Power to Decide

Why sex education matters.

Maggi LeDuc

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In 2014, a study found that 93% of parents supported having sex education in middle school and 96% supported teaching sex ed in high school. A 2017 study again found that 93% of parents favored sexuality education in schools. These are not isolated results; decades of research support the benefits of comprehensive, inclusive sex education.

Comprehensive sexuality education is also supported by professional organizations such as the American Medical Association, the American Academy of Pediatrics, the Society for Adolescent Health and Medicine, and the 184 organizations—including Power to Decide—who joined in coalition in May 2020 to support the Sex Ed for All movement. 

At the moment, 28 states (and DC) require some kind of sex education and HIV education and seven states only require HIV education. However, only 17 require that education to be medically accurate and 29 states require schools to stress abstinence . Because sex education in schools is legislated on the state (or individual school district) level, not the federal, the quality of what is taught varies widely across the country. The CDC’s 2018 School Health Profiles found that only 43% of high schools and 18% of middle schools taught ‘key’ topics in sex education. Some of the topics the CDC labels as ‘key’ include information on how to prevent STIs and unplanned pregnancy, maintaining healthy relationships, avoiding peer pressure, and using appropriate health services. 

The World Health Organization notes that the focus of sexuality education in Europe has shifted from preventing pregnancy in the 1960’s to preventing HIV in the ‘80’s to today covering these topics alongside such issues as sexism, homophobia, and online bullying gender norms, the sexuality spectrum, and emotional development. In contrast, a 2018 study reported that students in the US were less likely to receive sex education on key topics in 2015-2019 than they were in 1995. The same study found that only 43% of females and 47% of males who had penis-in-vagina sex covered safe sex in school before they engaged in sex for the first time. 

Truly comprehensive sex education includes, but isn't limited to:

  • Taught by trained sex educators. 
  • Begun early and progresses at an age-appropriate pace. 
  • Evidence-based. 
  • Inclusive of LGBTQ young people.
  • Explicitly anti-racist. 
  • Learner-centered. 
  • Community-specific. 

Sex ed that is for everyone includes (but isn't limited to) information about:

  • Healthy relationships.
  • Anatomy and physiology. 
  • Adolescent sexual development. 
  • Gender identity and expression. 
  • Sexual orientation and identity. 
  • The full range of birth control methods and pregnancy options. 

All young people have a right to this kind of high-quality, evidence-based information and care to ensure their lifelong sexual and reproductive health. Again , and again , and again both national and international research has found that young people who have experienced comprehensive sexuality education delay having sex for the first time, are less likely to engage in risky behavior, and are more likely to use birth control. 

Plus, beyond giving young people facts, inclusive sex ed provides skills such as effective communication, active listening, and the ability to make informed decisions that will help them to grow and live safe, healthy, and fulfilling lives.   

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  • What is Sex Education?
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Sex education helps people gain the information and skills they need to make the best decisions for themselves about sex and relationships. Planned Parenthood is the nation’s largest provider of sex education, reaching 1.2 million people a year through education and outreach.

Facts About Sex Education

Sex education is high quality teaching and learning about a broad variety of topics related to sex and sexuality. It explores values and beliefs about those topics and helps people gain the skills that are needed to navigate relationships with self, partners, and community, and manage one’s own sexual health. Sex education may take place in schools, at home, in community settings, or online. 

Planned Parenthood believes that parents play a critical and central role in providing sex education. Here are sex education resources for parents .  

Comprehensive sex education refers to K-12 programs that cover a broad range of topics related to:

  • Human development, including puberty, anatomy, sexual orientation, and gender identity
  • Relationships, including self, family, friendships, romantic relationships, and health care providers
  • Personal skills, including communication, boundary setting, negotiation, and decision-making
  • Sexual behavior, including the full spectrum of ways people choose to be, or not be, sexual beings
  • Sexual health, including sexually transmitted infections, birth control, pregnancy, and abortion
  • Society and culture, including media literacy, shame and stigma, and how power, identity, and oppression impact sexual wellness and reproductive freedom

There are several important resources that help with implementing sex education, including:

  • The Future of Sex Education Initiative (FoSE) seeks to create a national dialogue about the future of sex education and to promote the institutionalization of comprehensive sex education in public schools. They’ve developed the first-ever National Sexuality Education Standards , National Teacher Preparation Standards, and many additional toolkits and materials to strengthen comprehensive sex education implementation and professional development.
  • The SIECUS  Guidelines for Comprehensive Sexuality Education were developed by a national task force of experts in the field of adolescent development, health care, and education. They provide a framework of the key concepts, topics, and messages that all sex education programs would ideally include.

What Role Does Planned Parenthood Play In Sex Education?

Planned Parenthood education staff reach 1.2 million people each year, most of whom are in middle school and high school.

Planned Parenthood education departments around the country provide a range of programming options, including:

  • Evidence-based and evidence-informed education programs that have been proven to work
  • Peer education programs
  • Promotores programs and other community-driven, culturally relevant health education programs
  • Parent/family education programs
  • LGBTQ-focused programs for LGBTQ youth and their parents/caregivers
  • Training of professionals, including educators and school-staff, community-based organization staff, and faith-based leaders
  • Outreach and single session workshops

Sex Education Resources

The best sex education resource is your local Planned Parenthood education department!

There are also many other resources available to inform and guide sex education programs and policies:

Advocates for Youth

Advocates for Youth partners with youth leaders, adult allies, and youth-serving organizations to advocate for policies and champion programs that recognize young people’s rights to honest sexual health information and accessible, confidential, and affordable sexual health services.

AMAZE provides young adolescents around the globe with engaging, honest, and medically accurate sex education they can access directly online — regardless of where they live or what school they attend.  AMAZE also strives to assist adults — parents, guardians, educators and health care providers around the globe — to communicate effectively and honestly about sex and sexuality with the children and adolescents in their lives.  

Answer provides high-quality training to teachers and other youth-serving professionals.

ETR Associates

ETR offers science-based health and education products and programs for health professionals, educators, and others throughout the United States.

The Guttmacher Institute

The Guttmacher Institute is the leading research and policy organization committed to advancing sexual and reproductive health and rights in the United States and globally through high-quality research, evidence-based advocacy, and strategic communications.

Future of Sex Education

The Future of Sex Education Initiative (FoSE) was launched as a partnership between Advocates for Youth, Answer, and the Sexuality Information and Education Council of the U.S. (SIECUS) to create a national dialogue about the future of sex education and to promote comprehensive sex education in public schools.

Gay, Lesbian and Straight Education Network

GLSEN works to ensure that every student in every school is valued and treated with respect, regardless of their sexual orientation, gender identity, or gender expression.

Power to Decide

The mission of Power to Decide is to ensure that all young people—no matter who they are, where they live, or what their economic status might be—have the power to decide if, when, and under what circumstances to get pregnant and have a child. They do this by increasing information, access, and opportunity.

Sex Education Collaborative

The Sex Education Collaborative (SEC) advances and scales K–12 school-based sex education across the U.S. by leveraging its collective leadership, networks, and resources, including through it’s training hub for youth-serving professionals .

SIECUS: Sex Ed for Social Change advocates for the rights of all people to access accurate information, comprehensive sex education, and the full spectrum of sexual and reproductive health services.

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  • Comprehensive sexuality education

Comprehensive sexuality education – a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality – enables young people to protect and advocate for their health, well-being and dignity by providing them with a necessary toolkit of knowledge, attitudes and skills. It equips them with accurate information about human development, sexuality, reproduction and healthy relationships that is appropriate for their age and culture. It is a precondition for exercising full bodily autonomy and making informed choices about sexual and reproductive health and rights. It builds on and promotes an understanding of universal human rights, gender equality, and the rights and empowerment of young people. 

It is vital to advancing health outcomes and gender equality. Yet research shows that too many young people still make the transition from childhood to adulthood receiving inaccurate or incomplete information about sexual and reproductive health, leaving them vulnerable to coercion, sexually transmitted infections and unintended pregnancy. UNFPA works with governments to implement comprehensive sexuality education, both in schools and outside of schools through community-based training and outreach. By investing in young people's health and education, governments can support their engagement in society, ensure their well-being and help them achieve their full potential. UNFPA also promotes policies for, and investment in, sexuality education programmes that meet internationally agreed upon standards. 

Young people themselves called upon governments to ensure the provision of curriculum-based comprehensive sexuality education in and out of schools during the ICPD30 Global Youth Dialogue . They emphasized that the education must be scientifically accurate, evidence based, culturally relevant, gender transformative, and age and developmentally responsive, and that investments are needed to continuously train educators.

Comprehensive sexuality education can be taught in school to students as a part of the school curriculum or outside the school curriculum in non-formal settings; it is most effective when taught over several years by integrating age-appropriate information that accounts for the developing capacities of young people. It includes scientifically accurate information about human development, anatomy and reproductive health, as well as information about contraception, childbirth and sexually transmitted infections, including HIV.

But it also goes beyond information, helping young people to explore and nurture positive values regarding their sexual and reproductive health and rights. This education includes discussions about family life, relationships, culture and gender roles, and also addresses human rights , gender equality , bodily autonomy and threats such as discrimination, sexual abuse and violence.

Comprehensive sexuality education should recognize the unique needs of learners, especially vulnerable youth groups – such as LGBTQIA+ youth, young people living with disabilities, young people in humanitarian settings, young people who use drugs and those living with HIV – and should be tailored to reflect their realities.

Taken together, these programmes help young people develop self-esteem and life skills that encourage critical thinking, clear communication, responsible decision making and respectful and empathetic behaviour.

According to the UN International Technical Guidance on Sexuality Education , comprehensive sexuality education must be:

  • Scientifically accurate
  • Incremental 
  • Age and developmentally appropriate
  • Curriculum based 
  • Comprehensive 
  • Based on a human rights approach
  • Based on gender equality 
  • Culturally relevant and context appropriate 
  • Transformative
  • Able to help develop life skills needed to support healthy choices

Eight key concepts of comprehensive sexuality education, according to the UN

What is unfpa doing.

International Technical Guidance on Sexuality Education

List of 8 Key Concepts of Comprehensive Sexuality Education according to the International Technical Guidance on Sexuality Education

This type of education may go by other names, such as “life skills,” “holistic sexuality education,” “family life education,” “healthy lifestyle,” “sex ed” or “HIV education.” These names may imply differences in emphasis. For example, life skills education may include a focus on caring for sick family members, coping with loss or other similar issues. 

No matter what it’s called, comprehensive sexuality education empowers all young people to know, demand and protect their rights. The importance of sexuality education has been recognized by numerous international agreements, including the 2030 Agenda for Sustainable Development and the Political Declaration on HIV and AIDS .

UNFPA works to empower young people to shape the lives they want. This means mitigating adolescents’ risk of developing harmful behaviours, while promoting positive, protective actions and attitudes. Comprehensive sexuality education is a key component of UNFPA’s global strategy for adolescents and youth. 

UNFPA works with governments and partners to develop and implement comprehensive sexuality education programmes, in and out of school, that meet international technical standards. In 2019, UNFPA launched a global programme for out-of-school comprehensive sexuality education, specifically targeting frequently left-behind young people. Among many other initiatives, in Moldova, UNFPA is working with the government and partners to deliver comprehensive sexuality education to refugees from Ukraine, with sessions on life skills and resilience building, as well as mental health counseling and sexual and reproductive health referrals and information. UNFPA Malawi has a specific emphasis on delivering comprehensive sexuality education to young people living with HIV, by identifying and training facilitators from the same community. UNFPA Palestine has developed a digital educational platform for sexual education; the application has been made accessible to young people with hearing impairment and also has been adapted to audio for those with visual disabilities. 

In addition, many countries have been expanding the breadth of their in-school curricula in response to the UN International Technical Guidance on Sexuality Education . In Lao People’s Democratic Republic, the guidance was used to develop lesson plans and learning objectives after an analysis revealed a lack of content on gender, rights, sexual behavior and equitable social norms in the existing life skills curricula. In South Africa, the guidance was used to create lesson plans and training for teachers to empower them to address important sensitive topics that might otherwise be left out. Other examples can be found in the Global Status Report on Comprehensive Sexuality Education . 

In advocating for policies on, and investments in, comprehensive sexuality education, in and out of schools, UNFPA and partners recognized that traditional sexuality education does not meet the needs of all young people, such as populations outside of school. To address this, UNFPA and partners (UNESCO, WHO, UNICEF, UNAIDS) launched the International Technical and Programmatic Guidance on Out-of-School Comprehensive Sexuality Education in 2020. It provides evidence-based, human rights-centred guidelines and recommendations for reaching the most vulnerable young people. Out-of-school programmes often include community-based training and education, and may focus on groups such as young people with disabilities, young indigenous people, LGBTQIA+ youth, young people living with HIV or young people living in humanitarian settings. 

UNFPA also co-convenes the Global Partnership Forum on Comprehensive Sexuality Education together with UNESCO, with the aim to advance research, promote good practices, enhance collaboration and overcome challenges. Members include UN agencies, funding agencies, international civil-society organizations working in the area of sexual and reproductive health and rights, youth-led organizations, research or academic institutions, and education-related and other professional networks. 

UNFPA is building the evidence on comprehensive sexuality education. It is among others collaborating with the World Health Organization in conducting research on UNFPA’s comprehensive sexuality education programming, in partnership with local research institutions. In May 2023, a special edition of the journal Sexual and Reproductive Health Matters , titled “Learning beyond the classroom: comprehensive sexuality education for outside-of-school settings,” shared implementation research from Colombia, Ethiopia, Ghana and Malawi.

Updated on 3 July 2024

what is the importance of sexuality education

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The journey towards comprehensive sexuality education: global status report

The journey towards comprehensive sexuality education: global status report

Comprehensive sexuality education (CSE) is central to children and young people’s  well-being, equipping them with the knowledge and skills they need to make healthy  and responsible choices in their lives.

This report draws on multiple data sources to provide analysis of countries’ progress towards delivering good quality school-based CSE to all learners. 85 per cent of 155 countries surveyed have policies or laws relating to sexuality education, with considerably more countries reporting policies to mandate delivery at secondary education level than at primary level. However, the existence of policy and legal frameworks do not always equate to comprehensive content or strong implementation.

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Comprehensive sexuality education: why is it important?

This study, commissioned by the European Parliament’s Policy Department for Citizens’ Rights and Constitutional Affairs at the request of the FEMM Committee, examines the importance of sexuality education as an integral part of sexual and reproductive health and rights of children and young people in the EU. The study presents evidence for the effectiveness of sexuality education and its importance to achieve gender equality, to prevent gender-based violence and to improve health and well-being of young people. It provides an overview of the legal and policy frameworks and describes commitments made by the EU and EU Member States regarding sexuality education. Further, it examines the status of sexuality education in the EU and barriers to its successful implementation. The study concludes with recommendations for the EU institutions and Member States aimed at structurally improving the situation of sexuality education in the EU.

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The Importance of Access to Comprehensive Sex Education

Comprehensive sex education is a critical component of sexual and reproductive health care.

Developing a healthy sexuality is a core developmental milestone for child and adolescent health.

Youth need developmentally appropriate information about their sexuality and how it relates to their bodies, community, culture, society, mental health, and relationships with family, peers, and romantic partners.

AAP supports broad access to comprehensive sex education, wherein all children and adolescents have access to developmentally appropriate, evidence-based education that provides the knowledge they need to:

  • Develop a safe and positive view of sexuality.
  • Build healthy relationships.
  • Make informed, safe, positive choices about their sexuality and sexual health.

Comprehensive sex education involves teaching about all aspects of human sexuality, including:

  • Cyber solicitation/bullying.
  • Healthy sexual development.
  • Body image.
  • Sexual orientation.
  • Gender identity.
  • Pleasure from sex.
  • Sexual abuse.
  • Sexual behavior.
  • Sexual reproduction.
  • Sexually transmitted infections (STIs).
  • Abstinence.
  • Contraception.
  • Interpersonal relationships.
  • Reproductive coercion.
  • Reproductive rights.
  • Reproductive responsibilities.

Comprehensive sex education programs have several common elements:

  • Utilize evidence-based, medically accurate curriculum that can be adapted for youth with disabilities.
  • Employ developmentally appropriate information, learning strategies, teaching methods, and materials.
  • Human development , including anatomy, puberty, body image, sexual orientation, and gender identity.
  • Relationships , including families, peers, dating, marriage, and raising children.
  • Personal skills , including values, decision making, communication, assertiveness, negotiation, and help-seeking.
  • Sexual behavior , including abstinence, masturbation, shared sexual behavior, pleasure from esx, and sexual dysfunction across the lifespan.
  • Sexual health , including contraception, pregnancy, prenatal care, abortion, STIs, HIV and AIDS, sexual abuse, assault, and violence.
  • Society and culture , including gender roles, diversity, and the intersection of sexuality and the law, religion, media, and the arts.
  • Create an opportunity for youth to question, explore, and assess both personal and societal attitudes around gender and sexuality.
  • Focus on personal practices, skills, and behaviors for healthy relationships, including an explicit focus on communication, consent, refusal skills/accepting rejection, violence prevention, personal safety, decision making, and bystander intervention.
  • Help youth exercise responsibility in sexual relationships.
  • Include information on how to come forward if a student is being sexually abused.
  • Address education from a trauma-informed, culturally responsive approach that bridges mental, emotional, and relational health.

Comprehensive sex education should occur across the developmental spectrum, beginning at early ages and continuing throughout childhood and adolescence :

  • Sex education is most effective when it begins before the initiation of sexual activity.
  • Young children can understand concepts related to bodies, gender, and relationships.
  • Sex education programs should build an early foundation and scaffold learning with developmentally appropriate content across grade levels.
  • AAP Policy outlines considerations for providing developmentally appropriate sex education throughout early childhood, middle childhood, adolescence, and young adulthood.

Most adolescents report receiving some type of formal sex education before age 18. While sex education is typically associated with schools, comprehensive sex education can be delivered in several complementary settings:

  • Schools can implement comprehensive sex education curriculum across all grade levels
  • The Sexuality Information and Education Council of the United States (SIECUS) provides guidelines for providing developmentally appropriate comprehensive sex education across grades K-12.
  • Pediatric health clinicians and other health care providers are uniquely positioned to provide longitudinal sex education to children, adolescents, and young adults.
  • Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents outlines clinical considerations for providing comprehensive sex education at all developmental stages, as a part of preventive health care.
  • Research suggests that community-based organizations should be included as a source for comprehensive sexual health promotion.
  • Faith-based communities have developed sex education curricula for their congregations or local chapters that emphasize the moral and ethical aspects of sexuality and decision-making.
  • Parents and caregivers can serve as the primary sex educators for their children, by teaching fundamental lessons about bodies, development, gender, and relationships.
  • Many factors impact the sex education that youth receive at home, including parent/caregiver knowledge, skills, comfort, culture, beliefs, and social norms.
  • Virtual sex education can take away feelings of embarrassment or stigma and can allow for more youth to access high quality sex education.

Comprehensive sex education provides children and adolescents with the information that they need to:

  • Understand their body, gender identity, and sexuality.
  • Build and maintain healthy and safe relationships.
  • Engage in healthy communication and decision-making around sex.
  • Practice healthy sexual behavior.
  • Understand and access care to support their sexual and reproductive health.

Comprehensive sex education programs have demonstrated success in reducing rates of sexual activity, sexual risk behaviors, STIs, and adolescent pregnancy and delaying sexual activity. Many systematic reviews of the literature have indicated that comprehensive sex education promotes healthy sexual behaviors:

  • Reduced sexual activity.
  • Reduced number of sexual partners.
  • Reduced frequency of unprotected sex.
  • Increased condom use.
  • Increased contraceptive use.

However, comprehensive sex education curriculum goes beyond risk-reduction, by covering a broader range of content that has been shown to support social-emotional learning, positive communication skills, and development of healthy relationships.

A 2021 review of the literature found that comprehensive sex education programs that use a positive, affirming, and inclusive approach to human sexuality are associated with concrete benefits across 5 key domains:

Benefits of comprehensive sex education programs 

Benefits of Comprehensive sex education programs.jpg

When children and adolescents lack access to comprehensive sex education, they do not get the information they need to make informed, healthy decisions about their lives, relationships, and behaviors.

Several trends in sexual health in the US highlight the need for comprehensive sex education for all youth.

Education about condom and contraceptive use is needed:

  • 55% of US high school students report having sexual intercourse by age 18 .
  • Self-reported condom use has decreased significantly among high school students.
  • Only 9% of sexually active high school students report using both a condom for STI-prevention and a more effective form of birth control to prevent pregnancy .

STI prevention is needed:

  • Adolescents and young adults are disproportionately impacted by STIs.
  • Cases of chlamydia, gonorrhea, and syphilis are rising rapidly among young people.
  • When left untreated , these infections can lead to infertility, adverse pregnancy and birth outcomes, and increased risk of acquiring new STIs.
  • Youth need comprehensive, unbiased information about STI prevention, including human papillomavirus (HPV) .

Continued prevention of unintended pregnancy is needed:

  • Overall US birth rates among adolescent mothers have declined over the last 3 decades.
  • There are significant geographic disparities in adolescent pregnancy rates, with higher rates of pregnancy in rural counties and in southern and southwestern states.
  • Social drivers of health and systemic inequities have caused racial and ethnic disparities in adolescent pregnancy rates.
  • Eliminating disparities in adolescent pregnancy and birth rates can increase health equity, improve health and life outcomes, and reduce the economic impact of adolescent parenting.

Misinformation about sexual health is easily available online:

  • Internet use is nearly universal among US children and adolescents.
  • Adolescents report seeking sexual health information online .
  • Sexual health websites that adolescents visit can contain inaccurate information .

Prevention of sex abuse, dating violence, and unhealthy relationships is needed:

  • Child sexual abuse is common: 25% of girls and 8% of boys experience sexual abuse during childhood .
  • Youth who experience sexual abuse have long-term impacts on their physical, mental, and behavioral health.
  • 1 in 11 female and 1 in 14 male students report physical DV in the last year .
  • 1 in 8 female and 1 in 26 male students report sexual DV in the last year .
  • Youth who experience DV have higher rates of anxiety, depression, substance use, antisocial behaviors, and suicide risk.

The quality and content of sex education in US schools varies widely.

There is significant variation in the quality of sex education taught in US schools, leading to disparities in attitudes, health information, and outcomes. The majority of sex education programs in the US tend to focus on public health goals of decreasing unintended pregnancies and preventing STIs, via individual behavior change.

There are three primary categories of sex educational programs taught in the US :

  • Abstinence-only education , which teaches that abstinence is expected until marriage and typically excludes information around the utility of contraception or condoms to prevent pregnancy and STIs.
  • Abstinence-plus education , which promotes abstinence but includes information on contraception and condoms.
  • Comprehensive sex education , which provides medically accurate, age-appropriate information around development, sexual behavior (including abstinence), healthy relationships, life and communication skills, sexual orientation, and gender identity.

State laws impact the curriculum covered in sex education programs. According to a report from the Guttmacher Institute :

  • 26 US states and Washington DC mandate sex education and HIV education.
  • 18 states require that sex education content be medically accurate.
  • 39 states require that sex education programs provide information on abstinence.
  • 20 states require that sex education programs provide information on contraception.

US states have varying requirements on sex education content related to sexual orientation :

  • 10 states require sex education curriculum to include affirming content on LGBTQ2S+ identities or discussion of sexual health for youth who are LGBTQ2S+.
  • 7 states have sex education curricular requirements that discriminate against individuals who are LGBTQ2S+.Youth who live in these states may face additional barriers to accessing sexual health information.

Abstinence-only sex education programs do not meet the needs of children and adolescents.

While abstinence is 100% effective in preventing pregnancy and STIs, research has conclusively shown that abstinence-only sex education programs do not support healthy sexual development in youth.

Abstinence-only programs are ineffective in reaching their stated goals, as evidenced by the data below:

  • Abstinence-only programs are unsuccessful in delaying sex until marriage .
  • Abstinence-only sex education programs do not impact the rates of pregnancy, STIs, or HIV in adolescents .
  • Youth who take a “virginity pledge” as part of abstinence-only education programs have the same rates of premarital sex as their peers who do not take pledges, but are less likely to use contraceptives .
  • US states that emphasize abstinence-only education have higher rates of adolescent pregnancy and birth .

Abstinence-only programs can harm the healthy sexual and mental development of youth by:

  • Withholding information or providing inaccurate information about sexuality and sexual behavior .
  • Contributing to fear, shame, and stigma around sexual behaviors .
  • Not sharing information on contraception and barrier protection or overstating the risks of contraception .
  • Utilizing heteronormative framing and stigma or discrimination against students who are LGBTQ2S+ .
  • Reinforcing harmful gender stereotypes .
  • Ignoring the needs of youth who are already sexually active by withholding education around contraception and STI prevention.

Abstinence-plus sex education programs focus solely on decreasing unintended pregnancy and STIs.

Abstinence-plus sex education programs promote abstinence until marriage. However, these programs also provide information on contraception and condom use to prevent unintended pregnancy and STIs.

Research has demonstrated that abstinence-plus programs have an impact on sexual behavior and safety, including:

  • HIV prevention.
  • Increase in condom use .
  • Reduction in number of sexual partners .
  • Delay in initiation of sexual behavior .

While these programs add another layer of education, they do not address the broader spectrum of sexuality, gender identity, and relationship skills, thus withholding critical information and skill-building that can impact healthy sexual development.

AAP and other national medical and public health associations support comprehensive sex education for youth.

Given the evidence outlined above, AAP and other national medical organizations oppose abstinence-only education and endorse comprehensive sex education that includes both abstinence promotion and provision of accurate information about contraception, STIs, and sexuality.

National medical and public health organizations supporting comprehensive sex education include:

  • American Academy of Pediatrics .
  • American Academy of Family Physicians.
  • American College of Obstetricians and Gynecologists .
  • American Medical Association .
  • American Public Health Association .
  • Society for Adolescent Health and Medicine .

Pediatric clinics provide a unique opportunity for comprehensive sex education.

Pediatric health clinicians typically have longitudinal care relationships with their patients and families, and thus have unique opportunities to address comprehensive sex education across all stages of development.

The clinical visit can serve as a useful adjunct to support comprehensive sex education provided in schools, or to fill gaps in knowledge for youth who are exposed to abstinence-only or abstinence-plus curricula.

AAP policy and Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents provide recommendations for comprehensive sex education in clinical settings, including:

  • Encouraging parent-child discussions on sexuality, contraception, and internet/media use.
  • Understanding diverse experiences and beliefs related to sexuality and sex education and meeting the unique needs of individual patients and families.
  • Including discussions around healthy relationships, dating violence, and intimate partner violence in clinical care.
  • Discussing methods of contraception and STI/HPV prevention prior to onset of sexual intercourse.
  • Providing proactive and developmentally appropriate sex education to all youth, including children and adolescents with special health care needs.

Perspective

what is the importance of sexuality education

Karen Torres, Youth activist

There were two cardboard bears, and a person explained that one bear wears a bikini to the beach and the other bear wears shorts – that is the closest thing I ever got to sex ed throughout my entire K-12 education. I often think about that bear lesson because it was the day our institutions failed to teach me anything about my body, relationships, consent, and self-advocacy, which became even more evident after I was sexually assaulted at 16 years old. My story is not unique, I know that many young people have been through similar traumas, but many of us were also subjected to days, months, and years of silence and embarrassment because we were never given the knowledge to know how to spot abuse or the language to ask for help. Comprehensive sex ed is so much more than people make it out to be, it teaches about sex but also about different types of experiences, how to respect one another, how to communicate in uncomfortable situations, how to ask for help and an insurmountable amount of other valuable lessons.

From these lessons, people become well-rounded, people become more empathetic to other experiences, and people become better. I believe comprehensive sex ed is vital to all people and would eventually work as a part to build more compassionate communities.

Many US children and adolescents do not receive comprehensive sex education; and rates of formal sex education have declined significantly in recent decades.

Barriers to accessing comprehensive sex education include:

Misinformation, stigma, and fear of negative reactions:

  • Misinformation and stigma about the content of sex education curriculum has been the primary barrier to equitable access to comprehensive sex education in schools for decades .
  • Despite widespread parental support for sex education in schools, fears of negative public/parent reactions have led school administrators to limit youth access to the information they need to make healthy decisions about their sexuality for nearly a half-century.
  • In recent years, misinformation campaigns have spread false information about the framing and content of comprehensive sex education programs, causing debates and polarization at school board meetings .
  • Nearly half of sex education teachers report that concerns about parent, student, or administrator responses are a barrier to provision of comprehensive sex education.
  • Opponents of comprehensive sex education often express concern that this education will lead youth to have sex; however, research has demonstrated that this is not the case . Instead, comprehensive sex ed is associated with delays in initiation of sexual behavior, reduced frequency of sexual intercourse, a reduction in number of partners, and an increase in condom use.
  • Some populations of youth lack access to comprehensive sex education due to a societal belief that they are asexual, in need of protection, or don’t need to learn about sex. This barrier particularly impacts youth with disabilities or special health care needs .
  • Sex ed curricula in some schools perpetuate gender/sex stereotypes, which could contribute to negative gender stereotypes and negative attitudes towards sex .

Inconsistencies in school-based sex education:

  • There is significant variation in the content of sex education taught in schools in the US, and many programs that carry the same label (eg, “abstinence-plus”) vary widely in curriculum.
  • While decisions about sex education curriculum are made at the state level, the federal government has provided funding to support abstinence-only education for decades , which incentivizes schools to use these programs.
  • Since 1996, more than $2 billion in federal funds have been spent to support abstinence-only sex education in schools.
  • 34 US states require schools to use abstinence-only curriculum or emphasize abstinence as the main way to avoid pregnancy and STIs.
  • Only 16 US states require instruction on condoms or contraception.
  • It is not standard to include information on how to come forward if a student is being sexually abused, and many schools do not have a process for disclosures made.
  • Because of this, abstinence-only programs are commonly used in US schools, despite overwhelming evidence that they are ineffective in delaying sexual behavior until marriage, and withhold critical information that youth need for healthy sexual and relationship development.

Need for resources and training:

  • Integration of comprehensive sex education into school curriculum requires financial resources to strengthen and expand evidence-based programs.
  • Successful implementation of comprehensive sex education requires a trained workforce of teachers who can address the curriculum in age-appropriate ways for students in all grade-levels.
  • Education, training, and technical assistance are needed to support pediatric health clinicians in addressing comprehensive sex education in clinical settings, as a complement to school-based education.

Lack of diversity and cultural awareness in curricula:

  • A history of systemic racism, discrimination, and long-standing health, social and systemic inequities have created racial and ethnic disparities in access to sexual health services and representation in sex education materials. The legacy of intergenerational trauma in the medical system should be acknowledged in sex education curricula.
  • Sex education curriculum is often centered on a white audience, and does not address or reflect the role of systemic racism in sexuality and development .
  • Traditional abstinence-focused sex education programs have a heteronormative focus and do not address the unique needs of youth who are LGBTQ2S+ .
  • Sex education programs often do not address reproductive body diversity, the needs of those with differences in sex development, and those who identify as intersex .
  • Sex education programs often do not reflect the unique needs of youth with disabilities or special health care needs .
  • Sex education programs are often not tailored to meet the religious considerations of faith communities.
  • There is a need for sex education programs designed to help youth navigate sexual health and development in the context of their own culture and community .

Disparities in access to comprehensive sex education.

The barriers listed above limit access to comprehensive sex education in schools and communities. While these barriers impact youth across the US, there are some populations who are less likely to have access to comprehensive to sex education.

Youth who are LGBTQ2S+:

  • Only 8% of students who are LGBTQ2S+ report having received sexual education that was inclusive .
  • Students who are LGBTQ2S+ are 50% more likely than their peers who are heterosexual to report that sex education in their schools was not useful to them .
  • Only 13% of youth who are bisexual+ and 10% of youth who are transgender and gender expansive report receiving sex education in schools that felt personally relevant.
  • Only 20% of youth who are Black and LGBTQ2S+ and 13% of youth who are Latinx and LGBTQ2S+ report receiving sex education in schools that felt personally relevant.
  • Only 10 US states require affirming content on LGBTQ2S+ relationships in sex education curriculum.

Youth with disabilities or special health care needs:

  • Youth with disabilities or special health care needs have a particular need for comprehensive sex education, as these youth are less likely to learn about sex or sexuality form their parents , healthcare providers , or peer groups .
  • In a national survey, only half of youth with disabilities report that they have participated in sex education .
  • Typical sex education may not be sufficient for youth with Autism Spectrum Disorder, and special methods and curricula are necessary to match their needs .
  • Lack the desire or maturity for romantic or sexual relationships.
  • Are not subject to sexual abuse.
  • Do not need sex education.
  • Only 3 states explicitly include youth with disabilities within their sex education requirements.

Youth from historically underserved communities:

  • Students who are Black in the US are more likely than students who are white to receive abstinence-only sex education , despite significant support from parents and students who are Black for comprehensive sex education.
  • Youth who are Black and female are less likely than peers who are white to receive education about where to obtain birth control prior to initiating sexual activity.
  • Youth who are Black and male and Hispanic are less likely than their peers who are white to receive formal education on STI prevention or contraception prior to initiating sexual activity.
  • Youth who are Hispanic and female are less likely to receive instruction about waiting to have sex than youth of other ethnicities.
  • Tribal health educators report challenges in identifying culturally relevant sex education curriculum for youth who are American Indian/Alaska Native.
  • In a 2019 study, youth who were LGBTQ2S+ and Black, Latinx, or Asian reported receiving inadequate sex education due to feeling unrepresented, unsupported, stigmatized, or bullied.
  • In survey research, many young adults who are Asian American report that they received inadequate sex education in school.

Youth from rural communities:

  • Adolescents who live in rural communities have faced disproportionate declines in formal sex education over the past two decades, compared with peers in urban/suburban areas.
  • Students who live in rural communities report that the sex education curriculum in their schools does not serve their needs .

Youth from communities and schools that are low-income:

  • Data has shown an association between schools that are low-resource and lower adolescent sexual health knowledge, due to a combination of fewer school resources and higher poverty rates/associated unmet health needs in the student body.
  • Youth with family incomes above 200% of the federal poverty line are more likely to receive education about STI prevention, contraception, and “saying no to sex,” than their peers below 200% of the poverty line.

Youth who receive sex education in some religious settings:

  • Most adolescents who identify as female and who attended church-based sex education programs report instructions on waiting until marriage for sex, while few report receiving education about birth control.
  • Young people who received sex education in religious schools report that education focused on the risks of sexual behavior (STIs, pregnancy) and religious guilt; leading to them feeling under-equipped to make informed decisions about sex and sexuality later in life.
  • Youth and teachers from religious schools have identified a need for comprehensive sex education curriculum that is tailored to the needs of faith communities .

Youth who live in states that limit the topics that can be covered in sex education:

  • Students who live in the 34 states that require sex education programs to stress abstinence are less likely to have access to critical information on STI prevention and contraception.
  • Prohibitions on addressing abortion in sex education or mandates that sex education curricula include medically inaccurate information on abortion designed to dissuade youth from terminating a pregnancy.
  • Limitations on the types of contraception that can be covered in sex education curricula.
  • Requirements that sex education teachers promote heterosexual, monogamous marriage in sex education.
  • Lack of requirements to address healthy relationships and communication skills.
  • Lack of requirements for teacher training or certification.

Comprehensive sex education has significant benefits for children and adolescents.

Youth who are exposed to comprehensive sex education programs in school demonstrate healthier sexual behaviors:

  • Increased rates of contraception and condom use.
  • Fewer unplanned pregnancies.
  • Lower rates of STIs and HIV.
  • Delayed initiation of sexual behavior.

More broadly, comprehensive sexual education impacts overall social-emotional health , including:

  • Enhanced understanding of gender and sexuality.
  • Lower rates of homophobia and related bullying.
  • Lower rates of dating violence, intimate partner violence, sexual assault, and child sexual abuse.
  • Healthier relationships and communication skills.
  • Understanding of reproductive rights and responsibilities.
  • Improved social-emotional learning, media literacy, and academic achievement.

Comprehensive sex education curriculum goes beyond risk reduction, to ensure that youth are supported in understanding their identity and sexuality and making informed decisions about their relationships, behaviors, and future. These benefits are critical to healthy sexual development.

Impacts of a lack of access to comprehensive sex education.

When youth are denied access to comprehensive sex education, they do not get the information and skill-building required for healthy sexual development. As such, they face unnecessary barriers to understanding their gender and sexuality, building positive interpersonal relationships, and making informed decisions about their sexual behavior and sexual health.

Impacts of a lack of comprehensive sex education for all youth can include :

  • Less use of condoms, leading to higher risk of STIs, including HIV.
  • Less use of contraception, leading to higher risk of unplanned pregnancy.
  • Less understanding and increased stigma and shame around the spectrum of gender and sexual identity.
  • Perpetuated stigma and embarrassment related to sex and sexual identity.
  • Perpetuated gender stereotypes and traditional gender roles.
  • Higher rates of youth turning to unreliable sources for information about sex, including the internet, the media, and informal learning from peer networks.
  • Challenges in interpersonal communication.
  • Challenges in building, maintaining, and recognizing safe, healthy peer and romantic relationships.
  • Lower understanding of the importance of obtaining and giving enthusiastic consent prior to sexual activity.
  • Less awareness of appropriate/inappropriate touch and lower reporting of child sexual abuse.
  • Higher rates of dating violence and intimate partner violence, and less intervention from bystanders.
  • Higher rates of homophobia and homophobic bullying.
  • Unsafe school environments.
  • Lower rates of media literacy.
  • Lower rates of social-emotional learning.
  • Lower recognition of gender equity, rights, and social justice.

In addition, the lack of access to comprehensive sex education can exacerbate existing health disparities, with disproportionate impacts on specific populations of youth.

Youth who identify as women, youth from communities of color, youth with disabilities, and youth who are LGBTQ2S+ are particularly impacted by inequitable access to comprehensive sex education, as this lack of education can impact their health, safety, and self-identity. Examples of these impacts are outlined below.

A lack of comprehensive sex education can harm young women.

  • Female bodies are more prone to STI infection and more likely to experience complications of STI infection than male bodies.
  • Female bodies are disproportionately impacted by long-term health consequences of STIs , including pelvic inflammatory disease, infertility, and ectopic pregnancy.
  • Female bodies are less likely to have or recognize symptoms of certain STI infections .
  • Human papillomavirus (HPV) is the most common STI in young women , and can cause long-term health consequences such as genital warts and cervical cancer.
  • Women bear the health and economic effects of unplanned pregnancy.
  • Comprehensive sex education addresses these issues by providing medically-accurate, evidence based information on effective strategies to prevent STI infections and unplanned pregnancy.
  • Students who identify as female are more likely to experience sexual or physical dating violence than their peers who identify as male. Some of this may be attributed to underreporting by males due to stigma.
  • Students who identify as female are bullied on school property more often than students who identify as male.
  • Young women ages 16-19 are at higher risk of rape, attempted rape, or sexual assault than the general population.
  • Comprehensive sex education addresses these issues by guiding the development of healthy self-identities, challenging harmful gender norms, and building the skills required for respectful, equitable relationships.

A lack of comprehensive sex education can harm youth from communities of color.

  • Youth of color benefit from seeing themselves represented in sex education curriculum.
  • Sex education programs that use a framing of diversity, equity, rights, and social justice , informed by an understanding of systemic racism and discrimination, have been found to increase positive attitudes around reproductive rights in all students.
  • There is a critical need for sex education programs that reflect youth’s cultural values and community .
  • Comprehensive sex education can address these needs by developing curriculum that is inclusive of diverse communities, relationships, and cultures, so that youth see themselves represented in their education.
  • Racial and ethnic disparities in STI and HIV infection.
  • Racial and ethnic disparities in unplanned pregnancy and births among adolescents.
  • Nearly half of youth who are Black ages 13-21 report having been pressured into sexual activity .
  • Adolescent experience with dating violence is most prevalent among youth who are American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and multiracial.
  • Adolescents who are Latinx are more likely than their peers who are non-Latinx to report physical dating violence .
  • Youth who are Black and Latinx and who experience bullying are more likely to suffer negative impacts on academic performance than their white peers.
  • Students who are Asian American and Pacific Islander report bullying and harassment due to race, ethnicity, and language.
  • Comprehensive sex education addresses these issues by guiding the development of healthy self-identities, challenging harmful stereotypes, and building the skills required for respectful, equitable relationships.
  • Young people of color—specifically those from Black , Asian-American , and Latinx communities– are often hyper-sexualized in popular media, leading to societal perceptions that youth are “older” or more sexually experienced than their white peers.
  • Young men of color—specifically those from Black and Latinx communities—are often portrayed as aggressive or criminal in popular media, leading to societal perceptions that youth are dangerous or more sexually aggressive or experienced than white peers.
  • These media portrayals can lead to disparities in public perceptions of youth behavior , which can impact school discipline, lost mentorship and leadership opportunities, less access to educational opportunities afforded to white peers, and greater involvement in the juvenile justice system.
  • Comprehensive sex education addresses these issues by including positive representations of diverse youth in curriculum, challenging harmful stereotypes, and building the skills required for respectful relationships.

A lack of comprehensive sex education can harm youth with disabilities or special health care needs.

  • Youth with disabilities need inclusive, developmentally-appropriate, representative sex education to support their health, identity, and development .
  • Youth with special health care needs often initiate romantic relationships and sexual behavior during adolescence, similar to their peers.
  • Youth with disabilities and special health care needs benefit from seeing themselves represented in sex education to access the information and skills to build healthy identities and relationships.
  • Comprehensive sex education addresses this need by including positive representation of youth with disabilities and special health care needs in curriculum and providing developmentally-appropriate sex education to all youth.
  • When youth with disabilities and special health care needs do not get access to the comprehensive sex education that they need, they are at increased risk of sexual abuse or being viewed as a sexual offender.
  • Youth with disabilities and special health care needs are more likely than peers without disabilities to report coercive sex, exploitation, and sexual abuse.
  • Youth with disabilities and special health care needs report more sexualized behavior and victimization online than their peers without disabilities.
  • Youth with disabilities are at greater risk of bullying and have fewer friend relationships than their peers.
  • Comprehensive sex education addresses these issues by providing education on healthy relationships, consent, communication, and bodily autonomy.

A lack of comprehensive sex education can harm youth who are LGBTQ2S+.

  • Most sex education curriculum is not inclusive or representative of LGBTQ2S+ identities and experiences.
  • Because school-based sex education often does not meet their needs, youth who are LGBTQ2S+ are more likely to seek sexual health information online , and thus are more likely to come across misinformation.
  • The majority of parents support discussion of sexual orientation in sex education classes.
  • Comprehensive sex education addresses these issues by including positive representation of LGBTQ2S+ individuals, romantic relationships, and families.
  • Sex education curriculum that overlooks or stigmatizes youth who are LGBTQ2S+ contributes to hostile school environments and harms the healthy sexual and mental development .
  • Youth who are LGBTQ2S+ face high levels of discrimination at school and are more likely to miss school because of bullying or victimization .
  • Ongoing experiences with stigma, exclusion, and harassment negatively impact the mental health of youth who are LGBTQ2S+.
  • Comprehensive sex education provides inclusive curriculum and has been shown to improve understanding of gender diversity, lower rates of homophobia, and reduce homophobic bullying in schools.
  • Youth who are LGBTQ2S+ are more likely than their heterosexual peers to report not learning about HIV/STIs in school .
  • Lack of education on STI prevention leaves LGBTQ2S+ youth without the information they need to make informed decisions, leading to discrepancies in condom use between LGBTQ2S+ and heterosexual youth.
  • Some LGBTQ2S+ populations carry a disproportionate burden of HIV and other STIs: these disparities begin in adolescence , when youth who are LGBTQ2S+ do not receive sex education that is relevant to them.
  • Comprehensive sex education provides the knowledge and skills needed to make safe decisions about sexual behavior , including condom use and other forms of STI and HIV prevention.
  • Youth who are LBGTQ2S+ or are questioning their sexual identity report higher rates of dating violence than their heterosexual peers.
  • Youth who are LGBTQ2S+ or are questioning their sexual identity face higher prevalence of bullying than their heterosexual peers.
  • Comprehensive sex education teaches youth healthy relationship and communication skills and is associated with decreases in dating violence and increases in bystander interventions .

A lack of comprehensive sex education can harm youth who are in foster care.

  • More than 70% of children in foster care have a documented history of child abuse and or neglect.
  • More than 80% of children in foster care have been exposed to significant levels of violence, including domestic violence.
  • Youth in foster care are racially diverse, with 23% of youth identifying as Black and 21% of identifying as Latinx, who will have similar experiences as those highlighted in earlier sections of this report.
  • Removal is emotionally traumatizing for almost all children. Lack of consistent/stable placement with a responsive, nurturing caregiver can result in poor emotional regulation, impulsivity, and attachment problems.
  • Comprehensive sex education addresses these issues by providing evidence-based, culturally appropriate information on healthy relationships, consent, communication, and bodily autonomy.

Sex education is often the first experience that youth have with understanding and discussing their gender and sexual health.

Youth deserve to a strong foundation of developmentally appropriate information about gender and sexuality, and how these things relate to their bodies, community, culture, society, mental health, and relationships with family, peers, and romantic partners.

Decades of data have demonstrated that comprehensive sex education programs are  effective  in reducing risk of STIs and unplanned pregnancy. These benefits are critical to public health. However, comprehensive sex education goes even further, by instilling youth with a broad range of knowledge and skills that are  proven  to support social-emotional learning, positive communication skills, and development of healthy relationships.

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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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Building an evidence- and rights-based approach to healthy decision-making

As they grow up, young people face important decisions about relationships, sexuality, and sexual behavior. The decisions they make can impact their health and well-being for the rest of their lives. Young people have the right to lead healthy lives, and society has the responsibility to prepare youth by providing them with comprehensive sexual health education that gives them the tools they need to make healthy decisions. But it is not enough for programs to include discussions of abstinence and contraception to help young people avoid unintended pregnancy or disease. Comprehensive sexual health education must do more. It must provide young people with honest, age-appropriate information and skills necessary to help them take personal responsibility for their health and overall well being. This paper provides an overview of research on effective sex education, laws and policies that shape it, and how it can impact young people’s lives.

What is sexual health education?

Sex education is the provision of information about bodily development, sex, sexuality, and relationships, along with skills-building to help young people communicate about and make informed decisions regarding sex and their sexual health. Sex education should occur throughout a student’s grade levels, with information appropriate to students’ development and cultural background. It should include information about puberty and reproduction, abstinence, contraception and condoms, relationships, sexual violence prevention, body image, gender identity and sexual orientation. It should be taught by trained teachers. Sex education should be informed by evidence of what works best to prevent unintended pregnancy and sexually transmitted infections, but it should also respect young people’s right to complete and honest information. Sex education should treat sexual development as a normal, natural part of human development.

Why is sexual health education important to young people’s health and well-being?

Comprehensive sexual health education covers a range of topics throughout the student’s grade levels. Along with parental and community support, it can help young people:

  • Avoid negative health consequences. Each year in the United States, about 750,000 teens become pregnant, with up to 82 percent of those pregnancies being unintended.[1,2] Young people ages 15-24 account for 25 percent of all new HIV infections in the U.S.[3] and make up almost one-half of the over 19 million new STD infections Americans acquire each year.4 Sex education teaches young people the skills they need to protect themselves.
  • Communicate about sexuality and sexual health. Throughout their lives, people communicate with parents, friends and intimate partners about sexuality. Learning to freely discuss contraception and condoms, as well as activities they are not ready for, protects young people’s health throughout their lives. Delay sexual initiation until they are ready. Comprehensive sexual health education teaches abstinence as the only 100 percent effective method of preventing HIV, STIs, and unintended pregnancy – and as a valid choice which everyone has the right to make. Dozens of sex education programs have been proven effective at helping young people delay sex or have sex less often.[5]
  • Understand healthy and unhealthy relationships. Maintaining a healthy relationship requires skills many young people are never taught – like positive communication, conflict management, and negotiating decisions around sexual activity. A lack of these skills can lead to unhealthy and even violent relationships among youth: one in 10 high school students has experienced physical violence from a dating partner in the past year.[6] Sex education should include understanding and identifying healthy and unhealthy relationship patterns; effective ways to communicate relationship needs and manage conflict; and strategies to avoid or end an unhealthy relationship.[7]
  • Understand, value, and feel autonomy over their bodies. Comprehensive sexual health education teaches not only the basics of puberty and development, but also instills in young people that they have the right to decide what behaviors they engage in and to say no to unwanted sexual activity. Furthermore, sex education helps young people to examine the forces that contribute to a positive or negative body image.
  • Respect others’ right to bodily autonomy. Eight percent of high school students have been forced to have intercourse[8], while one in ten students say they have committed sexual violence.[9] Good sex education teaches young people what constitutes sexual violence, that sexual violence is wrong, and how to find help if they have been assaulted.
  • Show dignity and respect for all people, regardless of sexual orientation or gender identity. The past few decades have seen huge steps toward equality for lesbian, gay, bisexual, and transgender (LGBT) individuals. Yet LGBT youth still face discrimination and harassment. Among LGBT students, 82 percent have experienced harassment due to the sexual orientation, and 38 percent have experienced physical harassment.[10]
  • Protect their academic success. Student sexual health can affect academic success. The Centers for Disease Control and Prevention (CDC) has found that students who do not engage in health risk behaviors receive higher grades than students who do engage in health risk behaviors. Health-related problems and unintended pregnancy can both contribute to absenteeism and dropout.[11]

What does the research say about effective sex education?

  • A 2012 study that examined 66 comprehensive sexual risk reduction programs found them to be an effective public health strategy to reduce adolescent pregnancy, HIV, and STIs.[12]
  • Research from the National Survey of Family Growth assessed the impact of sexuality education on youth sexual risk-taking for young people ages 15-19 and found that teens who received comprehensive sex education were 50 percent less likely to experience pregnancy than those who received abstinence-only-until-marriage programs.[13]
  • Even accounting for differences in household income and education, states which teach sex education and/or HIV education that covers abstinence as well as contraception, tend to have the lowest pregnancy rates.[14]
  • National Sexuality Education Standards provide a roadmap. The National Sexuality Education Standards, developed by experts in the public health and sexuality education field and heavily influenced by the National Health Education Standards, provide guidance about the minimum essential content and skills needed to help students make informed decisions about sexual health.15 The standards focus on seven topics as the minimum, essential content and skills for K–12 education: Anatomy and Physiology, Puberty and Adolescent Development, Identity, Pregnancy and Reproduction, Sexually Transmitted Diseases and HIV, Healthy Relationships, and Personal Safety. Topics are presented using performance indicators—what students should learn by the end of grades 2, 5, 8, and 12.[16] Schools which are developing comprehensive sexual health education programs should consult the National Sexuality Education Standards to provide students with the information and skills they need to develop into healthy adults.
  • 16 programs demonstrated a statistically significant delay in the timing of first sex.
  • 21 programs showed statistically significant declines in teen pregnancy, HIV or other STIs.
  • 16 programs helped sexually active youth to increase their use of condoms.
  • 9 programs demonstrated success at increasing use of contraception other than condoms.
  • 40 percent delayed sexual initiation, reduced number of sexual partners, or increased condom or contraceptive use;
  • 30 percent reduced the frequency of sex, including return to abstinence; and
  • 60 percent reduced unprotected sex.[17]
  • The Office of Adolescent Health, a division of the U.S. Department of Health and Human Services, keeps a list of evidence-based interventions, with ratings based on the rigor of program impact studies and strength of the evidence supporting the program model. Thirty-one programs meet the OAH’s effectiveness criteria and that were found to be effective at preventing teen pregnancies or births, reducing sexually transmitted infections, or reducing rates of associated sexual risk behaviors (defined by sexual activity, contraceptive use, or number of partners).[18]

What’s wrong with abstinence-only-until-marriage programs?

Many students receive abstinence-only-until marriage programs instead of or in addition to more comprehensive programs. These programs:

  • Depict abstinence until heterosexual marriage as the only moral choice for young people
  • Mention contraception only in terms of failure rates
  • Focus on heterosexual youth, ignoring the needs of LGBTQ youth
  • Often use outdated gender roles, urging “modesty” for all girls while painting all boys as sexual aggressors.
  • Have been found to contain false information
  • Are not supported by the majority of Americans.[19]

Only one abstinence-only program has ever been proven effective at helping young people delay sex; yet in withholding information about contraception, it leaves those who do have sex completely at risk. Studies show that 99 percent of people will use contraception in their lifetimes,[20] and that the provision of information about contraception does not hasten the onset of sexual debut or increase sexual activity.[10] Meanwhile, thirty years of public health research clearly demonstrate that comprehensive sex education can help young people delay sexual initiation while also assisting them to use protection when they do become sexually active. We want young people to behave responsibly when it comes to decisions about sexual health, and that means society has the responsibility to provide them with honest, age-appropriate comprehensive sexual health education; access to services to prevent pregnancy and sexually transmitted infections; and the resources to help them lead healthy lives.

All young people need comprehensive sexual health education, while others also need sexual health services. Youth at disproportionate risk for sexual health disparities may also need targeted interventions designed specifically to build self efficacy and agency. Further, administrators and other policy makers must recognize that structural determinants, socio-cultural factors and cultural norms have been shown to have a strong impact on youth sexual health and must be tackled to truly redress sexual health disparity fueled by social inequity.

How is the content of a student’s sex education decided?

Many factors help shape the content of a student’s sex education. These include:

  • State and federal funding the school district receives
  • State laws and standards regarding sex education
  • School district level policies and/or standards regarding curricula and content
  • The program or curriculum a district or individual school selects
  • The individual(s) who delivers the program.

With thousands of school districts around the nation, students’ experiences can vary drastically from district to district and school to school.

What are federal, state, and local structures that affect sex education?

In the United States, education is largely a state and local responsibility, as dictated by the 10th Amendment of the U.S. Constitution. This amendment states that “the powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”[3] Because the Constitution doesn’t specifically mention education, the federal government does not have any direct authority regarding curriculum, instruction, administration, personnel, etc. In 1980, the U.S. Department of Education was created. While this move centralized federal efforts and responsibilities into one office, it did not come with an increase in federal jurisdiction over the educational system.

The U.S. Department of Education currently has no authority over sexual health education. However, there have been federal funds allocated, primarily through the Department of Health and Human Services that school systems and community-based agencies have used throughout the last three decades to provide various forms of sex education.[21]

  • Federal funding: Until FY2010, there was no designated funding for a comprehensive approach to sex education. In 1982, federal support of abstinence-only programs began, and in 1996, expanded drastically. From 1996-2010, over $1.5 billion in federal funding went to abstinence-only programs, which were conducted with little oversight and were proven ineffective. While one large stream of funding for abstinence-only programs was cancelled in 2010, at publication one still exists (as authorized by Congress through Title V funding) and is funded at $50 million per year.[22]

In 2010, two streams of funding became available for evidence-based sex education interventions.[22]

  • PREP: The Personal Responsibility Education Program (PREP) was authorized by Congress as a part of the Affordable Care Act of 2010. PREP provides grants ($75 million over five years) for programs which teach about both abstinence and contraception in order to help young people reduce their risk for unintended pregnancy, HIV, and STIs. In Fiscal Year 2012, 45 states applied for PREP. PREP grants are issued to states, typically the state health departments. All programs implemented with PREP funding are to educate adolescents about both abstinence and contraception for the prevention of pregnancy and STIs, including HIV/AIDS, and must cover at least three adulthood preparation subjects such as healthy relationships, adolescent development, financial literacy, educational and career success, and healthy life skills.
  • The President’s Teen Pregnancy Prevention Initiative (TPPI) funds medically-accurate and age-appropriate programs to reduce teen pregnancy. Seventy-five grantees in 32 states received TPPI funds in FY 2012. TPPI grants are distributed by the Office of Adolescent Health to local public and private entities. Grantees must implement an evidence-based program which has been proven effective at preventing teen pregnancy. According to OAH, 31 programs meet these criteria, including one abstinence-only-until-marriage program.
  • States may accept PREP, TPPI, or Title V funds. Many states accept funds for both abstinence-only programs and evidence-based interventions. In 2013, 19 SEAs and 17 LEA received five year cooperative agreements from CDC/DASH to implement ESHE within their school systems.

In addition, in 2013, CDC/Division of School Health issued a request for proposals to fund State Education Agencies (SEAs) and Large Municipal Education Agencies (LEAs) to implement Exemplary Sexual Health Education (ESHE). ESHE is defined as a systematic, evidence-informed approach to sexual health education that includes the use of grade-specific, evidence-based interventions, but also emphasizes sequential learning across elementary, middle, and high school grade levels.[23]

States may accept PREP, TPPI, or Title V funds. Many states accept funds for both abstinence-only programs and evidence-based interventions. In 2013, 19 SEAs and 17 LEAs received five year cooperative agreements from CDC/DASH to implement ESHE within their school systems.[22]

  • The Real Education for Healthy Youth Act: While there is as yet no law that supports comprehensive sexual health education, there is pending legislation. The Real Education for Healthy Youth Act (S. 372/H.R. 725), introduced in February 2013 by the late Senator Frank Lautenberg (D-NJ) and Representative Barbara Lee (D-CA), would ensure that federal funding is allocated to comprehensive sexual health education programs that provide young people with the skills and information they need to make informed, responsible, and healthy decisions. This legislation sets forth a vision for comprehensive sexual health education programs in the United States.
  • 30 states have no law that governs sex education, and schools are not required to provide it
  • 25 states mandate that sex education, if taught, must include abstinence, but do not require it to include contraception.
  • Six states mandate that sex education include either a ban on discussing homosexuality, or material about homosexuality that is overtly discriminatory.[22]

Each state has a department of education headed by a chief state school officer, more commonly known as the Superintendent of Public Instruction or the Commissioner of Education (titles vary by state). State departments of education are generally responsible for disbursing state and federal funds to local school districts, setting parameters for the length of school day and year, teacher certification, testing requirements, graduation requirements, developing learning standards and promoting professional development. Generally, the chief state school officer is appointed by the Governor, though in a few states they are elected.[23]

State departments of education may also have Standards which provide benchmark measures that define what students should know and be able to do at specified grade levels. These sometimes, but not always, address sexual health education. For instance, Connecticut and New Jersey have standards similar to the National Sexuality Education Standards in place and which address reproduction, prevention of STIs and pregnancy, and healthy relationships. A number of other states have general health education standards which do not directly address sexual health, while others make mention of HIV/STI prevention and abstinence but don’t demand the most thorough instruction in sexual health.[24]

  • Local Policy: At the school district level, Pre-K-12 public schools are generally governed by local school boards (with the exception of Hawaii which does not have any local school board system). Local school boards are typically comprised of 5 to 7 members who are either elected by the public or appointed by other government officials.[21]

Local school boards are responsible for ensuring that each school in their district is in compliance with the laws and policies set by the state and federal government. Local school board also have broad decision and rule-making authority with regards to the operations of their local school district, including determining the school district budget and priorities; curriculum decisions such as the scope and sequence of classroom content in all subject areas; and textbook approval authority. [21]

Typically, school boards set the sex education policy for a school district. They must follow state law. Some school boards provide guidelines or standards, while others select specific curricula for schools to deliver. Most school boards are advised by School Health Advisory Councils (SHACs). SHAC members are individuals who represent the community and who provide advice about health education.[21]

How can I work for comprehensive sexual health education for students in my community?

There are a number of ways to help ensure that students get the information they need to live healthy lives, build healthy relationships, and take personal responsibility for their health and well being.

  • Urge your Members of Congress to support the Real Education for Healthy Youth Act, in person, by phone, or online.
  • Contact your school board and urge them to adopt the National Sexuality Education Standards and require comprehensive sexual health programs.
  • Join a School Health Advisory Council in your area – both young people and adults are eligible to serve on most.
  • Organize within your community – a group of individuals, or a coalition of like-minded organizations – to do one or all of the above.

Young people have the right to lead healthy lives. As they develop, we want them to take more and more control of their lives so that as they get older, they can make important life decisions on their own. The balance between responsibility and rights is critical because it sets behavioral expectations and builds trust while providing young people with the knowledge, ability, and comfort to manage their sexual health throughout life in a thoughtful, empowered and responsible way. But responsibility is a two-way street. Society needs to provide young people with honest, age-appropriate information they need to live healthy lives, and build healthy relationships, and young people need to take personal responsibility for their health and well being. Advocates must also work to dismantle barriers to sexual health, including poverty and lack of access to health care.

Emily Bridges, MLS, and Debra Hauser, MPH

Advocates for Youth © May 2014

1. CDC. Youth Risk Behavior Surveillance, 2011. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2012.

2. Finer LB et al., Disparities in rates of unintended pregnancy in the United States, 1994 and 2001, Perspectives on Sexual and Reproductive Health, 2006, 38(2):90–96.

3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta: U.S. Department of Health and Human Services; 2012.

4. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2012. Atlanta: U.S. Department of Health and Human Services; 2013.

5. Alford S, et al. Science and Success: Sex Education and Other Programs that Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections. 2nd ed. Washington, DC: Advocates for Youth, 2008;

6. Dating Matters: Strategies to Promote Health Teen Relationships. Atlanta: Center for Disease Control and Prevention; 2013.

7. National Sexual Education Standards: Core Content and Skills, K-12. A Special Publication of the Journal of School Health. 2012: 6-9. http://www.futureofsexed.org/documents/josh-fose-standards-web.pdf. Accessed October 2, 2013.

8. Davis A. Interpersonal and Physical Dating Violence among Teens. National Council on Crime and Delinquency, 2008. Retrieved November 15, 2013 from http://www.nccdglobal.org/sites/default/files/publication_pdf/focus-dating-violence.pdf

9. Ybarra ML and Mitchell KJ. “Prevalence Rates of Male and Female Sexual Violence Perpetrators in a National Sample of Adolescents.” JAMA Pediatrics, December 2013.

10. Gay, Lesbian, and Straight Education Network. The 20011 National School Climate Survey: The School Related Experiences of Our Nation’s Lesbian, Gay, Bisexual and Transgender Youth. New York, NY: GLSEN, 2012.

11. CDC. Sexual Risk Behaviors and Academic Achievement. Atlanta, GA: CDC, (2010); http://www.cdc.gov/HealthyYouth/ health_and_academics/pdf/sexual_risk_behaviors.pdf; last accessed 5/23/2010. 12. Chin B et al. “The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: two systematic reviews for the Guide to Community Preventive Services.” American Journal of Preventive Medicine, March 2012.

13. Kohler PK, Manhart LE, Lafferty WE. Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy. Journal of Adolescent Health. 2007; 42(4): 344-351.

14. Stanger-Hall KF, Hall DW. “Abstinence-only education and teen pregnancy rates: why we need comprehensive sex education in the U.S.

15. National Sexual Education Standards: Core Content and Skills, K-12. A Special Publication of the Journal of School Health. 2012: 6-9. http://www.futureofsexed.org/documents/josh-fose-standards-web.pdf. Accessed October 2, 2013.

16. National Sexual Education Standards: Core Content and Skills, K-12. A Special Publication of the Journal of School Health. 2012: 6-9. http://www.futureofsexed.org/documents/josh-fose-standards-web.pdf. Accessed October 2, 2013.

17. Kirby D. Emerging Answers 2007. Washington, DC: National Campaign to Prevent Teen Pregnancy, 2007. 18. Office of Adolescent Health. “Evidence-Based Programs (31 Programs). Accessed March 5, 2014 from http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/programs.html

19. Public Religion Research Institute. Survey – Committed to Availability, Conflicted about Morality: What the Millennial Generation Tells Us about the Future of the Abortion Debate and the Culture Wars. 2011. Accessed from http://publicreligion.org/research/2011/06/committed-to-availability-conflicted-about-morality-what-the-millennial-generation-tells-us-about-the-future-of-the-abortion-debate-and-the-culture-wars/ on May 13, 2014.

20. Daniels K, Mosher WD and Jones J, Contraceptive methods women have ever used: United States, 1982–2010,National Health Statistics Reports, 2013, No. 62, <http://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf>, accessed Mar. 20, 2013.

21. Future of Sex Education. “Public Education Primer. “ Accessed from http://www.futureofsexed.org/documents/public_education_primer.pdf on May 13, 2014.

22. Sexuality Information and Education Council of the United States, Siecus State Profiles, Fiscal Year 2012. Accessed from http://www.siecus.org/index.cfm?fuseaction=Page.ViewPage&PageID=1369 on May 13, 2014.

23. Centers for Disease Control and Prevention. “In Brief: Rationale for Exemplary Sexual Health Education (ESHE) for PS13-1308. Accessed from http://www.cdc.gov/healthyyouth/fundedpartners/1308/strategies/education.htm on May 13, 2014.

24. Answer. “State sex education policies by state.” Accessed from http://answer.rutgers.edu/page/state_policy/ on May 13, 2014.

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UN Women Strategic Plan 2022-2025

The journey towards comprehensive sexuality education: Global status report

Publication year: 2021.

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Comprehensive sexuality education is central to children and young people’s health and well-being, equipping them with the knowledge and skills they need to make healthy, informed, and responsible choices in their lives, including to prevent HIV and promote gender equality.

This report seeks to provide an analysis of countries’ progress towards delivering good quality school-based comprehensive sexuality education to all learners around the world.

The report is intended to help inform continued advocacy and resourcing efforts, as governments and partners work towards the goal of ensuring all learners receive good quality comprehensive sexuality education throughout their schooling.

The review maps out a number of forward-looking recommendations to countries, including actions to ensure implementation of policies and programmes that:

  • support the availability of good quality comprehensive sexuality education for all learners;
  • increase investments in quality curriculum reform and teacher training; and
  • strengthen monitoring of the implementation of comprehensive sexuality education.

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By Clint Bruess, EdD, CHES, and Elizabeth Schroeder, EdD, MSW | October 16, 2018 Dean Emeritus, University of Alabama at Birmingham (CB) and Sexuality Educator, Trainer and Consultant, Elizabeth Schroeder Consulting (ES)

We’ve just finished writing a new edition of our book on sexuality education, which has been in print for almost 40 years. That’s a long time! A lot of people ask us, “What’s changed in sex ed over so many years?” The easy answer is, a lot has changed—and yet an astonishing amount has stayed the same. 

What Are The Goals of Sexuality Education? Probably Not What You Think

What Are The Goals of Sexuality Education? Probably Not What You Think

By Clint Bruess, EdD and Elizabeth Schroeder, EdD, MSW | March 19, 2019 Dean Emeritus, University of Alabama at Birmingham (CB) and Sexuality Educator, Trainer and Consultant, Elizabeth Schroeder Consulting (ES)

Although sexuality education has changed significantly since the early 20th century, many of the goals still focus primarily on public health outcomes. Federal and state-level funding streams tend to focus, for example, on reducing unplanned pregnancy and avoiding STIs. Now, don’t get us wrong—these are important parts of many sexuality education programs. If these are the only goals, however, they exclude other vital parts of who we are as human beings. They also connect human sexual experience exclusively to negative health outcomes. Doing so significantly contributes to the shame, fear and stigma surrounding human sexuality for far too many.

Sexuality Education: Theory and Practice, Seventh Edition

Cover of book Sexuality Education Theory and Practice

ETR is proud to offer this new edition of an outstanding standard in the field. The text is a useful resource for new students in the sexuality education field as well as for seasoned professionals seeking current information and updates on successful teaching methods. Highly recommended by an impressive group of researchers and educators. Learn more here .

Celebrate Being Human

If we wish to truly support the development of sexually healthy young people and adults, we need to teach about sexuality in ways that celebrate the vast range of human feelings and experiences. We need to stop trying to frighten people out of exploring their normal, natural feelings and instead teach them about the positive aspects of human sexuality. We can do this and still make room for discussing potential negative aspects and the importance of considering the outcomes of our actions.

For example, some schools still show students photographs of STI-infected genitals in an effort to scare students out of wanting to have sex. This is problematic for numerous reasons. First, the photos tend to show late-stage, untreated STIs, which is not typically what a young person would see if they were in a sexual relationship with another person. Considering the most common symptom of an STI is no symptom, showing these slides spreads misinformation. Second, fear is not an appropriate teaching method in sexuality education, especially when it is not coupled with information and skills for students to build self-efficacy in what they can do to avoid or manage STIs.

A conversation with Elizabeth Schroeder: Fear-based approaches

Author Elizabeth Schroeder

But those questions are different from scaring the kahooey out of someone and expecting that to result in behavior change. In fact, some folks–especially adolescents–will intentionally dig in their heels in the face of fear to prove they are invincible and that adults are wrong.

So the main thing is, fear alone doesn’t motivate behavior change, whether that has to do with sexual health or any other kind of health. And when there’s too much of it, or educators go over the top to make something sound scary, it can have deleterious effects on the individuals, whether youth or adult.

Put Decision-Making Skills Forward

Instead, we should be spending time teaching decision-making skills. Both youth and adults need to know about the potential outcomes, positive and negative, of shared sexual behaviors. They need opportunities to reflect on how they might respond if they were to experience any of those.

We should build self-efficacy by teaching skills young people will need well into their adult lives, such as open communication and negotiation skills, and how to ensure consent is clearly given and received as part of their relationships.

A number of sexual health education entities around the world have posited their thoughts about what the overall goals of sexuality education should be. According to UNESCO (2018) :

The goals of comprehensive sexuality education are to equip [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
  • understand and ensure the protection of their rights throughout their lives

Look at Deeper Implications

These goals may seem fairly straightforward, but there are deeper implications within each:

  • Realizing health, well-being and dignity includes not only our own health, well-being and dignity, but that of others. It means understanding and honoring the range of life experiences, desires and identities that exist in the world, even when they are different from our own.
  • Developing respectful social and sexual relationships refers to the many factors and decisions relating to being in relationship with others: friendships, love relationships and/or sexual relationships. It includes understanding that people may choose to be in relationships, or choose not to be. They may be in relationships with more than one person at a time. Relationships can look dramatically different from one to another. It includes understanding that some people will have feelings of attraction for one gender or more than one gender; or to people who have certain physical, emotional and/or intellectual traits; or, sometimes, to no one at all. All of these need to be acknowledged as equally valid human experiences, again, even when they are different from one’s own.
  • Considering how their choices affect their own well-being and that of others reinforces that how we interact with others can have powerful, long-lasting impacts for everyone involved. This is where lessons come in relating to respect, giving and receiving consent, avoiding pressure and coercion and getting help if one thinks one is being pressured or coerced.
  • Understanding and ensuring the protection of their rights throughout their lives frames human sexuality as far more than a course topic or something to be googled online. This powerful goal asserts that we all, regardless of age, have the right to understand what is happening with our bodies and in the world around us. It admonishes adults that withholding this information, or, even worse, misinforming young people about sexuality is harmful and dangerous. It states unapologetically that all people—of all races, ethnicities, cultures, physical and intellectual abilities, genders, sexual orientations, educational and socioeconomic levels—all people have the right to be treated with dignity and respect, and the responsibility to treat others with the same.

Just as “sexuality” is about far more than sexual anatomy and behaviors, the goals of sexuality education must reflect more than the possible outcomes of shared sexual behaviors. They must  teach young people and adults information and skills that contribute to the very fabric of the world in which we all live.

Clint E. Bruess, EdD, is Dean Emeritus, University of Alabama at Birmingham and Professor Emeritus, Birmingham-Southern College. He is a longtime teacher of graduate and undergraduate courses in sexuality education and in human sexuality.   He can be reached at [email protected] .

Elizabeth Schroeder, EdD, MSW, is an international sexuality education and youth development expert. See her website here .  She can be reached at [email protected] .

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Students in a technical education program supported by the World Bank in Antioquia, Colombia.

The world is changing, and changing fast, what with emerging technologies, environmental uncertainty and shifting global demographics. Young people leaving school or university today are facing a very different set of challenges to those experienced by previous generations.                         

A good quality education is paramount. It is indispensable in a world marked by complexity and uncertainty. This includes inclusive and equitable education and lifelong learning opportunities for all, the ambition of Sustainable Development Goal 4. This is a fundamental human right, and one of the most powerful tools for achieving sustainable development.

What a well-rounded education should include

Yet, when we talk about a good education, we must also go beyond the traditional academic focus. We must look to education that supports young people to develop the knowledge, skills, ethical values and attitudes they need to make conscious, healthy and respectful choices about relationships, sex and reproduction.

Comprehensive sexuality education is not just about reproduction, family planning and safe sexual behaviors. It also includes positive aspects of sexuality, such as love and relationships based on mutual respect and equality. It includes discussions about values, rights, culture and gender, about power dynamics based on race, gender, ability or sexuality and how to recognize, challenge and change harmful gender norms. 

The research behind comprehensive sexuality education

UNESCO commissioned two evidence-based reviews around comprehensive sexuality education, in 2008 and 2016, and the facts are now clear. Curriculum-based sexuality education programs do not increase sexual activity, sexual risk-taking behaviors or STI/HIV infection rates. Instead, comprehensive sexuality education increases young people’s knowledge and understanding of sexual and reproductive health, can delay sexual initiation and leads to safer sexual behavior.

The evidence tells us that comprehensive sexuality education also empowers young people to question their social context and challenge negative social norms, including gender norms, and to be part of broader societal efforts towards gender equality.

However, despite the evidence, millions of young people around the world are still making the transition from childhood to adulthood receiving inaccurate, incomplete and judgement-laden information around their physical, social and emotional development.

Moreover, without access to good quality comprehensive sexuality education, we cannot achieve the Sustainable Development Goals we have set for 2030. How can we expand education opportunities if we are not able to improve sexual and reproductive health-related outcomes, such as reducing HIV infection and adolescent pregnancy rates? How can we reduce or prevent gender-based violence and create safe and inclusive learning environments, if we are unable to disrupt harmful gender norms?

A new report: Facing the facts

UNESCO has presented the latest evidence at this year’s Women Deliver Conference 2019 , as part of a new report, produced with the Global Education Monitoring Report. The report, Facing the facts: the case for comprehensive sexuality education argues that comprehensive sexuality education is part of the delivery of a quality education. It shows how governments can overcome social resistance and operational constraints to scale up these programs as part of their commitment to SDG 4.

It tells us that one of the main barriers to comprehensive sexuality education is negative and misinformed public attitudes. These could be concerns that this type of education is at odds with local cultural or religious beliefs around sexuality, or that it is inappropriate for young children.

There are also operational constraints. Even in countries with an enabling policy environment, implementation can be thwarted by a lack of teacher preparation and support, a lack of appropriate learning materials, and a lack of planning, financing and monitoring.

Engaging all stakeholders

At UNESCO, our comprehensive sexuality education programming is a key pillar of efforts to strengthen the delivery of quality education for all. We have developed a suite of resources to assist governments in strengthening policy frameworks to ensure comprehensive sexuality education in schools, as well as advocacy tools for civil society partners, parents and teachers to use to assist governments in fulfilling this right.

Our activities in this area need to reach beyond ministers and decision-makers, to ensure teachers receive sufficient training, and guidance to deliver the content of comprehensive sexuality education. Together, we must commit to strong political leadership, invest in teacher education, and improve curricula.

Comprehensive sexuality education is an essential part of a good quality education that helps prepare young people for a fulfilling life in a changing world. It improves sexual and reproductive health outcomes, promotes safe and gender equitable learning environments, and improves education access and achievement.

Access more resources:

  • Report - Facing the facts: the case for comprehensive sexuality education
  • UNESCO’s work in comprehensive sexuality education

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What Works In Schools : Sexual Health Education

CDC’s  What Works In Schools  Program improves the health and well-being of middle and high school students by:

  • Improving health education,
  • Connecting young people to the health services they need, and
  • Making school environments safer and more supportive.

What is sexual health education?

Quality provides students with the knowledge and skills to help them be healthy and avoid human immunodeficiency virus (HIV), sexually transmitted infections (STI) and unintended pregnancy.

A quality sexual health education curriculum includes medically accurate, developmentally appropriate, and culturally relevant content and skills that target key behavioral outcomes and promote healthy sexual development. 1

The curriculum is age-appropriate and planned across grade levels to provide information about health risk behaviors and experiences.

Beautiful African American female teenage college student in classroom

Sexual health education should be consistent with scientific research and best practices; reflect the diversity of student experiences and identities; and align with school, family, and community priorities.

Quality sexual health education programs share many characteristics. 2-4 These programs:

  • Are taught by well-qualified and highly-trained teachers and school staff
  • Use strategies that are relevant and engaging for all students
  • Address the health needs of all students, including the students identifying as lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ)
  • Connect students to sexual health and other health services at school or in the community
  • Engage parents, families, and community partners in school programs
  • Foster positive relationships between adolescents and important adults.

How can schools deliver sexual health education?

A school health education program that includes a quality sexual health education curriculum targets the development of functional knowledge and skills needed to promote healthy behaviors and avoid risks. It is important that sexual health education explicitly incorporate and reinforce skill development.

Giving students time to practice, assess, and reflect on skills taught in the curriculum helps move them toward independence, critical thinking, and problem solving to avoid STIs, HIV, and unintended pregnancy. 5

Quality sexual health education programs teach students how to: 1

  • Analyze family, peer, and media influences that impact health
  • Access valid and reliable health information, products, and services (e.g., STI/HIV testing)
  • Communicate with family, peers, and teachers about issues that affect health
  • Make informed and thoughtful decisions about their health
  • Take responsibility for themselves and others to improve their health.

What are the benefits of delivering sexual health education to students?

Promoting and implementing well-designed sexual health education positively impacts student health in a variety of ways. Students who participate in these programs are more likely to: 6-11

  • Delay initiation of sexual intercourse
  • Have fewer sex partners
  • Have fewer experiences of unprotected sex
  • Increase their use of protection, specifically condoms
  • Improve their academic performance.

In addition to providing knowledge and skills to address sexual behavior , quality sexual health education can be tailored to include information on high-risk substance use * , suicide prevention, and how to keep students from committing or being victims of violence—behaviors and experiences that place youth at risk for poor physical and mental health and poor academic outcomes.

*High-risk substance use is any use by adolescents of substances with a high risk of adverse outcomes (i.e., injury, criminal justice involvement, school dropout, loss of life). This includes misuse of prescription drugs, use of illicit drugs (i.e., cocaine, heroin, methamphetamines, inhalants, hallucinogens, or ecstasy), and use of injection drugs (i.e., drugs that have a high risk of infection of blood-borne diseases such as HIV and hepatitis).

What does delivering sexual health education look like in action?

To successfully put quality sexual health education into practice, schools need supportive policies, appropriate content, trained staff, and engaged parents and communities.

Schools can put these four elements in place to support sex ed.

  • Implement policies that foster supportive environments for sexual health education.
  • Use health content that is medically accurate, developmentally appropriate, culturally inclusive, and grounded in science.
  • Equip staff with the knowledge and skills needed to deliver sexual health education.
  • Engage parents and community partners.

Include enough time during professional development and training for teachers to practice and reflect on what they learned (essential knowledge and skills) to support their sexual health education instruction.

By law, if your school district or school is receiving federal HIV prevention funding, you will need an HIV Materials Review Panel (HIV MRP) to review all HIV-related educational and informational materials.

This review panel can include members from your School Health Advisory Councils, as shared expertise can strengthen material review and decision making.

For More Information

Learn more about delivering quality sexual health education in the Program Guidance .

Check out CDC’s tools and resources below to develop, select, or revise SHE curricula.

  • Health Education Curriculum Analysis Tool (HECAT), Module 6: Sexual Health [PDF – 70 pages] . This module within CDC’s HECAT includes the knowledge, skills, and health behavior outcomes specifically aligned to sexual health education. School and community leaders can use this module to develop, select, or revise SHE curricula and instruction.
  • Developing a Scope and Sequence for Sexual Health Education [PDF – 17 pages] .This resource provides an 11-step process to help schools outline the key sexual health topics and concepts (scope), and the logical progression of essential health knowledge, skills, and behaviors to be addressed at each grade level (sequence) from pre-kindergarten through the 12th grade. A developmental scope and sequence is essential to developing, selecting, or revising SHE curricula.
  • Centers for Disease Control and Prevention. Health Education Curriculum Analysis Tool, 2021 , Atlanta: CDC; 2021.
  • Goldfarb, E. S., & Lieberman, L. D. (2021). Three decades of research: The case for comprehensive sex education. Journal of Adolescent Health, 68(1), 13-27.
  • Centers for Disease Control and Prevention (2016). Characteristics of an Effective Health Education Curriculum .
  • Pampati, S., Johns, M. M., Szucs, L. E., Bishop, M. D., Mallory, A. B., Barrios, L. C., & Russell, S. T. (2021). Sexual and gender minority youth and sexual health education: A systematic mapping review of the literature.  Journal of Adolescent Health ,  68 (6), 1040-1052.
  • Szucs, L. E., Demissie, Z., Steiner, R. J., Brener, N. D., Lindberg, L., Young, E., & Rasberry, C. N. (2023). Trends in the teaching of sexual and reproductive health topics and skills in required courses in secondary schools, in 38 US states between 2008 and 2018.  Health Education Research ,  38 (1), 84-94.
  • Coyle, K., Anderson, P., Laris, B. A., Barrett, M., Unti, T., & Baumler, E. (2021). A group randomized trial evaluating high school FLASH, a comprehensive sexual health curriculum.  Journal of Adolescent Health ,  68 (4), 686-695.
  • Marseille, E., Mirzazadeh, A., Biggs, M. A., Miller, A. P., Horvath, H., Lightfoot, M.,& Kahn, J. G. (2018). Effectiveness of school-based teen pregnancy prevention programs in the USA: A systematic review and meta-analysis. Prevention Science, 19(4), 468-489.
  • Denford, S., Abraham, C., Campbell, R., & Busse, H. (2017). A comprehensive review of reviews of school-based interventions to improve sexual-health. Health psychology review, 11(1), 33-52.
  • Chin HB, Sipe TA, Elder R. The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: Two systematic reviews for the guide to community preventive services. Am J Prev Med 2012;42(3):272–94.
  • Mavedzenge SN, Luecke E, Ross DA. Effective approaches for programming to reduce adolescent vulnerability to HIV infection, HIV risk, and HIV-related morbidity and mortality: A systematic review of systematic reviews. J Acquir Immune Defic Syndr 2014;66:S154–69.

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  • Open access
  • Published: 07 July 2024

LGBTQIA health in medical education: a national survey of Australian medical students

  • Sophia Nicolades Wynn 1 , 2 ,
  • Pravik Solanki 1 , 3 ,
  • Jayde Millington 1 , 2 ,
  • Anthony Copeland 1 , 4 ,
  • Jessie Lu 1 , 3 ,
  • Ruth McNair 5 &
  • Asiel Adan Sanchez 6  

BMC Medical Education volume  24 , Article number:  733 ( 2024 ) Cite this article

163 Accesses

Metrics details

Lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA) individuals experience poorer health outcomes than other individuals. Insufficient LGBTQIA health education of doctors in existing medical curricula contributes to these outcomes. We sought to explore medical students’ experiences of content coverage and mode of delivery, as well as their preparedness, attitudes and learning needs regarding LGBTQIA health education in Australia.

Using a conceptual framework specific to curricular development, we adapted a previous cross-sectional national survey. This included 28 questions (analysed statistically) and 5 free text responses (analysed deductively using Braun and Clarke’s thematic analysis framework). Data was compared between LGBTQIA and non-LGBTQIA respondents, and clinical and preclinical students.

There were 913 participants from 21 of 23 medical schools, with most preclinical (55%) and clinical (89%) students reporting no teaching specific to LGBTQIA health. Reported content coverage was highest for sexual history taking (30%), and especially low for transgender and intersex health (< 16%), and intersectional LGBTQIA health (< 7%). Participants had positive attitudes towards LGBTQIA health, with 89% agreeing LGBTQIA topics were important and need to be covered in detail. Students desired longitudinal integration of LGBTQIA content, and LGBTQIA community involvement and case-based teaching that allows for interaction and questions. Self-perceived competency was low in all LGBTQIA health topics, although LGBTQIA participants reported higher preparedness than non-LGBTQIA participants.

Conclusions

Majority of survey participants reported limited teaching of LGBTQIA health-specific content, highlighting the limited coverage of LGBTQIA health in Australian medical schools. Participants expressed positive attitudes towards LGBTQIA content and broadly agreed with statements supporting increased integration of LGBTQIA health content within medical curricula.

Peer Review reports

Introduction

There is an increasing interest in lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA) health content in medical curricula. This interest grows alongside recognition of the health disparities faced by LGBTQIA individuals across mental and general health outcomes, particularly for trans and gender diverse (TGD) people, bisexual people, and those with intersex variations [ 1 , 2 , 3 , 4 , 5 , 6 ]. These health disparities can be compounded by a lack of inclusive practices from health care providers [ 1 , 6 , 7 , 8 ].

International studies on lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA) health content in medical curricula suggest there is insufficient teaching on the topic, and little focus given to students’ experiences of the teaching provided [ 9 , 10 , 11 , 12 , 13 ]. Medical curriculum studies from Canada and the United States establish relatively little time dedicated to lesbian, gay, bisexual, transgender (LGBT) health, with a median of 5 h in undergraduate programs [ 10 ]. A study in Japan report a median of 1 and 0 h in preclinical and clinical training respectively [ 13 ]. Similarly, Australian medical students and doctors report insufficient training on LGBTQIA health issues and inclusive practices, with notable gaps in transgender and intersex health education [ 9 , 14 ]. A 2017 survey of medical school curriculum administrators in Australia and New Zealand indicated most medical schools (60%) dedicated 0–5 h to LGBTQIA health in preclinical years. Most of this content focused on same-sex sexual activity (80%), with half of the respondents (47%) unsure whether trans and gender diversity was covered in their curricula [ 9 ]. Students' experiences of teaching point towards low levels of self-reported preparedness, although their preferences and learning needs have not yet been comprehensively explored, and the samples surveyed were limited (low numbers of students or medical schools) [ 11 , 12 ]. Overall, the scope, coverage, and assessment of LGBTQIA material was found to be highly variable, with minimal focus given to the engagement and learning needs of students [ 9 ]. Given the variability of content, different modes of delivery, and knowledge gaps about student perceptions and needs, a student-focussed approach to the educational deficits in this area are needed.

This study aimed to address the following questions:

What are medical students’ recalled experiences of content coverage and mode of delivery of LGBTQIA health education in Australia?

What are medical students’ preparedness, attitudes and learning needs in relation to LGBTQIA health education in Australia?

In contrast to an objective audit of content included in LGBTQIA medical curricula (which may or may not align with students’ learning), we sought to go beyond this by taking medical students’ direct perspectives on these matters. Our findings could help to guide and standardise LGBTQIA medical curricular development to meet the learning experiences and needs of students. We envision this research to be of use to medical faculties, institutions, students and advocates in improving LGBTQIA health curricula.

This survey was adapted from a previous Medical Deans Australia and New Zealand (MDANZ) survey with permission from the lead author, [ 9 ] and this project was approved by the Human Ethics Advisory Group at The University of Melbourne (Project ID 2057068.1). The MDANZ survey instrument was developed from a previous study undertaken in North American medical schools, [ 10 ] and adapted to the Australian context. The original survey instrument was validated by a panel of LGBT health experts, and 13 Deans of medical schools [ 9 , 10 ]. Our adaptation of the survey was further piloted with 20 LGBTQIA medical students to assess the accessibility, clarity, and relevance of the instrument. Where appropriate, questions were subsequently reworded to ensure consistently between their intended meaning and trial participants’ interpretation of the questions.

Though not exhaustive of all topics pertaining to LGBTQIA curricula, the survey instrument is representative of critical topics and priorities in the field of LGBTQIA health. These topics and priorities are represented in the constructs the survey is intended to measure (content and coverage, learning preferences, attitudes and preparedness). As both the original survey instrument and the MDANZ survey were oriented to educators, [ 9 , 10 ] the wording and content of questions was adapted to better address the student population and elicit their perspectives and experiences.

The Qualtrics survey platform was used to conduct the survey. The survey consisted of 28 questions, comprised of multiple choice, checkbox, Likert scale and numerical answers. An additional 5 free-text questions were included to capture qualitative responses. Participants were not supplied with any additional information relating to survey content prior to completion. A curriculum development perspective was adopted from conceptualisation to analysis, using Kern et al.'s [ 15 ] six step conceptual framework, applying steps one to four as below:

Problem identification and general needs assessment

Targeted needs assessment

Goals and objectives

Educational strategies

Implementation

A curricula development framework provides a suitable conceptual framework for this study, as it provides a stepwise progression through which this research can be implemented for the betterment of medical curricula. This framework allows for the research to be implemented as a tool for these groups. In applying this conceptual framework, our problem was identified as a lack of safe and informed medical training on LGBTQIA health, as an upstream contributor to health inequities. This identified problem was based upon a trend in the literature that shows a dearth of LGBTQIA content, co-design and community-led practice in medical curricula globally. We assessed medical student needs through a mixed-methods survey as described below, and subsequently derived goals, objectives, and educational strategies at the meeting point of data and external literature.

These forward-looking steps in curricula development were derived by identifying from the data what elements of comprehensive LGBTQIA health education are lacking and the learning preferences of students in relation to improving their preparedness. We subsequently integrated evidence from the literature to validate the themes that were identified, and the success of the educational strategies recommended in improving LGBTQIA health provision and students experience across various medical education contexts.

Following from Greene et al.’s [ 16 ] five categories of purpose for mixed methods research, the use of a mixed-methods approach aimed to develop, complement, initiate, triangulate with and expand on the quantitative data collected. Through providing a space for students to elaborate on their perspectives and experiences, a richer, wider, and more granular understanding of LGBTQIA health coverage was derived from the data. Our mixed methods approach allowed us to explore both the thematic connections across curricula, whilst preserving the unique encounters of students with curricula across the continent. Further, the incorporation of qualitative data in this design approach allowed a grounding in the conceptual and experiential vocabulary of the participants. This grounding in student voices was supportive to our research aim, in particular research question 2, and the overarching focus of this study on eliciting student voices. The processes of implementation and evaluation are to follow (i.e. beyond the immediate scope of this manuscript).

Participants

Survey participants were students recruited from all 23 medical schools in Australia. Survey invitations were sent to universities’ administrative staff and distributed across newsletters and online learning portals. Additionally, student representatives circulated survey invitations amongst social media affiliated with tertiary institutions and the Australian Medical Student Association. Participants provided informed consent prior to survey response. The survey was active between 9th August and 4th December 2020. From the total 17,884 medical students in Australia, it was not known how many received survey invites via the numerous means described, and therefore the response rate was unknown.

Demographic variables collected were limited as to maximise anonymity, and focussed on intersectional identity markers (which could affect students’ learning experiences, given the complex interplay between LGBTQIA health and other minority populations) and status as a medical student (which could affect the amount of curricular exposure to LGBTQIA health teaching received thus far). Collected demographic variables included participants’ gender; sexuality; intersex status; Aboriginal and Torres Strait Islander status; domestic or international enrolment; metropolitan or rural, regional or remote clinical placement; and progression through degree (e.g. pre-clinical, or final year). The format of intersectional variables was multiple-choice (tick all that apply, with the option of free-text responses). The format of degree progression variables was binary, except for progression through degree which was assessed by one binary variable (pre-clinical or clinical) and two numerical responses (year of study, and total length of degree).

Data management

Prior to analysis, data was deidentified by removing email addresses. Survey responses were exported into Microsoft Excel format and stored on a secure, password-protected university drive. 17,884 medical students were enrolled in Australia’s 23 medical schools in 2020 [ 17 ]. We received responses from 1,016 students (5.7% of national total). Of the total 1,016 responses, 102 were discarded due to survey non-completion, or nonsensical answers (i.e. ticking all options). The cleaned dataset was imported into R for Windows version 4.0.2 (with tidyverse packages) for analysis.

Data analysis

Data was summarised as mean and standard deviation (for continuous variables with a normal distribution), median and interquartile range [IQR] (for continuous variables with a non-normal distribution), or number and percentage (for categorical variables). The number of missing answers for a particular question was noted, with missing answers excluded from all calculations. Likert scales ranged from 1 to 5, which for the purposes of analysis were simplified into ‘agree’ (4 or 5), ‘neither agree nor disagree’ [ 3 ], and ‘disagree’ (1 or 2).

Data was compared between the following demographics: LGBTQIA and non-LGBTQIA respondents, defined as those reporting a heterosexual, non-intersex male/female identity; and final-year students and non-final-year students, who may not yet have been exposed to all educational material throughout medical school. To compare responses between these subgroups, the Mann–Whitney U (Wilcoxon rank-sum) test was used for continuous variables, and the Chi-square test was used for categorical variables, with p  < 0.05 indicating statistical significance.

Free-text comments were analysed through Braun and Clarke's framework for thematic analysis, utilising a deductive approach with an experiential orientation as an underlying theoretical assumption. Retaining our focus on students’ perception and attitudes, this approach orients analysis toward participants’ experience, internal or relational state regarding phenomena [ 18 ]. Braun and Clarke’s six step approach for thematic analysis (as follows) guided the process of analysis in a non-linear manner:

Familiarisation with the data

Coding the data

Generating initial themes

Reviewing and developing themes

Refining, defining and naming themes

Producing the report.

A team of five coders analysed each question using Nvivo and met regularly for discussion, consolidation and collaborative reiteration of themes and codes. Responses were initially analysed separately for first-order codes, then organised into an overarching framework of second-order basic themes and third-order organising themes that were identified from both the qualitative data, and reflective of the quantitative data. The organisation of themes and codes occurred non-linearly, responsive to the recursive process of thematic analysis. In total, 2,327 comments were received and 656 included in the final analysis. Sufficient conceptual depth was determined when no new codes were identified from the data set, as agreed upon by all coders [ 18 ]. Unanswered prompts, responses without content (e.g. “nil”), and nonsensical responses were discarded for analysis.

The reiterative grouping of codes and generation of themes was guided by our research questions. For example, the topic of self-reported learning needs focussed coding on the learning experience of participants. Frequently occurring codes pertaining to learning needs (such as ‘clinical experience’, ‘longitudinal inclusion’ or ‘interactive learning’) were refined over the coding period, then grouped under basic themes according to the different dimensions of learning experience they represented themes (‘clinical practice’, ‘content’ or ‘format’). These themes were generated and named through a process of interrogating, and reinterrogating, the conceptual congruency of the codes. Organising themes were then created to identify the conceptual ties between themes and codes (‘curricula development’), with the intention of addressing our research foci.

Both semantic and latent coding were employed, as was appropriate to the relationship between the qualitative data and quantitative data [ 18 ]. Semantic coding was utilised when triangulating between data sets. For example, codes under the basic theme ‘format’ organise any description of learning format reported by participants, and were applied (where appropriate) to substantiate the desired formats present under ‘Learning Preferences’ (Table  5 in the quantitative data). Latent coding was of greater use in developing and expanding on patterns present in the quantitative data. For example, the codes constituting the 'Educational Environment' organising theme categorise responses that specifically address the diverse experiences and perspectives of both LGBTQIA and non-LGBTQIA students. This coding practice allowed us to better interpret and compare the disparities in quantitative data on metrics like preparedness and attitudes between these two groups.

Reflexivity

The research team interpreting the data was comprised of members of diverse positionalities from the queer and gender diverse community. We occupy different cultural standpoints, and work within the medical field as either medical students, public health professional and/or practicing doctors. Our embeddedness within both the LGBTQIASB + (lesbian, gay, bisexual, trans, queer, intersex, asexual, sistergirl and brotherboy) community and the medical field may have engendered a shared interpretation of the data and coding practice. Given the demographics of our participants (medical students with a 45.9% response rate from LGBTQIA peoples), we could thus be understood to have taken an insider position. Our relationship to LGBTQIA health and collective orientation to improving healthcare for this group undeniably influenced our interpretation of data, and acted as an organising concept through which themes were generated. Remaining mutually cognisant of this relationship, encouraging one another to interrogate the biases this may produce, exploring multiple perspectives and through this establishing a recursive and reiterative process was central to our coding practice.

In alignment with Beals et al. [ 19 ] we problematise this idea of insider and outsider positionality in LGBTQIA research, as all researchers bring situated knowledge to a coding process that are neither entirely subjective nor objective. Given the intersectional and heterogenous nature of identity in the queer, intersex and gender diverse community, and the variance in medical student participant demographics, it is impossible to fully occupy an insider position. Following from this, the personal, cultural and professional diversity of the research team worked to minimise shared bias, while also provide access to different experiences and prior knowledges that assisted the generation of relevant themes. As a team, we engaged with the subjective/objective tension that bridges insider/outsider epistemologies and utilised the multiplicity of our perspectives in a collaborative (rather than consensus) coding practice.

Demographics

N  = 913 students completed the survey, with 359 (40.4%) recruited through social media and 299 (32.7%) recruited through university channels (newsletters, portals etc.). A definitive LGBTQIA identity was expressed by 419 (45.9%), whilst 406 (44.5%) were non-LGBTQIA (cisgender, heterosexual, and non-intersex). Regarding gender identity, 298 (33.1%) identified as male, 577 (64.2%) as female, and 34 (3.8%) as trans and gender diverse. Of 838 reporting ethnicity, the most common were 426 (50.8%) Australian European, 182 (21.7%) South-East Asian, and 67 (8.0%) North-East Asian. Broader participant demographics are outlined in Table  1 .

Attitudes towards LGBTQIA patients

Students largely reported positive attitudes towards LGBTQIA patients, with no statistically significant differences between LGBTQIA and non-LGBTQIA participants, or between final-year and non-final-year students (data not shown). Student attitudes are displayed in Table  2 .

Attitudes towards LGBTQIA health in medical education

Student attitudes and perceptions towards LGBTQIA health in medical curricula were largely positive. Participants who identified as LGBTQIA reported higher positive attitudes towards LGBTQIA health compared to non-LGBTQIA participants across all statements. Student attitudes towards LGBTQIA health are displayed in Table  2 .

Preclinical and clinical teaching

Regarding clinical teaching, 43 (10.4%) students had completed clinical rotations specific to LGBTQIA health; of those that had, the median duration was six hours. Overall, amongst the 358 participants reporting data on both preclinical and clinical teaching, 197 (55.0%) reported no teaching at all, with the mean number of hours of overall teaching being 2.2 h (Fig.  1 ). Some respondents were ‘Unsure’ about the hours of preclinical ( n  = 147, 17.0%) and clinical ( n  = 29, 7.0%) teaching they had received.

figure 1

Hours of preclinical and clinical LGBTQIA teaching reported by students. The overall category includes participants with data on both preclinical and clinical teaching

There was notable inter-university variability. The median percentage of respondents reporting any content coverage was 60.0% [44.2%, 66.7%] for any preclinical teaching. There was greater variability in clinical teaching, with a median of respondents reporting any content being 9.4% [0.8%, 30.0%].

Preparedness and content coverage

The reported content coverage of LGBTQIA health competencies is shown in Table  3 . Reported content coverage did not significantly differ between final year and non-final year respondents.

Self-reported preparedness in LGBTQIA health competencies is shown in Table  4 . For all competencies, students reported preparedness at greater rates than content coverage.

Learning preferences

Students overwhelmingly preferred learning experiences facilitated by member of the community to be the most effective learning modalities. Learning preferences did not differ for between LGBTQIA and non-LGBTQIA participants, or between final-year and non-final-year students (Table  5 ).

Only 395 (48.2%) of students reported assessment of LGBTQIA health, and 424 (51.8%) of students reported no assessment of LGBTQIA health. Of those reporting assessment, the most common formats were questions in written exams ( n  = 167, 42.3%), short-case clinical discussions ( n  = 52, 13.2%), Objective Structured Clinical Examinations (OSCEs) ( n  = 46, 11.6%), and evaluation by standardised patient actors ( n  = 42, 10.6%).

Qualitative results

Qualitive data analysis of free-text responses (Fig.  2 ) identified four key themes (Fig.  3 ).

figure 2

Qualitative free text box questions

figure 3

Key themes in the qualitative data

Theme 1: Cultural safety

Participants articulated environments and relationships in which peoples feel safe or unsafe within their identity, culture and community group, characterised by an absence or presence of discrimination. This focus was identified in text responses related to curricula content, skill development, and institutional experiences. The organising theme ‘Cultural Safety’ was generated as representative of the conceptual alignment between the basic themes 'fundamental knowledge', 'cultural safety training', 'diversity' and 'intersectionality'. These were understood as elements of culturally safe learning environments, relationships, and practice.

Learning preferences for specialised training such as cultural safety and communication skills workshops were frequently repeated throughout the codes in text. This preference develops upon the quantitative discrepancies in self-reported preparedness to provide culturally safe care to diverse LGBTQIA patients, and desires for improved curricula delivery and content.

“We need workshops on cultural competency and on competency in delivering safe care to LGBTQIA people,” (R_vx)
"[My university] did have some LGBTQIA simulated patients in our communication skills course. One of these was to take a sexual history from a gay male patient and included asking about specific sexual practices. They also had a station with a transgender SP who was actually played by a transgender person. I really appreciated this!” (R_Rb)

Theme 2: Community embeddedness

Responses addressed the centring of LGBTQIA expertise and lived experience in the creation and teaching of LGBTQIA medical curricula. Codes pertaining to 'learning from lived experience' and 'clinical expertise' were linked through the varied but related ways in which they describe the lack or presence of, or desire for, community embedded curricula and delivery.

Preferences for LGBTQIA curricula to be embedded in the LGBTQIA community was present throughout the free-text responses. This was informed by a professed lack of guidance by LGBTQIA community members, educators and health experts, a lack of practical rotation through LGBTQIA health spaces and a perception that curricula design was not led by LGBTQIA peoples.

“Teaching FROM members of the LGBTQIA community” (R_3r )
“Our classes on this topic [LGBTQIA health] were delivered by cisgender heterosexual doctors who often did not understand these issues in depth.” (R_31)

The dearth of community embeddedness was associated with an absence of authenticity, intersectionality, and representation. This perception was in relation to reports of unchallenged practices such as stereotyping and misgendering. Aligning with student preferences for community embedded teaching elicited from the quantitative data, this theme expands upon why students hold these preferences, and clarifies this imperative through a grounding in student experience.

“I've raised the issue of misgendering to a consultant before and they were dismissive, arrogant and continued to misgender the patient in front of them for the entire admission.” (R_0B)

Theme 3: Curricular representation

Responses referred to the integration (or lack) of LGBTQIA peoples, communities, and healthcare needs in medical curricula. This organising theme was generated as representative of the conceptual connections between the basic themes 'content', 'clinical practice' and 'format' as essential elements of medical curricula, and the elements of curricula most frequently explored in the qualitative data.

Codes pertaining to diversity and representation were continuously identified throughout the text responses. The predominance of cis-gendered, heterosexual teaching staff on medical faculties was repeatedly raised as an issue:

“All teaching is based on heteronormative framework and there is a constant queer erasure in medical curriculum content delivery” (R_Zf)

Students perceived heightened levels of discomfort in discussing LGBTQIA health, poor staff preparedness, little reflexivity, outdated knowledge, discriminatory behaviours and the silencing of LGBTQIA community members. Multiple codes referred to faculty cultures of othering and erasure, accompanied by insufficient institutional mechanisms to address this culture:

“[I] do not feel like i can speak up in a clinical setting even when people are being homophobic or misgendering others because I am visibly queer myself and it would turn it back on me.” (R_2r)

Issues of representation within curricula itself was similarly present, with the codes emphasising a lack of content and/or depth occurring frequently. Further, the LGBTQIA resource supplementation required to fill in gaps in curricula was seen as invalid or simply not occurring.

“Literally anything would be better than what we're getting now, which is nothing except for a single HIGHLY offensive lecture on people who are intersex.” (R_YP)
“Lack of content taught to students, no extra reading/information provided for students who would like to learn more” (R_to)
“More casual inclusion of LGBTQIA + scenarios in practical and discussion classes; normalising the experiences of LGBTQIA + patients.” (R_3K)

These findings complement and triangulate with the lack of content reported in the quantitative data, develop insight into preferences for lived experience teaching, and expand upon the low rates of self-reported preparedness in LGBTQIA health competencies, particularly regarding LGBTQIA peoples with intersectional identities.

Theme 4: Educational environment

Participants explained the context, and experience of context, in which medical curricula is being delivered. This organising theme was interpreted as the conceptual connection between the basic themes: 'structural erasure', 'delivery', 'resourcing', 'LGBTIQA students' experience' and 'non-LGBTQIA students' experience' due to their representation of educational context beyond and within curricula.

Students described a deficit of safe facilitation by faculty between students, as well as between the student body and the LGBTQIA community. Both LGBTQIA students and non-LGBTQIA students expressed feeling unsafe in their classrooms. This experience of feeling unsafe took multiple forms. The recurrent issues for queer students related to a paradoxical sense of hypervisibility and invisibility (for example being called upon as an expert for LGBTQIA issues, whilst having your queerness and/or gender diversity suppressed elsewhere) and the emotional toll of having to navigate discriminatory environments:

“Personally [I experience] anxiety about facing prejudiced views from teachers/students.” (R_1g)
“Where I have been able to contribute, my opinions and views have been acknowledged positively by both classmates and facilitators of any sessions…. it can be difficult sharing an experience as the only LGBTQIA + identifying student in the room.” (R_3k)
“I keep pretty quiet about LBTQIA health unless I’m in small groups, and even then there is a lot of emotional labor involved. I have been surprised by the amount of homophobic and transphobic jokes from medical students and lecturers alike.” (R_3M)

For non-LGBTQIA students, a fear of offending LGBTQIA peoples due to a lack of knowledge (for example around the correct use of terminology) and a sense of feeling unheard was identified in data such as the following:

“If I have a differing viewpoint about LGBTQI health and I want to discuss it with an LGBTQI person, or expert in the area, to get a better understanding for myself, they make me feel bad about the way I think and it is difficult to learn more. (R_30)
“[I’m] worried about offending someone or saying the wrong thing” (R_1f)
“[A]s a person with a very boring heteronormative, cis lived experience, I do fear saying or doing the wrong thing and upsetting or traumatising patients identifying in this way... which makes me nervous!” (R_C4)

This initiates and expands upon the quantitative data displaying low coverage of cultural safety and communication content, and points to a need for better-facilitated classrooms.

This study is the first of its kind in Australia to use student data to map the perceived depth and breadth of LGBTQIA health education in Australian medical curricula. In contrast to previous literature surveying medical school deans providing more administrative data, this study has the benefit of focussing on direct student engagement and specific learner needs [ 9 , 10 , 13 ]. Through evidencing specific gaps and drawing on student experience, this study facilitates curricular recommendations driven by data. Given the limited LGBTQIA health education in Australian medical curricula and worldwide, alongside evidenced poorer health outcomes and healthcare experiences for this group globally, it is imperative that we continue developing LGBTQIA health teaching in medical curricula. [ 1 , 2 , 6 , 7 , 8 , 9 , 20 , 21 , 22 ].

We found that although students regarded LGBTQIA health education as important, relevant teaching was lacking, with most students not feeling confident that their peers were well prepared to provide care to LGBTQIA individuals. Consistent with a 2017 survey of medical school curriculum administrators in Australia and New Zealand, reported teaching hours were low in both clinical and preclinical years [ 9 ]. Topics related to intersex health, TGD health, and the health of individuals with intersecting identities (including First Nations LGBTQIA people) were found to have the lowest reported coverage, alongside consistently low self-rated preparedness and confidence. We identified community involvement, increased content, and longitudinal integration into the curriculum as important considerations for the delivery of LGBTQIA health in medical teaching. These findings can inform and guide ongoing curricular development, whilst highlighting opportunities for further medical education research.

Content coverage

Consistent with previous studies in Australia and internationally, reported content coverage and assessment regarding LGBTQIA health was generally low [ 9 , 10 , 14 , 23 , 24 ]. Only a third of our participants reported content in their preclinical curriculum, and only a tenth reported exposure to clinical rotations specific to LGBTQIA health. The percentage of students reporting any LGBTQIA health teaching was highly variable between universities, with some universities having no students reporting teaching, to others having all students reporting teaching.

Where present, content related to LGBTQIA health was largely focused on sexual health. The sexual health of gay, lesbian and bisexual patients had the highest coverage for any given topic, with close to a third reporting having covered it in their curriculum. On the other hand, coverage related to the health of intersex, TGD and other underserved communities were reported by less than a tenth of respondents. These findings correlate with negative healthcare experiences of TGD and intersex people reported in Australia and abroad, [ 25 , 26 , 27 , 28 , 29 ] many of whom have limited access to safe and sensitive care, for example, there being an excessive focus on sexual practices when presenting for non-sexual complaints [ 30 , 31 , 32 ]. They support the need for improved education of students and medical providers internationally [ 26 , 27 , 32 ].

Despite receiving the same coverage, LGBTQIA students reported higher levels of self-assessed preparedness (Table  4 ), greater desire for more coverage, and lesser confidence in their peers to provide safe care when compared to non-LGBTQIA students (Table  2 ). These discrepancies may be attributed to learning gained through lived experiences, greater awareness of deficits, alongside greater engagement in non-institutional and student-led learning. To ascertain, more research needs to be done on this topic.

Teaching and delivery

Despite low reported coverage, most (89.2%) participants thought LGBTQIA health was important and should be covered in their medical training. However, few participants thought that the current coverage was adequate, or felt confident that their peers would be able to provide adequate care to LGBTQIA patients. This suggests students perceive LGBTQIA health as a priority area but are aware of the deficiencies in their curricula. The qualitative data reflects these findings; students frequently reported dissatisfaction with the quality and quantity of content. Additionally, issues with safe classroom facilitation and teacher capability were repeatedly raised.

In terms of addressing gaps in curricula, participants expressed a strong preference for learning from members of the LGBTQIA community, for example lectures delivered by members of the LGBTQIA community. Other preferred modes of delivery included LGBTQIA-led teaching in small workshops and tutorials, learning about lived experiences, and panel-led discussions with clinicians. Content describing a “lack of learning from lived experiences”, and desired “interactive learning” were predominant in the qualitative data set, further demonstrating the gaps in current teaching practices. In the free-text responses, students called for increased LGBTQIA-led teaching and “case-based teaching” where discussion and direct feedback can occur. Whilst a growing body of evidence suggests that one-off educational interventions may improve attitudes, knowledge and skills in medical students, the educational effects of short-term interventions are often lost to follow-up [ 33 ]. Participants further commented that they wanted teaching to be integrated via “longitudinal inclusion” into the curriculum. Reponses speaking to “stigma” and “phobia” in the curricula content, infrastructure and delivery were frequent and reflected students’ desires to move away from a pathologising framework and have LGBTQIA identities normalised in healthcare. We hypothesise that normalising and integrating LGBTQIA patients in medical school may have a preventative effect on the stigma and discrimination that these patients regularly experience in healthcare settings.

There is little data available specifically on the association between increased LGBTQIA curricula content and the improvement of patient outcomes. However, studies that focus on improved outcomes for underserved groups, such as First Nations peoples, demonstrate better clinical outcomes, patient experiences and provider confidence [ 11 , 34 , 35 ]. Some studies also displayed increased understanding thereby efficacy of action related to concepts such as bias, discrimination and advocacy after targeted curricula inclusion [ 33 , 36 , 37 , 38 , 39 ]. Although minority experiences of discrimination are not and should not be commensurable, a common thread of enhanced patient safety can be drawn alongside a recognition of the intersections of identity between these groups.

Informing our hypothesis is the model of medical education as it currently stands, in which high-quality curricular content leads to better provision of care and better patient outcomes. As Ramsden [ 40 ] inquires, why wouldn't this same model apply to medical knowledge often relegated to the realm of the socio-political? Prior research internationally has found that greater LGBT patient contact and education hours significantly improved clinical preparedness and knowledge in LGBT healthcare [ 12 ]. As a result, medical curricula should consider longitudinal integration to allow medical students further opportunities to cement their knowledge and clinical skills when working with LGBTQIA patients.

Improved content exposure and delivery is particularly needed for intersex and TGD health education. Both qualitative and quantitative analyses demonstrated a clear deficit in both teaching and student preparedness when it comes to intersex and TGD health. This is important as intersex and TGD patients have poor health experiences and outcomes in the Australian health care system, and healthcare systems globally [ 25 , 27 , 33 ]. We suggest that addressing intersex and TGD health in medical education could lead to an improvement in future health outcomes.

Limitations

This study has several limitations. Firstly, our response rate of 913 students equates to only 5.1% of medical students across Australia [ 41 ]. The sample was skewed towards female-identifying individuals (approximately two-thirds of respondents) and LGBTQIA individuals (comprising half the sample). Similarly, non-LGBTQIA respondents may be biased towards those with an interest, knowledge, or experience in LGBTQIA health. Moreover, only respondents who were in their final year could be expected to have had complete exposure to their medical curriculum. To address these limitations, we compared LGBTQIA vs non-LGBTQIA individuals and final-year vs non-final year students in their responses. Since this involved many comparisons, this aspect of our analyses was predisposed to type I error.

Secondly, the psychometric validity of the survey was limited, as only a small number of trial participants were used to evaluate whether questions were interpreted and answered by participants in the manner intended. Questions rated on a Likert scale offered no further instructions or clarifications, leaving open to interpretation certain word choices (e.g. ‘feel’) which may have had heterogeneous interpretations by participants. However, in its original incarnation, the survey instrument was validated with LGBT health experts and medical deans, and we underwent out own piloting with a small number of medical students to assess for accessibility, clarity, and relevance. Reassuringly, the reliability of the survey (and reproducibility of results) was bolstered by a mixed methods approach, triangulating our data and providing opportunity for free text expression alongside fixed quantitative responses.

Thirdly, although we assessed self-reported delivery, coverage, attitudes, and preparedness, we did not assess the degree to which this translates into clinical knowledge, skills or competencies that could be objectively demonstrated. We likewise did not assess general self-rated preparedness to identify whether a lack of preparedness was specific to competency in LGBTQIA health. Moreover, we did not assess the quality of the content being delivered, e.g. whether education delivered was stigmatising and outdated in nature. Hence, we recommend further research and a formal audit into the quality of LGBTQIA medical curricula at present. Longitudinal research into the association between LGBTQIA curricula content and improved patient outcomes is also needed.

Lastly, while a mixed methods approach was employed, a direct relationship between the phrasing of the quantitative survey questions and free text questions would have allowed for greater clarity in triangulating, developing, and expanding the data between methods.

This large survey of medical students highlights areas of opportunity in Australian medical curricula, and medical curricula globally. Consistent with previous research both in Australia and internationally, reported teaching hours and content coverage of LGBTQIA health were limited, particularly for the health of intersex, TGD, and LGBTQIA peoples with intersecting identities. While students generally reported feeling comfortable providing health care to LGBTQIA patients, they did not feel prepared for many competencies, and did not feel confident that their peers were well prepared to provide care to LGBTQIA patients. Our findings support the need for increased preclinical and clinical content coverage of LGBTQIA health topics through integrated, longitudinal small group teaching and teaching led by LGBTQIA individuals, alongside greater depth and diversity in assessment. These findings can help guide further research in medical education and help inform the ongoing development of LGBTQIA medical curricula.

Definitions

LGBTQIA: Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual.

LGBTQIASB + : Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, Sistergirl and Brotherboy.

Lesbian: Women or non-binary people who experience sexual or romantic attraction to people of the same gender.

Gay: Men or non-binary people who experience sexual or romantic attraction to people of the same gender.

Bisexual: People who experience sexual or romantic attraction to more than one gender.

Transgender (‘trans’) and Gender Diverse: An umbrella term used to describe all those whose gender identity is different from the sex assigned to them at birth. This includes people who may identify as non-binary, having no gender, fluid gender, multiple genders, a gender other than man or woman, or consider their gender in another paradigm from these.

Queer: An umbrella term for those whose gender or sexual/physical/romantic attraction differs from cis-hetero norms of gender identity and sexuality.

Intersex: A general term describing congenital variations in anatomical, physiological, or genetic sexual characteristics. This includes primary and secondary sexual characteristics which do not fit cis-normative and/or endosex-normative medical conceptions of male or female bodies. While these variations are sometimes clinically labelled as Disorders of Sex Development (DSD) or hermaphroditism, these descriptors are derogatory and inappropriate.

Asexual/ Aromantic: Individuals who experience little or no sexual or romantic attraction to others regardless of gender.

A Note on the Acronym.

At the time the survey was undertaken, ‘trans’ was used as inclusive of all culturally specific trans identities, such as sistergirl and brotherboy, or two spirit. However, the current best practice is to delineate culturally specific trans identities to highlight their unique relationship to cultural protocol and practice, alongside the antecedence of gender diversity to colonialism. It is imperative we acknowledge the queer and gender diverse First Nations people of the land we are writing from. For this reason, the acronym LGBTQIASB + , in which the SB stands for sistergirl and brotherboy, is used when referring to the queer, intersex and gender diverse community as separate from our research focus. LGBTQIA is used when referring to the specific population included within in medical curricula, as these were the parameters used in the survey. Other incarnations of the acronym, such as LGBT or TGD, are similarly used to reflect the scope of research they are derived from, or to reference specific identities within the community.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to thank those who participated in our study, particularly LGBTQIA individuals who shared their experiences with us. We thank the Australian Medical Students’ Association for providing gift cards to incentivise participation, and university administrators and student representatives that distributed the survey. We offer deep gratitude to the Wurundjeri people of the Eastern Kulin Nation, the Jagera, Turball and Quandamooka people of South East Queensland, and the Noongar people of Western Australia, on whose lands this research was undertaken.

To incentivise participation in this survey, the Australian Medical Students’ Association provided funding for gift cards awarded to ten random participants. Article processing charge generously donated retrospectively by 'GLADD: The Association of LGBTQIA+ Doctors and Dentists', with a small contribution from the University of Melbourne.

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Sophia Nicolades Wynn, Pravik Solanki, Jayde Millington, Anthony Copeland & Jessie Lu

The University of Queensland, Brisbane, QLD, Australia

Sophia Nicolades Wynn & Jayde Millington

Monash University, Clayton, Victoria, Australia

Pravik Solanki & Jessie Lu

The University of Western Australia, Crawley, WA, Australia

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Department of General Practice, The University of Melbourne, Parkville, Victoria, Australia

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SNW: Methodology, Investigation, Formal analysis, Writing—Original Draft, Writing—Review & Editing, Supervision – qualitative analysis. JM: Conceptualisation, Methodology, Investigation, Formal analysis, Writing—Original Draft, Writing—Review & Editing. PS: Methodology, Software, Formal analysis, Data curation, Writing—Review & Editing, Visualization, Supervision – quantitative analysis. AC: Methodology, Investigation, Formal analysis, Writing – Review & Editing, Funding Acquisition JL: Methodology, Investigation, Formal analysis. RN: Writing—Review & Editing AAS: Conceptualisation, Project Administration, Methodology, Investigation, Formal analysis, Writing—Original Draft, Writing—Review & Editing, Supervision – qualitative analysis.

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This project was approved by the Human Ethics Advisory Group at The University of Melbourne (Project ID 2057068.1). The study was conducted in line with the National Health and Medical Research Council guidelines for human research ethics. Confidentiality, privacy, financial incentive, and the minimisation of harm were considered and addressed for all participants to the study. Ten random participants received gift cards from the Australian Medical Students’ Association, which may have influenced some individuals to participate in the study.

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Wynn, S.N., Solanki, P., Millington, J. et al. LGBTQIA health in medical education: a national survey of Australian medical students. BMC Med Educ 24 , 733 (2024). https://doi.org/10.1186/s12909-024-05099-6

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ISSN: 1472-6920

what is the importance of sexuality education

Sexuality education is about respect and equality

what is the importance of sexuality education

Comprehensive sexuality education (CSE) goes beyond education about reproduction, risks and disease, also teaching about love and relationships based on mutual respect and equality.  This was the message from the Zentano family from Santiago, Chile, who spoke to UNESCO about their experiences of sexuality education for the Foundation of Life and Love campaign.

Sebastian Zentano told UNESCO that responsible CSE should include messages about respect, and equality. His mother, Maria Valeska Gatica, said she had tried to impart this to her sons from an early age.

“I believe comprehensive sexuality education is a very important component of human development,” she said. “It promotes a world that is more peaceful, happier, more integrated, and more of a human community.”

The Foundation of Life and Love campaign highlights intergenerational stories from families across the world to show why it is so important for young people to learn about health, relationships, gender, sex and sexuality. It also includes interviews from Ghana , Thailand , China , and the UK.

CSE is based on universal human rights, including the rights of all people to health, education, information equality and non-discrimination. Through CSE, young people are able to recognise their own rights, to respect the rights of others, and help those whose rights are violated. It also respects a young person’s right to a high standard of health, including safe, responsible and respectful sexual choices.

Débora Solis Martinez, Director of the Chilean Association for the Protection of the Family, who was also interviewed for the Foundation of Life and Love campaign, said all young people should have access to quality CSE. 

“We do not want young girls getting pregnant, we do not want young people affected by sexually transmitted infections or with HIV, but in order to achieve that, young people need to be able to obtain the information needed to make the right choice,” she said.

“Beyond that, one of the greatest strengths of comprehensive sexuality education is that girls learn from the beginning that the condition of being a woman does not imply a relationship of subordination with man,” she said.  

Join the conversation at #CSEandMe .

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Students Partake in Innovative Research on Dysautonomia

Four women seated and standing by a desk.

From left, Svetlana Blitshteyn, MD, and medical students Anna Lange, Emily Fuster and Paige Guy have been collaborating on clinical research studies of autonomic disorders.

By Dirk Hoffman

Published December 18, 2023

A number of medical students are gaining valuable clinical research experience studying autonomic disorders under the direction of Svetlana Blitshteyn, MD, a clinical associate professor of neurology at the Jacobs School of Medicine and Biomedical Sciences .

The students see patients with Blitshteyn at the Dysautonomia Clinic in Amherst, which she founded in 2009.

Dysautonomia refers to a dysfunction of the autonomic nervous system (ANS) that generally involves disturbance or failure of the sympathetic or parasympathetic components of the ANS.

The ANS is the part of the nervous system that controls involuntary body functions such as heart rate, blood pressure, breathing, digestion, body and skin temperature, hormonal function, bladder function, sexual function and many other functions.

Rare Occurrence Leads to Published Case Report

Third-year medical student Emily Fuster recently collaborated with Blitshteyn as first author on a case report of a rare occurrence where a clinic patient presented with symptoms of two different syndromes.

The resulting case report, “A Tale of Two Syndromes: Nontraumatic Frey’s Syndrome in a Woman With Sjögren’s Syndrome,” was published earlier this year in the journal Clinical Autonomic Research.

“In this report, we discuss both syndromes. Sjögren’s syndrome is a chronic autoimmune disorder in which the glands that make moisture in the eyes, mouth and other parts of the body are attacked by a person’s own immune system,” Fuster says. “As a result, symptoms often include dry eyes and dry mouth as well as fatigue, joint pain, dry skin, acid reflux, dry cough, and swelling of the glands around the face and neck.”

Sjögren’s syndrome can be difficult to diagnose, especially in those patients who present with various neurologic manifestations, negative Sjögren’s antibodies and minimal or absent symptoms of dry eyes and dry mouth.

Frey’s syndrome is considered a relatively rare neurologic condition for which the cause is poorly understood, although current theory suggests the disease is caused by damage to sympathetic and parasympathetic nerves near the parotid gland (a type of salivary gland located just below and in front of each ear).

Most cases of Frey’s syndrome occur as a result of head and neck surgery, trauma to the face diabetes or infection, Fuster explains.

Symptoms typically include excessive facial sweating and flushing after eating or thinking about food. 

Diagnosis of Co-Occurring Syndromes

Blitshteyn says the patient, a 39-year-year old woman, was referred to her for a second opinion and possible diagnosis of an autonomic disorder.

The patient had an eight-month history of facial flushing following most meals, regardless of the type of food she had been eating. The episodes were occurring one to two times per day and would last for about five minutes, followed by milder flushing after the episodes.

The neurology consult resulted in the diagnosis of two disorders: one rare (Frey’s syndrome) and one common autoimmune disorder, Sjögren’s syndrome.

“I immediately thought, ‘what an interesting presentation,’ and upon my literature review, I did not see any cases of Frey’s syndrome described in association with Sjögren’s syndrome,” Blitshteyn says.

Knowing that Sjögren’s syndrome is associated with dysautonomia and small fiber neuropathy, Blitshteyn thought that it made sense for Frey’s syndrome, a rare neurologic and autonomic disorder, to occur in the context of Sjögren’s and was frankly surprised that it was never reported before in the literature.

Heartburn Medication Provides Some Relief

Blitshteyn ultimately referred the patient back to the rheumatologist for treatment of Sjögren’s syndrome with immunomodulatory therapy because she felt treatment of the underlying cause of flushing may improve flushing and other symptoms that she had been experiencing.

“Interestingly, on her follow-up visit, she reported some relief with famotidine, an over-the-counter heartburn medication that blocks histamine receptors, which I often try in patients with flushing of any kind, not just related to allergies.”

“Histamine is one of the major mediators released by mast cells, usually in response to external triggers like food or smells, but histamine can also be released in response to activation of the sympathetic nervous system that ties into Frey’s syndrome or in response to the inflammatory process that’s involved in Sjögren’s syndrome,” Blitshteyn says.

Fuster says because inflammation of the salivary gland is commonly seen in patients with Sjögren’s syndrome, a diagnosis of co-occurring syndromes should be considered by clinicians in patients with gland swelling and facial flushing, especially when accompanied by other autoimmune markers and symptoms.

“Otherwise, other patients with ‘Sjögren’s-associated Frey’s syndrome’ may be undiagnosed or misdiagnosed when their flushing is attributed to other causes, which would lead to a different and possibly ineffective course of treatment,” she says.

Anna Lange and Svetlana Blitshteyn, MD, at a podium.

Anna Lange, left, and Svetlana Blitshteyn, MD, at the Dysautonomic International Conference in Washington, D.C., where Lange presented the research group’s preliminary findings on a study of POTS and sexual dysfunction.

Studying POTS and Sexual Dysfunction

Fourth-year medical students Anna Lange and Paige Guy have also been working with Blitshteyn — on a study of postural orthostatic tachycardia syndrome (POTS) and sexual dysfunction.

Lange presented the group’s preliminary findings at the Dysautonomia International Conference in Washington, D.C., in July and is currently working on a full-length paper for the study.

Guy, a co-author on the same study, presented a continuing medical education lecture on dysautonomia and hormones with Blitshteyn in November to a national multidisciplinary physician group interested in mast cell disorders.

Blitshteyn notes that POTS is one of the most common autonomic disorders and a type of dysautonomia that may develop after COVID-19 infection.

“The field of autonomic disorders is very much evolving because autonomic dysfunction often occurs as a manifestation of systemic disorders,” she says. “Dysautonomia is also one of the major pieces of the long COVID puzzle, and with the ongoing COVID-19 pandemic, long COVID is a major public health issue so studying autonomic dysfunction as part of long COVID is essential to identifying the pathophysiology and treatment for long COVID.”

Unanswered Questions Provide Opportunities

Clinical research is an important part of patient care and medical education, according to Blitshteyn.

“There are many unanswered questions and opportunities for innovation and discoveries to improve diagnostic and therapeutic options for our patients,” she says.

Blitshteyn says she has always been interested in clinical research and completed a summer research program when she was a medical student at the Jacobs School and extra months of clinical research as a neurology resident at the Mayo Clinic.

“It’s why I pay it forward by being a research adviser and a mentor to medical students myself,” she says. ”Working with Emily, Paige and Anna has been wonderful and rewarding: they are very intelligent, motivated and hard-working students who are eager to learn new and complex topics and acquire new skills.”

The benefits of teaching medical students the basics of clinical research are enormous, according to Blitshteyn.

“The students learn how to investigate a multitude of unanswered clinical questions that we have in patient care, how to conduct clinical research studies to answer these questions and how to interpret the findings and put them in clinical context,” she says. 

Fuster says Blitshteyn is “a wonderful and incredibly well-connected mentor — I recommend her to any student interested in studying neurology or learning more about the brain, nervous system and dysautonomia.”

“She is especially gifted at supporting research-minded medical students and connecting them to fruitful, publication-worthy projects. She also has great insights into what a career in neurology looks like currently, and the direction the field is headed,” she says. “I entered medical school with an interest in neurology, and Dr. Blitshteyn has done nothing but further solidify this interest by fostering inquisitive exploration.”

Facilitating Students to Think as Scientists

Over the last decade, Blitshteyn and her mentees have completed multiple innovative studies on topics such as pregnancy, autoimmunity, immunotherapy, dietary changes and sexual dysfunction in patients with POTS — topics that have never been investigated previously.

“I am always pushing the envelope when it comes to creativity, innovation and clinical research at Dysautonomia Clinic, and because of that, we are doing the type of research that has not been done before,” she says.

“The papers and abstracts that have been published as a result of our research studies advanced our understanding of POTS and helped other researchers to investigate these topics further,” Blitshteyn says. 

“For many students, these research studies are their first experience presenting, writing and thinking as scientists, and that’s what we want our future physicians to be in order to advance and improve clinical medicine, neurology, autonomic disorders and patient care.”

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  23. 5 subtle ways to introduce sex education to your kids

    Teaching your children about boundaries and consent is an integral part of sex education. Discuss the importance of personal space, respect for others, and the concept of consent from an early age.

  24. LGBTQIA health in medical education: a national survey of Australian

    Purpose Lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA) individuals experience poorer health outcomes than other individuals. Insufficient LGBTQIA health education of doctors in existing medical curricula contributes to these outcomes. We sought to explore medical students' experiences of content coverage and mode of delivery, as well as their preparedness ...

  25. Sexuality education is about respect and equality

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  26. Full article: Fostering Culturally Responsive Teaching Through the

    As societies become more diverse, addressing a broader diversity of students becomes increasingly important in education. Yet, teachers often feel ill prepared or overwhelmed in dealing with cultural diversity and addressing educational inequalities (Cushner & Mahon, Citation 2009).In Germany, teachers are largely oriented toward German-speaking, culturally-Christian socialized middle-class ...

  27. Students Partake in Innovative Research on Dysautonomia

    Fourth-year medical students Anna Lange and Paige Guy have also been working with Blitshteyn — on a study of postural orthostatic tachycardia syndrome (POTS) and sexual dysfunction. Lange presented the group's preliminary findings at the Dysautonomia International Conference in Washington, D.C., in July and is currently working on a full ...