co-production approaches as part of an intervention in SRH and other public health fields.

Whilst not discussed in depth, our results also show that sex education with gender and power content does leave some entrenched norms unchanged (Namy et al., 2015 ; Ngabaza et al., 2016 ), calling for wider efforts targeting these norms. This should include interventions starting at a much younger age, that is before gender norms and roles become ingrained, continuing through childhood and adolescence (Goldfarb & Lieberman, 2021 ), and reaching beyond the classroom, including components targeting the broader school environment (Denford et al., 2017 ; Vanwesenbeeck, 2020 ). Further evidence suggests that school-based interventions should be coupled with interventions targeting social contexts outside of school, where both policies and community-wide interventions are needed to improve access to youth-friendly SRH services, address discriminatory practices, and support equitable gender norms at scale (Denford et al., 2017 ; DFID PPA Learning Partnership Gender Group, 2015 ; Starrs et al., 2018 ).

Data Availability

Search strategies are available as online supplementary material .

Code Availability

Not applicable.

Whilst CSE may be considered best practice in sex education, this label is not consistently used (Haberland, 2015 ). We therefore consider literature on sex education programmes without the CSE label as potentially relevant to inform CSE programming, as long as programmes are not abstinence-only.

We consider content on ‘gender and power’ as defined by Haberland as one component of sex education interventions and will use the terms content and component interchangeably throughout this article.

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Sell, K., Oliver, K. & Meiksin, R. Comprehensive Sex Education Addressing Gender and Power: A Systematic Review to Investigate Implementation and Mechanisms of Impact. Sex Res Soc Policy 20 , 58–74 (2023). https://doi.org/10.1007/s13178-021-00674-8

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There’s broad public support for sex education, but many young people aren’t receiving the sex education they need and deserve.

Who Supports Sex Education?

Sex education is widely supported by the vast majority of people in the U nited States. In Planned Parenthood’s most recent poll  on sex education, 84 percent of parents supported having sex education taught in middle school, and 96 percent of parents supported having sex education taught in high school. Parents support sex education covering a wide range of topics in age-appropriate ways from elementary through high school, including self-esteem, healthy relationships and peer pressure, how to stay safe online including how to deal with pornography, anti-bullying, and consent and setting boundaries. The vast majority of parents support teaching topics like STIs, birth control, sexual orientation and gender identity, and pregnancy options including abortion in high school. Other national, state and local polls on sex education have shown similarly high levels of support.

Sex education is supported by numerous health and medical organizations including the American Medical Association, the American Academy of Pediatrics, and the Society for Adolescent Health and Medicine. More than 150 organizations are members of the National Coalition to Support Comprehensive Sexuality Education.

Federal & State Policy Related to Sex Education

Sex education programming varies widely across the United States. Currently, 39 states and the District of Columbia mandate some kind of sex education and/or HIV education. 

Although almost every state has some guidance on how and when sex education should be taught, decisions are often left up to individual school districts, creating a patchwork of inconsistent policies and practices within states. The sex education someone receives can come down to what school district they live in or which school they attend.

Planned Parenthood advocates for federal funding that supports sex education, such as the Teen Pregnancy Prevention Program (TPPP) and the Division of Adolescent and School Health . Planned Parenthood also advocates for better sex education policies, practices, and funding at the state and local levels.

What Sex Education Do Teens Get in the US?

The gap between the sex education students need and what they actually get is wide. According to the 2018 CDC School Health Profiles , fewer than half of high schools and less than a fifth of middle schools teach all 20 topics recommended by the CDC as essential components of sex education. These topics range from basic information on how HIV and other STIs are transmitted — and how to prevent infections — to critical communication and decision-making skills.

A  study published by the Guttmacher Institute found that adolescents were less likely to report receiving sex education on key topics in 2015–2019 than they were in 1995  Overall, in 2015–2019, only half of adolescents reported receiving sex education that met the minimum standard articulated in Healthy People 2030. Among teens reporting penis-in-vagina sex, fewer than half (43% of females and 47% of males) received this instruction before they had sex for the first time. Despite these declines in formal education, there was no increase in the proportion of teens who discussed these sex education topics with their parents.

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Article contents

Comprehensive sexuality education.

• Ine Vanwesenbeeck Ine Vanwesenbeeck Interdisciplinary Social Sciences, Utrecht University, the Netherlands; Rutgers, Centre of Expertise on Sexual and Reproductive Health and Rights, Utrecht, the Netherlands
• https://doi.org/10.1093/acrefore/9780190632366.013.205
• Published online: 29 May 2020

Comprehensive sexuality education (CSE) is increasingly accepted as the most preferred way of structurally enhancing young peoples’ sexual and reproductive well-being. A historical development can be seen from “conventional,” health-based programs to empowerment-directed, rights-based approaches. Notably the latter have an enormous potential to enable young people to develop accurate and age-appropriate sexual knowledge, attitudes, skills, intentions, and behaviors that contribute to safe, healthy, positive, and gender-equitable relationships. There is ample evidence of program effectiveness, provided basic principles are adhered to in terms of content (e.g., adoption of a broad curriculum, including gender and rights as core elements) and delivery (e.g., learner centeredness). Additional and crucial levers of success are appropriate teacher training, the availability of sexual health services and supplies, and an altogether enabling (school, cultural, and political) context. CSE’s potential extends far beyond individual sexual health outcomes toward, for instance, school social climates and countries’ socioeconomic development. CSE is gaining worldwide political commitment, but a huge gap remains between political frameworks and actual implementation. For CSE to reach scale and its full potential, multicomponent approaches are called for that also address social, ideological, and infrastructural barriers on international, national, and local levels. CSE is a work never done. Current unfinished business comprises, among others, fighting persevering opposition, advancing equitable international cooperation, and realizing ongoing innovation in specific content, delivery, and research-methodological areas.

• comprehensive sexuality education (CSE)
• sexual and reproductive health and rights (SRHR)
• adolescents and young people
• implementation
• multicomponent approaches

Introduction

Sexuality education is indispensable to adolescents and young people. Their whole “being in the world” is fundamentally interlaced with sexuality. Adolescents are eager to learn about sex and have a right to accurate information. Sexuality is a central aspect of being human, encompassing sexual behaviors, gender identities, sexual orientations, eroticism, and reproduction. It is crucial to the development of identity, morality, and the capacity of intimacy. And weighty public health issues are at stake, certainly but not exclusively in the area of sexuality and reproduction. Obviously, parents (or other educators), have a broad socializing role, as do peers, but it is widely acknowledged that their capacities in the area of sexual socialization aren’t always optimally suited to meet young peoples’ health needs and evolving social contexts. States and formal educational bodies are therefore important duty bearers in this respect.

In Europe, school-based sexuality education has been around since the second half of the 20th century . It has become increasingly widespread since the sexual revolution in the 1970s and the rise of the HIV epidemic in the 1980s. The 1994 International Conference on Population and Development (ICPD) provided a vital impetus for states and non-governmental organizations (NGOs) around the world to meet young people’s needs for sexuality education. Initiatives have intensified since. However, ideological battles on overall purpose, content, and methods of sexuality education also seem to have deepened. At one extreme of the spectrum, there are abstinence only until marriage (AOUM) models, primarily aiming at discouraging young people from sexual intercourse until they marry. AOUM has been powerfully promoted in the United States, where the Bush administration spend billions of dollars on the effort and also attempted to insert the framework into the international arena (see Corrêa, Petchesky, & Parker, 2008 ). At the other end, comprehensive (increasingly also qualified as holistic) sexuality education (CSE/HSE) has come to typify the “European standard” and principally aims at enhancing young people’s capacity for informed, satisfactory, healthy, and respectful choices with regard to sexuality (Ketting, Friele, & Michielsen, 2016 ; WHO & BZgA, 2010 ).

On international platforms, CSE is increasingly promoted as the preferred and most effective way to enhance young peoples’ sexual and reproductive health and rights, in formal as well as non-formal settings (e.g., UN, 1999 ; UNESCO, 2012 , 2013 , 2015 , 2016 , 2018 ; UNFPA, 2010 , 2014 , 2015 ; WHO & BZgA, 2010 ). CSE is gaining worldwide acceptance and political commitment (for an overview of international and regional resolutions, see UNESCO, 2018 , Appendix 1). A survey of CSE in Europe and Central Asia (WHO & BZgA, 2017 ) demonstrates remarkable progress in developing and integrating CSE in formal school settings. A worldwide review of the status of CSE in 48 countries (UNESCO, 2015 ) also demonstrates that a majority of those countries are embracing the concept of CSE and are engaged in strengthening its implementation at a national level. However, a huge gap remains between legal frameworks and the actual implementation of CSE. Few policies are fully operationalized, but an indication of overall implementation level is difficult to provide. However, it’s fair to say that in most low- and middle-income countries, CSE is a long way from being institutionalized (see Haberland & Rogow, 2015 ). Many obstacles to effective implementation have been identified (e.g., Chandra-Mouli et al., 2015 ; UNESCO, 2012 ; UNFPA, 2015 , Vanwesenbeeck, Westeneng, de Boer, Reinders, & van Zorge, 2016 ). In the employment of CSE around the world, substantial progress has been made, but progress is also seriously confined by persistent barriers and regretful setbacks on international, national, and local levels.

This article provides an overview of the theoretical underpinnings, core elements, and learning objectives of CSE. It reviews evidence on effectiveness and discusses factors in successful implementation and scale-up. Finally, some matters of unfinished business are highlighted to illustrate how the implementation of CSE is always a work in progress.

Principles of CSE

A number of publications (e.g., IPPF, 2017 ; UNFPA, 2014 ; WHO & BZgA, 2017 ) elucidate the core principles and essential elements of CSE. Remarkably, they all present slightly different definitions. The latest revised United Nations Educational, Scientific and Cultural Organization (UNESCO) guidance on sexuality education presents the following, “commonly agreed” (Herat, Castle, Babb, & Chandra-Mouli, 2018 ) one:

Comprehensive sexuality education (CSE) is a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. It aims to equip children and young people with knowledge, skills, attitudes and values that will empower them to: realize their health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and, understand and ensure the protection of their rights throughout their lives (UNESCO, 2018 , p. 16).

Clearly, the aims of CSE are ambitious. Moreover, they have broadened over time and continue to evolve. CSE always needs to respond to progressive insights and emerging evidence, as well as to relevant developments in technology and society (e.g., young peoples’ Internet and social media use). Comprehensiveness may rightfully be qualified an “elastic term” (Hague, Miedema, & Le Mat, 2017 ). A distinction may be made between “conventional,” health-based programs and empowerment-directed, rights-based approaches (see Bonjour & van der Vlugt, 2018 ; Haberland & Rogow, 2015 ). When applied appropriately, the latter approaches have proven particularly effective. Although both have been practiced since the early 21st century , the distinction in part reflects historical developments.

“Conventional,” Health-Based CSE

The main goal of conventional CSE is the prevention of sexual risks and negative outcomes such as sexually transmitted infections (STIs), HIV infections, and unplanned (teenage) pregnancies. As all CSE does, it provides curriculum-based, scientifically appropriate (be it sometimes markedly limited) information on reproductive and sexual physiology and a diversity of contraceptive and protective methods. Conventional CSE distinguishes itself from AOUM approaches in that it promotes all available strategies to sexual risk prevention. Next to abstinence, safe(r) sexual practices, particularly the use of condoms (and/or other forms of contraception) are encouraged. Conventional CSE may be more or less similar to so-called abstinence-plus programs that promote ABC (Abstinence, Be faithful, use a Condom) and/or DEF+ (Delay intercourse, Equal consent, Fewer partners, and testing).

Behavior change theory provides the most important theoretical underpinning of conventional CSE, calling for attention to social values and norms, attitudes, relationships, and social skills that are theoretically seen as determinants of (in this case sexual) health behavior. In their attention for norms, attitudes, and skills, programs should be needs-based and culturally appropriate on the basis of an assessment of important local specificities. Preferably, they apply a logic-model approach, specifying behavioral goals, their determinants, and ways to address them (Kirby, 2007 ) or intervention mapping, a protocol for developing effective behavior change interventions (see Schaalma, Abraham, Gillmore, & Kok, 2004 ). In focusing on skills, conventional CSE shows a resemblance to life skills education (LSE), but the latter may be broader, also taking, for instance, livelihood skills into consideration. In paying attention to the relational context and negotiating skills, some parallels may be seen with sexuality and relationships education (SRE). Conventional CSE recognizes that girls may have less control over their sexuality than boys do and may thus apply a certain gender-sensitiveness. But the focus on gender is much stronger in “empowerment” CSE.

A Rights-Based, Empowerment Approach

Gradually, it has become apparent that narrow risk- and health-focused educational approaches do not match well with young peoples’ complex sexual and relational realities and overall developmental tasks. A positive approach to sexuality that accepts young people as sexual beings with sexual feelings and desires is more realistic and can bear much more fruit. In general, sexual health has come to be understood as more than just the absence of disease and, moreover, as fundamentally reliant on the fulfillment of sexual rights (WHO, 2006 ). CSE is thus required to go beyond education on risks, danger, and disease and be sex-positive and rights-based (Hirst, 2012 ; Ingham & Hirst, 2010 ). The promotion of sex education as rights-based encompasses the affirmation of sexuality education itself as a human right for young people as laid down in the Convention on the Rights of the Child in 1990 . The Netherlands, with its pragmatic, liberal, so-called “Dutch approach” to sexuality education, has long been considered a forerunner in sex-positive and rights-based sex education (e.g., Brown, 2012 ; Ferguson, Vanwesenbeeck, & Knijn, 2008 ). Since the early 21st century , these principles of a rights-based approach (RBA) have been widely shared internationally (Hague et al., 2017 ; OHCHR, 2006 ; UNESCO, 2016 , 2018 ; UNFPA, 2010 , 2015 ; Vanwesenbeeck, Flink, van Reeuwijk, & Westeneng, 2019 ).

An important extension of an empowerment approach stems from critiques of the early, health-focused CSE traditions as promoting gender conformity and silencing, in particular, girls’ desire (Allen, 2005 ; Fine, 1988 ; Fine & McClelland, 2006 ; Holland, Ramazanoglu, Sharpe, & Thomson, 1998 ; Rogow & Haberland, 2005 ; Tolman, 1994 ). Authors observe that girls’ sexuality is often pictured exclusively in terms of risks, danger, and vulnerability, with girls figuring as gatekeepers of boys’ “natural” sexual urges. Programs built on gendered assumptions, the sexual double standard, and the discursive silencing of girls’ sexual desire lead to distorted understandings of (particularly) girls’ sexual agency, subjectivity, and autonomy, so it is argued. Calls to include gender and pleasure in CSE are thus first and foremost advocated to serve the empowerment of girls. But when absent, all young people’s understandings of sexual choices, rights, consent, sexualised harassment, and violence are affected (Sundaram & Sauntson, 2016 ). Increasingly, the benefits of addressing gender for boys and young men are also being stressed, inside (e.g., Limmer, 2010 ) as well as outside the sphere of sexuality education (e.g., American Psychological Association (APA), 2018 ).

Rights-based, empowerment CSE aims to encourage non-sexist attitudes and behaviors in girls and boys and aims to empower them to achieve safe, consensual, egalitarian, mutually satisfying relationships and gender equality. This also highlights the relevance to include sexual coercion and violence, sexual consent, and ethical relations (Lamb, 2010 ) in (empowerment) CSE. Complex ethical and legal questions such as coerced sex and unethical sexual subjectivity have been avoided in many CSE programs (Allen & Carmody, 2012 ). The prevention of sexual violence is habitually addressed in separate interventions (Carmody & Ovenden, 2013 ; Schneider & Hirsch, 2019 ). However, empowerment CSE cannot be fully comprehensive without addressing (gendered) sexual violence and consent and is, increasingly, seen to do so.

Historically speaking, the paradigm shift toward the inclusion of gender and rights as core elements in CSE programming is most outstanding (see UNFPA, 2010 ). This is true for CSE as well as for HSE, a term predominantly applied for the sexuality education developed in Europe (see WHO & BZgA, 2010 ). Empowerment-focused CSE may have a slightly stronger focus on gender transformativity than HSE does, while HSE focusses relatively strongly on sex-positivity and also more explicitly offers support following (traumatic) incidents and sexual health problems and services (Hague et al., 2017 ). Gradually, the two may merge completely.

A rights-based approach implies the adoption of a broad curriculum. UNESCO’s latest guidelines describe content comprehensiveness as covering the full range of topics that are important for all learners to know, including those that may be challenging in some social and cultural contexts (UNESCO, 2018 , p. 16). The authors list eight concepts they consider key to CSE curricula:

Relationships

Values, rights, culture, and sexuality

Understanding gender

Violence and staying safe

Skills for health and well-being

The human body and development

Sexuality and sexual behavior

Sexual and reproductive health

Advancing young people’s knowledge, attitudes, and skills supportive of making informed sexual choices and of building safe and respectful relationships is key to CSE. This includes awareness of cultural (ideological, religious, political) contexts and of the ways these contexts affect people’s sexual choices, behaviors, and relationships. Empowerment, rights-based CSE is notably non–value-free in this respect. It promotes positive values such as mutual respect, human (sexual and reproductive) rights, and gender equality. It aims to contribute to societal transformation and to strengthen young peoples’ roles in these processes. The capacity of critical reflection and successful navigation of normative contexts (see Cense, 2019b ) is broadly acknowledged as one of CSE’s primary learning objectives (UNESCO, 2018 ). Related goals are the cultivation of “sex cultural intelligence” (Mukoro, 2017 ), of “media-literacy” (the skills to critically use, evaluate and create media content), of help-seeking and advocacy skills, and of young peoples’ capacities for sexual citizenship (Illes, 2012 ; Lamb, 2010 ).

Empowerment CSE Delivery Principles

Schools are no doubt the most important locations for CSE delivery, in which they show huge variation. CSE may be provided as a stand-alone subject or as integrated in other courses. It may be mandatory or optional. In addition, health centers and community-based settings provide many opportunities for CSE as well. These settings are particularly important to make CSE available to out-of-school young people and children—often the most vulnerable to misinformation, coercion, and exploitation (UNESCO, 2018 ). CSE should always be age- and developmentally appropriate, i.e., responsive to the changing needs and capabilities of young people and addressing developmentally relevant topics in a timely, diversity accommodating fashion. CSE is preferably “incremental,” i.e., engaging learners in a continuing educational process that starts at an early age and builds new information upon previous learning in a spiral-curriculum approach (UNESCO, 2018 ).

Crucial for adequate CSE delivery is a learner-centered approach. Empowering methods need to put young people at the center; be sensitive to (the heterogeneity of) their concerns, realities, suggestions, interests, and resistance; and aim at fine-tuning a program to fit all of these requirements (see Vanwesenbeeck et al., 2019 ). Instead of merely being recipients, the active participation of students is key in empowering them to become capable of representing themselves and making their own decisions. Teachers are supposed to facilitate the empowerment process rather than teach content, improve knowledge, or regulate behaviors. This model of learning is closely aligned with rights-based pedagogy and what has been called “critical pedagogy” (e.g., Kincheloe, 2008 ), aiming to improve young people’s lives not merely through behavioral change but also through cognitive and social transformation. The didactic vision is also aligned with Freirian theory, which emphasizes engaging learners to question prevailing norms through critical thinking, and current educational strategies such as outcomes-based learning and competency-based education (e.g., Power & Cohen, 2005 ).

Finally, CSE should be delivered by well-trained and supported teachers and educators and take place in a safe, healthy, and supportive learning environment. The educational context is preferably fully in line with what the program aims to achieve and the messages it brings across. It is also essential that sexuality education efforts are further complemented by a sexual and reproductive health system that provides young people with the adequate and high-quality services and supplies they need, both in and out of school (WHO, 2002 ). But with those requirements, we drift away from principles of CSE to the area of preconditions for successful delivery. Those will be elaborated upon later.

CSE’s Potential

A significant body of evidence (Fonner, Armstrong, Kennedy, O’Reilly, & Sweat, 2014 ; Kirby, 2011 ; for overviews see UNESCO, 2018 ; UNFPA, 2010 , 2014 , 2015 ; WHO, 2011 ) shows that good-quality CSE indeed enables young people to develop accurate and age-appropriate sexual knowledge, attitudes, skills, intentions, and behaviors that contribute to safe, healthy, and positive relationships. CSE has the potential to provide young people with the necessary information about their bodies and sexuality; reduce misinformation, shame, and anxiety; clarify and solidify positive attitudes and perceptions; increase communication; help them reflect on social norms and cultural values; and improve their overall sexual agency and abilities to make safe and informed choices about their sexual and reproductive health. Most evidence stems from secondary schools, but some studies in Dutch primary education show that CSE can also improve 9- to 12-year-old pupils’ knowledge, awareness, attitudes, and skills (e.g., Bagchus, Maratens, & van der Sluis, 2010 ). Students in primary as well as secondary education (see Vanwesenbeeck et al., 2016 ) often experience high satisfaction with CSE programs, as do many teachers, parents, and school boards.

In terms of actual sexual behavior change, research has shown that CSE may help young people delay debut of sexual intercourse, reduce the frequency of unprotected sex, reduce the number of sexual partners, and increase the utilization of sexual and reproductive health services, contraceptives, and condoms. Two-thirds of rigorously evaluated CSE programs lead to reductions in one or more risk behaviors. In contrast, CSE has been persuasively shown not to foster early sexual debut or unsafe sexual activity (UNFPA, 2014 ). In comparison to less comprehensive programs, notably to abstinence-only programs, CSE has invariably been found to contribute more adequately to gains in young peoples’ sexual health (de Castro et al., 2018 ; Fine & McClelland, 2006 ; Haberland & Rogow, 2015 ; Kirby, 2008 ; McCave, 2007 ; Santelli et al., 2017 ; Shepherd, Sly & Girard, 2017 ; Trenholm et al., 2007 ; Underhill, Montgomery, & Operario, 2007 ; UNFPA, 2015 ). Abstinence-only programs typically focus exclusively on discouraging young people from sexual activity, which leaves them ill-prepared to enhance the safety, equity, and pleasure of the sexual interactions once they engage in them anyway.

General access to good-quality CSE may also contribute to more distant, “hard” outcomes such as reductions in early childbirth, (unsafe) abortion, sexual violence, and sexual ill health. However, studies on the (long-term) effects of CSE on biomarkers, such as the prevalence of STIs/HIV and teenage pregnancies, are notably scarce. Research that assesses “hard” biological outcomes is time-consuming, expensive, and complex. Besides, employing the “golden standard” of randomized controlled trials in resource-poor contexts and in an area as complex as adolescent sexuality is associated with many ethical and methodological difficulties (Kippax, 2003 ; Michielsen et al., 2010 ; Vanwesenbeeck, 2011b , 2014 ). Studies and meta-analyses that are available for “hard” outcomes show, at most, only moderately strong, often even weak effects (Doyle et al., 2010 ; Kirby, 2007 ; Haberland & Rogow, 2015 ; Kohler, Manhart, & Lafferty, 2008 ; Oringanje et al., 2016 ; UNFPA, 2010 ; Vanwesenbeeck et al., 2016 ; Yankah & Aggleton, 2008 ). In addition to methodological problems, this must be attributed to the many persistent shortcomings in CSE design, content, and delivery as well as by normative, cultural, and political environments that are notably unsupportive of empowering CSE messages. Nevertheless, young people’s sexual and reproductive health is often better in countries where CSE is widely implemented. For the Netherlands, the relatively low STI rates, high prevalence of contraceptive use, low teenage pregnancy and abortion rates, and overall good adolescent sexual and reproductive health have invariably been explained by its long-standing tradition of sex-positive sexuality education (e.g., Brown, 2012 ; Ferguson et al., 2008 ). A study in Finland (Apter, 2011 ) has shown that prevention behavior has improved and abortion rates have declined after a national curriculum and accompanying teacher training was introduced in 2003 and vastly improved the quality of sex education in Finnish schools. In contrast, high teenage pregnancy rates in a number of central Asian countries (such as Georgia, Russian Federation, Tajikistan) have been connected to the infancy stage of sexuality education in these areas (IPPF & BZgA, 2018 ).

CSE’s potential extends beyond individual sexual health outcomes. Qualitative research suggests, for instance, that CSE may have benefits for students’ self-esteem, assertiveness, and overall well-being, as well as for teacher–student relationships in the classroom, parent–child communication, community norms, school social climate, and school drop-out rates (e.g., Vanwesenbeeck et al., 2016 ). Again, rigorous studies are scarce. Outcomes such as greater gender equality, critical thinking skills, psychological well-being, and sexual pleasure have hardly been addressed because of the challenge they pose in terms of reliable and valid assessment and, in particular, because of the dominant focus on (HIV-related) health behaviors in most evaluation research (see Boonstra, 2011 ). The dominance of a HIV-related public health perspective has seriously limited views of CSE as relevant to the attainment of broader goals such as social health and development, livelihoods, emancipation, and community well-being (Germain, Dixon-Mueller, & Sen, 2009 ; Rotheram-Borus, Swendeman, & Flannery, 2009 ). CSE could support adolescents, not least girls, in a safe passage to adulthood and in reaching their full potential in educational achievement, earning capacity, and societal participation. Widespread availability of CSE could contribute to the socioeconomic development of countries and to the sustainable development goals (SDGs) of the global 2030 development agenda. Inclusive access to high-quality CSE is deemed vital to realizing human rights, gender equality, and health and well-being for all. Hague et al. ( 2017 ) also value CSE’s potential in peace-building processes.

In the early 21st century , verification of CSE’s potential has been limited by biomedical perspectives on sexual health behaviors and a rather narrow conceptualization, actually an underestimation, of CSE’s many promises on many levels, as well as of the processes underlying positive effects. Employment of a wider range of success indicators in CSE evaluation (as well as a more diverse palette of research methodologies) has been called for by many (e.g., Haberland, 2015 ; Keogh et al., 2018 ; Ketting, Friele, & Michielsen, 2016 ; Leung, Shek, Leung, & Shek, 2019 ; Shearn, Allmark, Piercy, & Hirst, 2017 ; UNFPA, 2015 ; Vanwesenbeeck, 2011b , 2014 ). Nevertheless, we do have some knowledge about its levers of success.

Levers of Success

Levers of success (as measured in relation to short term positive changes in knowledge, attitudes, and preventive behaviors, unless indicated differently) have been identified in program content and methods of delivery and implementation. In addition, the political and cultural contexts in which CSE is provided and adjacent strategies to improve those contexts have also proven important in program success, most certainly when reach and scale-up are looked at as outcome measures.

Comprehensive Program Content

Regarding program content, first, it is important that recommended procedures are adhered to during the development phase, such as using a logic model, involving young people and other stakeholders, assessing local needs, and pilot testing the program (Keogh et al., 2018 ; UNFPA, 2014 ). Other content features proven beneficial include focusing on specific behaviors, providing clear messages, focusing on risks or factors that are amenable to change and on situations that might lead to unsafe sex, while addressing personal values, norms, and perceptions and enhancing skills and self-efficacy (Kirby, 2007 ; UNFPA, 2014 ). Context specificity of program content is another prerequisite in program effectiveness. This requires culturally appropriate inclusion of all issues relevant to the specific circumstances faced by children and young people in their context (IPPF, 2017 ). Often, however, this requirement produces tension when key CSE elements, programmatic values, or core principles are considered controversial or taboo in a certain context. Hague, Miedema, and LeMat ( 2017 ) identify the problem that CSE can “work against itself” in that sociocultural sensitivity may lead to undesirable reductions of a program’s comprehensiveness.

One chief characteristic of effective program content stands out: addressing gender and power explicitly, by purposefully raising the subject and/or fostering personal reflection and critical thinking about how gender norms manifest and operate. Based on her comprehensive review of evaluation studies, Haberland ( 2015 ) concludes that education programs that address gender or power are five times more likely to be effective in terms of reduced rates of pregnancy or STIs as those that do not. Limitations in study designs have not granted us decent evidence for outcome measures other than individual health behaviors.

An explicit rights-based approach in CSE programs is another crucial content-related impact factor. There is evidence that a well-designed rights-based approach in CSE programs can lead to short-term positive effects on knowledge and attitudes, increased communication with parents about sex and relationships, and greater self-efficacy to manage risky situations, such as the risk of abuse, sexual exploitation, and domestic violence. Long-term significant positive effects have also been found for psychosocial and some behavioral outcomes (Constantine et al., 2015 ; Rohrbach et al., 2015 ; UNESCO, 2016 ).

Adequate Delivery and Implementation

Program fidelity, i.e., high-quality programs being delivered as intended, is an obvious impact-enhancing factor. Program fidelity may be hampered by factors related to students, teachers, and school contexts (see Vanwesenbeeck et al., 2016 ). Students may not be able to attend lessons. Teachers may skip key messages deemed too controversial, eliminate or shorten certain (sensitive) elements, and reduce the number or length of sessions. Schools may be unable to provide materials or effective lesson plans. UNESCO’s ( 2015 ) review of curricula shows that key competencies, including critical thinking, and the examination of how norms, religion, and culture affect learners choices, are often attributed little or no attention in existing sexuality education programs. A study on the effects of program fidelity for a CSE program in Uganda revealed that almost all significant positive effects disappeared in those schools that implemented less than 50% of the lessons (Rijsdijk et al., 2013 ).

A related element in adequate program implementation that stands out are teacher skills and norms. A study in Finland on the impact of school-based sexuality education on pupils’ sexual knowledge and attitudes showed that positive effects were largely due to the motivation, attitudes, and skills of teachers and the ability to employ participatory teaching techniques (Kontula, 2010 ). However, many teachers may grapple to come to terms with conflicts they experience between teaching CSE and dominant socio-cultural and religious norms. Girls, in particular, may be seen as the vulnerable sex for whom teachers feel abstinence is the best option. Traditional gender norms may often be strengthened rather than transformed. All pupils may potentially feel embarrassment and discomfort with sexuality as a topic. Gendered processes may further impede proper student engagement, not least among girls (see Pound, Langford, & Campbell, 2016 ). Educators’ professional norms and identity, in addition, may require a form of teacher authority that is at odds with the participatory teaching methods proposed by the program (e.g., De Haas, 2013 ). Much is expected in terms of CSE educator skills, as an overview of desired competencies shows (WHO & BZgA, 2017 ). A study by the Dutch Inspectorate for Education ( 2016 ) showed that even in the Netherlands there is still much room for improvement in this area.

The active involvement of students and learner-centered teaching are a prerequisite for positive results. The methods employed by teachers who say they do use interactive, participatory, or critical thinking pedagogy seem to, however, vary widely, and relevant research is scarce. In the review by Haberland ( 2015 ), “good pedagogy” alone could not distinguish effective from ineffective programs. What is clear, though, is that it does require proper training and a supportive school environment. Priority number one for an effective delivery of CSE is to better support teachers in being able to do so (see Poobalan et al., 2009 ; Pound, Langford, & Campbell, 2016 ). The ideal form of teacher training is a continuous process, which includes coaching and provides guidelines on how to successfully adapt a program to local needs, groups, and contexts (see Rotheram-Borus et al., 2009 ), preferably without compromising its key elements of effectiveness. There is heightened awareness that sexuality educators need proper facilitation, training, and support, both within and outside schools, to deliver sexuality education in an effective, enabling, and inclusive way (e.g., Vanwesenbeeck et al., 2016 ; WHO & BZgA, 2017 ). And there is increasing evidence that there is a lack of such support in the Global South (see Vanwesenbeeck et al., 2016 ) and East (Leung et al., 2019 ) as well as in the North or West (e.g., Martínez, 2012 , for Spain; Spencer, Maxwell, & Aggleton, 2008 , for the United Kingdom).

An Enabling (School) Environment

The school environment is essentially conducive of program success in many additional ways. Program fidelity, teacher performance, and program effectiveness all profit enormously when sexuality education is structurally embedded in the official school curriculum and does not need to be provided in after-school hours with little organizational support. For CSE to be given sufficient weight when integrated in the curriculum, Keogh et al. ( 2018 ) suggest it might be useful to choose a dedicated topic that can be made formally examinable so as to increase the educational status of a program. All infrastructural barriers to program fidelity, as mentioned above, should, of course, be reduced as much as possible. Sufficient funding (for materials and technical support or even proper teacher wages) is an obvious priority that is, unfortunately, all too often not conceded to. Conservative U.S. funding strategies play an important role in (inadequate) funding of CSE in resource-poor settings (see Center for Health and Gender Equity (CHANGE), 2018 ; Corrêa et al., 2008 ; Vanwesenbeeck, 2011a ) as well as in the United States itself (e.g., Cushman, Kantor, Schroeder, Eicher, & Gambone, 2014 ).

In addition, positive messages, even from high-quality programs, may be seriously undermined by gender and status power differentials between teachers and learners and risks of harassment, exploitation, and violence against and among students (see Jewkes, 2010 ). The prevention of school-based gender-based (sexual) violence is a priority in this respect. Development and broad advertisement of school policies and careful implementation of action plans to this purpose may be highly effective. A promising strategy to build a supportive, enabling school base for CSE is the employment of a so-called whole school approach for sexuality education (WSA for SE) (Rutgers, 2016 ; Vanwesenbeeck et al., 2019 ). Pilot evaluations of this approach show positive results in terms of school safety, the development of a teacher supportive infrastructure, student participation in school policies, parental involvement, links with nearby SRH service providers, and relations with the community and political stakeholders. WSA for SE schools were shown to have developed a number of techniques to increase teacher motivation, such as teacher teams to improve collaboration and mentorship. Moreover, teachers have reported changes in their own beliefs, attitudes, and knowledge regarding the teaching of sensitive topics such as contraception, abortion, and sexual diversity, which they had previously skipped. Teachers also reported the increased use of and confidence in participatory teaching methods (see Flink, Schaapveld, & Page, 2018 ).

Positive support from parents and communities and availability of a range of out-of-school educational possibilities and, not least, of accessible (youth-friendly) sexual health services and supplies are of crucial importance. Links with outside school settings and partnerships with community and religious leaders in marginalized areas, including rural areas, may be particularly important in order to reach the most vulnerable populations (UNESCO, 2018 ). Clearly, adolescent sexual and reproductive health and rights cannot be realized by CSE alone (see Vanwesenbeeck et al., 2019 ). Successful behavior change is best achieved if multilevel inputs are provided to support and reinforce this change synergistically (Palmer, 2010 , p. 23).

Multicomponent Approaches

The desirability of so-called multicomponent approaches (bringing together actions to improve individual empowerment, strengthen the health system, and create a more CSE and SRHR supportive environment) has become particularly evident when HIV programming shifted from an emergency to a longer-term response. This has called for a shift from individualistic to social/structural approaches that address the key drivers of HIV vulnerability (e.g., Auerbach, Parkhurst, & Caceres, 2011 ; Fitzpatrick, 2018 ; UNESCO, 2018 ; Vanwesenbeeck, 2011a ). Multicomponent approaches are also more sustainable than single-component interventions since they also achieve change in social and cultural factors. They are more synergetic because they address both demand and supply in relation to the uptake of health education and services. They target different groups and are therefore more diverse in reach (see Chandra-Mouli et al., 2015 ; Denno, Hoopes, & Chandra-Mouli, 2015 ; Fonner et al., 2014 ; Kesterton & Cabral de Mello, 2010 ; Svanemyr, Amin, Robles, & Greene, 2015a ; Svanemyr, Baig, & Chandra-Mouli, 2015b ; UNESCO, 2018 ; Vanwesenbeeck et al., 2019 ).

Svanemyr et al. ( 2015b ) have argued for an “ecological framework” to enable the environment at different levels: at the individual level (empower girls, create safe spaces), at the relationship level (build parental support, peer support networks), at the community level (engage men and boys, transform gender and other social norms), and at the broad societal level (promote laws and policies that protect and promote human rights). A 20-year ICPD progress report by Chandra-Mouli et al. ( 2015 ) shows that sexuality education is most impactful when school-based programs are complemented by community elements, including condom distribution, building awareness and support, and increasing demand for SRH education and services among youth. Additionally, addressing gender inequalities, providing training for health providers, and involving parents, teachers, and other community gatekeepers such as religious leaders may be beneficial. The authors argue for “SRH intervention packages” to improve CSE’s effectiveness.

Multicomponent approaches are indispensable to bringing CSE to appropriate scale. If CSE is not accessible to substantial and diverse masses of adolescents, its effects may remain no more than the proverbial drop in the ocean. Scale-up also improves cost-effectiveness. Kivela, Ketting, and Balthussen ( 2011 ) calculated that costs of school-based sexuality education may be as low as $5 to $7 per student when integrated in regular curricula, taught by regular teachers, and reaching many students per class/school. These calculations do not yet take into account the huge costs (to the individual, societies, and countries at large) that are being saved when good CSE substantially reduces unintended pregnancies, STIs and other aspects of sexual and reproductive ill-health. And we can’t even begin to estimate the financial profits of broader benefits, such as increased self-esteem and gender equality, not least when CSE reaches proper scale. An effective strategy in scale-up processes may be the whole school approach for sexuality education (Rutgers, 2016 ). The approach aims to include more pupils per school, reach them earlier, and develop a cost-effective, scalable implementation model. Selected schools are facilitated in taking the lead in designing feasible interventions, making the best possible use of available school budgets, staff, relationships, and resources in order to overcome challenges. Combined with support from local governments, these schools will become advocates for other schools and further bring CSE to scale. Frameworks for scale-up, e.g., ExpandNetwork, propose starting to develop a plan for scale-up early, during intervention design and implementation, developing that into a detailed scale-up strategy and a careful, systematic management of scale-up processes (see Chau, Traore, Seck, Chandra-Mouli, & Svanemyr, 2016 ). Keogh et al. ( 2018 ) studied scale-up processes in four different (low-income) countries and conclude that the prime conditions for successful scale-up are positive cultural norms and values, presence of infrastructural needs (such as accessibility of services, links with communities, and supportive media), and overall policy and community level support. These authors suggest that installment of dedicated permanent teams at the central and regional levels could enable greater coordination of activities around CSE and could significantly enhance coverage and continuity of programs within countries.

Overall, a CSE-positive cultural climate and state politics are crucial for CSE to fulfill its potential to the fullest. However, CSE-negative cultural contexts are highly prevalent everywhere, in the Global South (e.g., Michielsen, Chersich, Temmerman, Dooms, & van Rossem, 2012 ; Wood & Rolleri, 2014 ) as well as in the Global North (e.g., Cushman, et al., 2014 ). In the United States, Cavazos-Rehg et al. ( 2012 ) found that the effects of sexuality education were constrained by state-level characteristics, notably religiosity and political conservatism/abortion politics, and that state characteristics also influenced adolescent birth rates above and beyond sexuality education. CSE-negative environments hamper programs’ effectiveness in producing barriers to program development, implementation, delivery, and scale-up and provide major challenges for the realization of the whole range of CSE’s potential benefits. Particularly in conservative contexts, careful community engagement to increase support for and reduce resistance toward CSE is widely considered a prime lever of success in CSE implementation and scale-up (Chau et al., 2016 ; Svanemyr et al., 2015b ; Vanwesenbeeck et al., 2019 ).

Unfinished Business

As illustrated, there is still much room for improvement in most settings in terms of vitally important requirements for successful CSE programming. In this section, a couple of aspects in pressing need of (unremitting) attention are highlighted.

Fighting Opposition

Despite all the evidence of positive CSE effects on adolescent sexual health, its compelling logic, the intrinsic values of human rights and gender equity, and the many satisfied users, opposition to CSE remains astoundingly strong. In many countries, overall public opinion may be notably positive, but small yet extremely vocal conservative and religious groups strongly keep resisting CSE in many places (Chau et al., 2016 ; Keogh et al., 2018 ). Unfortunately, these groups often manage to negatively influence national educational politics as well as political agreements by international bodies such as the UN. Twenty-five years after the landmark ICPD 1994 , UNFPA emphasizes that “the struggle for rights and choices is an ongoing one” ( 2019 , p. 7). And increasingly so, one might add. During the session of the Commission on the Status of Women in 2019 (CSW63), attainments of the landmark ICPD in 1994 with regard to the sexual and reproductive rights of women and girls could only barely be retained. Particularly the U.S. delegation, in an “unholy alliance” with the Vatican, Russia, and orthodox Muslim countries, has been pushing vehemently toward a conservative, religious agenda. Nationally in the United States, “sex education wars” (Kendall, 2012 ) have long raged between believers in AOUM and activists for CSE. The Bush administration adopted AOUM as the singular approach to adolescent sexual and reproductive health, resulting in up to 49 of the 50 states accepting federal funds to promote AOUM in the classroom (Hall, McDermott Sales, Komro, & Santelli, 2016 ). In the early decades of the 21st century , CSE is gaining popularity in the United States, but in the more socially and politically conservative states, schools often still prefer AOUM (e.g., Leung et al., 2019 ).

Partly because of the Americanization of international sexual and reproductive health politics (see Altman, 2001 ; Corrêa et al., 2008 ; Vanwesenbeeck, 2019 ), opposition against CSE is also and sometimes increasingly strong in many conservative countries in the Global South. UNESCO Bangkok ( 2012 ) found only 6 of 28 countries in the Asia Pacific region to even discuss sexuality education in any detail in their national policies at the time. Opponents criticize CSE for being “sex positive,” sometimes for being “Western,” and persist to believe, against all evidence, that sexual knowledge is dangerous and might encourage experimentation. Religion-based morality politics are notably evidence resistant. Overall, the transformative goals of CSE may be unsettling because they are considered threatening to gender norms, family values, and the status quo. Nevertheless, UNESCO successfully mobilized substantial high-level political support in East and Southern Africa for the improved provision of sexuality education and sexual and reproductive health services for young people. In December 2013 , in Cape Town, 20 ministers of health and education from the region affirmed their commitment. However, inclusion of sexual diversity (LGBTQ) issues have not been addressed in these commitments due to social and cultural constraints. Particularly sexual rights and sensitive topics such as same-sex sexual relationships and abortion remain extremely controversial, both in sex education and beyond (Bijlmakers, de Haas, & Peters, 2018 ; UNFPA, 2019 ). Public controversy around sexuality and gender issues seems to also be on the rise in Europe. A strengthened focus on reproduction and family values, a prominent backlash against reproductive rights, and an infringement on women’s rights and LGBT organizations can be observed, notably in the Eastern region and the Balkans (Kuhar & Paternotte, 2017 ; Outshoorn, 2015 ; Verloo, 2016 ). Štulhofer ( 2016 ) notes that this growing public controversy over gender equity and sexual rights in a number of countries also seriously threatens the comprehensive nature of sexuality education. Štulhofer calls for a European-wide collaboration on CSE.

Clearly, opposition to CSE needs to be persistently fought. In international fora, the presence of CSE advocates is indispensable to keep a balance with the CSE opposition movement. And, as said, there is a huge need for community building to strengthen positive attitudes toward sexuality education in general and to sexual rights specifically. This has been shown to be possible and fruitful, even in sex-conservative settings, provided it is implemented with tact and care (e.g., Chandra-Mouli, Plesons, Hadi, Baig, & Lang, 2018 ; Denno et al., 2015 ; Institute for Reproductive Health, 2016 ). In Pakistan, for instance, NGO Rutgers Pakistan has been successful in advancing support for sexuality education with careful implementation of a number of key strategies that included sensitizing and engaging key stakeholders, including religious groups, schools, health and education government officials, parents, and young people themselves; tactfully designing and framing the curricula with careful consideration of context and sensitive topics; institutionalizing programs within the school system; showcasing school programs to increase transparency; and engaging the media to enhance and build positive public perceptions (Chandra-Mouli et al., 2018 ; Svanemyr et al., 2015a , 2015b ). Comparable positive results have been described for a community building project by BRAC University in Bangladesh (Rashid, Standing, Mohiuddin, & Ahmed, 2011 ). Community building to enhance attitudes toward sexuality education is also vital to (parts of) conservative Global North countries such as the United States (e.g., Secor-Turner, Randall, Christensen, Jacobson, & Meléndez, 2017 ), Australia (Ferfolja & Ullman, 2017 ), and Ireland (Wilentz, 2016 ). In the Netherlands, relentless advocacy has brought about continued success, but sometimes religious groups protest against one or another intervention there as well, particularly when CSE programs in primary schools are at stake. In addition to community building at a national level, the usefulness of regional cooperation at the level of continents has also been illustrated, for instance, for Latin America (Steinhart et al., 2013 ; see also UNFPA, 2015 ).

Advancing Equitable International Cooperation

In addition to national and regional cooperation, international cooperation in relation to CSE programming is, obviously, commonplace and standard procedure in international development aid. However, North–South partnerships in international development aid are precarious. Colonial histories, strong versus weak positions in the global economy, and the (assumed) unidirectional nature of funding streams may hamper the establishment of an equitable power balance between international partners (see Vanwesenbeeck et al., 2019 ). Imperialist tendencies and (northern) countries wishing to impose their values on other (southern) ones are well-known phenomena in international cooperation.

Clearly, such relations have been met with criticism, for instance, in anti- or postcolonial scholarship. Ethical debate about development aid has grown and diversified (Gasper, 1999 ). Shaping CSE has been one area in which signs of notable inequity between stakeholders from the Global North versus the Global South have been noted. After thorough review of the international literature on CSE-related implementation processes, Hague et al. ( 2017 ) are wary of the fact that guidance still appears to remain strongly top-down. A problematic binary between “progressive secular” and “backward religious” cultures and the idea that secularity would guarantee sexual freedom have been criticized (Le Mat, Kosar-Altinyelken, Bos, & Volman, 2019 ; Rasmussen, 2012 ; Roodsaz, 2018 ). LeMat et al. ( 2019 ) disapproved of uncritical conceptions of tradition versus modernity and of “good” versus “bad” cultures in relation to teaching young people in Ethiopia about the determinants of sexual violence. Relying on such a distinction fails to address and discuss gender relations and patriarchy as the root causes of gender-based violence, enhances the vulnerability of young women, and reduces CSE effectiveness, the authors avow. Roodsaz ( 2018 ) found evidence of frustration, annoyance, and resistance to, in particular, a rights-based approach among some stakeholders in CSE implementation in Bangladesh. The interviewees claimed that sensitive topics such as sexual diversity, gender norms, and child marriage are difficult to discuss in the context of Bangladesh. By promoting a rights-based approach to CSE in countries in the South, European development organizations and NGO representatives risk being culturally insensitive by seeking to advantage “the dominant, the transnational” over “the particular,” Roodsaz argues. Her analysis strongly condemns the downplay of local modes of sexuality knowledge, and politics and provides a strong plea for equal collaboration between parties.

Remarkably, however, it is exactly the human rights framework that has, gradually over the years, become the standard for ethical relations in development cooperation and in dealing with the clash of values that may present itself between countries and stakeholders (OHCHR, 2006 ). There are two main rationales for the adoption of a human rights-based approach: (1) the intrinsic rationale, acknowledging that a human rights–based approach is the right thing to do, morally or legally; and (2) the instrumental rationale, recognizing that a human rights–based approach leads to better and more sustainable human development outcomes. In practice, the reason for pursuing a human rights–based approach is usually a blend of these two. In international cooperative work on CSE, a human rights–based approach needs to be employed with respect to both program content as well as the implementation process. For one thing, a proper balance needs to be found between Northern and Southern stakeholders in defining and tuning concepts such as “empowerment,” “rights” and “agency” (for girls as well as boys), or “comprehensiveness” in the first place. Collaborative tuning with local stakeholders is one of the most crucial aspects of the implementation of sexuality education in the context of development cooperation (see Vanwesenbeeck et al., 2016 , 2019 ).

Differences in approaches to CSE show at macro, meso, and micro levels of international cooperation and shape the varied understandings and delivery of CSE as a result (Hague et al., 2017 ). These variations are bound to change over time. Hague et al. ( 2017 ) express hope that, rather than the still all-too-prevalent top-down approach to guidance of CSE, a circular learning process will gradually prevail that will increasingly create understanding and consensus among different sets of actors and across varying contexts as to what CSE should encompass. Sexual rights are bound to be a crucial area about which actors may have widely divergent opinions, as they are essential to CSE while at the same time extremely controversial in many cultural contexts. Respect for sexual rights may always remain patchy, with proponents and adversaries entangled in eternal battles and/or with support for some rights being relatively strong (e.g., the right to information) but not so for others (e.g., same-sex sexuality or abortion rights). Indeed, appropriate attention to non-normative sexualities may be one of the biggest challenges in many contexts. In general, CSE has been criticized for LGBT silencing, both in the North and the South (Bang Svendsen, 2012 ; Ferfolja & Ullman, 2017 ; Haggis & Mulholland, 2014 ; Sherlock, 2012 ). Hague et al. ( 2017 ) stress that comprehensiveness does not automatically equal inclusivity. The circular learning process for international cooperation in development aid contexts, as suggested by these authors, will often, maybe always, necessarily involve subtle maneuvering, balancing, and compromise, most likely in the area of sexual rights and inclusivity.

Ongoing Innovation

CSE requires constant innovation in other areas as well. CSE needs to be continually adaptive to progressive insights, societal developments, and shifting conditions and is, principally, always a work in progress. Every new generation of young people has at least slightly different needs, possibilities, and perspectives. Contexts change. Globalization and the intense mediatization of our modern world have, for instance, brought about a totally different landscape for sex education. The extent to which new technologies, such as social media and Internet access, and their implications for young peoples’ sexual development should be covered in CSE, and how, is a matter of unresolved consideration. Likewise, new technologies may add to (the diversification of) educational methods and strategies. Ways in which new options may be benefited best need to be investigated on an ongoing basis. Innovation in terms of methods and implementation processes is a constant challenge. The jury is still out on issues such as the role of parents, the right of withdrawal, how to deal with complaints, how to adequately incorporate young people’s views, etc. The same is true for the treatment of topics that are notably complex and therefore far from easily dealt with in educational settings. Sexual empowerment, choice, agency, and pleasure are central aims in a gender transformative approach to young peoples’ sexuality, but their conceptualization and approach remain to be subject to heated (scientific) debate. Inclusion of these themes in CSE in truly transformative and evolutionary ways turns out to be far from a self-evident endeavor and certainly needs further and careful consideration (see, e.g., Allen, 2012 , 2013 ; Allen & Carmody, 2012 ; Bay-Cheng, 2019 ; Cense, 2019a ; Naezer, Rommes, & Jansen, 2017 ; Rasmussen, 2012 ; Vanwesenbeeck et al., 2019 ).

Comprehensive sexuality education (CSE) may be considered the flagship of the worldwide social movement for sexual and reproductive health and rights (SRHR). CSE is the prime premise, the ultimate requirement to even come close to realizing SRHR for all. CSE clearly sets the bar high. Its aims are ambitious. The potential of CSE is enormous and at least partly shown to be realized indeed, but research investigating success and its levers is limited at the same time. Long-term investigations are rare. Outcome measures mostly used have been dictated by a biomedical perspective on health interventions. The wider, psychological, social, and cultural potential of CSE has hardly been the subject of scientific research, no doubt in part due to the complexity and versatility of young peoples’ sexual well-being. Also in the area of planning, monitoring, and evaluation (PME), a world is still to be gained. There is progress in guidance for high-quality methods and procedures in CSE research (e.g., UNESCO, 2018 ; UNFPA, 2015 ). Tools for standardized PME procedures have become available (e.g., UNESCO’s Serat, IPPF’s Inside & Out, Rutgers’s planning and support tool). Multiple research designs and multiple methods are required to assess multi-layered processes. The many promises of CSE will remain unknown and underestimated until the body of knowledge on its processes, outcomes, and impact is substantially increased and, not least, diversified.

At the same time, cautiousness about CSE’s potential is warranted. In the past, the field has been criticized for breathing “pan-optimism” (Lesko, 2010 ) in assuming that individual decision-making is the key site of risk minimization and progress toward sexual health (Bromnick & Swinburn, 2003 ; Dworkin & Ehrhardt, 2007 ). It has now, gradually, been brought home to CSE advocates that “SRHR for all” will not be realized by CSE alone. We should neither underestimate nor overestimate CSE’s potential. CSE needs to be bolstered by an enabling (cultural, political, economic) environment with an overall sound (sexual and reproductive) health system. The structural and social drivers of SRHR must be unrelentingly addressed at multiple levels. Multi-track policies are vital. Adequate training and support systems for educators and schools rank high on the list. And, not least because of persistent opposition to CSE, careful community building and advocacy around CSE are key, on the level of local and regional as well as international cooperation. Great care will have to be taken to make CSE available to all, including the more vulnerable populations and in the more isolated regions. This means CSE will also have to spread to out-of-school settings. True inclusivity is still a challenge in many, probably all, contexts.

Clearly, developing and implementing CSE is a treacherous, complex process with many risks, threats, and pitfalls, truly a job never done. There is no alternative to simply moving on with unrelenting purpose and energy. Fortunately, CSE advocates and practitioners are strengthened by the notion that CSE, in all its ambition and potential, is a sine qua non for young peoples’ productive sexual citizenship and for sexual and reproductive health and rights for all.

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Development of Contextually-relevant Sexuality Education: Lessons from a Comprehensive Review of Adolescent Sexuality Education Across Cultures

As reported by the World Health Organization in 2017, there are 2 million+ young people living with HIV worldwide. The World Health Organization also reported that a third of all new HIV infections around the world are estimated to occur among youths (aged 15–25). and teen pregnancy rates are on the rise in many places. These worrying trends suggest that existing sexuality education programs and interventions may be inadequate and/or ineffective. Although the 1994 International Conference on Population and Development’s (ICPD) Programme of Action highlighted the roles of Governments to offer sex education to young people to promote teenage reproductive health, yet inconsistency exists in the related initiatives in the global context. The present article aims to provide a comprehensive literature review of the existing sexuality programs in selected places in both English-speaking (i.e., the United States of America, the United Kingdom) and Chinese-speaking contexts (i.e., Hong Kong, Mainland China, and Taiwan). Based on the review, observations and implications for sexuality education policy and practice, as well as recommendations for future research for youths are outlined.

1. Introduction

Adolescence marks a developmental phase where one has relatively sound health, a time where physical sexual maturity is acquired. However, it is also during this period marked by increased autonomy, social immaturity, risk taking, and spontaneity which make them more susceptible to reproduction and sexual health risks. These risks include unplanned, or unprotected sex, which may lead to an elevated risk of sexually transmitted infections (STIs), unintended pregnancy, and unsafe abortion [ 1 , 2 ]. Although STIs and sexually transmitted diseases (STDs) are sometimes used interchangeably, it is important to highlight the technical differences between the two. STIs refer to bacteria, viruses, and parasites transmitted through vaginal, anal, and oral sex. It is a sexually transmitted infection that has not developed into a disease. Simply put, STDs (e.g., pelvic inflammatory disease, cervical cancer) start out as STIs. At present, four curable STIs include syphilis, gonorrhea, chlamydia, and trichomoniasis, while, hepatitis B, herpes, HIV, and human papillomavirus (HPV) are incurable. These pathogens are associated with higher incidence of STDs [ 3 ]. As reported by the World Health Organization [ 3 ], there are currently more than 2 million adolescents living with HIV worldwide. In the United States (U.S.), young people (aged 15–24 years old) account for 50% of all new STDs. Furthermore, 25% of sexually active adolescent females have an STD (e.g., chlamydia or HPV) [ 4 ]. However, in the present study, we will focus on providing a broader picture, as such the rates of particular types of sexually transmitted infections and diseases will not be outlined in detail. According to the 2017 national Youth Risk Behavior Survey [ 4 ], 39.5% of high school students in the U.S. reported ever having engaged in sexual intercourse. While the figures have decreased significantly in the past decade from 47.8% in 2007, unfortunately, those who reported using a condom during their last sexual contact decreased significantly from 61.5% in 2007 to 46.2% in 2017. Moreover, 70.6% of U.S. high school students did not use birth control pills, implants, or birth control rings before last intercourse.

In non-Western contexts such as Hong Kong, the Department of Health reported that HIV infection cases increased from 181 in 1997 to 692 in 2016 [ 5 ]. The premarital pregnancy rate among youngsters had also increased from 2011 to 2016 [ 6 ]. Furthermore, improved health and nutrition in most developed countries have resulted in youths maturing at a younger age, accompanied by an earlier sexual debut [ 7 ]. In the UK, The National Survey of Sexual Attitudes and Lifestyle showed that roughly three-tenths of young people aged 16–24 had sexual intercourse when they were younger than 16 [ 8 ].

In fact, the resolution of the International Conference on Population and Development’s (ICPD) Programme of Action adopted in 1994 underscored the importance of governments to offer sex education to young people [ 9 ]. A critical need for young people to obtain information and skills to protect adolescent sexual and reproductive health (ASRH) was recognized [ 10 ]. Consequently, many countries have adopted sex education policies aimed at preventing adolescent unintended pregnancy, unsafe abortions, and HIV transmission. In the United Nations Global Strategy for Women’s, Children’s and Adolescents’ Health 2016, strategies to guide and catalyze global collaboration on promoting ASRH for the next 15 years were established. Unfortunately, despite investments in comprehensive sexuality and HIV education for young people over the past decades, grave trends are still being observed, which continues to point toward the necessity for better sexual health education and services [ 4 ].

1.1. Sex Education

Sex education refers to “an age-appropriate, culturally relevant approach to teaching about sex and relationships by providing scientifically accurate, realistic, non-judgmental information” [ 2 ] (p. 69). This definition acknowledges that the aim of sex education extends beyond the transfer of knowledge on human physiology, reproductive system, or the prevention of STIs. Rather, sex education is conceptualized holistically with the goal of empowering youths to better understand their sexuality and relationships, which will ultimately improve adolescents’ sexual health and overall quality of life [ 11 ]. This is in line with WHO’s delineation of sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled.” [ 12 ] (p. 4).

Generally, sex education focuses on delivering facts about sexual and reproductive health. However, the content, messages, and approaches of delivering sex education vary across countries [ 13 ]. In both the West and non-Western Chinese contexts, the implementation of sex education remains a contentious subject in public health and education policy on several grounds. First, it is the deep-rooted perception of sex as a “taboo” itself, especially in the Asian cultures. Some skeptics argue that sex education encourages promiscuity among youths, and believe that this issue should be avoided so as not to “awaken the sleeping bear”. Second, while policy makers, educators, and parents witnessed that adolescent sexual behavior is getting “out of control”, they disagree on how youngsters’ problematic sexual behaviors can be minimized; and third, on whose responsibility it is to control our youths in this area [ 14 ]. Sex education programs may be school-based that are led by teachers, social workers, health professionals, or peers; community-based; or family-based. In addition, there are various approaches to sex education including abstinence-only, abstinence-only-until-marriage, abstinence, and comprehensive sex education.

1.2. Abstinence-only or Abstinence-only-until-marriage Education Approaches

Abstinence-only education (AOE) or abstinence-only-until-marriage (AOUM) programs, with its religious origins, advocate the complete refraining of sex outside of wedlock, including masturbation. Abstinence is perceived moralistically, where notions of virginity and chastity are highlighted and “teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity” [ 15 ] (p. 97). Students’ character and morality are core issues. Under this approach, policies prohibit or limit the mention of contraception in sex education, and biased findings of contraceptive methods (e.g., condoms and birth control pills) as failures are often presented. Advocates believe that providing students with information on where to obtain and how to use contraception will undermine the abstinence-only message and encourage immoral and health-compromising sexual behaviors which will, in turn, increase the rates of sexually transmitted diseases (STDs) and unwanted pregnancy [ 16 ]. As such, they believe that abstinence-only is the sole unfailing way to prevent STDs and unwanted pregnancies. The implementers of abstinence-only programs discourage sexual activity by employing tactics to instill fear, shame, and guilt in relation to sexual activity. Moreover, it has been criticized that AOE programs present scientifically inaccurate information, use stereotypical gender roles that discriminate against female students (e.g., portraying women as the “gatekeepers” of men’s virginity, blaming women for men’s sexual indiscretions), and overemphasize religious messages [ 17 ]. Nevertheless, this approach is mostly welcomed by conservative and religious groups [ 18 ].

1.3. Abstinence or Stress-abstinence Approach

While AOE and AOUM approaches perceive abstinence under a moral lens, proponents of abstinence approach conceptualize it as a behavioral and public health issue, encompassing behaviors such as delaying sex, never having vaginal sex, or refraining from engaging in further sexual intercourse even if one has already had sexual experience. Abstinence, however, does not include other sex-related behaviors such as petting, kissing, mutual masturbation, oral, and anal sex [ 19 ].

1.4. Comprehensive Sex Education

Under comprehensive sex education (CSE), abstinence is also included in the curriculum. However, in contrast to the aforementioned approaches, abstinence needs not be stressed. Rather, comprehensive sex education incorporates a range of prevention strategies on contraception to prevent STDs and unwanted pregnancy, and highlights the importance of safe sexual practice [ 19 ]. According to The International Planned Parenthood Federation, CSE refers to “education about all matters relating to sexuality and its expression. Comprehensive sexuality education covers the same topics as sex education but also includes issues such as relationships, attitudes towards sexuality, sexual roles, gender relations and the social pressures to be sexually active, and it provides information about sexual and reproductive health services. It may also include training in communication and decision-making skills” [ 20 ].

CSE is an empowerment-based rooted with values and practices emphasizing human rights, gender equality, participative learning, youth advocacy and civic engagements, as well as cultural appropriateness. It aims to equip students with knowledge, values/attitudes, and skills to facilitate students to make informed decisions that promote sexual health [ 10 , 21 ]. Research supports the implementation of CSE. For instance, the United Nations Population Fund (2016) reported that CSE does not lead to earlier sexual debut or risky sexual behaviors which may be a misconception held traditionally [ 22 ]. Rather, approximately two in three CSE programmes evaluated showed reductions in risky sexual behaviors. 60% of the CSE programmes yielded positive effects such as increased condom use or reduced teenage pregnancies. In addition to the aforementioned effective outcomes of CSE, the authors firmly believe that healthy sexuality plays a crucial role in holistic positive youth development. Without healthy sexual attitudes and behaviors, adolescent development will be adversely affected.

2. Methodology

A comprehensive review on evidence-based sex education programs in developed countries from the West (i.e., the U.S., the UK), and non-Western Chinese regions (i.e., Mainland China, Hong Kong, and Taiwan) was conducted. These countries were selected as they provide a diversity in terms of their political and cultural background, the role that the government plays in sex education policy making, as well as its varying approaches in implementation, training, research, and evaluation. More specifically, despite continuous declines in the past decades and currently at its record lowest, U.S. pregnancy rates remain to be the highest in the developed world (43 per 1000 females in 2013) [ 23 ]. While in Europe, the highest adolescent pregnancy rates were reported in England and Wales (47 per 1000 females in 2011) [ 24 ]. The U.S. and the UK are also the largest English-speaking countries in the globe.

Compared to the Netherland which mandated sex education with the second lowest adolescent pregnancy rates in Europe, the education system in the U.S. and UK are far less consistent in terms of their provisions. These inconsistencies therefore warrant more detailed analyses [ 24 ]. In a recent Lancet article [ 25 ], figures from Asia in 2014 revealed that unintended pregnancy rates per 1000 women aged 15-44 had a 20% decrease since 1990, among which Southeast Asia reported the highest percentage decrease (31%). Mainland China and Taiwan were included in the present study due to their shared deeply entrenched roots of Chinese Confucian culture. Hong Kong serves as a unique region for examination as well, given its intermingled influences from traditional Confucian ideology and Christian values brought along from its former British colonization (from 1842 to 1997) which has been found to impact on citizens’ sexual attitudes [ 26 ].

For published materials, using a combination of search terms such as sex education, evidenced-based sex education programs, relationships and sexuality education, schools, adolescents, youths, STIs, HIV, or AIDs were used to search for relevant information in the online databases (PsychINFO, PubMed, the Cochrane Central Register of Controlled Trials, Web of Science), Internet searches (Google Scholar, Guttmacher Institute, UNIAIDS, WHO) to identify articles that detailed and evaluated evidence-based sex education programs. In addition, we conducted searches for grey literature using relevant keywords on Google to identify sex education programs and policies led by government bodies or other agencies and organizations relevant to adolescent health.

In the present review, we focused on analyzing the selected regions based on their policy, practice, training, and evaluation; which have been previously identified as key aspects of sex education in schools to ensure that students’ health and wellbeing are maximized [ 27 ]. Moreover, in this review, whether a sex education program is effective will be determined by various outcome as outlined by Kirby (1998) [ 28 ]. These indicators include (a) enhanced knowledge; (b) changed attitudes (e.g., attitudes towards premarital sex, birth control, STDs, etc.); (c) acquired skills (e.g., making decisions pertaining to sexual relations, being able to communicate feelings about the use of contraception and sexuality); and (d) learned behaviors (e.g., frequency of sex, use of contraception).

The present review contributes to the existing literature in various manners.

First, up until now, to the best of our knowledge, articles have not been published to paint such a comprehensive picture on sex education of different Chinese societies. Second, this review provides a thorough landscape of sex education in two English-speaking countries with the largest populations in the Western world. Finally, this paper identifies common issues and challenges faced in both the Western and Chinese communities concerning the provision of sex education.

3. Sex Education in the United States of America

3.1. policy.

In response to the increased prevalence of out-of-marriage pregnancies and the pandemic of HIV/AIDS, sex education has been an important public health policy issue in the U.S. over the past four decades. There was an obvious pressing need for formal education targeted at adolescents on protective health topics such as the use of contraception, and knowledge on sexually transmitted diseases. In the late 1990s, the U.S. government proposed a singular Abstinence Only Until Marriage (AOUM) approach to sex education with up to 49 of the 50 states implementing programs to promote AOUM at schools. However, over the years, empirical evidence pointed toward the lack of effectiveness of AOUM approach in delaying sexual debut or reducing risky sexual behaviors [ 29 ]. Thus, under President Obama’s administration, the AOUM approach was proposed to be eliminated and replaced by a more comprehensive programs—one that “normalizes teen sex” [ 30 ]. This approach is based on the assumption that it will not be possible to dissuade a certain proportion of the adolescent population from sexual activity. Therefore, the best approach is to teach and promote the use of contraception which may lower the rate of unwanted pregnancy and STDs. Simultaneously, for youths that have yet to become sexually active, continued abstinence is still promoted [ 31 ]. Under Obama’s leadership, the proposed budget was increased to support programs such as the Teen Pregnancy Prevention Program, which equipped youths with the necessary skills to ensure lifelong sexual health and wellbeing [ 30 ]. Yet a turn was taken under Trump’s administration which reverted back to supporting the abstinence approach, as reflected by the priority of funding programs that promote abstinence, sexual risk avoidance, and provide cessation support (i.e., encouraging sexually active youths to deter having sex) [ 32 ].

At present, sex education is mandated on a state-level, where different states, districts, and school boards have the autonomy to determine the implementation of federal policies and funds for sex education. Since there is a lack of cohesive and consistent policies governing the implementation, the system has been criticized to be a “highly diverse patchwork of sex education laws and practices” [ 29 ] (p. 595). Of the 50 states and the District of Columbia, merely 24 of them have mandated sex education classes in public schools and 34 states mandate HIV education [ 33 ]. However, in terms of content, there is great variation across states. For instance, Rhode Island, West Virginia, and the District of Columbia provide a detailed age-appropriate standard on the topics to be covered in sex education. However, the majority of the states such as Kentucky and Nevada offer minimal guidelines as to what should be included in the sex education curriculum [ 34 ]. Although comprehensive sex education (CSE) is gaining popularity, and is supported by many organizations, given its effectiveness in delaying sexual activity and decreasing risky sexual behavior among young people have been evidenced [ 35 ], the Abstinence-Only Education approach is still adopted by states that are more likely to hold socially and politically conservative beliefs, such as Tennessee and Montana [ 36 ].

3.2. Practice

In terms of implementation, while every state provides guidance on the content of sex education, individual school districts possess the autonomy to decide on how and when sex education should be taught. In the U.S., sex education is often included as part of health or physical education (PE) curriculum for high school students, which is delivered by health and PE teachers. Unfortunately, [ 29 ] up until now, there remains a lack of evidence-based conceptual models on comprehensive sex education for adolescents in the U.S. According to the Center for Disease Control and Prevention (CDC) [ 37 ] (p. 3) “Exemplary sexual health education is a systematic, evidence-informed approach to sexual health education that includes the use of grade-specific, evidence-based interventions”.

Indeed, efforts have been dedicated to developing guidelines for the implementation of sex education. In 2014, the CDC [ 37 ]“proposed 16 critical topics that should be included in sex education as a part of the School Health Profile, including (1) How to create and sustain healthy and respectful relationships; (2) Influences of family, peers, media, technology and other factors on sexual risk behavior; (3) Benefits of being sexually abstinent; (4) Efficacy of condoms; (5) Importance of using condoms consistently and correctly; (6) Importance of using a condom at the same time as another form of contraception to prevent both STDs and pregnancy; (7) How to obtain condoms; (8) How to correctly use a condom; (9) Communication and negotiation skills; (10) Goal-setting and decision-making skills; (11) How HIV and other STDs are transmitted; (12) Health consequences of HIV, other STDs and pregnancy; (13) Influencing and supporting others to avoid or reduce sexual risk behaviors; (14) Importance of limiting the number of sexual partners; (15) How to access valid and reliable information, products and services related to HIV, STDs, and pregnancy; and (16) Preventive care that is necessary to maintain reproductive and sexual health” (p. 1). However, a nationwide survey across 48 states revealed that less than half of the high schools and merely one-fifth of middle schools cover all of the 16 proposed essential sex education topics. Moreover, within a school year, an average of merely 6.2 hours of instruction was dedicated to human sexuality, 4 hours or less on HIV, STDs, and pregnancy prevention [ 37 ].

Despite efforts to promote adolescent sexual health, teen pregnancy rates in the U.S. continues to be ranked as the highest among Western countries. This phenomenon has been attributed to the resistance towards the incorporation of a standardized sex education curriculum across districts. A report published by the Guttmacher Institute [ 38 ] illuminated on this disparate implementation where it was found that merely 26 states mandate that the content of instruction be age-appropriate, 13 states to be medically accurate, eight that the materials must be free from race or gender bias, eight that the content must include information on sexual orientation, and two that it should be religion-neutral. The lack of consensus across districts on the approach and content of sex education may be due to various reasons, including individuals’ attendance at religious services and political orientation [ 39 ].

3.3. Training

The effectiveness of school-based education programs depends highly on teachers. Studies have shown that instructors’ commitment to, as well as comfort with the delivering of sex education impacted on ones’ teaching ability [ 40 ]. The positive relation between teachers training and implementation fidelity has been documented. Teacher workshops on sex education should provide strong justification, knowledge, and skills for program delivery, enhance commitment and support to the program, and underscore the significance of program fidelity to teachers [ 41 ].

In the 2018 Sex Ed State Legislative Mid-Year Report [ 42 ], 109 bills across 27 states were introduced or carried forth in hopes of advancing sex education instruction in schools; 48 of the bills were related to teacher training requirements. Although there were few specific guidelines regarding teachers’ training, it was required that the State Department of Education or other organizations set minimum training criteria. The National Teacher Preparation Standards for Sexuality Education was developed to provide guidance for educators teaching sex education in middle and high schools. A total of seven standards with reference to: (1) professional character; (2) diversity and equity; (3) knowledge on materials; (4) legal and professional ethics; (5) preparation; (6) implementation; and (7) assessment were outlined. In addition to training, CDC also noted that it was critical to provide educators with materials needed to effectively teach sexual health topics [ 37 ], as well as strong support from administration, and ongoing technical assistance [ 41 ].

3.4. Evaluation and Research

Findings from evaluation studies on the effectiveness of different sex education approaches have been mixed. While some reviews and meta-analyses provided support to comprehensive sexual risk reduction programs in reducing targeted sexual risk behaviors; studies suggest otherwise [ 10 , 43 ]. In an analysis consisting of 60 studies examining the impact of school-based comprehensive sex education, Weed and Ericksen [ 31 ] found that CSE was not effective to decrease teen pregnancy as well as STD rates and to increase abstinence and condom use at 12-months post-program [ 16 ]. Several studies were identified to have yielded negative effects including higher levels of sexual initiation, oral sex, and reduced contraceptive use [ 44 , 45 ]. On the other hand, some school-based abstinence education programs revealed sustained increases in teen abstinence.

In order to gain an understanding of the effectiveness of the implementation of sex education, CDC [ 46 ] highlighted the importance of evaluating program outcomes. Due to the inconclusive results obtained from studies evaluating the effectiveness of programs adopting various approaches in promoting adolescent sexual health, the Institute for Research and Evaluation called for more evaluation studies using rigorous methodologies and meaningful indicators (e.g., sustained post-program effects), as well as replication studies to verify positive findings of existing sex education programs which would better inform public policy [ 31 ]. This was echoed by Chandra-Mouli, Lane, and Wong [ 47 ] who recommended “greater attention to the adaptation of evidence-based prevention science approaches that simultaneously address risk and protective factors… This should include the creation of a database that documents best and promising practices in prevention science and adolescent health” [ 47 ] (p. 339). Please refer to Table 1 for a systematic presentation of the sex education initiatives in the U.S.

Summary of sex education aspects in the two large English-speaking societies.

4. Sex Education in the United Kingdom

4.1. policy.

In the 1960s, sex and relationship education (SRE) was introduced as a part of the UK school curriculum. However, because of diverging sociopolitical ideologies and the absence of consensus among stakeholders (e.g., parents, religious groups), the objectives of sex education remain unclear. Particularly, a contention lies in whether health or moral values should be primarily addressed [ 48 ]. In the 1980s, the Conservative government instilled traditional sexual values through moral teachings. By the late 1980s, sex education was intended to ensure social stability by addressing public health issues such as the rising prevalence of unplanned pregnancies, STIs, and HIV/AIDS. This resulted in the passing of legislation which was largely prohibitive, such as Section 28 of the Local Government Act in 1988 which banned the “promotion” of same-sex relationships in schools.

While there is no standardized curriculum for SRE in the UK, progressive developments were made in 2000, when the Department of Education and Employment published a statutory Sex and Relationship Education Guidance which provided guidelines for SRE within schools where the importance of respecting social, cultural, and sexual diversity was highlighted: “young people, whatever their developing sexuality, need to feel that sex and relationships education is relevant to them and sensitive to their needs” [ 49 ] (p. 12). Under legislation passed in 2017, relationship education is compulsory in all primary schools. Whereas, SRE must be a part of the secondary school curricula [ 20 ]. Earlier in 2018, the Government announced that sex education will become compulsory for school children from September 2020 and is currently consulting stakeholders including parents, subject matter experts, and youngsters on the content of the curriculum [ 50 ].

4.2. Practice

At present, there is no standardized SRE curriculum for schools which implies that schools have the autonomy to develop their own programs to cater to their respective students. Taken as a whole, UK sex education places sexual intercourse within the contexts of marriage and fidelity [ 51 ] and emphasizes abstinence. SRE can be categorized into five types, namely: (1) sexual abstinence-only programs; (2) comprehensive programs; (3) pregnancy-prevention programs; (4) HIV-prevention programs; and (5) school-based or school-linked sexual health services (e.g., primary care clinics, youth service drop-in facilities, and outreach services which provide contraception and sexual health support or advice) [ 52 ]. Although there is no standardized curriculum or program, the government has set out a number of broad requirements that every state-funded school must adhere to when implementing SRE [ 49 ]. Since SRE is delivered within the Personal, Social and Health Education (PSHE) framework and its content is determined at the school level, the content of the SRE programs are heavily influenced by localized district factors including prevalence rates of unwanted pregnancy, STIs, parents’ needs, etc. Some counties dictate what SRE should contain, but often individual teachers are left to decide on the approach and method of implementation [ 51 ].

This self-governing arrangement has been prized by stakeholders including parents, governors, and school management. However, experts have criticized that this value-led approach merely reflects the interests and principles of stakeholders, while overlooking the actual needs and wellbeing of youths [ 53 ]. The content commonly found in most programs includes knowledge on HIV and AIDS, contraception, methods to prevent STIs, as well as risks and consequences of unprotected sex, pregnancy, STIs, and reproductive health [ 52 ]. These topics heavily focus on biological aspects covering topics such as puberty and sexual reproduction, spread of viruses, etc. with the aim of delaying early sexual activity and reducing sexual partners, and encouraging contraceptive use. Youths are deprived of certain knowledge about sex and sexuality [ 54 ]. Specifically, present guidelines on SRE fails to include contemporary issues such as sexting, internet pornography, cyberbullying, or LGBTQ identities, and the notion of consent [ 20 ]. Moreover, students reported that they felt uncomfortable having their own teachers teach them about sex due to blurred boundaries and a lack of anonymity [ 55 ].

In addition to school-based efforts, members of the wider community also play crucial roles in the provision of SRE for youths. For instance, some schools work with health professionals such as doctors and nurses in the development and delivering of SRE programs. Youth workers also play important roles in outreach work to provide confidential advisory services to children and young people outside of the school context [ 49 ].

4.3. Training

Evidently, the effectiveness of school-based SRE relies predominantly on teachers. Yet, students reported dislike of their own teachers delivering SRE as they sensed the teachers being embarrassed and were poorly trained in this aspect [ 55 ]. It can be difficult “… to discuss sex, particularly when the discussion is led by untrained teachers who are not given sufficient help to deliver the material, and who as a result may be uncomfortable talking about it” [ 56 ]. Indeed, teachers themselves have reported feelings of awkwardness when delivering SRE [ 57 , 58 ]. Up to 80% of teachers were not confident and perceived inadequately trained on SRE.

When teachers were asked about the barriers they faced having to implement SRE, about half of the interviewed teachers identified the lack of training, and lack of time to develop and coordinate the SRE programs. Fortunately, teachers do receive training or support from external agencies in relation to the delivery of SRE. These workshops were usually coordinated by the local education authority and took place at local hospitals where teachers are given the opportunity to work together and exchange ideas with health professionals such as doctors and nurses on sex education [ 59 ]. In terms of resources support, merely 9% of the teachers found the materials and resources provided to be useful to their SRE teaching. Approximately, one in four teachers believed that the current SRE fails to prepare children for the future [ 60 ]. This further highlights the pressing need for the development and implementation of effective SRE teachers training. For example, an evaluation study was conducted on an in-service program for training SRE teachers to deliver a sex education program entitled “SHARE”. Participants of the teacher training program found it to be highly beneficial. Particularly, teacher participants received social support from colleagues which they found to be valuable. The training component also enabled teachers to be familiarized with the teaching resources which helped to boost their confidence in delivering SRE [ 61 ].

Finally, one of the main criticisms of the existing SRE is its heterosexist orientation which highlights the importance for teachers to reflect on different aspects of SRE practice, update their knowledge on sex and sexuality through attending training and workshops. Specifically, it was recommended that training should equip teachers with knowledge and skills that would enable the development and implementation of up-to-date curriculum that takes into account youngsters’ sexual identities, relationships, and cultural backgrounds [ 62 ].

4.4. Evaluation and Research

According to the National Survey of Sexual Attitudes and Lifestyles [ 56 ], young people’s sexual practices have changed over the last 20 years. The proportion of sexually active 16 to 26 year olds who reported having had sexual intercourse with opposite-sex partners during the previous year increased from one in 10 females and one in 10 males in 1990–1991, to one in five females and one in four males in 2010–2012. These figures call for the pressing need for SRE in schools, families, and the community. Wight [ 63 ] conducted a review of evaluations on three nationwide large-scale comprehensive sex education programs (i.e., SHARE, RIPPLE, and HEALTHY RESPECT) implemented in the UK. The sample included over 22,000 students from nearly 80 schools. It was found that all three programs helped to enhance students’ sexual health knowledge and certain attitudes. However, findings revealed that the programs did not yield remarkable improvements in adolescents’ sexual health outcomes.

Using a meta-ethnographic method reviewing 55 publications mainly from the UK, the current SRE was criticized for its lack of statutory status, outdated government guidance and the observation that one-third of UK schools delivered unsatisfactory SRE [ 55 ]. These problems are attributed to two main reasons. First, schools overlooked the emotional laden and unique nature of sexuality. As a result, the curriculum was taught in a way similar to that of any other academic subjects. Second, there is a reluctance to accept that sexual activity is high in some adolescents. This results in a discrepancy between what is taught and what students are experiencing [ 55 ]. Moreover, the current SRE content fails to address contemporary sexuality issues. For instance, over 50% of lesbian, gay, and bisexual youngsters reported that issues surrounding non-heterosexual relationships have not been taught in their schools. Similarly, 85% of students shared that SRE education did not include biological or physical aspects of homosexual relationships [ 64 ]. Researchers pointed out that more research must be conducted on same-sex attitudes and sexual behaviors among youngsters which will guide education policy to safeguard and enhance the health and well-being of youths. See Table 1 for a systematic presentation of the sex education initiatives in the UK.

In the following, sex education in three Chinese societies, including Hong Kong, Mainland China, and Taiwan will be reviewed with reference to policy, practice, training, and evaluation as well as research. (Please refer to Table 2 ). They are included because they are under the strong influence of Chinese culture and social thoughts, such as Confucianism.

Summary of sex education aspects in the three Chinese-speaking societies.

5. Sex Education in Hong Kong

5.1. policy.

The Family Planning Association of Hong Kong (FPAHK) began to promote sex education in Hong Kong in the 1960s, focusing on family planning and contraceptive knowledge [ 65 ]. Until 1971, the memorandum issued by the Education Department (now Education Bureau) then suggested including topics of sex education in some formal subjects in all Hong Kong schools [ 5 ]. In 1986, the Education Department published a more detailed guideline on sexuality education in secondary schools with recommendations on topics, resources, and references for promoting relevant programs. This set of the guideline was revised further in 1997 for strengthening the promotion, but it has not been revised since then [ 5 ].

According to the guidelines formulated in 1997, sexuality education includes five key concepts, including “human development, health and behavior, interpersonal relationships, marriage and family, and society and culture” [ 5 ] (p. 23). Unfortunately, this framework is for reference only. In 2000, the Education Department integrated sexuality education into the curriculum of Moral and Civic Education, and revised its framework in 2008, with the purpose of assisting schools in implementing sexuality education systematically. One problem of this curriculum is that it lacks a well-articulated conceptual framework. For example, while psychosocial development such as positive youth development shapes the sexual and reproductive health of adolescent [ 66 ] the proposed curriculum just focuses on the social and sexual relationship in a shallow manner without covering psychosocial development such as emotional competence and moral competence.

5.2. Practice

Regarding the implementation of sexuality education in schools, it is suggested by the Government to name it as “life education”, especially for junior students [ 67 ]. Teachers are also assigned to take up sex education that covered wider topics using various teaching resources and learning activities [ 68 ] (p. 90). Nearly all schools in Fok’s survey reported that sex education is provided by adopting the comprehensive approach that aims at preparing students for expressing their sexuality appropriately, but not just focusing on the prevention of negative consequences of casual sex. However, Lee [2005] argued that most schools still passively rely on school social workers, community resources and NGOs in carrying out sexuality education [ 65 ].

The Government findings showed that 72% of the 134 interviewed schools provided “life-skills based” AIDS or sex education in the 2011/12 school year [ 5 ]. For others, about 67% and 46% of the interviewed schools arranged an average of only three hours for each academic level, by relying on the programs of NGOs and the Department of Health respectively per year [ 5 ]. In the implementation, prevention of HIV had been mentioned by 60% of interviewed schools, and the use of condom had been taught by about 80% of interviewed schools via multiple learning activities or programs [ 5 ]. Besides “life-skills based” programs, 86% of the interviewed schools spent around 4 hours to provide AIDS or sex education in the main subjects, and 28% used about 3 hours to provide relevant information in the life-wide learning activities [ 5 ]. However, there is a lack of a systematic database recording diverse sex education programs in schools. As a result, the schools might have difficulties and low incentive to adhere to an evidence-based sex education program. Most importantly, evidence-based programs on sex education for schools do not exist in Hong Kong.

5.3. Training

As for teachers’ training, it is revealed that the training programs of sexuality education for teachers are usually short-term, scattered, and without clear objectives [ 65 ]. As reported by the government, only 66% of teachers had received training on AIDS, sex or life-skills based education. The training sessions were provided in the form of professional development programs by the Education Bureau, training programs by the Department of Health or NGOs, or simply materials from the Internet [ 5 ]. In the findings, only 4.1 teachers in one school on average had received relevant training since they had been working in their schools, and about 2.1 of them had taught sex education topics in the last school year. At the same time, a mean of 4.9 teachers per school had taught relevant topics without attending any relevant training program [ 5 ]. Besides, roughly nine-tenths of the 198 secondary schools under study expressed that they lacked trained teachers for teaching sexuality education [ 65 , 69 ]. At the same time, collaboration with multiple disciplines is also rare. Lee pointed out that teachers and schools could gain more inspirations from working with other professionals like clinical practitioners in conducting sex education in schools [ 65 ].

5.4. Evaluation and Research

Concerning the evaluation of sexuality education in Hong Kong, the former Education Department had carried out an investigation on the sexuality education implementation in secondary schools in 1987, 1990, and 1994. The findings showed that most schools had difficulties in the implementation [ 65 ]. In 2012–2013, the Government further conducted a territory-wide survey which aimed to understand the implementation of life skills-based curriculum in the junior secondary schools, especially on HIV/AIDS and sex topics [ 5 ]. Besides, several NGOs and research groups had conducted multiple types of research. For example, a survey regarding the implementation was conducted by the research centre of the Hong Kong Institution of Education in 2001 [ 65 , 69 ]. In 2016, the Family Planning Association of Hong Kong and the Aids Concern also reported that more young people have engaged in sexual activity with insufficient information and support from school-based sexuality education [ 6 , 70 ]. Even though findings from the Government and NGOs actually indicated the sexuality education in Hong Kong have to be strengthened, continuous and specific evaluations of the Government and schools are inadequate. With the lack of regular research and assessment, the effectiveness of sex education programs in Hong Kong remains unknown.

6. Sex Education in Mainland China

6.1. policy.

In mainland China, the development of sex education began in the early Republican period. During the 1920s, it was believed that the population was a key source that would help China to become a strong and rich country, so it should be carefully measured and monitored by the State. Links between modernization and “issues of sex, reproduction, women’s liberation and eugenics” were developed [ 71 ] (p. 533). Until the People’s Republic of China (PRC) established in 1949, the new Communist leadership regarded “eugenics, genetics and physical anthropology as ‘bourgeois science’ that should be criticized” severely, and sexuality was an area under the control of the State [ 71 ] (p. 534). In the late 1950s, the Government introduced birth control in the curricular of middle schools. In the 1950s to 1960s, sex education was perceived as a vital part in sexual physiology. In 1963, the Government declared the necessity of promoting scientific sexual knowledge among young people, where sex education was stressed as an essential element in a healthy growth of the Chinese population [ 71 ]. However, the sex education in China was once paused during the Cultural Revolution as sex was banned from all aspects [ 71 ].

After the Cultural Revolution in the late 1970s, the One Child Policy and a shifted focus on the quality of the population instead of quantity were proposed. The topics related to “birth control, eugenics and sex education” were brought back to the debates, and The State Family Planning Commission also added sex education in the agenda of the 7th Five Year Plan (1986–1990) and the 9th Five Year Plan (1995–2000) [ 71 ] (p. 535). Then, the first school-based health education policy with guidelines listed was carried out by the Government in both primary and secondary schools in 1992 [ 71 ]. The China’s Ministry of Education further revised it in 2003 and 2008 [ 72 ]. It is noticed that sex education of China has long been guided by the developmental direction of the nation, instead of any theoretical model. This influenced the practice in schools.

6.2. Practice

In the early 1920s, school-based sex education was only perceived as a supplement at that time [ 71 , 73 ]. After the announcement of birth control policy in the 1950s, sex education became mandatory in schools. Then “the State Education Commission and the State Family Planning Commission jointly issued the ‘Notification on the Development of Adolescent Education in the Middle Schools’ in 1988”, which announced schools should take the major role in sex education and formally integrated it into the middle school curricula all over the country [ 71 ] (p. 537). The abstinence-based approach was adopted and “sexual physiology, sexual psychology, sexual morality, and socialist moral education” were the foci [ 71 ] (p. 537). In view of earlier sexual maturation of adolescents in 1990s, the focus shifted to more life skill-based that issues related to premarital sex, HIV/AIDS, and unwanted pregnancies were incorporated in the Health Education of the secondary schools and universities [ 71 , 74 ]. Although the youths could be granted with limited sexual rights and responsibilities in the current practice, prevention of STIs and importance of contraception are not clearly stated in the guidelines [ 72 ]. Apart from the insufficiency in the guidelines, evidence-based sex education programs and relevant database are also lacking in guiding the practice in China. The effectiveness of the current practice is indeed found to be unsatisfactory [ 72 ].

6.3. Training

Improving teachers’ training course on sex education was one of the main objectives in the Notification published by the State Education Commission and the State Family Planning Commission in 1988 [ 71 ]. Although some training programs were provided to part of the teachers in previous years, when it comes to the topic of safe sex education, it created discomfort in most teachers as nearly all training programs stem from the abstinence-based approach [ 71 ]. This issue still remains unsolved although efforts in interdisciplinary collaboration have been made. For example, in the “International Conference on Sexual Health Education for Youth in China” held in 2005, professionals such as teachers, doctors, scholars, and social workers gathered and discussed the pressing issues of sex education in China [ 71 ] (p. 539). Other than the content covered in the training, cultural sensitivity is also a critical issue to work on.

6.4. Evaluation and Research

Scientific works on sex education were noticed since the 1920s. Zhang’s “Sex Histories” published in 1926 is regarded as the first scientific work in China that systematically gathered informants’ sexual experiences plus his suggestions on sex education [ 71 ]. In fact, many scholars have conducted various research on sex education in China with its growing debates in society. These findings not only encourage further evaluation and research in sex education, but also provide the Government with more information to review the current implementation. In fact, several studies in the 1980s showed that the Government recognized the importance of schools in providing information on birth control [ 71 ]. However, in contrast to the numerous studies done by the scholars and different organizations such as the UNESCO, official evaluation conducted by the Government on the mandatory sex education programs and training appears to be inadequate.

7. Sex Education in Taiwan

7.1. policy.

After the Chinese Civil War in 1949, sex education was introduced in Taiwan, where the education system was strictly guided by the Government and legislation [ 75 ]. There are three stages of development to sex education in Taiwan from initiation, developing, to integration [ 76 , 77 ]. The initiation stage refers to the period from 1960 to 1988. Due to the announcement of the Guide for Policy on Population in 1969, birth control was started via the practice of population education in Taiwan. Starting from 1972, content regarding sex education was greatly added in different subjects like Health Education and Biology [ 77 ], and population education was implemented in all primary as well as secondary schools in 1983 in order to promote the Government policy [ 77 , 78 ]. From 1989, sex education in Taiwan moved on to the developing stage after several non-Governmental organizations had been established. In this period, conferences on sex education were held and social movement and research aiming at gender equality were also initiated, which indicated that public awareness of sexual health issues was growing [ 77 , 78 ]. In 1991, The Department of Health and the Ministry of Education began to collaborate in promoting sex education in schools, with the new focus on promotion of “understanding the harmonious relationship between genders” [ 77 ] (p. 35). In 1997, sex education stepped forward to the integration stage with the help of the education reform policy) [ 79 ]. The Ministry of Education introduced “The Nine-Year Joint Curriculum” in 1998, where gender education became a key teaching element in solving gender inequality [ 77 ] (p. 35). The implementation of education reform policy made a significant impact on sex education in Taiwan.

7.2. Practice

In the National Curriculum Standard, all subjects had statutory status and textbooks were all published by the Government agencies. After the introduction of the Nine-Year Joint Curriculum, the status of all the learning areas remained unchanged, but the schools could have more autonomy in the implementation. Under Government monitoring, the teaching materials still adhered to the Government guidelines systematically [ 77 ]. Teachers are provided with relevant studies and practical information on the policy to guide their practice [ 77 ]. Different ideologies in sex education like sexual liberation, gender issues and health education were included [ 76 , 77 ]. Tu [ 77 , 80 ] noticed that the content in the new curriculum is richer especially on topics related to the social relationship than before, and the condition was similar across different areas in Taiwan. It is believed that the statutory status of sex education and the clear guidelines provided by the Government contributed to such uniformity in practice [ 77 , 81 ]. More specifically, it is found that most teachers adopted lecturing as the main way to teach sex education, with the assistance of multimedia and occasional demonstration [ 77 , 82 ]. However, students indeed showed more interests in the additional and non-traditional methods [ 77 , 83 ]. This might reflect an inadequate investigation into the pedagogy of sex education, as compared with the emphasis on its knowledge and information [ 77 ]. Therefore, though sex education is implemented in all primary and secondary schools in Taiwan with clear suggested topics, the teaching methods require more reflection.

7.3. Training

In order to ensure the teachers are qualified to conduct sex education programs, a lot of training, conferences and programs have been provided by the Government. Besides promoting gender education, theoretical knowledge and practical skills are included in teachers’ training programs at universities in the four-year institutional training. The graduates would have to complete a half-year field practice before officially recognized as a qualified teacher. The “Teacher Act” in 1995 led to more teacher training programs provided in the Taiwanese universities [ 77 ]. The Ministry of Education also authorizes the non-Governmental organizations to conduct additional training programs, talks, conferences and events for schools, professionals, as well as the public on sex education since the 1990s [ 75 ]. These organizations promote interdisciplinary communication by inviting members and collaboration from different backgrounds and professions. Teachers agreed that their “development of educational ideology and theories, professionalism and knowledge of sex education” [ 77 ] (p. 42) are strengthened with ongoing and additional training [ 84 ]. While the ongoing training is effective, Yu [ 77 , 85 ] realized that the participation rate in the training could be promoted by rearranging the training schedule. Instead of having the training during school time, teachers expressed that they would like to have the training during school holidays more [ 77 , 82 ].

7.4. Evaluation and Research

It was claimed that sex education in Taiwan is evidence-based in nature [ 77 ] and the research can be found in specific databases. From the information captured from 1979 to 2004, it was found that research on sex education had significantly increased. For example, the total amount of relevant research in the three databases was only four in 1979–1984, but it greatly increased to 103 in 2000–2004 [ 75 ]. Apart from the research projects commissioned by the Department of Health, there are also heaps of research to evaluate the effectiveness and impact of the implemented sex education conducted by different scholars and organizations [ 75 ]. For instance, Yen and colleagues [ 77 , 83 , 86 ] found that sex education improved students’ knowledge on sexuality, and extending the time and extra activities for sex education could bring more impacts to their knowledge and attitude. This influenced the development of the teaching approach on sex education as the findings in research would be used to provide advice for the Government [ 77 ]. Regardless of the diverse comments on the research, the need for sex education is consistently recognized by multiple parties in Taiwan.

8. Discussion

The purpose of this paper is to outline the school-based sex education policies and programs in three Chinese-speaking societies in Asia and two English-speaking countries in the Western context. There are several unique features of this review. First, the review can enable researchers to understand school-based sex education in more individualistic societies (United States and the UK) and collectivistic societies (three Chinese societies in Asia). In the Chinese culture, collectivistic interests such as social stability and family harmony are emphasized. As individual sexuality such as free sex may pose a threat to social order and family harmony, sexuality is commonly seen in an inhibitory manner in traditional Chinese cultures. Second, in view of the rapid urbanization and Westernization in different Asian societies, it would be theoretically and practically to know what school-based sex education is implemented in Chinese societies and the content of such programs. Third, several Chinese societies including mainland China, Hong Kong, and Taiwan were studied which can give a comprehensive view of school-based sex education in multiple Chinese communities. This is essential because Chinese people roughly constitute one-fifth of the world’s population [ 87 , 88 ]. Finally, this is the first scientific study which attempts to review school-based sex education policies and programs in Chinese societies in contrast to two largest English speaking societies.

Several observations can be highlighted from the present review. First, different policies are implemented in different societies under study. For example, while comprehensive sex education covering contraception and safe sex is implemented in some states in the United States, abstinence-only and abstinence-plus programs are implemented in other states of the US. In Chinese societies, different policies are implemented in different places. For instance, while conservative coverage of sexual issues is covered in school programs in mainland China, Taiwan is relatively more liberal. Topics such as the involvement in premarital sex and the use of contraceptive methods are covered in Taiwan high school sex education [ 89 ].

The second observation is that theories and scientific findings are seldom taken into account when formulating policies on school-based sex education (i.e., lack of evidence-based policies). For example, the sex education policy in Hong Kong is rather atheoretical, as the practice of letting schools design their “home-baked” sex education program is not evidence-based. In the contemporary literature on positive youth development, it is commonly proposed that psychosocial competencies are an important protective factor for adolescent risk behavior, including health-compromising sexual behavior [ 90 , 91 ]. In other words, with the development of psychosocial competencies such as resilience, emotional competence, connectedness, moral competence, and positive identity such as self-esteem, adolescents would not easily engage in unhealthy sexual behavior. However, sex education usually focuses on knowledge and attitude without making reference to these foundational psychosocial competencies. Another example is that the adoption of the “diffusion” approach is also not supported by empirical evidence. This observation is not surprising because school-based sex education policy-makers who are relatively distant from research and practice of sex education. In the Western context, there is also the criticism that school-based sex education lacks well-articulated theoretical frameworks and robust research evidence. For instance, as mentioned earlier, the U.S. Institute for Research and Evaluation has urged for evaluations adopting more meticulous and clearly articulated methods and indicators, so that the public policy could be refined consistently [ 31 ].

Third, there is a dearth of evidence-based sex-education programs, particularly in the Chinese contexts. The existing practice is that schools are “baking” their own school-based sex education program which lacks empirical support. Logically speaking, there can be four types of school-based education programs: (a) programs with negative effect; (b) programs with no effect; (c) programs with unclear effects; (d) programs with a potentially positive effect (i.e., programs with promise); and (e) programs with positive effects. As evaluation is not emphasized in Chinese societies, it can be concluded that school-based sex education programs are basically programs with unclear effects. Most of the time, sex education are window dressing and make the policy-makers and service providers feel contended. As sex education influences the attitude and practice of adolescents, there is a strong need to ascertain whether existing programs would create unintended negative impacts on adolescents [ 92 ].

Fourth, there is a lack of databases describing and evaluating validated sex education programs in different Asian societies. In North America, there are several databases which provide useful information on different sex education programs. These include the Cochrane database, Campbell Collaboration, MEASURE Evaluation, and Evidence-Based Practices Resource Center etc. For example, the Evidence-Based Practices Resource Center was launched in 2018 by the U.S. government, aiming at providing reliable information and scientifically-based resources for the public, policymakers and the field to improve the practice [ 93 ]. These databases with information on validity and effectiveness will enable stakeholders to understand the details of the available programs in the field, and inform practitioners on what “works” or what “does not work”. Stakeholders may then make use of this valuable information to develop or revise existing programs to cater to the needs of their students. This method of knowledge management may help to save resources and redundant overlaps. A similar recommendation has been made to develop such databases in the social work field [ 94 ].

Fifth, in Chinese societies, there is a lack of multi-disciplinary collaboration in designing school-based sex education and programs. As there are different dimensions underlying adolescent sexuality, such as the anatomical, physiological, hormonal, physical, cognitive, social, cultural and spiritual dimensions, different professionals have different views on school-based sex education. The different professionals include teachers, principals, social workers, youth workers, counselors, clinical psychologists, pediatricians, health workers, nurses and religious workers. For example, while social workers may adopt a more liberal perspective in implementing school-based sex-education, religious teachers would have great hesitation to teach the knowledge on sexual intercourse and contraception methods. Hence, engagement of different professionals in the process can help to create consensus and “buy-in” and foster multi-disciplinary collaboration. Besides, as students and parents are the major stakeholders, they should be invited in the design of school-based sex education policy and programs. This is important because parents and adolescents commonly have different views on the necessity of implementing school-based sex education and what should be taught. In some places such as the United Kingdom and Singapore, parents may request that their children not to participate in school-based sex education programs. On the other hand, such provision is not present in societies such as Hong Kong and mainland China.

Sixth, despite the importance of school-based sex education programs, there are no systematic and validated training programs for teachers and allied professionals on sex education. With systematic and validated programs, it is not clear whether the teachers are professional and passionate enough to implement the related sex education programs. Essentially, several areas should be covered in training programs for the potential implementers of school-based sex education programs which include knowledge, attitude, value and behavior in adolescent sexuality with reference to the specific cultural context. Besides, sex education teachers should be familiar with the arguments for and against different positions of sex education (e.g., abstinence versus comprehensive sex education programs). They should also understand how different pedagogical factors and process variables influence the impact of sex education programs in the school context. In the area of positive youth development, Shek and his associates argued that training programs are very important for program success [ 95 ].

Finally, while there are many studies on adolescent sexuality, there are comparatively fewer studies examining the factors influencing teaching and learning process and outcomes in sex education. Based on the 5P model, it is recommended that future research should examine how program, people, process, policy and place would influence the outcomes of school-based sex education program. Besides research on teaching and learning, it is necessary to conduct more evaluation on the effectiveness of school-based sex education programs. There is a need to understand the impact of school-based sex education programs over time which is severely lacking in the scientific literature. There is also a shortage of randomized controlled trials and longitudinal evaluation studies to examine the effectiveness of different modes of school-based sex education programs. Besides quantitative evaluation studies, qualitative studies should also be adopted to collect the subjective experiences of program participants and program implementers of school-based sex education programs. This is in line with the spirit of utilization-focused evaluation paradigm [ 96 ].

As a limitation of this review, we acknowledge that the literature included in this article remains non-exhaustive. For example, we are aware that there are other European countries such as Netherlands, France, and Australia that adopt a pragmatic approach to sex-positive government policies which have been shown to be more effective than programs in the U.S. and UK. Owing to the “relative” ineffectiveness of sex education programs in the US and the UK, as well as Hong Kong, Mainland China, and Taiwan, we propose further effort should be made to identify the success factors in these countries. Besides, future studies may be conducted in a more systematic manner (e.g., in accordance with the PRISMA guidelines).

Also, we are aware that teenage pregnancy rates in the Mainland China may be underrepresented due to the high abortion rates. In a recent study of 2370 Chinese adolescents (aged 13–19), 39% reported that they have undergone repeated abortions, and 9% had three or more abortions [ 97 ]. As aforementioned, we observed that existing research in the field of sex education often lack methodological rigor and thus is unable to provide conclusive evidence on programs’ effectiveness. Despite the limitations, important implications for policy and practice as well as suggestions for future research were put forth.

9. Conclusions

Evidently, worrying trends in sexual wellbeing of adolescents are observed globally with increasing prevalence rates of teenage pregnancy in certain regions and STIs which urged scholars, practitioners, policy makers, parents and young people to examine the implementation and effectiveness of sex education targeted at youths. In addition, the call for stronger Government involvement in promoting sex education in young people can be seen in the 1994 International Conference on Population and Development’s (ICPD) Programme of Action. Against this background, the present review provides an overview of the policy, practice, training, and evaluation and research on sex education in the two largest English speaking countries as well as three Chinese speaking societies. The review shows that there are many gaps and inadequacies in sex education in the places under review. Given the importance of sex education, it is advised that more efforts and actions are required. Particularly, sex education policies and programs should be developed based on scientifically evidence-based theories related to contemporary adolescent development theories and ecological models. Moreover, there is a dire need to equip implementers (e.g., teachers and social workers), as well as parents with the necessary skills to enhance the effectiveness of sex education programs. In addition, in order to gain a more informed perspective as to which factors contribute to program effectiveness, methodologically rigorous evaluation studies adopting both quantitative and qualitative methodologies using longitudinal designs should be employed. Also, databases containing effective programs and measures should be established for more effective dissemination of informed practice. Finally, to promote sexual wellbeing among adolescents in today’s contemporary society, program implementers should take into consideration the complexities of sexual development during adolescence and include topics such as gender, diversity, relationships, empowerment, and consent into existing curricula, rather than merely focusing on the biological aspects of reproduction. In particular, strengthening psychosocial competence in young people may protect them from risky sexual behaviors.

Author Contributions

Conceptualization: D.T.L.S., H.L., E.L.; Literature search and assembly of data: E.Y.W.S.; Data analysis and interpretation: All authors; Writing-Original Draft Preparation: D.T.L.S., H.L., E.L.; Writing-Review& Editing: D.T.L.S., H.L., E.L.; Supervision: D.T.L.S., H.L.; Final approval of manuscript: All authors.

Conflicts of Interest

The authors declare no conflict of interest.

• Open access
• Published: 21 July 2021

Delaying sexual onset: outcome of a comprehensive sexuality education initiative for adolescents in public schools

• Dolores Ramírez-Villalobos 1 ,
• Eric Alejandro Monterubio-Flores 2 ,
• Tonatiuh Tomás Gonzalez-Vazquez 1 ,
• Juan Francisco Molina-Rodríguez 1 ,
• Ma. Guadalupe Ruelas-González 3 &
• Jacqueline Elizabeth Alcalde-Rabanal 1  

BMC Public Health volume  21 , Article number:  1439 ( 2021 ) Cite this article

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A common risk behavior in adolescence is the early initiation of unprotected sex that exposes adolescents to an unplanned pregnancy or sexually transmitted infections. Schools are an ideal place to strengthen adolescents’ sexual knowledge and modify their behavior, guiding them to exercise responsible sexuality. The purpose of this article was to evaluate the knowledge of public secondary school teachers who received training in comprehensive education in sexuality (CES) and estimate the counseling’s effect on students’ sexual behavior.

Seventy-five public school teachers were trained in participatory and innovative techniques for CES. The change in teacher knowledge ( n  = 75) was assessed before and after the training using t-tests, Wilcoxon ranks tests and a Generalized Estimate Equation model. The students’ sexual and reproductive behavior was evaluated in intervention ( n  = 650) and comparison schools ( n  = 555). We fit a logistic regression model using the students’ sexual debut as a dependent variable.

Teachers increased their knowledge of sexuality after training from 5.3 to 6.1 ( p  < 0.01). 83.3% of students in the intervention school reported using a contraceptive method in their last sexual relation, while 58.3% did so in the comparison schools. The students in comparison schools were 4.7 ( p  < 0.01) times more likely to start sexual initiation than students in the intervention schools.

Training in CES improved teachers’ knowledge about sexual and reproductive health. Students who received counseling from teachers who were trained in participatory and innovative techniques for CES used more contraceptive protection and delayed sexual debut.

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Adolescence is the stage in which reproductive capacity is developed, identity is affirmed, independence is built, and self-assertion is strengthened [ 1 ]. During adolescence, life plans are established, but behavioral patterns may represent health risks. One of the patterns is the early debut of unprotected sex that exposes the adolescent to an unplanned pregnancy or sexually transmitted infection (STI) [ 2 ]. According to the World Health Organization (WHO), teenage pregnancy is a public health problem, which has negative effects such as: 1) school dropout, 2) abuse of children raised by adolescents, and 3) limited academic and/or job growth; these factors often serve to perpetuate the cycle of poverty [ 3 , 4 , 5 , 6 ].

The WHO reported in 2012 that around sixteen million teenagers worldwide between the ages of 15 and 19 give birth each year. The children of teenage mothers represent 11% of all births, of which 95% occur in low and middle-income countries [ 7 ]. In 2016, Mexico ranked first in adolescent pregnancies (ages 15–19) among members of the Organization for Economic Cooperation and Development (OECD). Mexico’s birth rate of 64.2 per thousand adolescents is much higher than the rest of the member countries [ 5 , 8 ]. Consequently, the sexual and reproductive health of the adolescent population is a national priority. To address this problem, the Mexican government launched the National Strategy for the Prevention of Adolescent Pregnancy (ENAPEA) in 2015 [ 9 ]. ENAPEA aims to reduce births in girls aged 10–14 to zero and to decrease the fertility rate of adolescents aged 15–19 by 50% by 2030. The national average for teenage pregnancy in 2016 was 35 per 1000, with high variability between states. Morelos is a state located in the center of the country near Mexico City and it has one of the highest teen pregnancy rates (36.2 per 1000 adolescents) [ 10 ].

Previous research shows that high school students have little knowledge and low perception of the risks and consequences of unprotected sexual practices. Early sexual debut (SD) is a risk factor for adolescent pregnancy and sexually transmitted diseases [ 11 ]. International recommendations support the need for comprehensive sexuality education (CSE) programs for adolescents. These programs aim to strengthen knowledge, attitudes and skills in seven areas: gender, sexual and reproductive health, sexual citizenship, pleasure, violence, diversity and interpersonal relationships. Their implementation has been associated with improved knowledge in sexual and reproductive health and fewer risky practices that result in pregnancy and sexually transmitted infections [ 12 , 13 ]. On the other hand, proper sexual education has been shown to delay sexual initiation, reduce the risk of teenage pregnancies, the frequency of sexual intercourse, the number of sexual partners, and increase the use of condoms and other contraceptive methods [ 14 , 15 , 16 ].

Schools are an ideal place to strengthen adolescents’ knowledge and modify their behavior, guiding them to exercise responsible sexuality [ 17 ]. It has been documented that teachers who are trained in sex education can act as agents of change and provide students with good quality information, which in turn helps prevent reproductive risk behaviors [ 18 , 19 , 20 , 21 ]. Research shows encouraging results of sex education interventions that have a multidisciplinary perspective, focus on sexual and reproductive rights, and involve teachers, adolescents, and parents [ 13 , 14 , 15 ]. In Mexico, as in other parts of the world, sexual education initiatives for adolescents have been developed in schools but face challenges, such as: teachers’ inadequate knowledge of sexuality issues and limited skills for addressing these topics; occasional educational content that does not match students’ concerns and needs; as well as resistance from parents and educational authorities [ 22 ]. Given these problems, it is important to support initiatives for sexual education among adolescents and measure their results. This article aims to assess the knowledge of public secondary school teachers in Morelos, Mexico who received sexual education training and estimate the effect of counseling on students’ sexual behavior.

Materials and methods

Description of the intervention.

The training model is based on best practices for a Comprehensive Sexuality Education. CSE is built on a framework of rights; it aims to provide adolescents with knowledge, skills, attitudes and values that allow them to enjoy their physical and emotional sexuality on an individual level and in their relationships. CSE views sexuality in a holistic manner, as an integral part of adolescents’ emotional and social development. It recognizes that information alone is not enough; sexual education should provide the opportunity to acquire essential life skills and develop positive attitudes and values towards sex [ 23 ]. CSE was implemented in Mexican public schools in two stages. The first focused on teachers and the second on students.

The first stage consisted of two phases. In the first phase, we defined objectives, designed the content and prepared evaluation instruments. In the second phase, teachers were invited to participate in training through the Institute of Basic Education of the State of Morelos (IEBEM). The training workshop was held to improve teachers’ knowledge and skills in CSE for adolescents. The workshop lasted 3 days and focused on four theoretical-methodological axes, which are defined by the following concepts and content: 1) Gender perspective, which distinguishes the differential characteristics, attitudes and behaviors that society attributes to men and women that must be recognized in order to achieve equity [ 24 ] (Gender and its expressions in the community, expectations and life-plans, gender inequalities, empowerment, assertive communication); 2) Adolescence and sexuality, which refers to the period of life between 10 and 19 years when sexuality is explored [ 25 ] (sexual debut, mythos in sexuality, sexually transmitted infections, Internet and appropriate information sources); 3) Teenage pregnancy and responsible sexuality, which refers to pregnancies during ages 10 to 19 and the responsibility that adolescents must assume when exercising their sexuality [ 26 ] (anatomy of pregnancy, implications of teenage pregnancy, sexual self-care); and 4) Teenage contraceptive methods, which focuses on adolescents’ right to know about contraceptive methods and how to use them [ 12 ] (contraceptive methods, advantages and disadvantages). The workshop was developed using participatory and innovative methodology with a Gestalt philosophy that included reflection and discussion of each topic [ 25 ]. On the basis of the teachers’ tacit knowledge (knowledge embedded in the human mind through experience and jobs) [ 26 ] in each theme, a reflective process was carried out and misconceptions and myths were identified. A technique was developed to facilitate teacher-student communication, so that the teacher could learn how to use it and replicate it in class. The workshop facilitators were expert researchers in the subject, knowledgeable about assertive communication skills, and had work experience with teenagers. At the end of the workshop, each teacher was given a kit of materials (electronic folder with the themes developed in the workshop, a flip chart, a poster and leaflets).

The second stage also had two phases. In the first phase, the trained teachers selected the order in which the themes they learned in the workshop (from all four theoretical-methodological axes) would be taught in the classroom (35–40 adolescents from second and third secondary grade). All the topics were addressed in 24 sessions. The methodology employed in each session was diverse, using questions that adolescents proposed and cases that described their sexuality problems, as well as theatrical performances or fairs. Regardless of the technique used, each topic began with a reflection process to recognize positive and negative aspects. Each discussion developed according to the adolescents’ knowledge, while teachers clarified erroneous ideas and myths. To close, teachers and students identified healthy behaviors they should adopt. The teachers covered the themes in the classroom for an average of 8 months, in weekly sessions of 1 h (a total of 24 sessions). In the second phase, the evaluation was performed. At the end of the school year, students who received CES in intervention schools and students from comparison schools were selected to answer a questionnaire. The comparison schools used traditional public-school sex education (TSE) [ 27 ], which is requiered for all students in all schools in Mexico. Exceptions are only made for students whose parents have requested exemption due to cultural or religious reasons. The themes in the school curriculum are adjusted according to grade level, although the topics are discussed at the teacher’s discretion. Classes are usually given 1 h a week for an average of 8 months. The themes are oriented towards the anatomy of sexual organs and the use of contraceptives.

Population and sample

The intervention was designed for teachers and students in second and third grade in public secondary schools in Morelos, Mexico. It was carried out during October 2015–June 2016. For the intervention, 45 schools were randomly selected and 45 for comparison schools. Technical secondary schools are similar to general secondary schools; however, technical secondary emphasizes technological education, according to the economic activity of each region (agriculture, fishing, forestry or services), both in rural and urban communities. Tele secondary is an educational option for communities of less than 2500 inhabitants.

To participate in training of CSE, two teachers who taught sex education were randomly selected from each intervention school. The sample of students who received training in CSE was estimated at 693 (from 3540 students in intervention schools) and for students who received TSE, 738 (4329 students from comparison schools). The questionnaires were answered by randomly selected students in both intervention and comparison schools (Fig.  1 ).

Selection of the study population

For teachers, the outcome was knowledge of comprehensive sexuality education, which includes knowledge of gender, adolescence, pregnancy prevention, contraceptive use and sexually transmitted diseases. For adolescents, the outcome was sexual debut, which was measured by self-report of their first sexual intercourse.

Evaluation design

The change in the knowledge of the trained teachers was evaluated before and after the workshop. We used the questionnaire by the Mexican Foundation for Family Planning, made up of 22 questions [ 28 ]. It explored the perspective of gender equality, adolescence and sexuality, teenage pregnancy, responsible sexuality and contraceptive methods. Additionally, it included sociodemographic information like age, sex, the teacher’s main duty (teaching, principal or assistant principal), and type of school (general, technical or tele secondary). The answers to the questions were multiple choice and only one answer was correct; where 0 = incorrect and 1 = correct. The score obtained by each teacher was transformed into a 10-point scale; the score for each methodological axis was multiplied by 10 and divided by the maximum possible score of each methodological axis. To estimate the global score, we added up the scores obtained in all methodological axes, multiplied by 10 and divided by the maximum possible score (twenty two). We classified the score between 0 and 5 as: inacceptable, 5.1–6: regular, 6.1–7: acceptable, 7.1–8: very acceptable, and 8 or more: excellent.

For students, to estimate the effect of CSE, we measured sexual debut as 0 = if the first sexual intercourse occurred more than 6 months prior to the time of answering the questionnaire and 1 = if the first sexual intercourse occurred less than 6 months prior. We applied a questionnaire with 20 items that included sociodemographic variables and explored their reproductive knowledge (gender differences, ITS, Knowledge of contraceptive methods, social effect of pregnancy) and sexual behavior (sexual debut, use of contraceptive in the first and last sexual interaction). The questions to explore reproductive knowledge were multiple choice, e.g. what is the recommended method that provides double protection against pregnancy and sexually transmitted infections? 1 = Abstinence, 2 = Intrauterine device, 3 = Condom, 4 = Hormonal method 5 = I don’t know. The questions to explore sexual behavior were dichotomous, e.g. did you use contraceptive methods during your sexual interaction? 1 = yes 2 = not. The instrument was applied at the end of the school year to both intervention and comparison schools after they had received orientation and counseling in sexual education.

Data collection

Teachers answered the self-administered questionnaire electronically on a computer provided by the research team before and after the workshop. At the end of the school year, the students received the questionnaire in their e-mails. After answering it, their responses were linked to the google docs platform. The questionnaires from teachers and students were answered anonymously.

Analysis of information

Teachers’ overall knowledge was estimated with the sum of correct answers. The average level of knowledge about the four theoretical-methodological axes was also estimated. Descriptive statistics were estimated for all study variables (percentages, means, medians and confidence intervals). To analyze differences by sex, the Cohen Chi 2 test was used. To estimate the change in teacher knowledge, the paired Student t-test was used when the scores presented a normal distribution. The Wilcoxon rank sum test for paired data was used when the distributions did not have a normal distribution. We fit a Generalized Estimation Equations model with mixed effects to analyze the characteristics associated with the change in the overall rating. The model was adjusted considering the effect of conglomerates at the school level.

Sociodemographic information, knowledge and reproductive behavior was reported for students. To compare the percentages between intervention and non-intervention schools, the Cohen Chi 2 statistic was used. We fit a logistic regression model using sexual debut as the dependent variable and used age, sex, school grade and type of school as covariates. Robust variance estimators were calculated by adjusting for the cluster effect at the school level.

Ethical considerations

The Ethics and Research Committee of the National Institute of Public Health of Mexico (record number 767) approved this project and authorized verbal informed consent for all informants. Therefore, we requested verbal consent from teachers, parents of minors (under the age of 18), and adolescents. Only those informants who freely agreed to participate were included in the study.

Effect of the intervention on teachers

Of the 89 teachers who attended the CES training workshop, 84% (75) participated in both measurements (before and after). The teachers came from 26 municipalities in the state. 36% (27) were women, the mean age was 49 ± 9.9 years and 63% (46) were between 40 and 59 years old. 66% of the teachers worked in general secondary schools and 62.7% (47) were Directors or Deputy Directors who also worked as counselors in sex education in the schools (Table  1 ).

Table 2 shows the scores that the teachers obtained before and after the workshop. Overall, their score before the workshop was 5.1 and afterwards, it was 6.1 out of a total of 10 points. An increase of 0.8 points ( p  < 0.001) was observed in the unadjusted model and 0.9 when the model was adjusted by age, sex, type of school and teacher duties. In general, teachers’ knowledge of adolescence and sexuality, adolescent pregnancy and responsible sexuality and contraceptive methods improved after their participation in the workshop, both in the unadjusted and in the adjusted analysis. ( p  < 0.007).

Effect of the intervention on students

A total of 1205 students (650 in intervention group and 555 in comparison group) were included to assess the effect of the CSE intervention. The median of age of adolescents in the intervention group was 13.4 and for adolescents in the comparison group, it was 13.8. However, a greater percentage of younger adolescents was observed in the intervention group. Regarding the school grade in the intervention group, there was a higher percentage of students in the second grade, while in the comparison group there was a higher percentage of students in the third grade. Finally, in the intervention group, the majority of the participants were in general secondary schools and in the comparison group, in technical secondary schools (Table  3 ). 89.4% of students in the intervention group vs. 81.1% in the comparison group responded that they received pregnancy prevention advice. Regarding the effects of pregnancy on adolescents, 84.5% of participants in the intervention group reported they would consider dropping out of school in case of pregnancy and in the comparison group, 79.1%. About 2% of participants in the intervention group reported their sexual debut was (on average) at 14.1 ± (1.5) years, while in the comparison group 5.4% started their sexual debut at 13.1 ± (0.7) years; these differences were statistically significant ( p  < 0.01) (Table 3 ).

With respect to the place where they got a contraceptive method, 38.4% (462) of the adolescents reported that they could only acquire them in health centers, 24.8% (299) in pharmacies, 32.4% (390) in health centers and pharmacies, and the remaining (4.4%) obtained contraceptive methods at school, with their parents, with their partner, or they did not specify. There were no statistically significant differences between the comparison and intervention group. 83.3% of participants used a contraceptive method in their last sexual relation in the intervention group and in the comparison group, it was 58.3%.

The ratio of data of the SD as an indicator of reproductive risk was estimated (Table  4 ). It was found that students in the comparison group had a higher risk of starting sex life earlier compared to the intervention group (OR = 4.7).

Results from the evaluation of the CSE training model demonstrated that teachers who participated in the workshop increased their knowledge of sexual education. Among the students, there was a significant reduction in SD among those who received sex education from the teachers in the intervention schools vs. the students from the schools in the comparison group.

To strengthen sex education in schools, teachers should be trained in CES to promote adequate knowledge of adolescent sexual health and facilitate teacher-student interactions [ 29 ]. It has been documented that sex education in schools in Mexico focuses on a biological approach and that CSE is not sufficiently and adequately addressed in the curricula, plus a lack of teacher training [ 27 ]. The Kirby study showed that many issues related to SD in adolescents are not covered by the teacher in the classroom, which is why training is needed to prepare teachers as facilitators in sex education [ 17 , 30 ]. Currently, traditional and conservative norms and pedagogical practices are imposed in school sex education programs [ 17 ]. Implementing sexuality-related educational strategies with adolescents through teachers is a challenge [ 31 ].

Several studies have shown that school training interventions that improve teachers’ skills in sexual health maximize the effectiveness of interactions with their students. These interventions have shown results in reducing risky sexual behaviors and preventing teenage pregnancy [ 32 ]. Furthermore, CSE is effective in influencing adolescents’ decisions, such as delaying sexual debut [ 23 ]. Therefore, training teachers in sex education is a strategy that is recommended worldwide, but its development and implementation is still limited [ 33 ]. It is interesting to note that the training offered to teachers in this intervention included topics related to STIs and showed positive results in their knowledge improvement, despite the short period of training. These results could be attributed to the use of a reflective methodology and the teacher’s recovery of tacit knowledge, which they could have applied to the subject [ 34 ]. It is also important to highlight that young people identify different actors to meet their reproductive health needs; from parents as confidants in courtship issues, to doctors for sexuality problems (sexual impotence and pregnancy), and to teachers as counselors in sexuality issues [ 35 ].

Likewise, the evidence shows that STIs occur at an earlier age and that the risk perception is non-existent for adolescents [ 36 ]. Therefore, it exposes adolescents to having a greater number of sexual partners which is associated with unsafe sexual practices and carries greater risks of contracting STIs [ 37 , 38 ]. It also exposes them to an unplanned pregnancy that forces them to take responsibility for the care of a child and alters their personal development plans [ 34 ]. The results of this study show that adolescents who receive adequate counseling on sexuality will delay SD. Similar studies show that for the programs to be effective and achieve the expected result in sexual behavior, they must address issues related to pregnancy prevention, STIs, HIV / AIDS, encourage contraceptive use and provide tools to cope with peer pressure [ 39 ]. These topics were extensively developed in the training model with the teachers of the intervention schools.

The main limitation of this study lies in the design of the evaluation. The ideal effect evaluation design should include before and after measurements of teachers and students in both the intervention and comparison groups. For budgetary reasons, it was not possible to fully implement this design, so the evaluation in teachers was limited to before-after measurements only performed in the group of teachers who received the training. The other limitation is that we do not evaluate teachers’ knowledge and skills in CSE at the end of the school year. It is likely that these skills improved, since they had to review the information in order to teach the themes to their students. In the students, a cross-sectional measurement was conducted after the CSE implementation in the intervention and comparison schools. Although schools were randomly selected for both the intervention and comparison groups, there were differences in the types of schools included in each group. Additionally, we cannot rule out that other events outside the intervention (social networks and internet use that were not measured in the study) may have influenced the increase in knowledge. It could also be argued that the differences between intervention and comparison groups (in the case of students) are due to differences in their characteristics. In the case of the students, the analysis was adjusted by characteristics (age, sex and schooling and type of school) to control the effect that the differences between the groups could have. It is possible that students in secondary schools have a greater interest in continuing their studies than those in technical secondary schools and tele schools. They may place more importance on staying in school because it is an important part of their future life plans [ 27 , 40 , 41 ]. Finally, we do not know if teachers and students from the schools that participated in the intervention shared materials with teachers and students from the comparison schools.

Conclusions and recommendations

Training teachers in issues related to comprehensive sexuality through participatory and reflexive methodology strengthens their knowledge and skills to transmit information to their students in an appropriate manner. In this study, students who received information from teachers who were trained in CSE used more contraceptive protection and delayed SD [ 27 , 29 ]. Consequently, in light of the results presented, we recommend that schools develop innovative and attractive sex education programs for adolescents as they are ideal settings to implement responsible sexuality programs for this population. Therefore, teachers must be continuously trained in innovative methodology to become sexual education counselors and help students reduce their sexual risk behaviors [ 28 , 32 ].

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available since we made an agreement with the Institute of Basic Education of the State of Morelos not to publish the database for free access. It will be used only for academic purposes. For this reason, the data are available from the corresponding author on reasonable request .

Abbreviations

Acquired Immune Deficiency Syndrome

Comprehensive sexuality education

National Strategy for the Prevention of Adolescent Pregnancy

Human Immunodeficiency Virus

Institute of Basic Education of the State of Morelos

Organization for Cooperation and Development Economic

• Sexual debut

Sexually transmitted infection

Traditional sex education

World Health Organization

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Acknowledgements

To the Institute of Basic Education of the State of Morelos for its interest and support of the Integral Education training project in its public schools.

This study was supported by Consejo Nacional de Ciencia y Tecnologia (CONACYT) México, Distrito. Federal [grant number 233761]; 30/1/2015.

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Dolores Ramírez-Villalobos, Tonatiuh Tomás Gonzalez-Vazquez, Juan Francisco Molina-Rodríguez & Jacqueline Elizabeth Alcalde-Rabanal

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MRV, EMF, JAR conceptualized the research; MRV and EMF analyzed the data; MRV, JAR and GRG conducted data analysis and interpretation; MRV, JAR, EMF and JMR and TGV critically revised the article; MRV, JAR and EMF supervised; MRV, EMF, JAR, JMR, TGV, GRG, and JMR drafted the article and approved the final version. The author(s) read and approved the final manuscript.

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The Ethics and Research Committee of the National Institute of Public Health in Mexico (record number 767) approved this project and authorized verbal informed consent for all informants. The use of verbal informed consent was suggested by the Institute of Basic Education of the State of Morelos. They recommended that mothers authorize their children’s participation orally because many have poor reading habits and/or they could be apprehensive about signing documents. In addition, to avoid differences in how the research was implemented, they suggested using verbal consent for all informants. Therefore, we requested verbal consent from teachers, parents of minors (under the age of 18), and adolescents.

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Ramírez-Villalobos, D., Monterubio-Flores, E., Gonzalez-Vazquez, T.T. et al. Delaying sexual onset: outcome of a comprehensive sexuality education initiative for adolescents in public schools. BMC Public Health 21 , 1439 (2021). https://doi.org/10.1186/s12889-021-11388-2

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Comprehensive Sexuality Education

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Current quality of sexuality education, the role of the obstetrician–gynecologist, effective programs, reaching special populations, online communication and using cyberspace as a source of information, for more information.

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Number 678 (Reaffirmed 2023)

Committee on Adolescent Health Care

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care in collaboration with committee member Joanna H. Stacey, MD.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

ABSTRACT: Current sexuality education programs vary widely in the accuracy of content, emphasis, and effectiveness. Data have shown that not all programs are equally effective for all ages, races and ethnicities, socioeconomic groups, and geographic areas. Studies have demonstrated that comprehensive sexuality education programs reduce the rates of sexual activity, sexual risk behaviors (eg, number of partners and unprotected intercourse), sexually transmitted infections, and adolescent pregnancy. One key component of an effective program is encouraging community-centered efforts. In addition to counseling and service provision to individual adolescent patients, obstetrician–gynecologists can serve parents and communities by supporting and assisting sexuality education. Because of their knowledge, experience, and awareness of a community’s unique challenges, obstetrician–gynecologists can be an important resource for sexuality education programs.

Comprehensive sexuality education should be medically accurate, evidence-based, and age-appropriate, and should include the benefits of delaying sexual intercourse, while also providing information about normal reproductive development, contraception (including long-acting reversible contraception methods) to prevent unintended pregnancies, as well as barrier protection to prevent sexually transmitted infections (STIs).

Comprehensive sexuality education should begin in early childhood and continue through a person’s lifespan.

Programs should not only focus on reproductive development (including abnormalities in development, such as primary ovarian insufficiency and müllerian anomalies), prevention of STIs, and unintended pregnancy, but also teach about forms of sexual expression, healthy sexual and nonsexual relationships, gender identity and sexual orientation and questioning, communication, recognizing and preventing sexual violence, consent, and decision making.

Obstetrician–gynecologists can serve parents and communities by supporting and assisting sexuality education, by developing evidence-based curricula that focus on clear health goals (eg, the prevention of pregnancy and STIs, including human immunodeficiency virus [HIV]), and providing health care that focuses on optimizing sexual and reproductive health and development.

Obstetrician–gynecologists have the unique opportunity to act “bi-generationally” by asking their patients about their adolescents’ reproductive development and sexual education, human papillomavirus vaccination status, and contraceptive needs.

Comprehensive sexuality education should be medically accurate, evidence-based, and age-appropriate, and should include the benefits of delaying sexual intercourse, while also providing information about normal reproductive development, contraception (including long-acting reversible contraception methods) to prevent unintended pregnancies, as well as barrier protection to prevent STIs Box 1 . Comprehensive sexuality education should begin in early childhood and continue through a person’s lifespan. Programs should not only focus on reproductive development (including abnormalities in development, such as primary ovarian insufficiency and müllerian anomalies), prevention of STIs, and unintended pregnancy, but also teach about forms of sexual expression, healthy sexual and nonsexual relationships, gender identity and sexual orientation and questioning, communication, recognizing and preventing sexual violence, consent, and decision making. They also should include state-specific legal ramifications of sexual behavior and the growing risks of sharing information online 1 . Additionally, programs should cover the variations in sexual expression, including vaginal intercourse, oral sex, anal sex, mutual masturbation, as well as texting and virtual sex 2 . The American Academy of Pediatrics provides an overview of the published research on evidence-based sexual and reproductive health education 3 .

What Constitutes Comprehensive Sexuality Education

The following are components of comprehensive sexuality education:

Comprehensive sexuality education should be medically accurate, evidence-based, and age-appropriate, and should include the benefits of delaying sexual intercourse, while also providing information about normal reproductive development, contraception (including long-acting reversible contraception methods) to prevent unintended pregnancies, as well as barrier protection to prevent sexually transmitted infections.

Emphasis on human rights values of all individuals, including gender equality, gender identity, and sexual diversity, and differences in sexual development.

Encourage consideration of implants and intrauterine devices for all appropriate candidates.

Include information on consent and decision making, intimate partner violence, and healthyrelationships.

Participatory and culturally sensitive teaching approaches that are appropriate to the student’s age as well as identification with distinct subpopulations, including adolescents with intellectual and physical disabilities, sexual minorities, and variations in sexual development.

Knowledgeable about and inclusive of statespecific consequences of sexual activity duringadolescence, including online and social media activity.

Discussion of the benefits and pitfalls of online information (eg, gross misinformation on sexuality in cyberspace).

Current sexuality education programs vary widely in the accuracy of content, emphasis, and effectiveness. Evaluations of biological outcomes of sexuality education programs, such as pregnancy rates and STIs, are expensive and complex, and they can be unreliable, often relying on self-reported behaviors to measure effectiveness. Between 1996 and 2010, there was a strong emphasis in sexuality education on abstinence until marriage because of federal and state funding bans on comprehensive information about contraception. Several states have responded to parents’ and communities’ calls to provide education on not only abstinence, but on contraception, STIs (including human immunodeficiency virus [HIV]), and the proper use of condoms 4 .

State definitions of “medically accurate” vary widely, and most states require school districts to allow parental involvement in sex education programs 5 . Many states have requirements regarding topics that must be included in sex education programs. Although most federal funding goes to comprehensive sexual education programs, Title V Abstinence Education Grant funding is available to states that choose to provide activities meeting abstinence-only specifications, which can be found at www.ssa.gov/OP_Home/ssact/title05/0510.htm and www.siecus.org/index.cfm?fuseaction=Page.ViewPage&PageID=1158 . Up-to-date state-level policy information can be found at the Guttmacher Institute’s State Center www.guttmacher.org/state-policy/explore/sex-and-hiv-education .

In addition to counseling and service provision to adolescent patients, obstetrician–gynecologists can serve parents and communities by supporting and assisting sexuality education by developing evidence-based curricula that focus on clear health goals (eg, the prevention of pregnancy and STIs, including HIV) and providing health care that focuses on optimizing sexual and reproductive health and development, including, for example, education about and administration of the human papillomavirus vaccine 6 . Because of their knowledge, experience, and awareness of a community’s unique challenges, obstetrician–gynecologists can be an important resource for sexuality education programs 7 . Additionally, obstetrician–gynecologists can encourage patients to engage in positive behaviors to achieve their health goals and discourage unhealthy relationships and behaviors that put patients at high risk of pregnancy and STIs. Clinicians also can evaluate adolescents’ level of engagement in risky behaviors, including those occurring online, and educate patients and guardians of the risks of social media and the Internet; and provide support to the parents and guardians of adolescents by encouraging them to be actively involved in their children’s sexuality education. Obstetrician–gynecologists have the unique opportunity to act “bi-generationally” by asking their patients about their adolescents’ reproductive development and sexual education, human papillomavirus vaccination status, and contraceptive needs. Although obstetrician–gynecologists are well-suited to provide sexuality education, some may encounter obstacles; local laws have been proposed to restrict family planning providers from giving sexual health information to adolescents outside of a medical setting (a physician’s office or community health clinic) 8 .

When a responsible adult communicates about sexual topics with adolescents, there is evidence of delayed sexual initiation and increased birth control and condom use 9 . Although many parents talk with their adolescents about risks and responsibilities of sexual activity, one third to one half of females aged 15–19 years report never having talked with a parent about contraception, STIs, or “how to say no to sex” 9 . Community and school-based programs also are an important facet of sexuality education.

Data have shown that not all programs are equally effective for all ages, races and ethnicities, socioeconomic groups, and geographic areas; there is no “one size fits all” program. However, one key component of an effective program is to encourage community-centered efforts. Innovative, multicomponent, community-wide initiatives that use evidence-based adolescent pregnancy prevention interventions and reproductive health services (including inclusion of moderately or highly effective contraceptive methods, such as long-acting reversible contraception) have dramatically reduced pregnancy rates among African American and Hispanic individuals aged 15–19 years old 10 . Although formal sex education varies in content across schools, studies have demonstrated that comprehensive sexuality education programs reduce the rates of sexual activity, sexual risk behaviors (eg, number of partners and unprotected intercourse), STIs, and adolescent pregnancy 11 . However, despite concerns raised by some involved in health education, a study of four select abstinence-only education programs reported no increase in the risk of adolescent pregnancy, STIs, or the rates of adolescent sexual activity compared with students in a control group 12 .

Adolescents with physical and cognitive disabilities often are considered to be asexual and, thus, have been excluded from sexuality education 13 . However, they have concerns regarding sexuality similar to those of their peers without disabilities. Their knowledge of anatomy and development, sexuality, contraception, and STIs (including HIV), should be on par with their peers, and they should be included in sexuality programs through their schools and communities.

Comprehensive sexuality education should not marginalize lesbian, gay, bisexual, questioning, and transgender individuals and those that have variations in sexual development (eg, primary ovarian insufficiency, müllerian anomalies). Curricula that emphasize empowerment and gender equality tend to engage learners to question prevailing norms through critical thinking and encourage adolescents to adopt more egalitarian attitudes and relationships, resulting in better sexual and health outcomes 14 .

Adolescents may use a variety of media sources to fill in gaps from the sexuality education they receive from schools, community programs, and parents; thus, media literacy is increasingly a key factor in children’s sexual health. Three quarters of adolescents use a social networking site, more than 80% own a cell phone, and the Internet is available to almost all adolescents at school and home 15 . Comprehensive sexuality programs should consider the benefits and pitfalls of social media. Adolescents should be aware of their “digital footprint” and the physical and legal dangers of their online behavior 1 .

There is a growing interest among adolescents to access sexual health information online that is written in language they can understand, that is in an interactive format, and that is presented in an entertaining manner 16 17 . Educational opportunities may be limited by the Internet because popular search engines often will include inappropriate sites or pornography as the first available choice, and some reputable sexual education sites will have their content blocked by social networking sites as “offensive.” Finally, adolescents are not likely to seek out and follow an organization through a social networking site, but will heed an RSS feed (an aggregation of information, including blog entries, news headlines, audio, and video) or text messages 18 . For more information, see Committee Opinion No. 653, Concerns Regarding Social Media and Health Issues in Adolescents and Young Adults 1 .

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/ComprehensiveSexualityEducation .

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s web site, or the content of the resource. The resources may change without notice.

• Concerns regarding social media and health issues in adolescents and young adults. Committee Opinion No. 653. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e62–5. [ PubMed ] [ Obstetrics & Gynecology ] Article Locations: Article Location Article Location Article Location
• Addressing health risks of noncoital sexual activity. Committee Opinion No. 582. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:1378–82. [ PubMed ] [ Obstetrics & Gynecology ] Article Locations: Article Location
• Breuner CC, Mattson G. Sexuality education for children and adolescents. AAP Committee on Adolescence, AAP Committee on Psychosocial Aspects of Child and Family Health. Pediatrics 2016;138(2):e20161348. [ PubMed ] [ Full Text ] Article Locations: Article Location
• Bleakley A, Hennessy M, Fishbein M. Public opinion on sex education in US schools. Arch Pediatr Adolesc Med 2006;160:1151–6. [ PubMed ] [ Full Text ] Article Locations: Article Location
• National Conference of State Legislatures. State policies on sex education in schools . Washington, DC: NCSL; 2016. Available at: http://www.ncsl.org/research/health/state-policies-on-sex-education-in-schools.aspx . Retrieved June 27, 2016. Article Locations: Article Location
• Human papillomavirusvaccination . Committee Opinion No. 641. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e38–43. [ PubMed ] [ Obstetrics & Gynecology ] Article Locations: Article Location
• Kirby D. Emerging answers 2007: new research findings on programs to reduce teen pregnancy . Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; 2007. Available at: https://thenationalcampaign.org/sites/default/files/resource-primary-download/EA2007_full_0.pdf . Retrieved June 27, 2016. Article Locations: Article Location
• Sexuality Information and Education Council of the United States. 2015 sex ed state legislative year-end report: top topics and takeaways . Washington, DC: SIECUS; 2016. Available at: http://siecus.org/index.cfm?fuseaction=document.viewDocument&documentid=574&documentFormatId=657 . Retrieved July 13, 2016. Article Locations: Article Location
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Philly has highest STI rates in the country – improving sex ed in schools and access to at-home testing could lower rates

Assistant Professor of Public Health, Purdue University

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Philadelphia ranks No. 1 among U.S. cities for new sexually transmitted infections – STIs – according to the latest data from the Centers for Disease Control and Prevention.

This is up from fifth place in 2023 and puts Philadelphia ahead of four cities that previously rated higher: Memphis, Tennessee; Jackson, Mississippi; New Orleans and St. Louis.

Among 15- to 24-year-olds in Philadelphia, syphilis cases have shot up 30% since 2019, while cases of gonorrhea [increased 18%]. Chlamydia cases are down 13% from pre-pandemic numbers among this age group, but remain high.

As a public health professor, I research sexual health issues and disparities among Black men who have sex with men and other marginalized groups. I work directly with these communities to research and create health interventions that meet their needs.

I know that two important barriers to young people’s sexual health are high-quality sex education and access to confidential STI testing.

Sex ed in schools

In the U.S., 28 states and Washington D.C. mandate sex education in both elementary and high schools. These programs are typically comprehensive and include education on STIs.

Pennsylvania, however, is not one of those states.

Pennsylvania state law does require schools to provide instruction on the prevention of HIV and AIDS and other “life-threatening and communicable diseases” – though it does not specify STIs.

Each school district in the state can decide which education materials are used to meet the requirements. This information isn’t required to be medically accurate or supported by evidence-based research .

Schools are also not required to discuss consent, sexual orientation and gender identity, or healthy sexual relationships.

Abstinence-based vs. comprehensive

The absence of more specific policies and standards led to controversial sex education instruction in the Wallingford-Swarthmore School District, in suburban Philadelphia, in 2018. A 17-year-old student filed a complaint to the school district that the RealEd “relationship education” program they received advised avoiding kissing or cuddling, which could deprive them of hormones and make “bonding with a future spouse difficult.”

Other students reported that the curriculum taught them that having too many sexual partners makes them “less sticky,” like a reused piece of tape, and prevents them from having healthy relationships.

Research suggests that sex education programs that stress abstinence do not decrease rates of STIs and HIV. In some instances, they could lead to an increase in STIs .

In contrast, studies have shown that comprehensive sex education programs in schools have resulted in lower rates of sexual activity , increased use of contraception , and fewer teen pregnancies . These comprehensive programs are medically accurate and age appropriate, and provide broad knowledge for youth on sexual health beyond the topics of HIV, STIs and abstinence.

It’s not clear whether comprehensive sex education programs directly lead to fewer STI rates. However, research does show that increased safe-sex practices is a consistent result from comprehensive sex education.

While the School District of Philadelphia does not report having any specific mandates around sex education, it confirmed via email that all 218 district schools – this does not include their alternative and charter schools – use selected lessons from the 3Rs: Rights, Respect, Responsibility sex ed curriculum as part of their health education for grades K-12.

In addition, their Office of Health, Safety and Physical Education works closely with a grant-based program called Promoting Adolescent Student Health, or PASH, . The program “focuses on reducing youth risk behaviors that lead to unintended pregnancy, STI and HIV” at 17 priority schools in the city.

Confidential testing and other strategies

In the absence of tailored, comprehensive sex education programming for all school-age youth in Philadelphia, here are some evidence-based strategies that can be implemented to reduce the rates of new STI infections.

More relevant curricula: Current sex ed programs could include a broader range of sexual health topics , such as healthy communication and sexual pleasure. Curricula could also be adapted and implemented for younger age groups , and health professionals could collaborate directly with students to determine what they want included in a sex education program. Providing the information online can help make it more accessible and easier to keep updated.

LGBTQ+-inclusive curricula: LGBTQ+ youth are often more vulnerable to STIs due to stigma and lack of access to culturally affirming health care . They are also more likely to experience harmful outcomes from abstinence-based programs and to disengage from comprehensive sex education programs that are not tailored to their needs . Research shows much better outcomes from comprehensive sex education programs that are inclusive of the needs of LGBTQ+ youth and delivered prior to youth engaging in sexual activity.

At-home testing: Testing can slow the spread of STIs, and at-home testing in particular can address many young people’s concerns of confidentiality and access. Research has shown that young people want at-home STI and HIV screening kits, which are affordable and convenient.

Affirming health care: I believe it’s also important that health care providers receive education and training on how to provide culturally affirming sexual health care to young people. This includes providers being able to initiate what they may deem as uncomfortable conversations with patients of different racial or ethnic backgrounds, sexual orientations and gender identities .

Comprehensive treatment: Researchers who conducted a study of over 5,000 Philadelphia teens age 16-17 recommend that health care professionals implement what’s called an “ STI Care Continuum ” to improve STI screening and treatment for young people. This means youth who have STI symptoms are not only tested and treated, but also provided contact-tracing resources and prevention counseling, and are retested.

When it comes to testing, national guidelines recommend health care providers screen all women ages 25 or younger for chlamydia and gonorrhea annually. A minimum of annual testing of chlamydia, gonorrhea and syphilis is recommended for young men who have sex with men.

If schools , communities , health care professionals and other groups pursued these strategies concurrently and in collaboration, I believe STI rates among Philadelphia youth would decline significantly.

• Sexual health
• Sex education
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• Pennsylvania
• Sexually transmitted infections

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• Published: 05 May 2020

The roles of attitudes towards learning and opposite sex as a predictor of school engagement: mixed or single gender education?

• Mustafa Yüksel Erdoğdu   ORCID: orcid.org/0000-0001-6403-5630 1  

Palgrave Communications volume  6 , Article number:  81 ( 2020 ) Cite this article

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Students’ attitudes towards learning and their school engagement play important roles on the success of educational programs. Therefore, the main purpose of this research is to examine the roles of attitude towards learning and attitude towards the opposite sex as a predictor of school engagement and to determine the correlation between mixed gender education vs. single gender education and school engagement. Eight hundred and forty-three students (525 females and 318 males) who were studying in single gender or mixed gender schools were included in the research. Data were collected through School Engagement Scale, Attitude Scale towards Learning and Opposite Sex Attitude Scale. The Pearson moment correlation coefficient, multiple regression and stepwise regression were used to analyze the data. Findings showed that attitudes towards learning scores are the most predictive for school engagement. Results also showed that school engagement was higher in single gender schools for girls than in single gender schools for boys and mixed gender schools. The success of the student and the attitude towards the opposite sex were also variables that predict school engagement. The democratic attitude and education levels of parents also had important effects on students’ school engagement. The findings have important implications for educational policy making and curriculum designs. Some general recommendations were made based on the findings.

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Introduction.

The development of societies is possible with the presence of trained and equipped manpower. Undoubtedly, the important impact of the school cannot be ignored in the training of qualified manpower required by the modern times. The school not only is an environment that provides students with academic knowledge and improve their mental processes, but also bears features that affect their emotional, social, physical, and moral development. Hence, it is important for children to have positive feelings towards school so that they can benefit from the educational activities at the highest level. There are many factors originating from individual and family that affect students’ attitudes towards the school. One of them is school engagement.

There have been many definitions of school engagement to date. While Silins Mulford ( 2002 ) defined school engagement as going to school regularly, participating in school-related decisions and social activities, Finn ( 1993 ) described it as feeling the sense of belonging to the school and adopting school’s objectives. The common ground in school engagement is that students identify themselves with the school and participate in school-related activities (Audas and Willms, 2002 ; Finn and Voelkl, 1993 ). In this context, school engagement in general can be defined as how the individual embraces the school, integrates themselves with school’s objectives, participates in cultural and social activities in the school and wants to be together with their friends and teachers.

School engagement is addressed in affective, cognitive, and behavioral dimensions. Cognitive dimension refers to students’ willingness to learn, their positive attitude towards learning; behavioral dimension is about students’ participation in sporting and cultural activities; and emotional dimension is described as students’ having a positive attitude towards school and friends at school (Finlay, 2006 ; Fredricks et al., 2004 ). It has been observed that students with high school engagement go to school more frequently, are less absent from school and have lower dropout rates (Connell et al., 1994 ; Hirschfield and Gasper, 2011 ; Janosz et al., 2008 ; McNeely and Falci, 2004 ). Furthermore, research results have explored that students with high school engagement levels are also those who are academically successful (Appleton et al., 2006 ; Hirschfield and Gasper, 2011 ; Klem and Connell, 2004 ; Simons-Morton and Chen, 2009 ).

Studies on school engagement in the literature seem to address many different variables. In the study conducted by Erdoğdu ( 2016 ), friendship relations predicted school engagement on a higher level than teacher attitudes, and school engagement of those who attended cultural and sporting activities was on higher levels. Shin et al. ( 2007 ) achieved similar results and explored that peer support had a positive effect on school engagement. Thaliah and Hashim ( 2008 ) reported that students’ school engagement levels were higher when they had more teacher support. Arastaman ( 2009 ) and Conchas ( 2001 ) found that children of parents with low socio-economic status experienced more school engagement.

There are several variables that affect students’ school engagement, and one of them is the attitude towards learning. The concept of learning has been defined in many different ways. According to some scientists, learning is a relatively permanent change in behavior resulting from experiences in the interaction with environment (Hergenhann, 1988 ; Hoy and Miskel, 2010 ; Schunk, 2009 ). Whereas behaviorists describe learning as only observable behavioral changes since they ignore internal processes (Schwartz and Reisberg, 1991 ), cognitive theorists focus on mental processes and state that there is no need for observable behavior to occur in learning. Ormrod ( 1990 ) defines the concept of learning as the association of new knowledge with existing knowledge based on the knowledge-processing approach. Positive attitudes towards learning affect the learning of individuals both in school and real life. In the case of positive attitudes towards learning, it is observed that individuals perform more successfully in academic terms (Bråten and Strømsø, 2006 ; Duarte, 2007 ) and that emotions and thoughts about learning affect student behaviors (Pierce et al., 2007 ). Prokop et al. ( 2007 ) showed that there was a positive correlation between the level of knowledge and individuals’ positive emotions towards learning. A study by Aktürk ( 2012 ) concluded a positive relationship between the preservice teachers’ positive attitudes towards learning and their academic achievement. Erdoğdu ( 2017 ), observed that the students with a positive attitude towards learning were more successful, had higher motivation for the courses, participated more in cultural activities in the school and listened to the teacher in the class more carefully.

One of the variables which is assumed to relate to school engagement is students’ opposite-sex attitudes; that is the relationship between opposite-sex attitude and school engagement (Liem and Martin, 2011 ). Opposite-sex attitude refers to emotional tendencies against opposite sex. These tendencies shape sexes’ behaviors towards each other cognitively, behaviorally and affectively. Formation of opposite-sex friendships, which can be defined as the desire of two different sexes to coexist with each other, purpose of this coexistence, and the way it is realized vary by developmental processes. During the developmental period between the ages of 3 and 6, also called early childhood, opposite-sex friendships are observed in plays whereas in late childhood which refers to 7–11 years of age such friendships is observed in activities of learning, investigating and being successful In adolescence, opposite-sex friendship might result in emotional coexistence and marriage.

According to the psychoanalytic theory, efforts to develop intimacy with the parent of the same sex in the phallic era tend to shift towards the opposite-sex parent in the latent period (Öztürk, 1995 ), and immediately afterwards, opposite-sex friendships gain importance in the genital period. Sullivan ( 1953 ) argues that efforts to establish friendship with the opposite sex increase further during adolescence, and these efforts of becoming intimate happen to be the developmental task of this period. Purposes of establishing friendship with the opposite sex may differ by gender. In the study conducted by Lacey et al. (2004), the preference of the women in opposite-sex friendships was the social status and income of men whereas the men attached more importance to the physical attractiveness of women. Another study by Underwood et al. ( 2009 ) reported that the adolescent girls expected to become only friends with boys while the boys were in the expectation of an emotional relationship. Adolescents can learn their self, gender-based identity and role by befriending the opposite sex. In this context, positive attitudes towards the opposite sex are important for them, since they help them acquire their developmental characteristics (Collins and Sprinthall, 1995 ). Studies on opposite-sex friendship in Turkey seem to address the relationship between opposite-sex friendship and social self-efficacy (Başaranoğlu, 2011 ; Türkoğlu et al., 2015 ), but there has been no study performed on the relationship between attitude towards opposite-sex friendship and academic achievement at school.

Of research interest is whether school engagement differed by attending a coed or single-sex school. Coeducation can be described as female and male students’ receiving education in the same environment while single-sex education refers to how only students of the same sex receive education in the same environment (Hammaker, 1995 ; Mael, 1998 ). Not only in Turkey but also around the world, the effects of coeducation or single-sex education on the development of individuals have still been investigated (Gibb et al., 2008 ; McFarland et al., 2011 ; Rycik, 2008 ; Schober et al., 2004 ). Debates on coeducation arose for the first time after the foundation of the republic in Turkey when girls wanted to enroll in boy high schools in Tekirdağ (Kamer, 2013 ). The implications of coeducation or single-sex education are the matter of concern not only in education policies but also in political and ideological debates. There are those who argue that coeducation is more effective as it increases respect among opposite sexes, improve their confidences and make them study together while others advocate the idea that single-sex education is more effective because coeducation leads to moral degeneration.

At the US congress, Hillary Clinton ( 2001 ) said, “There should be no obstacles to single-sex education in the education system of the state. We have to see the successes of single-sex schools. These schools encourage students and parents”, emphasizing the effectiveness of single-sex education. Some studies show that female students studying in single-sex classes are more successful than in co-educational schools (Kohlhaas et al., 2010 ; McFarland et al., 2011 ; Mulholland et al., 2004 ). Thom ( 2006 ) achieved similar results in another research. According to Leonard ( 2007 ), this is because such schools are more careful about choosing students.

Moreover, some studies have shown that academic achievements of schools significantly differ by being a coed or single-sex school (Fritz, 1997 ; Garcia, 1998 ; Schober et al., 2004 ; Scoggins, 2009 ; Spielhofer et al., 2004 ). There are also research findings indicating that coeducation yields more positive results than single-sex education setting in terms of academic education (Elam, 2009 ; Marsh and Rowe, 1996 ). As abovementioned, previous research studies achieved different findings on whether coed or single-sex schools increase academic achievement more. In Turkey, to the best of the researcher knowledge, no research has been conducted on the relationship between coed or single-sex education and academic achievement.

This study aims to make contributions to the literature by testing the effects of variables which are assumed to be related to school engagement with regression analysis. It is anticipated that the research findings will guide future studies on increasing students’ school engagement. In the light of discussion made above study examined, the questions to be addressed in this study are: (1) is there a relationship between school engagement, attitude towards learning, opposite-sex attitude, type of school, parental attitude, and parents’ educational level? (2) is there a relationship between school engagement and achievement level? (3) to what extent does type of school, achievement level, parental attitude, and parents’ educational level predict school engagement?

Research model

This research was carried out in the relational survey model since it aimed to determine how the variables that are assumed to relate to school engagement predict the level of school engagement. According to Heppner et al. ( 2013 ), research aiming to explore the relationship(s) between two or more variables is called relational research.

Study group

As the research was performed on coed and single-sex schools, stratified purposive sampling method of purposive sampling methods was used to choose the schools. In this method, the sample is composed of subgroups of interest to show, describe, and compare their characteristics. It is also called quota sampling (Büyüköztürk et al., 2012 ). The research was conducted on the students attending girls’, boys’, and coed high schools within the boundaries of Istanbul Metropolitan Municipality. Table 1 shows the number of girls and boys attending the schools that were selected for the research sample.

Participants were 525 (62.3%) girls and 318 (37.7%) boys. Instruments were applied to 316 (37%) students from girls’ vocational high schools, 154 (19%) students from boys’ high schools and 373 (44%) students from coed high schools (843 volunteered students in total).

Of the total students who participated in the study, 264 (31%) perceived themselves as successful, 531 (63%) as moderately successful, and 48 (6%) as unsuccessful. The students reported that their parents had authoritarian attitude (93 [11%]), democratic attitude (163 [19%]), over-protective attitude (366 [43%]), over-demanding attitude (136 [16%]) and other parental attitudes (79 [10%]). As for education levels of the students’ mothers, 35 (4%) are illiterate, 306 (36%) are primary school graduates, 351 (42%) are high school graduates and 147 (17) are university graduates. Of their fathers, 10 (1%) are illiterate, 243 (29%) are primary school graduates, 377 (45%) are high school graduates and 208 (25%) are university graduates.

Data collection instruments

School engagement questionnaire (seq) (arastaman, 2006 ).

The SEQ developed by Arastaman is graded on a 5-point Likert scale. The instrument consists of 9 items and 5 factors. The subscales are Student’s Internal Engagement, School Environment Engagement, School Program Engagement, School Administration’s Engagement Relationship, Teacher’s Engagement Relationship. Cronbach’s Alphas of the subscales vary between 0.65 and 0.83. The variances explained by the subscales were calculated to be between 7.94% and 14.72% (Arastaman, 2006 ). Since all items provided a total score on school engagement, the subscales were not used in this study. In this current study, the Cronbach’s Alphas of all items were recalculated, and the reliability value was found to be 0.95.

Scale of Attitudes Towards Learning (SATL) (Kara, 2010 )

The SATL was applied to determine students’ attitudes towards learning. The scale consists of 4 factors which are Nature of Learning (7 items), Expectation (9 items), Openness (11 items), and Anxiety (13 items). Cronbach’s Alphas of the subscales range from 0.72 to 0.78. The factor analysis concluded the factor loadings of the scale to be within acceptable limits. Test-retest reliability coefficient of the scale was calculated to be 0.87. For this study, the Cronbach’s Alpha of the scale was recalculated, and the reliability value was 85.

Opposite-Sex Attitude Scale (OSAS) (Erdoğdu, 2018 )

The OSAS is a 26-item 5-point Likert scale. An exploratory factor analysis was performed for the validity study, and all 26 items were observed to group under a single great factor with an eigenvalue >1. The variance explained by this single factor is 53.13%. Common variances of the single factor vary between 0.321 and 0.614. KMO values, Bartlett’s Test, and Cronbach’s Alpha internal consistency coefficients of the final version of the scale were calculated, and the obtained data were found within acceptable limits. The Cronbach’s Alpha of the scale was calculated to be 0.95 for the reliability study. Item discriminations were calculated to support the construct validity, and each item’s discriminants were found to be significant. The Cronbach’s Alpha of the scale was recalculated, and the reliability value was found to be 0.96.

An information form was prepared by the researcher to obtain students’ demographic data.

Procedure and data analysis

Consent letters were obtained from the volunteer students and their parents and the required permissions were also obtained from the school authorities where the study was conducted, and the instruments were applied to volunteered students in groups in the classroom setting.

The relationships between predictor variables and predicted variables were calculated with Pearson’s product moment correlation coefficient. In the research, the categorical variables were converted to dummy variables produced in the amount that is one minus the number of levels by excluding one of the levels. Next, a multiple regression analysis was performed to determine to what extent the independent variables converted to dummy variables predicted the dependent variable. Then, a stepwise regression analysis was carried out to determine which of the independent variables contributed significantly to the prediction of school engagement level. How each of these independent variables contributed to the variance when predicting school engagement were also calculated.

Descriptive statistics of the instruments used in the research are given in Table 2 .

As shown in Table 2 , the mean score was 100.87 and the standard deviation was 17.72 for the SEQ, the mean score was 93.35 and the standard deviation was 21.20 for the OSAS, and the mean score was 146.40 and the standard deviation was 16.78 for the SATL.

The correlation coefficients among the variables addressed in the study are given in Table 3 .

As shown in Table 3 , a moderate positive correlation was found between the scores of SEQ and Scale of Attitudes toward Learning ( r  = 0.486, p  < 0.01). There was no significant correlation between the scores of SEQ and Scale of Attitude towards Learning ( r  = −0.028, p  > 0.01). A positive correlation was observed between the achievement levels and the scores of SEQ ( r  = 0.236, p  < 0.01). There were low, negative, significant correlations between the scores of SEQ and mother’s education level ( r  = −0.154, p  < 0.01) and father’s education level ( r  = −0.185, p  < 0.01). A low, negative, significant correlation was found between the scores of SEQ and the type of school ( r  = −0.335, p  < 0.01). No significant correlation was observed between the scores of SEQ and the perceived parental attitudes ( r  = −0.056, p  > 0.01).

Since the students’ demographics were categorical variables, these variables were converted to dummy variables before the analysis, and a multiple regression analysis was carried out to determine to what extent each of these categorical variables predicted school engagement. The findings are presented in Table 4 .

The scores obtained by the students attending different types of school (Boys’ High School, Girls’ High School, Coed High School) significantly predicted students’ school engagement ( R  = 0.342, R 2  = 0.117, p  < 0.001). These three variables explained 12% of the variance on the level of school engagement. According to the standardized regression coefficient ( β ), the relative order of significance of the predictor variables for school engagement is the scores obtained by girls’ high school, boys’ high school and coed high school students, respectively. There was a negative correlation between the scores obtained by the boys’ high school students and their school engagement scores. As for the t -test results regarding the significance of the regression coefficients, the scores obtained by the boys’ high school and girls’ high school students were found to be significant predictors of school engagement.

The scores obtained by the students with different achievement levels (successful, moderately successful, unsuccessful) predicted their school engagement ( R  = 0.261, R 2  = 0.068, p  < 0.001). These three variables explained 7% of the variance on the level of school engagement. According to the standardized regression coefficient ( β ), the relative order of significance of the predictor variables for school engagement is the scores obtained by the unsuccessful, successful and moderately successful students, respectively. There was a negative correlation between the scores of the unsuccessful students and their school engagement scores. Given the t -test results concerning the significance of the regression coefficients, the scores obtained only by the successful and unsuccessful students significantly predicted school engagement.

The scores obtained by the students with different perceived parental attitudes (democratic, over-protective, authoritarian, over-demanding) significantly predicted students’ school engagement ( R  = 0.145, R 2  = 0.021, p  < 0.001). These four variables explained only 2% of the variance on the level of school engagement. According to the standardized regression coefficient ( β ), the relative order of significance of the predictor variables for school engagement is the scores obtained by the students who had parents with democratic, over-protective, over-demanding, and authoritarian attitudes, respectively. In regard to the t -test results concerning the significance of the regression coefficients, the scores obtained by the students who had parents with democratic and over-protective attitudes were found to be significant predictors of school engagement.

The scores obtained by the students whose mothers have different educational levels (illiterate, primary school, secondary education, university) significantly predicted students’ school engagement ( R  = 0.165, R 2  = 0.027, p  < 0.001). However, no significant correlation was observed between the scores of the students whose mothers have different educational levels and their school engagement scores.

The scores obtained by the students whose fathers have different educational levels (illiterate, primary school, secondary education, university) significantly predicted students’ school engagement ( R  = 0.228, R 2  = 0.052, p  < 0.001). These four variables explained only 5% of the variance on the level of school engagement. According to the standardized regression coefficient ( β ), the relative order of significance of the predictor variables for school engagement is the scores obtained by the students whose fathers are primary school graduates, secondary education graduates, university graduates, and illiterate, respectively. As for the t -test results regarding the significance of the regression coefficients, the scores obtained only by the students whose fathers are primary school and secondary school graduates were found to be significant predictors of school engagement.

Stepwise regression analysis of the predictors of students’ school engagement levels is shown in Table 5 .

The analysis was completed in seven steps. The variable of attitude towards learning, which explained the greatest variance at 24% in the school engagement variable, was included in the first step of the analysis. There was a positive correlation between positive attitudes toward learning and school engagement. With the inclusion of type of school, which had a 7% contribution to the variance, in the second step, the explained variance increased to 31%. A negative significant correlation was found between attending a coed high school and school engagement. Achievement level, which contributed to the variance at 2%, was included in the third step, and the explained variance increased to 33%. There was a negative significant correlation between students’ perceiving themselves as unsuccessful and school engagement. The boys’ high schools were included in the fourth stage of the analysis. Boys’ schools contributed 2% to variance, and the explained variance increased to 35%. There was a negative significant correlation between the scores obtained by boys’ high school students and school engagement. Achievement level, which contributed to the variance at 2%, was included in the fifth step again, and the explained variance increased to 37%. There was a positive significant correlation between high achievement levels of the students and their school engagement levels. In the sixth step of the analysis, the opposite-sex attitude scores, with very little contribution of 4% to the variance, was included, and the explained variance increased to 38%. A low, negative correlation was found between the opposite-sex attitude scores and school engagement. In the last step, primary school graduate fathers were included with 3% contribution to the variance, and the total explained variance increased to 38%.

Discussion, conclusion and recommendations

The research results indicate that the scores obtained by girls’ high school students predicted the school engagement levels more than boys’ high school students and mix-gender school students. While a negative correlation was found between the scores obtained by the boys’ high school students and their school engagement scores, there was no significant correlation between the scores obtained by the coed high school students and school engagement. It is thought that the girls had higher levels of school engagement because they interact with each other more in school. They experience problems with going out of house unless they go to school which is due to their conservative family structures. Furthermore, the reason why they had high levels of school engagement could be associated with the fact that they become mature more rapidly than their male peers and are more willing to succeed. Similar results were obtained in several studies (Deem, 1984 ; Fullarton, 2002 ; Gauley, 2017 ; Neel and Fuligni, 2013 ; Spender and Sarah, 1980 ), and the girls were found to have lower achievement levels in coed schools (Lee and Bryk, 1986 ). Nevertheless, there are research findings indicating that there were no significant differences between the coed school students and the achievements of the single-sex school students (Marsh, 1989 ; Roberson, 2010 ; Smithers and Robinson, 2006 ).

As Table 3 shows, there is a positive significant correlation between students’ school engagement levels and their achievement level. In other words, the academically more successful students were found to have higher school engagement levels. Enjoying being in school and participating in school activities, certainly, create a sense of belonging and responsibility in students, which therefore leads to higher levels of school engagement. Previous studies showed that the academically successful students had higher levels of school engagement (Erdoğdu, 2016 ; Finn and Rock, 1997 ; Fredricks et al., 2004 ).

The students who perceived their parents’ attitudes as democratic and protective against external threats had higher levels of school engagement. The reason for students’ higher levels of school engagement could be that their parents respect child’s development and decisions, support their decisions and engagement in child’s school life and achievements. Research has shown that family participation in the child’s school life (Simons-Morton and Crump, 2003 ) and the presence of family support (Mengi, 2011 ) contribute to higher school engagement levels among these students. Another study by Finn and Rock ( 1997 ) showed that the family structure had a decisive role in school engagement.

While there was no significant correlation between mother’s educational level and the students’ school engagement levels, the levels of school engagement were higher among the students whose fathers have low educational levels. The reason why higher levels of school engagement were found among the students with parents with low educational levels might be due to the fact that they live under relatively more difficult conditions. As a result, such students might perceive attending school as an obligation to improve their living standards. Similarly, Arastaman ( 2009 ) explored that the children whose mothers have lower educational levels had higher levels of school engagement. Fullarton (2002) and Gemici and Lu ( 2014 ) also showed that the higher the education level of parents was; the higher students’ school engagement was. As children’s quality of life increases, the level of school engagement increases too (Savi, 2011 ).

The findings obtained in the stepwise regression analysis indicated that school engagement was predicted by students’ positive attitudes towards learning at the highest level. That is to say, as students’ attitudes toward learning increased, their sense of school engagement increased too. In the literature, it shows that there is a positive relationship between school engagement and desire to learn and success (Weinstein and Mayer 1986 ; Thomson, 2005 ). In a similar study, Orthner et al. ( 2010 ) found that as the value of students increases, their school engagement also increases. When students participate in off-classroom learning activities and cultural activities, their levels of school engagement increase (Shin et al., 2007 ). As discussed by Cernkovich and Giordano ( 1992 ), if students have high school responsibility, their school engagement levels are high too.

According to the research findings, being a coed or single-sex school is the second important variable that predicted school engagement. This suggests that the type of school (coed-single sex) should be taken into account in increasing the school engagement. A negative correlation was observed in the research between attending a boys’ high school and a coed high school and school engagement. In other words, the boys’ and coed high school students generally had lower levels of school engagement. In the research, the male students were selected from vocational high schools. It is assumed that the students attending vocational high schools had lower levels of school engagement for reasons, such as their desire to start working sooner and their unwillingness to participate in academic activities. Thompson and Ungerleider ( 2004 ) argue that male students want to participate in learning activities when these activities are more competitive, active, and appropriate to their interests; when such conditions are not provided, they become more unsuccessful in the academic field. Similarly, the school engagement levels of these students in coed schools were also low. Previous research found that girls attending single sex schools had higher achievement levels and more positive school attitudes than the students of coed schools (Bryk et al., 1993 ; Collins et al., 2000 ; Riordan, 1985 ; Shmurak, 1998 ). The present study also achieved similar results. Other studies, on the other hand, found no significant difference between the academic activities of the students attending coed and single-sex schools (Brittmon, 2008 ; Scoggins, 2009 ).

The variable that predicted school engagement in the third and fifth model is achievement level. The findings showed no negative correlation between being unsuccessful and school engagement. That is to say, the more successful the students were, the higher levels of school engagement they had. It is assumed that as the school engagement level increases, the students take more responsibilities, become happier to be at school and take part in school activities, and these positive attitudes enable them to embrace their own schools, leading to higher school engagement levels. In most of the studies, it was observed that school engagement increased academic achievement (Eith, 2005 ; Finn and Rock, 1997 ; Lee and Smith, 1995 ; Osterman, 2000 ).

The findings of this research showed that there was a negative correlation between opposite-sex attitude and school engagement. In other words, if the opposite-sex attitude was positive, the level of school engagement decreased. It should be borne in mind that the research was conducted on adolescent students. It is thought that adolescents’ attitudes towards school are reduced by their increased interest in the opposite sex during this period. The typical developmental feature of this period is the increasing desire of adolescents to make friends with the opposite sex. As a result, it is assumed that the students who participated in this study had lower school engagement levels because they orientated their adolescent energy, interest, and pursuits towards the opposite sex.

It is generally expected that opposite-sex attitudes will be more positive in coed schools. Although there is no research on this subject, a study conducted by Yıldırım ( 1998 ) in a coed school indicated that the students who had friends of the opposite sex had higher perceived social support. The study conducted by Dale ( 1969 ) found that the students in a coeducation environment became more socialized with the opposite sex. It is assumed that the reason why the students of coed schools had lower levels of school engagement is that opposite-sex attitudes among the coed school students are more positive than the attitudes of the single-sex school students. It is also thought that the coed school students’ levels of school engagement were lower due to their desire to be together with the opposite sex in the same environment rather than being in the school in the first place. The “negative correlation between opposite-sex attitude and school engagement” which is a finding of this research coincides with these assumptions.

Lastly, the students whose fathers are primary school graduates were found to have higher school engagement levels. As seen in the multiple regression analysis conducted in the study, parents’ low educational levels were observed to be a predictor of school engagement whereas the stepwise regression analysis concluded that the students whose fathers are primary school graduates were found to have higher school engagement levels. There may be many possible reasons for higher social engagement levels of the students whose parents’ have low educational levels. It is thought that the students of families with lower educational and financial levels had higher levels of school engagement because they believe that the best way to escape from their disadvantageous conditions is to receive a good education and acquire a good occupation. The research carried out by Arastaman ( 2006 ) showed that the lower the parents’ educational levels were, the lower school engagement levels the children had. Another study by Conchas ( 2001 ) found that the children of families with a low socio-economic level had high levels of school engagement. However, another study by Fullarton ( 2002 ) achieved a different result indicating that the children had higher levels of school engagement when their parents had higher educational and socio-economic levels. Different results achieved by studies necessitate carrying out even more research on the relationship between these two variables.

School engagement affects not only students’ sense of belonging to the school, but also their academic, mental and emotional development. According to the research results, positive attitudes towards learning increased school engagement. It is therefore considered important to perform studies at schools to inform students of learning how to learn. Efforts to increase school engagement undoubtedly increase students’ academic achievement. In this context, it can be recommended to organize programs that will enable school counseling services to play a more active role in increasing school engagement. The research findings showed that the girls’ school students had higher levels of school engagement in their schools. Contrary to expectations, the coed school students were found to have lower levels of school engagement. Given that it is important to consider individual differences and it is attempted to regulate contents of courses accordingly in today’s education systems, it is imperative to do research that take into consideration gender differences. Indeed, male and female students vary by their interests, attitudes, and behaviors. Hence, different studies on the effects of coeducation or single-sex education on student development are required. It is also considered important to establish pilot schools formed by single-sex classes and conduct research on their effects on developmental characteristics of students. The study showed that as the education level of parents increased, school engagement decreased. New research should be performed to explore the reasons and the precautions to be taken. Finally, the findings of the study should be interpreted with regard to the context where it was carried and the participants who took part in it. It is therefore important to conduct similar studies on different contexts and different sample groups.

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All data analyzed or generated are available in the paper.

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Erdoğdu, M.Y. The roles of attitudes towards learning and opposite sex as a predictor of school engagement: mixed or single gender education?. Palgrave Commun 6 , 81 (2020). https://doi.org/10.1057/s41599-020-0457-9

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Three Decades of Research: The Case for Comprehensive Sex Education

Affiliations.

• 1 Department of Public Health, Montclair State University, Montclair, New Jersey. Electronic address: [email protected].
• 2 Department of Public Health, Montclair State University, Montclair, New Jersey.
• PMID: 33059958
• DOI: 10.1016/j.jadohealth.2020.07.036

Purpose: School-based sex education plays a vital role in the sexual health and well-being of young people. Little is known, however, about the effectiveness of efforts beyond pregnancy and sexually transmitted disease prevention. The authors conducted a systematic literature review of three decades of research on school-based programs to find evidence for the effectiveness of comprehensive sex education.

Methods: Researchers searched the ERIC, PsycINFO, and MEDLINE. The research team identified papers meeting the systematic literature review criteria. Of 8,058 relevant articles, 218 met specific review criteria. More than 80% focused solely on pregnancy and disease prevention and were excluded, leaving 39. In the next phase, researchers expanded criteria to studies outside the U.S. to identify evidence reflecting the full range of topic areas. Eighty articles constituted the final review.

Results: Outcomes include appreciation of sexual diversity, dating and intimate partner violence prevention, development of healthy relationships, prevention of child sex abuse, improved social/emotional learning, and increased media literacy. Substantial evidence supports sex education beginning in elementary school, that is scaffolded and of longer duration, as well as LGBTQ-inclusive education across the school curriculum and a social justice approach to healthy sexuality.

Conclusions: Review of the literature of the past three decades provides strong support for comprehensive sex education across a range of topics and grade levels. Results provide evidence for the effectiveness of approaches that address a broad definition of sexual health and take positive, affirming, inclusive approaches to human sexuality. Findings strengthen justification for the widespread adoption of the National Sex Education Standards.

Keywords: CSE; K-12; National Sex Education Standards; National Sexuality Education Standards; Sex education; Sexuality education; Systematic Literature Review; comprehensive sex education.

Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

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• Sex Education: Broadening the Definition of Relevant Outcomes. Kantor LM, Lindberg LD, Tashkandi Y, Hirsch JS, Santelli JS. Kantor LM, et al. J Adolesc Health. 2021 Jan;68(1):7-8. doi: 10.1016/j.jadohealth.2020.09.031. J Adolesc Health. 2021. PMID: 33349360 No abstract available.

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Study Finds that Comprehensive Sex Education Reduces Teen Pregnancy

Researchers from the University of Washington found that adolescents who receive comprehensive sex education are significantly less likely to become pregnant than adolescents who receive abstinence-only-until-marriage or no formal sex education. The study, based on a national survey of 1,719 teens ages 15 to 19, is the first population-level evaluation of the effectiveness of both abstinence-only and comprehensive sex education programs. The results are very promising for comprehensive sex education.According to Pamela Kohler, the study’s lead author, “It is not harmful to teach teens about birth control in addition to abstinence.”This study joins a host of others that prove that abstinence-only does little and comprehensive sex education does much for our teens. The dangers of abstinence-only are nothing new – one well-known study by Mathematica found that students who participated in abstinence-only programs are just as likely to have sex as their peers who did not participate.Yet in the face of this overwhelming evidence, 1 in 4 teens receive only abstinence-only instruction. On top of that, 9 percent of teens receive no sex education at all, particularly those in rural or poor areas. Thankfully, that leaves two-thirds of students in comprehensive sex ed. As temporarily reassuring as that might be, we cannot also lose sight of the fact that 1 in 4 teen girls have an STD.This sobering fact also points to how much work we have left to do. The University of Washington study does not speak to how comprehensive sex ed should be implemented. Clearly this is a question to be handled carefully by both parents and administrators alike, as we continue to improve and expand the reach of comprehensive sex education programs.

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• Society and culture
• Online safety

Relationships and sex education (RSE) and health education

Statutory guidance on relationships education, relationships and sex education (RSE) and health education.

Applies to England

Relationships education, relationships and sex education (rse) and health education.

PDF , 622 KB , 50 pages

Foreword by the Secretary of State

About this guidance, introduction to requirements, relationships education (primary), relationships and sex education (rse) (secondary), physical health and mental wellbeing (primary and secondary), delivery and teaching strategies, annex a: regulations for relationships education, relationships and sex education (rse) and health education, annex b: resources for relationships education, relationships and sex education (rse) and health education, annex c: cross government strategies for relationships education, relationships and sex education (rse) and health education, implementation of relationships education, relationships and sex education and health education 2020 to 2021.

This is statutory guidance from the Department for Education (DfE) issued under section 80A of the Education Act 2002 and section 403 of the Education Act 1996.

Schools must have regard to the guidance and, where they depart from those parts of the guidance which state that they should, or should not, do something, they will need to have good reasons for doing so.

This statutory guidance applies to all schools, and is for:

• governing bodies of maintained schools (including schools with a sixth-form) and non-maintained special schools
• trustees or directors of academies and free schools
• proprietors of independent schools (including academies and free schools)
• management committees of pupil referral units (PRUs)
• teachers, other school staff and school nurses
• headteachers, principals and senior leadership teams
• diocese and other faith representatives
• relevant local authority staff for reference

To help school leaders follow this statutory guidance, we have published:

• an implementation guide to help you plan and develop your curriculum
• a series of training modules to help train groups of teachers on the topics within the curriculum
• guides to help schools communicate with parents of primary and secondary age pupils

Updates to the page text to make it clear this guidance is now statutory. Updated the drugs and alcohol section of annex B to include a link to the teacher training module on drugs, alcohol and tobacco and to remove the link to the research and briefing papers. We have not made changes to any of the other guidance documents.

Added 'Implementing relationships education, relationships and sex education and health education 2020 to 2021'.

Added a link to the sex and relationship education statutory guidance.

Added link to guides for parents.

First published.

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Which states are restricting, or requiring, lessons on race, sex and gender

Since 2017, dozens of states have enacted more than 120 laws and policies reshaping the teaching of race, racism, sexual orientation and gender identity. These new rules now affect how three-fourths of the nation’s students learn about topics ranging from the role of slavery in American history to the lives of nonbinary people.

The Washington Post is tracking state laws, rules and policies that regulate instruction about race, as well as lessons on sex and gender, and will continue to update this page as state leaders take action.

Much of the first wave of curriculum legislation — from the late 2010s to 2021 — focused on how schools can teach about race, racism and the nation’s racial history.

How race education has changed in each state

Mostly blue states have passed expansive laws that do things like require that students learn about Black or Native American history. For example, a 2021 Delaware law says schools must offer K-12 students instruction on Black history including the “central role racism played in the Civil War” and “the significance of enslavement in the development of the American economy.”

Mostly red states, meanwhile, have passed laws that, among other things, outlaw teaching a long list of concepts related to race, including the idea that America is systemically racist or that students should feel guilt, shame or responsibility for historical wrongs due to their race. For example, a 2021 Texas law forbids teaching that “slavery and racism are anything other than deviations from, betrayals of, or failures to live up to, the authentic founding principles of the United States, which include liberty and equality.”

The target of curriculum laws has shifted over time to include determining how teachers can discuss — or whether they can discuss — gender identity and sexual orientation with students.

Changes to sex/gender education in each state

Mostly blue states have passed expansive laws that do things like require teaching about prominent LGBTQ individuals in history. For example, a 2024 Washington state law says school districts must adopt “inclusive curricula” and “diverse, equitable, inclusive” instructional materials that feature the perspectives of historically marginalized groups including LGBTQ people.

But at the same time, mostly red states have passed restrictive laws that would, among other things, outlaw lessons about gender identity and sexual orientation before a certain grade or require parental permission to learn about these topics. In one example, a 2023 Tennessee law says schools must obtain parents’ written consent for a student to receive lessons featuring a “sexual orientation curriculum or gender identity curriculum.”

Who is affected by these restrictions?

The laws cumulatively affect about three-fourths of all Americans aged 5 to 19, The Post found. The restrictive laws alone affect nearly half of all Americans in that age group. The majority of laws apply to K-12 campuses, where First Amendment protections are less potent as compared to the freedoms the courts have afforded to college and university professors.