Sex education can result in young adults delaying first intercourse or, if they are already sexually active, in using contraception. Virtually all studies conclude that sex education does not lead to earlier or increased sexual activity.
"Youth are interested in sex because of biological reasons, hormones," says Dr. Cynthia Waszak, an FHI senior scientist who focuses on adolescent health. "Suggestions about sex in music, radio, advertisements, films and television reinforce that interest. Kids talk about sex and have questions about it. We should find ways to give youth the right information so they can make better, informed decisions about their sexual behavior."
Learning about reproductive health is part of the larger developmental process as children become adults. Developing self-esteem, a sense of hope and goals for the future, and respect for others are also part of the process. Aspects of education on sexuality are incorporated into various types of programs, sometimes called family life skills or family life education in many developing countries. Married as well as unmarried adolescents need education, on contraception in particular, especially in countries such as Bangladesh and India where 50 to 75 percent of women under age 18 are married.
Sex education programs have been successful in various settings, including schools, community centers, youth groups and the workplace, explains Judith Senderowitz, a U.S.-based consultant who has written extensively on adolescence. The programs often include peer-based approaches and media activities to reach more people. A characteristic of programs that appears critical to success is "an interactive and experiential learning environment where young people can comfortably and safely explore issues and concerns and develop skills to practice safer sexual behavior," reports Senderowitz in one analysis.1
Elements for success
Successful sex education programs have common elements that can be adapted to various cultural situations. These common elements include certain features in curriculum and adequate teacher training.
Dr. Douglas Kirby, an analyst for ETR Associates, a U.S.-based educational research company, reviewed sex education programs and found 10 common elements of the most effective programs.2 Giving a clear, consistent message is critical. "The programs that give the pros and cons to having sex or using condoms and then implicitly say, 'Choose what is best for you,' were not as effective at changing behaviors as the ones that consistently made a specific case. A common effective message was 'always avoid unprotected sex.' Abstinence is the best way -- if you have sex, always use a condom."
Making the message appropriate to the age and sexual experience of the participants is also essential. "If few of the participants are having sex, focusing almost entirely on abstinence may be appropriate," he says. The most effective programs concentrated on reducing one or more sexual behaviors that lead to unintended pregnancy or HIV/STD infection.
Another important component, he says, is to identify what should change. "The successful programs," Dr. Kirby says, "all look at the factors that affect sexual behavior -- beliefs, attitudes, norms and skills -- and design a curriculum to address those factors." Effective programs also provided opportunities for students to practice communication and negotiation skills, and had them personalize the information.
Traditionally, sex education messages are targeted to one of two groups: those who are sexually active or those who are not. A study suggests that messages could be tailored to address four groups instead: those who do not anticipate having sex in the next year (delayers), those who anticipate initiating sex in the next year (anticipators), those who have had one sexual partner (singles) and those who have had two or more partners (multiples).
As a group, the anticipators showed riskier behaviors and looser ties to family, school and church when compared with the delayers. Youth with multiple sex partners also reported more risks, compared with those who have had only one partner. Health educators should "address the social and psychological context in which sexual experiences occur," recommended researchers from the U.S. Centers for Disease Control and Prevention, which studied 900 students ages 15 to 18 in the United States and Puerto Rico.3
The U.S.-based Sexuality Information and Education Council (SIECUS) has developed sex education guidelines. They emphasize beginning early, when children are in primary school, and continuing through adolescence. Teachers need to be trained, and programs should involve the community, parents, administrators and religious leaders. The curriculum should include information on human development, reproductive anatomy, relationships, personal skills, sexual behavior and health, and gender roles.4
As countries begin to implement sex education programs, they are drawing to some extent on international guidelines and acknowledged common elements for success. Brazil, for example, has mandated that sex education begin with primary school children. In Mexico, a course developed by the Instituto Mexicano de Investigación de Familia y Población (IMIFAP) called "Planning Your Life" incorporates sex in the larger context of life development. A study by IMIFAP and the New York-based Population Council showed that the course can increase students' knowledge and, among sexually active students, increase contraceptive use.5
In Nigeria, a new curriculum emphasizes the development of skills, teacher training and community involvement. A national task force has developed guidelines for comprehensive sex education, working with the SIECUS model. Using the Nigerian guide, the Association for Reproductive and Family Health (ARFH), a Nigerian nongovernmental organization working with the Oyo state government, has developed a curriculum being implemented in 26 schools for 10- to 18-year-olds.
"A needs assessment and baseline survey revealed that, since first sexual experience occurred between ages 13 and 16, youth more than ever before require sexual and reproductive health information as well as some life-building skills -- negotiation skills, values clarification, refusal skills, decision-making and goal setting. These skills will enable youth to cope with the demands and challenges of growing up, self-management and other transitions," explains Grace Delano, ARFH executive director. ARFH is also emphasizing training that helps teachers clarify their own values of sexuality. Modifying youths' sexual behavior requires a multidimensional approach, says Delano. "Mass media involvement, advocacy and community involvement are some of the strategies adopted to ensure that the teachings in the school are complemented by the community."
Educators agree on the importance of curricula helping youth to develop and practice decision-making skills. "Sex education is not just about sex," says Hally Mahler, a trainer at FHI who has facilitated sessions on sex education for teachers, guidance counselors, parents and youth in Asia, Africa and Latin America. "Self-esteem, decision-making skills, feeling you have options and can control things -- that is what the curriculum needs to emphasize." For kids to learn skills about negotiating safe sex, teachers have to be comfortable with the content of the curriculum and make it interesting for youth. "We have to get them excited and answer their questions in a real way. So we use music that is popular with kids and exercises that will help people talk about taboo subjects."
One exercise Mahler is incorporating into a new curriculum in Senegal is what she calls a condom fashion show. "Kids, teachers and parents open the condoms and make them into belts, bracelets and earrings. It desensitizes them to this subject, and they can then talk more honestly and openly." Government and nongovernmental organizations are working with FHI to develop the curriculum for use with 10- to 19-year-olds. The Frontiers in Reproductive Health project coordinates this work by the New York-based Population Council.
Little research on sex education among newlyweds exists, and what is available focuses on contraceptive use. China and Bangladesh have used family planning field workers successfully among married adolescents. In Bangladesh, when family planning field workers targeted newlyweds with letters of congratulations and motivational talks, contraception use among newlyweds increased from 19 percent in 1993 to 42 percent in 1997. In Indonesia, counselors use marriage registries to contact newlyweds. Attending talks on family planning is a prerequisite to a civil marriage in several states in Mexico. And in Bangladesh and Taiwan, media campaigns have focused on reaching newlyweds.6
Education can help
In the most comprehensive analysis of sex education, the Joint United Nations Programme on HIV/AIDS (UNAIDS) examined 68 evaluations of sex education projects, 53 of which evaluated specific interventions.
Of these 53 interventions, 22 "delayed the onset of sexual activity, reduced the number of sexual partners or reduced unplanned pregnancy and STD rates," the UNAIDS analysis concluded. There were neither increases nor decreases in sexual activity and attendant rates of pregnancy and STDs in nearly all of the other interventions evaluated. In one of the few exceptions, a program that included only abstinence in the curriculum resulted in an increase in noncoital sexual activity such as breast touching.7
In the United States, a review of nearly 80 sex education programs also found that "programs that focus upon sexuality, including sex and HIV education programs, school-based clinics, and condom availability programs, do not increase any measure of sexual activity." While nearly all of the programs increased knowledge among youth about sexuality, only a few resulted in measurable reductions in sexual risk-taking, such as delayed onset or reduced frequency of sex, reduced number of sexual partners, or increased use of condoms or other forms of contraception.8
Most of the successful programs have included strong community involvement and clear messages about avoiding pregnancy or sexually transmitted diseases (STDs). A study in Senegal found that family life education programs needed to put more emphasis on skill development. The study used focus groups and surveys with 225 boys and girls 14- to 18-years-old who participated in the programs at schools, youth clubs and sports associations. "This [education] allows us to be more mature and to be able to face some of life's problems," said one boy.9
The youth also brought up issues involving respect and responsibility. "Discussions about what boys and girls want from each other in relationships suggest a lack of respect between the sexes," the study found. Boys thought that girls were primarily interested in money and other material things from boys, while boys and girls mentioned "the possibility of beatings or rape if a woman refuses to have sexual relations. Values that instill respect for women while teaching that violence is never acceptable need to be emphasized." The Institut de Sciences et l'Environment Université Cheikh Anta Diop de Dakar and FHI conducted the study, working with several ministry offices and nongovernmental organizations.
In a rural, low-income area of the United States, sexual health education for students 5- to 18-years-old involved community agencies, religious leaders, parents, media messages and health promotion. After three years, annual pregnancies fell from 60 to 25 pregnancies per 1,000 young women 14- to 17-years-old. In two control areas with no intervention, annual pregnancies in the same age group increased. The program taught about reproductive anatomy and contraception, and focused on ways to improve decision-making, interpersonal communication skills and self-esteem. It emphasized the need to balance personal values with those of the family, religious institutions and community.10
Simply providing educational materials without other key elements, such as community involvement, can be counterproductive. A study in Nicaragua found that placing health education materials in motel rooms used by commercial sex workers actually lowered the frequency of condom use.11
Teacher training
Other factors critical for good sex education programs include adequate teacher training and resources for implementing the program. "Training teachers is a key element of successful sex education programs, and the lack of good training has been a big problem," says Dr. Waszak of FHI. "The teachers do not get trained, so they ignore the curriculum or do not know how to deal with it. The training has to desensitize the discomfort the teachers feel in talking about subjects that were taboo when they grew up. And, once you start talking about sexual health with youth, you have to listen to them. You have to deal with their questions, and often, that is not comfortable for teachers."
A recent evaluation of the Peru sex education program suggests the potential limitations of training and resources. "There is still resistance by some teachers asked to implement the program, which undercuts its effectiveness," says Dr. Robert Magnani of Tulane University, who works with FOCUS on Young Adults, a U.S.-based research program. "Not enough time and resources had been committed to gain the support of teachers and principals. This is a big issue in conservative societies."
In South Africa, life-skills training is mandated in all schools by 2005. "But life-skills training curricula and teaching methods vary significantly," says Dr. Magnani. "It is fairly well done in some schools but not done well in others." While recommended national guidelines are important, he says, local provinces have to make financial and other commitments to implement the guidelines.
Good training requires creative approaches. In Jamaica, FHI has worked with the Ministry of Education to train guidance counselors to teach family life skills using a manual called Preparing for the VIBES in the World of Sexuality. It teaches counselors how to guide youth in developing skits, dances, songs and other theatrical expressions of their questions, concerns, fears and scenarios for sexual situations, working with the Ashe Performing Arts Academy and Ensemble. An evaluation of the program is under way, following for two years youth who participated in the family life skills course at age 12.
The need for good training goes beyond school-based curricula. Involving parents and community leaders is also important. Working in Jamaica with the National Family Planning Board and Ashe, FHI is developing an adolescent reproductive health program for parents. It includes a training manual and video to help parents communicate better with their teenagers. Using the manual, a group of parents will be trained to work with other parents. In an initial needs assessment, about 90 parents expressed concerns about STDs, rape, pregnancy and homosexuality. Reflecting on their own adolescent experiences and concerns for their children, they identified what they thought should go into the manual.
The AIDS epidemic has generated many ways to reinforce sex education messages, including mass media campaigns, hotlines and computers. A campaign in the Philippines targeted young people by using popular music groups and advertising an information hotline. An evaluation of the project found that half of those recalling the music changed their sexual behavior, and 44 percent talked with friends or parents about sex-related information.12 With the help of young people, the International Planned Parenthood Federation (IPPF) is preparing a Web site with sex education materials. IPPF currently cosponsors a Web site with the BBC World Service called "Sexwise."
Many community organizations have taken an interest in sex education. FHI has worked with the World Association of Girl Guides and Girl Scouts to provide sex education to adolescents in several African countries and India. The Arab-based boy scouts organization has been training youth in peer counseling skills and sensitization about gender and sexual health. In Ghana, the Young Women's Christian Association is working with the U.S.-based Centre for Development and Population Activities to involve parents and church leaders in counseling.
Peer education programs are particularly popular with HIV-prevention projects. An evaluation of 21 peer-based projects supported by FHI in 10 countries (Brazil, Cameroon, Dominican Republic, Ethiopia, Haiti, Jamaica, Nigeria, Tanzania, Thailand and Zimbabwe) found that 81 percent of the target audience said they preferred getting information on HIV/AIDS from peer educators. A student peer educator in Zimbabwe said, "With someone your own age, you will be serious. You'll feel at ease. With someone older, you do not want to discuss some things, problems, what is in your heart."13
-- William R. Finger
References
Senderowitz J. A review of program approaches to adolescent reproductive health. Unpublished paper. U.S. Agency for International Development, 2000.
Kirby D. Sexuality and sex education at home and school. Adolesc Med 1999;10(2):195-209; Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Rep 1994;109:339-60.
Whitaker DJ, Miller KS, Clark LF. Reconceptualizing adolescent sexual behavior: beyond did they or didn't they? Fam Plann Perspect 2000;32(3):111-17.
National Guidelines Task Force, Guidelines for Comprehensive Sexuality Education, Second Edition. Available online. June 12, 2000.
Pick de Weiss S, Hernandez JC, Alvarez M, et al. Family life education increases contraceptive knowledge and use. In Operations Research Summaries. New York: Population Council, 1998.
Alauddin M, MacLaren L. Reaching Newlywed and Married Adolescents. Washington: FOCUS on Young Adults, 1999.
Grunseit A. Impact of HIV and Sexual Health Education on the Sexual Behavior of Young People: A Review Update; Grunseit A, Kippax S, Aggleton P, et al. Sexuality education and young people's sexual behavior: a review of studies. J Adolesc Res 1997;12(4):421-53.
Kirby D. No Easy Answers: Research Findings of Programs to Reduce Teen Pregnancy (Summary). Washington: The National Campaign to Prevent Teen Pregnancy, 1997.
Nguer R, Niang CI, Katz K, et al. Identifying Ways to Improve Family Life Education Programs. Senegal. Research Triangle Park, NC: Family Health International, 1999.
Vincent ML, Clearie AF, Schluchter MD. Reducing adolescent pregnancy through school and community based education. JAMA 1987;257(24):3382-86.
Egger M, Pauw J, Lopatatzidis A, et al. Promotion of condom use in a high-risk setting in Nicaragua: a randomised controlled trial. Lancet 2000;355(9221):2101-5.
Rimon JG, Treiman KA, Kincaid DL, et al. Promoting Sexual Responsibility in the Philippines through Music: An Enter-Educate Approach, Occasional Paper Series No. 3. Baltimore: Center for Communication Programs, Johns Hopkins University School of Public Health, 1994.
Flanagan D, Williams C, Mahler H. Peer Education in Projects Supported by AIDSCAP. Arlington,VA: Family Health International, 1996.
Studies have consistently found that youth lack basic knowledge about sexuality and contraception.
In a survey of nearly 3,000 youth in Senegal, only one-third of those 15- to 19- years-old could correctly identify the fertile time in the menstrual cycle, and 80 percent incorrectly thought that oral contraceptives could cause sterility. Those youth who had participated in a family life education program had more knowledge about contraception and used contraception more often.1
A study of sex education programs in South Africa found that youth want more information, including help with decision-making and coping skills, and the opportunity for individual counseling with someone they trust. In focus groups with 60 students, youth said their parents ought to be the main source of information on sex education but were not giving them what they needed.2
In a survey among 2,460 students 14- to 19-years-old in Nigeria, just one in three could correctly identify when conception was most likely to occur. In focus groups, "students expressed a strong desire for better education about contraception and the consequences of sexual intercourse, and recommended that both schools and parents participate in educating young people about reproductive health."3
In nearby Guinea, a survey of more than 3,600 unmarried men and women 15- to 24-years-old found that one of four women had been pregnant and 22 percent of these pregnancies ended in an abortion. The average age at first intercourse was 16.3 years for girls and 15.6 years for boys, but more than half of those who were sexually active had never used contraception. "School-based sexuality education could benefit even out-of-school youths because their partners often are students," the study concluded.4
-- William R. Finger
References
Nare C, Katz K, Tolley E. Measuring Access to Family Planning Education and Services for Young Adults in Dakar, Senegal. Research Triangle Park, NC: Family Health International, 1996.
Bailie R, Steinberg M. The focus group method in a formative evaluation of a South African high school sexuality education programme. Br J Fam Plann 1995;21(2):71-75.
Amazigo U, Silva N, Kaufman J, et al. Sexual activity and contraceptive knowledge and use among in-school adolescents in Nigeria. Int Fam Plann Perspect 1997;23(1):28-33.
Gorgen R, Yansane M, Marx M, et al. Sexual behavior and attitudes among unmarried urban youths in Guinea. Int Fam Plann Perspect 1998;24(2):65-71.
Today's Internet technology allows adolescents, parents and providers to find helpful information quickly and easily about sexually transmitted diseases, contraception and other reproductive health topics. Among the Web sites offering adolescent reproductive health information are the following:
The American Social Health Association site includes a guide to help adults discuss sensitive matters with their children. Daily stories of fictional characters facing sexual health issues are given in soap opera fashion.
The American Medical Association offers information about adolescent health services. The site also offers fact sheets to help providers discuss specific topics with parents.
"Talking with Kids", a site by Children Now and the Kaiser Family Foundation, encourages parents to talk with their children about sexual health, violence and drug abuse. Information is available in English and Spanish.
Planned Parenthood Federation of America's "Teenwire" provides information about teen sexuality, sexual health and relationships. Answers to commonly asked questions about sexual health and a magazine written by teens for teens are available.
The International Planned Parenthood Federation and the BBC World Service provide adolescent reproductive health information from various national family planning programs and educational radio reports, offered in 22 languages at the BBC's "Sexwise" page.
This United Nations Children's Fund site provides an online forum for young adults to discuss a number of topics, including reproductive health. The Web site is available in English, Spanish and French.
Click to select preferred language, if other than English: French | Spanish.
