Many youth who become sexually active do so without accurate information about reproductive health. This lack of information can put them at risk of unplanned pregnancy or sexually transmitted diseases (STDs). Sexual health education can be one means of helping young people prevent these problems and improve their future reproductive health.
Several studies have shown that sex education can help delay first intercourse for adolescents who are not sexually active. For teenagers already sexually active, including those who are married, sex education can encourage correct and consistent use of contraception or STD protection. Fears that sex education programs encourage or increase sexual activity appear to be unfounded, research suggests.
The most effective sexual health programs are those that include more than information on reproductive health. These programs also help youth to enhance communication and negotiation skills, clarify their values, and change risky behaviors.
"Basic information on reproductive health is important for youth -- just as basic information about other types of health issues is important," says Dr. Cynthia Waszak, an FHI researcher who is an expert on adolescent health. "Sex education programs may be the only place that young people can learn accurate information about reproductive health. Sex education programs may offer the only setting in which young people can practice the skills necessary to maintain good reproductive health."
Lack of knowledge
Misinformation and misunderstandings about conception, family planning and STD risks abound among young adults. In Jamaica, research conducted by the University of the West Indies and FHI's Women's Studies Project found that one group of adolescents had little accurate information about reproductive health issues. The study surveyed about 500 students, ages 11 to 14, as they began an in-school family life education program designed to delay first pregnancy. Students in this group were considered to be at high-risk for early sexual activity.
Although 52 percent of girls and 77 percent of boys knew that condoms could protect against STDs, only 4 percent of girls and 10 percent of boys knew that conception is most likely to occur during the mid-point of a woman's menstrual cycle. Only 27 percent of girls and 32 percent of boys knew it was possible to become pregnant during first intercourse, and approximately 15 percent of girls and boys thought oral contraceptives protected against STDs. Students will be surveyed twice more, at completion of family life education and a year later, to learn how this program affects their knowledge, attitudes and behaviors.1
Studies of young people in other regions have shown a similar lack of accurate information. In India, of 100 girls who came to a hospital seeking abortion, 80 percent did not know that sexual intercourse could lead to pregnancy or STDs, and 90 percent did not know about contraception.2
A study of Russian adolescents' knowledge of AIDS found that, among 370 high school students surveyed, only 25 percent of the girls and 35 percent of the boys knew that condoms should be used just once. Thirty-eight percent of students incorrectly believed that condoms could be washed and used several times.3 In Chile, where 948 public school students were surveyed in Santiago's poorer communities, 57 percent of boys and 59 percent of girls said condoms could be re-used. Sixty-seven percent did not know the fertile or infertile times of a woman's menstrual cycle.4
Lack of information may be one reason that adolescents' use of family planning methods is generally low. In South America, for example, only 43 percent of young married women, ages 15 to 19, are using contraception, according to data compiled by the Population Reference Bureau (PRB). Among unmarried sexually active women, 29 percent use contraception. In western Africa, 5 percent of married teens use a family planning method, compared with 34 percent of sexually active unmarried teens. In southeast Asia, 36 percent of married youth use contraception, compared with 28 percent of unmarried adolescents.5
Evaluating sex education
Evaluating the impact of sex education programs on adolescent knowledge and behavior has been problematic. Programs vary in content, making comparisons difficult. In addition, the personal nature of the questions may make young people reluctant to answer truthfully, and researchers find it hard to isolate the effects of sex education programs from those of other sources of information, such as mass media or parents.
However, evaluations that have been done among young adults in both developing and industrialized countries show that formal sex education programs can increase knowledge of reproductive health and can improve the use of methods to protect against pregnancy and STDs.
A study in Banjul, The Gambia, found that knowledge about contraception was greater for adolescent students who had attended family life education (FLE) programs than for those who did not. Additionally, contraceptive use at first intercourse was higher among females who attended FLE programs.6
In Tanzania, a school-based program for young people ages 13 to 15 showed an increase in knowledge about AIDS and a decrease in the number of students who planned to have sex in the near future.7
A retrospective study of 8,450 women in the United States, ages 15 to 44, examined the relationship between sex education and use of contraception at first intercourse. Women who received formal instruction on contraceptive use before their first sexual intercourse were more likely to use a method. Women were less likely to use a method if they received information on contraception the same year they began sexual activity.8 A survey, conducted among 1,800 15- to 19-year-old males in the United States, found that among those who had received formal education about AIDS and family planning, there was a decrease in number of sexual partners and an increase in consistent use of condoms.9
The World Health Organization (WHO) recently published a review of 1,050 scientific articles on sex education programs. Researchers found "no support for the contention that sex education encourages sexual experimentation or increased activity. If any effect is observed, almost without exception, it is in the direction of postponed initiation of sexual intercourse and/or effective use of contraception." Failure to provide appropriate and timely information "misses the opportunity of reducing the unwanted outcomes of unintended pregnancy and transmission of STDs, and is, therefore, in the disservice of our youth," the report says.10
Young people need two types of messages in sex education programs, the WHO report said: messages for those who have not begun sexual activity and messages for those who are already sexually active. Also, because some young people begin having sex as early as age 12, the report recommended that formal sex education programs begin well before this age. While the goal of many sex education programs is to reduce the incidence of unplanned pregnancy, WHO recommends that programs also consider ways to reduce the incidence of unprotected intercourse, since teens who experience unprotected intercourse are vulnerable to STDs as well as unplanned pregnancies.
While some studies have found benefits of sex education programs, others have shown negligible results. A study in St. Kitts-Nevis, in the eastern Caribbean, compared students who took sex education courses and those who did not. The course, which was held twice weekly for 26 weeks, included information on reproduction and contraception, emotional development and sexuality. Students completed a questionnaire on sexual activity and contraceptive use before they took the course, then at the end of the course. Approximately one-third of sexually active students said they used contraception before they began the sex education course, and the percentage changed very little afterward.11
Programs that stress abstinence as the only means of preventing STDs and unplanned pregnancy appear to have little effect. One study followed 320 students who participated in a program that recommended abstinence as the only option for unmarried youth. Researchers found an increase in sexual activity among young people enrolled in the program. There was no increase in sexual activity among a group of young people not participating in the abstinence program.12
Behavior change
While sex education programs can increase knowledge about reproductive health, knowledge does not always translate into action.
In Uganda, for example, a study of 4,510 young people ages 15 to 24 found that knowledge about condoms was high, and that men and women had a positive attitude about condoms. Yet, while more than three-quarters of young men and women knew that condoms prevent STDs, fewer than 13 percent of males and virtually no females (fewer than 1 percent) said they used condoms.13 A program in the Philippines, designed to teach AIDS prevention to more than 800 adolescents, did increase knowledge about AIDS. However, the program did not result in changes in condom use, nor was there an increase in the number of students who agreed that young people should delay sexual intercourse until adulthood or marriage.14
In examining ways to improve adolescents' reproductive health, experts say that successful sex education programs share some common characteristics. They focus on changing risky behaviors; they reinforce the message that unprotected sex is not desirable and explain ways in which young people can protect themselves; they actively involve students in learning, such as activities that allow students to put a condom on a model or purchase a condom; they help students practice their communications and negotiation skills; they discuss sociocultural pressures on teens to become sexually active; and they provide training for people who will teach sex education.15
Changing risky behavior requires more than education; it requires an individual's commitment, says Donna Flanagan of FHI's AIDS Control and Prevention (AIDSCAP) project. A young adult must then acquire the skills necessary to make the change, such as the skill of negotiating condom use. "A lot of what young people need is the experience and the practice of making decisions and feeling responsible for their own actions," says Flanagan of AIDSCAP's behavioral change communications unit.
"We adults do not give them a chance to be responsible for very many things," she says. "Young people do not make a decision about whether to go to school -- we tell them they must go. Young people do not even make decisions about when to go to bed or when to get up. Suddenly, they are faced with decision-making about sexual issues, and they don't have those skills."
To encourage young people to develop their decision-making skills, AIDSCAP has developed radio and television messages in the Dominican Republic that are aimed at getting young people to delay first intercourse and to use condoms when they do become sexually active. After providing information on AIDS and STDs, the messages end by saying: "Go talk to your dad about AIDS," or "Go talk to your mother about STDs."
The FOCUS on Young Adults program recently analyzed reproductive health programs in developing countries and found few studies that demonstrate sex education results in behavioral change. Experts say more research is needed, and evaluation measures need to be refined. However, the FOCUS project says sex education programs that include activities to help young people build skills in communication and negotiation are likely to be more successful than programs that only provide information on reproductive health.
Several family planning programs have incorporated elements of behavior change into sex education programs for young people. One example is the Planeando tu Vida (Planning your Life) program in Mexico. The program provides youth with information about pregnancy, disease prevention and STDs, plus information on relationships, decision-making, communications and assertiveness.
Begun by the Instituto Mexicano de Investigación de Familia y Población (IMIFAP), in collaboration with the Mexican government, the program was developed based on research with young people. More than 865 teenage girls, ages 12 to 19, were interviewed, plus 355 teens who had an unplanned pregnancy. The young people's responses became the foundation for Planeando tu Vida, which was introduced as a pilot program into Mexico City schools in 1988-89, then expanded.
One study on the program's impact compared three groups of students: adolescents who had not received sex education; those who participated in a sex education program that included information on menstruation, anatomy, physiology, contraception and STDs; and adolescents who participated in the Planeando tu Vida program. When interviews with study participants were conducted four months and eight months later, there was no change in initiation of sexual activity among the groups. For those students who were not sexually active when the Planeando tu Vida course began, their levels of contraceptive use were higher when they did become sexually active. Another study compared more than 900 students who took the Planeando tu Vida course with students who did not. The program had no effect on program participants' sexual activity and no effect on contraceptive use among those who were already sexually active. However, among boys who were not sexually active when the course began, contraceptive use increased when they did become sexually active.16
Another example of a sex education program that encourages behavior change is the Centro para Jóvenes (Center for Youth) in Colombia. Established in 1990 by PROFAMILIA, the center offers information and education to adolescents, education for parents and teachers, and reproductive health services.
During the center's first year, staff found that a high percentage of students had received some information on reproduction, but the information did not deter young people from having sex. Many of the girls who came to the center came because they feared they were pregnant. Among the girls who did have unplanned pregnancies, they shared common characteristics -- low self-esteem, little or no knowledge of contraception, and poor communication with family members.17
PROFAMILIA staff decided to expand the content of its sex education programs, which traditionally had focused on the biological aspects of reproduction, to include information on pregnancy and STD prevention, plus activities designed to promote self-esteem, communication, and decision-making. One of the services PROFAMILIA has begun to offer is a "psychological orientation," or a counseling session in which young people can discuss fears or concerns about sexuality and health.
"Young people need to understand and accept the physical changes, to talk about relationships with adults, to learn decision-making and self-esteem and to develop a general vision of their own sexuality," says German A. Lopez of PROFAMILIA. "That is the purpose of this activity."
Today, PROFAMILIA operates adolescent health centers, which provide education, information and services, in 20 cities in Colombia. Among the information and education programs it provides are annual health fairs for adolescents, which coincide with students' vacations from school. Last year the health fair was held in 15 cities and drew more than 10,000 young people. In addition, PROFAMILIA holds education sessions for parents and teachers, plus workshops that provide 120 hours of training for people who want to become educators in reproductive health programs. While programs have been offered for young people 16 to 19 years old, PROFAMILIA now offers education and services to younger teens, ages 13 to 15.
What, who and where
In establishing a sexual health education program, providers and policy-makers must consider several questions. What should the curriculum include? Who should be involved in program planning and implementation? And where should services be offered?
The U.S.-based Sexuality Information and Education Council (SIECUS) recently updated its guidelines for sex education programs. Originally published in 1991, the guidelines were designed to help local communities develop their own curricula or evaluate existing programs. New guidelines include information on contraceptive options that were not available when the first report was published (the female condom, for example).
SIECUS lists six key concepts that should be included in a comprehensive sex education program. These are information about:
human development, which includes reproductive anatomy and physiology
relationships, which include relationships with families and friends, as well as relationships in dating and marriage
personal skills, which include values, decision-making, communication, negotiation
sexual behavior, which includes abstinence as well as sexuality throughout the life cycle
sexual health, including contraception, STD and HIV prevention, abortion and sexual abuse
society and culture, which includes gender roles, sexuality and religion.
According to SIECUS guidelines, sex education should begin in early elementary school, when children are ages five to eight, and continue through adolescence, ages 15 to 18. Courses should be taught only by trained teachers, and community involvement is essential in the development and implementation of the programs. "Parents and other important family members, teachers, administrators, community and religious leaders, and students should all be involved," the SIECUS report says.18
SIECUS has worked in Brazil, Nigeria and Russia to help local government and nongovernmental organizations that work with adolescents develop their own guidelines for sex education programs.
Involving young people in the design and implementation of sex education programs, including planning the content of the curriculum, is an important element in ensuring that the program addresses teens' needs. The Youth for Youth Foundation in Romania, supported by the Centre for Development and Population Activities (CEDPA), began with a survey of students at 17 high schools in Bucharest, to determine young people's knowledge of reproductive health issues and their health needs. Lack of basic information on reproductive health was one of the main reasons for unplanned pregnancies and abortions among Romanian youth. More than one in five young people were sexually active before marriage, researchers found.
Survey results were the basis for a teaching manual, designed to be used by trainers in the Youth for Youth sex education program. The program's curriculum includes information on reproductive biology, STDs, pregnancy and contraception, as well as activities designed to help young people improve skills in communications and decision-making and clarify values. Sex education classes are taught by peer educators in school to students ages 15 to 16. The curriculum is continually revised and updated to reflect students' concerns and evaluations of their knowledge, attitudes and behaviors.
As was true in Romania, involving community members, especially parents and teachers, is critical to implementation of a sex education program. Parents' acceptance of or resistance to programs can determine whether children will participate. For example, a survey of adolescents in India helped convince parents and community members of the need for a sex education program; the survey revealed that many adolescents were sexually active, contrary to adults' beliefs that they were not.19
Additionally, parents and teachers are important sources of information for teens; consequently, they need accurate information. When asked who was responsible for talking with children about sex, husbands tended to say it was the wife's responsibility, while wives said it was the husband's responsibility, according to a Population Council study among 500 parents in Zaire.20
"Involving parents and community leaders and asking them to provide input into the curriculum regarding community norms and needs may reduce opposition to sex education programs, may calm parents' unrealistic fears, and may even enlist adults as partners in their children's education," says Dr. Waszak.
-- Barbara Barnett
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