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Article Contents

Introduction, purpose of the study, literature search and selection criteria, coding of the studies for exploration of moderators, decisions related to the computation of effect sizes.

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The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis

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Mónica Silva, The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis, Health Education Research , Volume 17, Issue 4, August 2002, Pages 471–481, https://doi.org/10.1093/her/17.4.471

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This review presents the findings from controlled school-based sex education interventions published in the last 15 years in the US. The effects of the interventions in promoting abstinent behavior reported in 12 controlled studies were included in the meta-analysis. The results of the analysis indicated a very small overall effect of the interventions in abstinent behavior. Moderator analysis could only be pursued partially because of limited information in primary research studies. Parental participation in the program, age of the participants, virgin-status of the sample, grade level, percentage of females, scope of the implementation and year of publication of the study were associated with variations in effect sizes for abstinent behavior in univariate tests. However, only parental participation and percentage of females were significant in the weighted least-squares regression analysis. The richness of a meta-analytic approach appears limited by the quality of the primary research. Unfortunately, most of the research does not employ designs to provide conclusive evidence of program effects. Suggestions to address this limitation are provided.

Sexually active teenagers are a matter of serious concern. In the past decades many school-based programs have been designed for the sole purpose of delaying the initiation of sexual activity. There seems to be a growing consensus that schools can play an important role in providing youth with a knowledge base which may allow them to make informed decisions and help them shape a healthy lifestyle ( St Leger, 1999 ). The school is the only institution in regular contact with a sizable proportion of the teenage population ( Zabin and Hirsch, 1988 ), with virtually all youth attending it before they initiate sexual risk-taking behavior ( Kirby and Coyle, 1997 ).

Programs that promote abstinence have become particularly popular with school systems in the US ( Gilbert and Sawyer, 1994 ) and even with the federal government ( Sexual abstinence program has a $250 million price tag, 1997 ). These are referred to in the literature as abstinence-only or value-based programs ( Repucci and Herman, 1991 ). Other programs—designated in the literature as safer-sex, comprehensive, secular or abstinence-plus programs—additionally espouse the goal of increasing usage of effective contraception. Although abstinence-only and safer-sex programs differ in their underlying values and assumptions regarding the aims of sex education, both types of programs strive to foster decision-making and problem-solving skills in the belief that through adequate instruction adolescents will be better equipped to act responsibly in the heat of the moment ( Repucci and Herman, 1991 ). Nowadays most safer-sex programs encourage abstinence as a healthy lifestyle and many abstinence only programs have evolved into `abstinence-oriented' curricula that also include some information on contraception. For most programs currently implemented in the US, a delay in the initiation of sexual activity constitutes a positive and desirable outcome, since the likelihood of responsible sexual behavior increases with age ( Howard and Mitchell, 1993 ).

Even though abstinence is a valued outcome of school-based sex education programs, the effectiveness of such interventions in promoting abstinent behavior is still far from settled. Most of the articles published on the effectiveness of sex education programs follow the literary format of traditional narrative reviews ( Quinn, 1986 ; Kirby, 1989 , 1992 ; Visser and van Bilsen, 1994 ; Jacobs and Wolf, 1995 ; Kirby and Coyle, 1997 ). Two exceptions are the quantitative overviews by Frost and Forrest ( Frost and Forrest, 1995 ) and Franklin et al . ( Franklin et al ., 1997 ).

In the first review ( Frost and Forrest, 1995 ), the authors selected only five rigorously evaluated sex education programs and estimated their impact on delaying sexual initiation. They used non-standardized measures of effect sizes, calculated descriptive statistics to represent the overall effect of these programs and concluded that those selected programs delayed the initiation of sexual activity. In the second review, Franklin et al . conducted a meta-analysis of the published research of community-based and school-based adolescent pregnancy prevention programs and contrary to the conclusions forwarded by Frost and Forrest, these authors reported a non-significant effect of the programs on sexual activity ( Franklin et al ., 1997 ).

The discrepancy between these two quantitative reviews may result from the decision by Franklin et al . to include weak designs, which do not allow for reasonable causal inferences. However, given that recent evidence indicates that weaker designs yield higher estimates of intervention effects ( Guyatt et al ., 2000 ), the inclusion of weak designs should have translated into higher effects for the Franklin et al . review and not smaller. Given the discrepant results forwarded in these two recent quantitative reviews, there is a need to clarify the extent of the impact of school-based sex education in abstinent behavior and explore the specific features of the interventions that are associated to variability in effect sizes.

The present study consisted of a meta-analytic review of the research literature on the effectiveness of school-based sex education programs in the promotion of abstinent behavior implemented in the past 15 years in the US in the wake of the AIDS epidemic. The goals were to: (1) synthesize the effects of controlled school-based sex education interventions on abstinent behavior, (2) examine the variability in effects among studies and (3) explain the variability in effects between studies in terms of selected moderator variables.

The first step was to locate as many studies conducted in the US as possible that dealt with the evaluation of sex education programs and which measured abstinent behavior subsequent to an intervention.

The primary sources for locating studies were four reference database systems: ERIC, PsychLIT, MEDLINE and the Social Science Citation Index. Branching from the bibliographies and reference lists in articles located through the original search provided another source for locating studies.

The process for the selection of studies was guided by four criteria, some of which have been employed by other authors as a way to orient and confine the search to the relevant literature ( Kirby et al ., 1994 ). The criteria to define eligibility of studies were the following.

Interventions had to be geared to normal adolescent populations attending public or private schools in the US and report on some measure of abstinent behavior: delay in the onset of intercourse, reduction in the frequency of intercourse or reduction in the number of sexual partners. Studies that reported on interventions designed for cognitively handicapped, delinquent, school dropouts, emotionally disturbed or institutionalized adolescents were excluded from the present review since they address a different population with different needs and characteristics. Community interventions which recruited participants from clinical or out-of-school populations were also eliminated for the same reasons.

Studies had to be either experimental or quasi-experimental in nature, excluding three designs that do not permit strong tests of causal hypothesis: the one group post-test-only design, the post-test-only design with non-equivalent groups and the one group pre-test–post-test design ( Cook and Campbell, 1979 ). The presence of an independent and comparable `no intervention' control group—in demographic variables and measures of sexual activity in the baseline—was required for a study to be included in this review.

Studies had to be published between January 1985 and July 2000. A time period restriction was imposed because of cultural changes that occur in society—such as the AIDS epidemic—which might significantly impact the adolescent cohort and alter patterns of behavior and consequently the effects of sex education interventions.

Five pairs of publications were detected which may have used the same database (or two databases which were likely to contain non-independent cases) ( Levy et al ., 1995 / Weeks et al ., 1995 ; Barth et al ., 1992 / Kirby et al ., 1991 /Christoper and Roosa, 1990/ Roosa and Christopher, 1990 and Jorgensen, 1991 / Jorgensen et al ., 1993 ). Only one effect size from each pair of articles was included to avoid the possibility of data dependence.

The exploration of study characteristics or features that may be related to variations in the magnitude of effect sizes across studies is referred to as moderator analysis. A moderator variable is one that informs about the circumstances under which the magnitude of effect sizes vary ( Miller and Pollock, 1994 ). The information retrieved from the articles for its potential inclusion as moderators in the data analysis was categorized in two domains: demographic characteristics of the participants in the sex education interventions and characteristics of the program.

Demographic characteristics included the following variables: the percentages of females, the percentage of whites, the virginity status of participants, mean (or median) age and a categorization of the predominant socioeconomic status of participating subjects (low or middle class) as reported by the authors of the primary study.

In terms of the characteristics of the programs, the features coded were: the type of program (whether the intervention was comprehensive/safer-sex or abstinence-oriented), the type of monitor who delivered the intervention (teacher/adult monitor or peer), the length of the program in hours, the scope of the implementation (large-scale versus small-scale trial), the time elapsed between the intervention and the post-intervention outcome measure (expressed as number of days), and whether parental participation (beyond consent) was a component of the intervention.

The type of sex education intervention was defined as abstinence-oriented if the explicit aim was to encourage abstinence as the primary method of protection against sexually transmitted diseases and pregnancy, either totally excluding units on contraceptive methods or, if including contraception, portraying it as a less effective method than abstinence. An intervention was defined as comprehensive or safer-sex if it included a strong component on the benefits of use of contraceptives as a legitimate alternative method to abstinence for avoiding pregnancy and sexually transmitted diseases.

A study was considered to be a large-scale trial if the intervention group consisted of more than 500 students.

Finally, year of publication was also analyzed to assess whether changes in the effectiveness of programs across time had occurred.

The decision to record information on all the above-mentioned variables for their potential role as moderators of effect sizes was based in part on theoretical considerations and in part on the empirical evidence of the relevance of such variables in explaining the effectiveness of educational interventions. A limitation to the coding of these and of other potentially relevant and interesting moderator variables was the scantiness of information provided by the authors of primary research. Not all studies described the features of interest for this meta-analysis. For parental participation, no missing values were present because a decision was made to code all interventions which did not specifically report that parents had participated—either through parent–youth sessions or homework assignments—as non-participation. However, for the rest of the variables, no similar assumptions seemed appropriate, and therefore if no pertinent data were reported for a given variable, it was coded as missing (see Table I ).

Once the pool of studies which met the inclusion criteria was located, studies were examined in an attempt to retrieve the size of the effect associated with each intervention. Since most of the studies did not report any effect size, it had to be estimated based on the significance level and inferential statistics with formulae provided by Rosenthal ( Rosenthal, 1991 ) and Holmes ( Holmes; 1984 ). When provided, the exact value for the test statistic or the exact probability was used in the calculation of the effect size.

Alternative methods to deal with non-independent effect sizes were not employed since these are more complex and require estimates of the covariance structure among the correlated effect sizes. According to Matt and Cook such estimates may be difficult—if not impossible—to obtain due to missing information in primary studies ( Matt and Cook, 1994 ).

Analyses of the effect sizes were conducted utilizing the D-STAT software ( Johnson, 1989 ). The sample sizes used for the overall effect size analysis corresponded to the actual number used to estimate the effects of interest, which was often less than the total sample of the study. Occasionally the actual sample sizes were not provided by the authors of primary research, but could be estimated from the degrees of freedom reported for the statistical tests.

The effect sizes were calculated from means and pooled standard deviations, t -tests, χ 2 , significance levels or from proportions, depending on the nature of the information reported by the authors of primary research. As recommended by Rosenthal, if results were reported simply as being `non-significant' a conservative estimate of the effect size was included, assuming P = 0.50, which corresponds to an effect size of zero ( Rosenthal, 1991 ). The overall measure of effect size reported was the corrected d statistic ( Hedges and Olkin, 1985 ). These authors recommend this measure since it does not overestimate the population effect size, especially in the case when sample sizes are small.

The homogeneity of effect sizes was examined to determine whether the studies shared a common effect size. Testing for homogeneity required the calculation of a homogeneity statistic, Q . If all studies share the same population effect size, Q follows an asymptotic χ 2 distribution with k – 1 degrees of freedom, where k is the number of effect sizes. For the purposes of this review the probability level chosen for significance testing was 0.10, due to the fact that the relatively small number of effect sizes available for the analysis limits the power to detect actual departures from homogeneity. Rejection of the hypothesis of homogeneity signals that the group of effect sizes is more variable than one would expect based on sampling variation and that one or more moderator variables may be present ( Hall et al ., 1994 ).

To examine the relationship between the study characteristics included as potential moderators and the magnitude of effect sizes, both categorical and continuous univariate tests were run. Categorical tests assess differences in effect sizes between subgroups established by dividing studies into classes based on study characteristics. Hedges and Olkin presented an extension of the Q statistic to test for homogeneity of effect sizes between classes ( Q B ) and within classes ( Q W ) ( Hedges and Olkin, 1985 ). The relationship between the effect sizes and continuous predictors was assessed using a procedure described by Rosenthal and Rubin which tests for linearity between effect sizes and predictors ( Rosenthal and Rubin, 1982 ).

Q E provides the test for model specification, when the number of studies is larger than the number of predictors. Under those conditions, Q E follows an approximate χ 2 distribution with k – p – 1 degrees of freedom, where k is the number of effect sizes and p is the number of regressors ( Hedges and Olkin, 1985 ).

The search for school-based sex education interventions resulted in 12 research studies that complied with the criteria to be included in the review and for which effect sizes could be estimated.

The overall effect size ( d +) estimated from these studies was 0.05 and the 95% confidence interval about the mean included a lower bound of 0.01 to a high bound of 0.09, indicating a very minimal overall effect size. Table II presents the effect size of each study ( d i ) along with its 95% confidence interval and the overall estimate of the effect size. Homogeneity testing indicated the presence of variability among effect sizes ( Q (11) = 35.56; P = 0.000).

An assessment of interaction effects among significant moderators could not be explored since it would have required partitioning of the studies according to a first variable and testing of the second within the partitioned categories. The limited number of effect sizes precluded such analysis.

Parental participation appeared to moderate the effects of sex education on abstinence as indicated by the significant Q test between groups ( Q B(1) = 5.06; P = 0.025), as shown in Table III . Although small in magnitude ( d = 0.24), the point estimate for the mean weighted effect size associated with programs with parental participation appears substantially larger than the mean associated with those where parents did not participate ( d = 0.04). The confidence interval for parent participation does not include zero, thus indicating a small but positive effect. Controlling for parental participation appears to translate into homogeneous classes of effect sizes for programs that include parents, but not for those where parents did not participate ( Q W(9) = 28.94; P = 0.001) meaning that the effect sizes were not homogeneous within this class.

Virginity status of the sample was also a significant predictor of the variability among effect sizes ( Q B(1) = 3.47 ; P = 0.06). The average effect size calculated for virgins-only was larger than the one calculated for virgins and non-virgins ( d = 0.09 and d = 0.01, respectively). Controlling for virginity status translated into homogeneous classes for virgins and non-virgins although not for the virgins-only class ( Q W(5) = 27.09; P = 0.000).

The scope of the implementation also appeared to moderate the effects of the interventions on abstinent behavior. The average effect size calculated for small-scale intervention was significantly higher than that for large-scale interventions ( d = 0.26 and d = 0.01, respectively). The effects corresponding to the large-scale category were homogeneous but this was not the case for the small-scale class, where heterogeneity was detected ( Q W(4) = 14.71; P = 0.01)

For all three significant categorical predictors, deletion of one outlier ( Howard and McCabe, 1990 ) resulted in homogeneity among the effect sizes within classes.

Univariate tests of continuous predictors showed significant results in the case of percentage of females in the sample ( z = 2.11; P = 0.04), age of participants ( z = –1.67; P = 0.09), grade ( z = –1.80; P = 0.07) and year of publication ( z = –2.76; P = 0.006).

All significant predictors in the univariate analysis—with the exception of grade which had a very high correlation with age ( r = 0.97; P = 0.000)—were entered into a weighted least-squares regression analysis. In general, the remaining set of predictors had a moderate degree of intercorrelation, although none of the coefficients were statistically significant.

In the weighted least-squares regression analysis, only parental participation and the percentage of females in the study were significant. The two-predictor model explained 28% of the variance in effect sizes. The test of model specification yielded a significant Q E statistic suggesting that the two-predictor model cannot be regarded as correctly specified (see Table IV ).

This review synthesized the findings from controlled sex education interventions reporting on abstinent behavior. The overall mean effect size for abstinent behavior was very small, close to zero. No significant effect was associated to the type of intervention: whether the program was abstinence-oriented or comprehensive—the source of a major controversy in sex education—was not found to be associated to abstinent behavior. Only two moderators—parental participation and percentage of females—appeared to be significant in both univariate tests and the multivariable model.

Although parental participation in interventions appeared to be associated with higher effect sizes in abstinent behavior, the link should be explored further since it is based on a very small number of studies. To date, too few studies have reported success in involving parents in sex education programs. Furthermore, the primary articles reported very limited information about the characteristics of the parents who took part in the programs. Parents who were willing to participate might differ in important demographic or lifestyle characteristics from those who did not participate. For instance, it is possible that the studies that reported success in achieving parental involvement may have been dealing with a larger percentage of intact families or with parents that espoused conservative sexual values. Therefore, at this point it is not possible to affirm that parental participation per se exerts a direct influence in the outcomes of sex education programs, although clearly this is a variable that merits further study.

Interventions appeared to be more effective when geared to groups composed of younger students, predominantly females and those who had not yet initiated sexual activity. The association between gender and effect sizes—which appeared significant both in the univariate and multivariable analyses—should be explored to understand why females seem to be more receptive to the abstinence messages of sex education interventions.

Smaller-scale interventions appeared to be more effective than large-scale programs. The larger effects associated to small-scale trials seems worth exploring. It may be the case that in large-scale studies it becomes harder to control for confounding variables that may have an adverse impact on the outcomes. For example, large-scale studies often require external agencies or contractors to deliver the program and the quality of the delivery of the contents may turn out to be less than optimal ( Cagampang et al ., 1997 ).

Interestingly there was a significant change in effect sizes across time, with effect sizes appearing to wane across the years. It is not likely that this represents a decline in the quality of sex education interventions. A possible explanation for this trend may be the expansion of mandatory sex education in the US which makes it increasingly difficult to find comparison groups that are relatively unexposed to sex education. Another possible line of explanation refers to changes in cultural mores regarding sexuality that may have occurred in the past decades—characterized by an increasing acceptance of premarital sexual intercourse, a proliferation of sexualized messages from the media and increasing opportunities for sexual contact in adolescence—which may be eroding the attainment of the goal of abstinence sought by educational interventions.

In terms of the design and implementation of sex education interventions, it is worth noting that the length of the programs was unrelated to the magnitude in effect sizes for the range of 4.5–30 h represented in these studies. Program length—which has been singled out as a potential explanation for the absence of significant behavioral effects in a large-scale evaluation of a sex education program ( Kirby et al ., 1997a )—does not appear to be consistently associated with abstinent behavior. The impact of lengthening currently existing programs should be evaluated in future studies.

As it has been stated, the exploration of moderator variables could be performed only partially due to lack of information on the primary research literature. This has been a problem too for other reviewers in the field ( Franklin et al ., 1997 ). The authors of primary research did not appear to control for nor report on the potentially confounding influence of numerous variables that have been indicated in the literature as influencing sexual decision making or being associated with the initiation of sexual activity in adolescence such as academic performance, career orientation, religious affiliation, romantic involvement, number of friends who are currently having sex, peer norms about sexual activity and drinking habits, among others ( Herold and Goodwin, 1981 ; Christopher and Cate, 1984 ; Billy and Udry, 1985 ; Roche, 1986 ; Coker et al ., 1994 ; Kinsman et al ., 1998 ; Holder et al ., 2000 ; Thomas et al ., 2000 ). Even though randomization should take care of differences in these and other potentially confounding variables, given that studies can rarely assign students to conditions and instead assign classrooms or schools to conditions, it is advisable that more information on baseline characteristics of the sample be utilized to establish and substantiate the equivalence between the intervention and control groups in relevant demographic and lifestyle characteristics.

In terms of the communication of research findings, the richness of a meta-analytic approach will always be limited by the quality of the primary research. Unfortunately, most of the research in the area of sex education do not employ experimental or quasi-experimental designs and thus fall short of providing conclusive evidence of program effects. The limitations in the quality of research in sex education have been highlighted by several authors in the past two decades ( Kirby and Baxter, 1981 ; Card and Reagan, 1989 ; Kirby, 1989 ; Peersman et al ., 1996 ). Due to these deficits in the quality of research—which resulted in a reduced number of studies that met the criteria for inclusion and the limitations that ensued for conducting a thorough analysis of moderators—the findings of the present synthesis have to be considered merely tentative. Substantial variability in effect sizes remained unexplained by the present synthesis, indicating the need to include more information on a variety of potential moderating conditions that might affect the outcomes of sex education interventions.

Finally, although it is rarely the case that a meta-analysis will constitute an endpoint or final step in the investigation of a research topic, by indicating the weaknesses as well as the strengths of the existing research a meta-analysis can be a helpful aid for channeling future primary research in a direction that might improve the quality of empirical evidence and expand the theoretical understanding in a given field ( Eagly and Wood, 1994 ). Research in sex education could be greatly improved if more efforts were directed to test interventions utilizing randomized controlled trials, measuring intervening variables and by a more careful and detailed reporting of the results. Unless efforts are made to improve on the quality of the research that is being conducted, decisions about future interventions will continue to be based on a common sense and intuitive approach as to `what might work' rather than on solid empirical evidence.

References marked with an asterisk indicate studies included in the meta-analysis.

Description of moderator variables

Effect sizes of studies

Tests of categorical moderators for abstinence

Weighted least-squares regression and test of model specification

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• least-squares analysis
• sex education

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“But Everything Else, I Learned Online”: School-Based and Internet-Based Sexual Learning Experiences of Heterosexual and LGBQ + Youth

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• Published: 21 November 2023
• Volume 46 , pages 461–485, ( 2023 )

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• Joshua Gamson 1 &
• Rosanna Hertz 2  

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A Correction to this article was published on 06 December 2023

This article has been updated

Building upon scholarship on sex education, our research aims to understand how youth with a range of sexual identities have experienced school-based sex education, how they have explored sexual content online, and how they see the two in relation to each other. We thus ask: (1) How do youth with varied sexual identities recall experiencing formal school-based sex education from elementary through high school offerings? (2) How do heterosexual and LGBQ + youth utilize the Internet and social media sites for sexual learning? Through in-depth interviews with college students, we find that heterosexual and LGBQ + youth report that formal sex education was both limited and heteronormative; LGBQ + youth felt particularly unprepared for sexual experiences and health hygiene, and sometimes found ways to translate the information provided for their own needs. Despite some overall similarities in online sexual explorations, experiences of online sexual learning proved quite divergent for youth of different sexual identities. Heterosexual youth were likely to search for information on sexual pleasure and entertainment; in contrast, LGBQ + youth sought information to fill in knowledge gaps about non-conforming sexualities, and often used the digital space for identity discovery, confirmation, and affirmation. For both groups, online explorations interacted with offline ones through a back-and-forth in which youth tested out in one arena what they had learned in the other. These findings highlight the dynamic interaction between formal school curriculum, informal online sexual learning, and sexual scripts, identities and practices.

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Contraceptives and stuff like that I think I learned mostly through sex ed class. But everything else, I learned online. Anal sex, learned online. Oral sex and the details about that, learned online. Self-pleasure, masturbation, learned that online. Histories of queer communities, different sexualities and gender identities, learned online. Different ways that queer communities engage in sex, learned it online. Everything except penis-penetration type of sex, I learned everything else online. Everything. – Abby (age 20, Latinx, queer, non-binary)

Our research aims to understand how youth with a range of sexual identities have experienced school-based sex education, how they have explored sexual content online and how they see the two in relation to each other. It emerges from a recognition that while the existing literature on sex education is well developed, the research on sexual learning online is less robust. In particular, we know little about how school-based and Web-based sexual learning experiences differ for youth with non-normative sexual and gender identities and those who identify as straight. We also know little about the interaction between school-based and online sexual learning.

In this study, based on in-depth interviews with 56 college students from a variety of backgrounds and identities, we ask: (1) How do youth with varied sexual identities recall experiencing formal school-based sex education from elementary through high school offerings? (2) How do heterosexually-identified and LGBQ + -identified youth utilize the Internet and social media sites for self-discovery and for acquiring information not offered in their formal sex education curriculum, and how do they assess that information?

Bridging and building upon the scholarship on LGBQ + student experiences (Beattie et al. 2021 ) and on formal and informal sex education, we find that while both heterosexual and LGBQ + youth report that formal sex education was both limited and heteronormative, their experiences of online sexual learning are quite divergent. Largely excluded from their school’s sex education curriculum, LGBQ + youth often seek online content related to their identity or imagined partners and practices—in ways that may be both affirming and confusing. This dynamic points to ways the reform of school-based sex education remains significant, despite its diminished role as an information source (Lindberg et al. 2016 ), and highlights the interaction between formal school curriculum, informal online learning, and sexual “scripts” (Simon and Gagnon 1986 ), identities and practices.

Sex Education and Online Sexual Learning

Decades of research have established three clear characteristics of formal sex education in the USA: (1) governed largely at the local and state level, it varies widely from place to place; (2) it is usually both narrow in scope and short in duration; and (3) it is almost exclusively heteronormative.

Informed by competing sex education policy frameworks—one advocating “comprehensive” sex education and the other “abstinence” education (Fields 2012 ; Fine and McClelland 2006 ; Irvine 2002 ; Luker 2006 )—the curriculum runs the gamut from conservative just-say-no to liberal here’s-how-it-works to total silence (Kramer 2019 ). Regardless of ideological bent, American sex education tends to reinforce dominant understandings of race, class, gender, and sexuality (Connell and Elliott 2009 ; Fields 2005 , 2008 ; McNeill 2013 ). In particular, sex education in the USA has been almost exclusively focused on heterosexual identities and practices (Hirst 2004 ; Irvine 2002 ; Luker 2006 ; Fine and McClelland 2006 ; Pascoe 2007 ) and at times outright hostile towards non-normative ones (McNeil 2013; Gowen and Winges-Yanez 2014 ).

Formal sex education has been one major institutional source of sexual scripts at what Simon and Gagnon ( 1986 , 105) call the “cultural scenario” level, a kind of collective “instructional guide” specifying the “appropriate objects, aims, and desirable qualities of self-other relations,” instructing the “times, places, sequences of gesture and utterance and… what the actor and his or her coparticipants (real or imagined) are assumed to be feeling,” which are then “rehearsed at the time of our initial sexual encounters.” These cultural scripts are then adapted and molded by individuals into “interpersonal scripts” that shape “the materials of relevant cultural scenarios into scripts for behavior in particular contexts,” and brought into the self as “intrapsychic scripts,” the “private world of wishes and desires that are experienced as originating in the deepest recesses of the self” (Simon and Gagnon 1986 , 99–100).

Formal sex education, of course, is not the only source of sexual information, scripts, and learning. Young people also learn about sex and sexuality outside of schools from people around them (family, peers, community, and religious leaders) and, though often passively, through the consumption of popular culture. Since the inception of popular media in the early twentieth century, generally speaking, “depictions of sexual content and imagery abound in popular film, television, and advertising”; in centralized, risk-averse, commercial cultural industries, the sexual content was typically characterized by “regressive and often objectifying portrayals of sex and sexuality,” routinely rendering non-normative sexualities invisible or stigmatizing them, if still open to “queer readings” (Grossman 2020 , 281). That is, the cultural scripts and sexual content provided by popular culture was—until more recent structural changes such as the expansion of cable and then streaming outlets—quite a thin and narrow source for sexual learning, particularly for people experiencing desires and identities outside of the sexual and gender mainstream. Digital technologies have plainly altered that, rendering new popular culture far more diverse, more individualized, and more emphemeral, not only “personal, mass, and global but also decentralized” (Grossman 2020 , 286). This is, of course, a very different cultural environment for sexual learning.

While the relevance of school-based sex ed is in decline (Lindberg et al. 2016 ), in recent years social media and online spaces, and the popular culture circulating within them, have become a crucial informal curriculum through which young people learn about sexuality (Adams-Santos 2020 ; Boyd 2015 ; Fields 2012 ; Orenstein 2016 ; Orenstein 2020 ; Simon and Daneback 2013 ) and “craft and articulate their sexualities” (Adams-Santos 2020 , 2)—what some have called “the new sex ed” (Orenstein 2020 , 52). The Internet’s “availability, acceptability, affordability, anonymity, and aloneness” make it “unique in the delivery of sexual information in the digital age” (Simon and Daneback 2013 , 315, 306). For youth with non-normative sexual desires and identities, some researchers have found, the various available online platforms hold a particular draw, interacting with offline experiences “in ways that shape their emerging identities, social lives, romantic relationships, sexual behaviors, and physical and sexual health” (DeHaan et al. 2013 ). The prevalence of “techno-sexuality” (Waskul 2014 ), which allows youth to explore and experience sexuality beyond adult control, combined with the continued heteronormative emphasis of school-based sex education, points to the questions that animate our research.

While research on online sexual learning is increasing, and has established that “online sex education plays a role in adolescents’ lives,” just what sort of role, and how, and for whom, remains more poorly understood. Scholars have suggested, for instance, that “there is little knowledge on adolescents’ use of online sexual information for sexuality education in particular” (Nikkelen et al. 2020 , 190); that “the qualitative experiences of adolescents who engage with sex information online, from their initial interest in information to the effects such information could have on their lives,” the “process of applying online information offline” and “demographic differences” all remain understudied (Simon and Daneback 2013 , 312–314). Furthermore, the dynamic relationship between formal sex education—what it does and does not provide to youth—and online sexual explorations, the decentering of traditional sexual scripts (at the cultural, interpersonal, and intrapsychic levels) and the impact of this destabilization, have received scant scholarly attention (for an exception, see DeHaan et al. 2013 ). Our research addresses these gaps.

Methods and Data

We recruited college-age students between the ages of 18 and 22 years. Given national differences in sex education, we limited our respondents to the USA and territories. We found respondents primarily through posting flyers (online due to COVID restrictions) on websites affiliated with Boston-area colleges. These colleges attracted students from varied geographic locations in the USA and Puerto Rico, types of schooling, sexual identities, race and social class backgrounds (see Table 1 ).

On the flyers we indicated that we were interested in learning about sex education programs in their schools and also their use of digital spaces. We restricted the recruitment to young people enrolled in college because we wanted to understand how these youth made sense of the “sexual scripts” (Simon and Gagnon 1986 ), or social underpinnings of sexuality and sexual identity taught in high school sex ed programs and augmented or challenged by private Internet searches and social media interactions, once they were away from home. Given our particular interest in the experiences of lesbian, gay, bisexual, asexual (LGBQ +) youth, we indicated on organization posts that we were particularly interested in LGBQ + youth and their experiences. In total we conducted 56 in-depth interviews with college students.

This paper compares college age youth who currently identify as heterosexual or straight (39.3%) with the experiences of those who identify as LGBQ + or queer (60.7%) youth. While we distinguish between straight and queer respondents on the basis of their current self-reported identities, many of our respondents described experiences of fluid or changing sexual practices and desires. While youth are coming out as lesbian, gay, queer, questioning, bisexual at younger ages than in the past, data indicates that most reveal their sexual identity to family and friends in college (Beattie et al. 2021 ; Dunlap 2016 ). For instance, 20% reported that in high school they either identified as heterosexual or were questioning their sexual or gender identities but currently identify as LGBQ + . In the sections that follow we capture this fluidity in their descriptions of identify shifts and discoveries, both in the context of sex education in schools and in online explorations, which we note when we introduce quotes from our respondents.

Online flyers included a link to a Google form that college students from 18 to 22 years old completed in order to volunteer. On the form we asked for contact information and background information (age, pronouns, race, sexual identity in high school and currently, gender identity, region of the country where they grew up). We re-checked this information at the time of the interview and used it for coding purposes. When we reached out to our respondents, we also sent then a consent form that included information on audio and video recording and confidentiality. Interviews lasted between 1.5 and 2 hours, were audio recorded and videotaped, and transcribed verbatim. Since Zoom allows us to record with simultaneous transcription, we destroyed the video recording within a week after checking the accuracy of the transcript. To protect our respondents’ confidentiality, we informed them that we would use pseudonyms in any publications and presentations.

The study protocol was approved by the Institutional Review Boards for the protection of human subjects at the University of San Francisco and Wellesley College (for Zoom interviews only because of pandemic restrictions on in-person interviewing in 2021). All interviews were conducted between March and November 2021.

We chose qualitative interviews as the most effective method to access interviewees’ opinions and recollections, within their social context, and for understanding multiple aspects of the same experience (Gerson and Damaske 2021 ). We developed a semi-structured interview guide that asked questions related to experiences of sex education both in their schools as well as in digital spaces, including what students recalled learning from elementary school through high school; what material was taught, for how long and by whom; the major messaging frameworks they encountered; how useful and inclusive they thought the curriculum was at the time and in retrospect; whether and how students sought information online, and if so what types of information; where they searched; and how they evaluated the information they found. We also asked for what they discussed with parents, other family members and their peers.

In the convention of interview data analysis, we developed a detailed coding scheme in order to discern patterns across interviews. Both inductive and deductive codes were developed. Construction of the codes was guided by the principles of grounded theory, with emerging themes identified and then reanalyzed for consistency and completeness (Charmaz 2006 ; Gerson and Damaske 2021 ; Glaser and Strauss 1967 ). We coded interviews to reveal the topics interviewees recalled learning in schools; how they were presented, where, for how long, and by whom; the frames through which the sexual information was presented; school-based learning outside of classroom settings; feelings and perceptions of inclusion in the curriculum; when they began consuming online content and what kinds of information or activities they sought; what sites they most frequently visited; whether they also created online content; with whom they discussed sex education content or online learnings; and how accurate and reliable they took sexually-related information to be both at schools and online. This allowed us to quantify the content, generating the figures and tables referred to in this paper.

In addition, we generated a related qualitative coding document in which interviewees’ quotes were gathered according to thematic content, in order to more deeply understand their accounts of their own learning and how they made sense of their experiences of school-based and online sexual learning, with particular attention to the divergent circumstances that led our interviewees to turn to the various online platforms available to them. Each interview was coded by at least two researchers to facilitate intercoder reliability. Coders met weekly to discuss their individual coding, referring back to the original interviews to reach consensus.

Since our respondents were in college at the time of the interviews the summer provided a natural break in interviewing. We used the summer to code the interviews conducted in the first round (March–June 2021). This allowed us to discuss where we had achieved “conceptual depth” (Nelson 2017 , 556) both with regard to the open-ended questions we were asking and also with regard to understanding the interplay between schools and online learning, and how they might differ for our two groups.

Our interviews were retrospective by necessity, and retrospective accounts hit up against the “limitations of chronological memory, the potential for hindsight-based rationalizations, as well as people’s tendencies to construct stories that place themselves in a favorable light” (Langley and Meziani 2020 , 373). People look back through the filters of the present, and details become fuzzy or distorted, and that was certainly the case in our research. Our investigations, however, are not so much aimed at a factual account of what took place in classrooms or online as at what stands out in participants’ memories, and the related “imagined meanings of their activities, their self-concepts, their fantasies about themselves” (Lamont and Swidler 2014 , 159); that is, how participants remember their sex education and online explorations, and how they understand those in relation to their life paths and identities.

Formal Sex Education: Experiences of a Limited and Heteronormative Curriculum

Most of our respondents recalled having some version of sex education, particularly in the latter parts of their schooling (see Table 1 ), though not a lot of it; what they did receive they report finding quite limited in scope and heterosexually focused. In elementary school, almost two thirds of the respondents (61.4%) had sex education, and most (77.1%) reported that it was for one class on puberty and hygiene. Almost three quarters recalled having sex education in middle school; of these, the majority (72%) said that the class was a module or a brief part of another course (such as health or biology). The largest portion of respondents (85.9%) reported having sex education in high school, again typically as a module of a course (60.4%), though a third (33.3%) recounted having a full sex education course for half a year.

Generally speaking, our respondents recall elementary school sex education focused on puberty and menstruation, typically in class meetings segregated by sex. Despite often having some exposure to this sort of information through parents (usually mothers), and finding the emphasis on bodily changes and hygiene “embarrassing,” many respondents recalled being excited for their first sex education class. As one respondent, Erika (21, Asian, cisgender woman, lesbian, attended public school in the Northeast) put it, “It was a really highly anticipated conversation. Everyone in the class knew the day we were going to talk about it and people were talking about it, like, ‘Wait, do you know this, this and this about [puberty]?’” Interestingly, our respondents recalled only learning information related to their sex assigned at birth.

By middle and high school, class content became more varied, in part to cover state-mandated material, and all students were in classes together. In some school districts these classes were supplemented by professionals from the community. In other schools, students could elect a human development course or a section of a biology course that presented information on reproduction. Respondents recalled putting condoms on bananas, learning about sexually transmitted infections (STIs), watching videos about birth, sometimes discussing consent and sexual assault and mostly being told not to have intercourse. Many noted that no answer to the central question “What is sex?” was provided.

Few of the respondents recalled learning much novel or in depth in school, regardless of whether they went to private or public schools. Some respondents told us that the sex education came too late: they had already learned quite a bit about sex from peers and other sources, and some were already involved in sexual activity. Others reported that they did not pay a lot of attention because the topics they were interested in, such as sexual pleasure and sexual practices, were not covered. All agreed that in addition to pleasures and practices, a vast range of sex- and sexuality-related topics were almost entirely absent from the curriculum, including cultural representations of sexuality, pornography, relationships and dating, non-cisgender and non-heterosexual identities, and abortion.

Overarching Cultural Scripts: Abstinence, Danger, Gender, and Heterosexuality

Our respondents articulated, looking back, the cultural scripting their school-based education provided, in terms of the appropriate “objects, aims, and desirable qualities,” as well as the appropriate “times, places, sequences” and emotional content, for sexual encounters (Simon and Gagnon 1986 , 105). The focus, they reported, was most often on the dangers of sex (disease, unplanned pregnancy) and ways to avert them (condoms, occasionally sexual consent tools), often with a fear or abstinence message, and often from a male perspective. (While we expected that secular private schools would be more progressive in sex education content, the evidence from our interviews suggested that this was not the case.)

For instance, John, a 21-year-old white, cisgender, straight man from rural Colorado, received minimal sex education from his private school. He recalled,

I don’t think I learned anything new. I think all I got out of it is like, “Oh that’s how you have heterosexual sex, this is what a penis looks like going into a vagina,” from a cheesy video – and I already kind of knew this… It was the biology of how it works. I wouldn’t say I remember anything about pleasure or things like that. It was mainly just the scientific aspects of it.

As Jessica, a 20-year-old, white, cisgender woman from the Northeast who came out as bisexual in her junior year of high school, put it, “teachers had to walk a fine line between informing us and not seeming like they were encouraging us to have sex.” Even so, she recalls, the focus was on male pleasure. “Male ejaculation was discussed. Why was there no discussion of oral sex or lube or that women could have an orgasm?” Elena, age 20, Latinx, non-binary, queer and asexual, who attended public school in southeast LA, echoed this view. Her elementary school sex education was brief (“a one-time, thirty-minute to an hour class”) and focused on puberty, and her middle school offered one session in seventh grade (“how to put a condom on a banana”). Recalling her “penis-heavy” 9 th grade health class, she said:

The biggest thing I remember was just abstinence. “Don't have sex. The best contraceptive is never have sex, so just don't have sex." Which is not helpful at all, because most people engage in sexual activity. I don't remember anything about other forms of sex ed, like how to have sex or different forms of pleasure or anything like that. The knowledge about how to apply a condom and what you can catch is not really helpful because then you don't even know how to engage in sex…. So then, well, I know that I can catch chlamydia, for example, but what are ways that I can prevent it? None of that. What ways can I engage in sex? Never taught. So were they ever that helpful? Not really.

As another respondent put it, “Abstinence is [presented as] the gold standard.”

The majority of our respondents, regardless of identity, understood the focus on abstinence to be tied to the primary framing of sex as risky, dangerous, and fearful; their classes focused primarily on disease and pregnancy (See Fig.  1 ). As Jocelyn (African American, cisgender, straight woman, from an urban, East Coast public school) recalled, the message was: “If you want to avoid STI, don’t have sex. If you don’t want to get pregnant, don’t have sex.” Similarly, Shenita, a 21-year-old, African American, cisgender, straight woman who attended a public school in the mid-Atlantic suburbs, recalled her teacher comparing sex to “operating heavy machinery, dangerous” and telling the class of 13-year-olds that “none of us should be having sex within the next ten years.”

Primary Framing of the Sex Ed Curriculum

We also found a general consensus—again in line with most popular and academic accounts of American sex education (Gowen and Winges-Yanez 2014 ; McNeill 2013 ) —that the sex ed curriculum youth encountered generally assumed everyone in the room was heterosexual, implicitly or explicitly equated heterosexuality with sexual normalcy, and treated non-heterosexual sexualities as rare, a side note, or nonexistent. Youth repeatedly recalled that teachers “very much emphasized that heterosexual dynamic” (Ana Luisa, 18, Latinx, cisgender woman, lesbian and educated in public school), with a “very heterosexual” take on pregnancy and an “overall emphasis on heterosexual couples” in discussions of and videos about sexually transmitted infections (Lizzie, 19, white, cisgender woman, asexual, queer, public school-educated). Nearly three-quarters of the LGBQ + youth, and more than nine-tenths of the heterosexual youth, said that only heterosexual relationships were discussed in their sex ed classes; four-fifths of the LGBQ + youth and all of their heterosexual counterparts indicated that non-cisgender identities were never discussed. LGBQ + youth rarely asked for information that might be more applicable to their lives because, some reported, they felt they would be “flagged” in school peer cultures that emphasized heteronormativity.

When non-normative sexualities were discussed, a few respondents noted, it was often in the context of HIV. For instance, Julia, a 19-year-old, Latinx/white, nonbinary, lesbian, educated in public school in rural Georgia, recalls:

I knew I was queer in middle school and I was hoping to hear something. The only time I ever heard about queer people in sex ed was when they were talking about HIV and AIDS. So that was a scary thing because I had just figured out I was queer, and then the gym teacher comes in and says, “This is a bunch of dead gay people, and you can be like them, too,” and I was like, “I could be like them too?”

The absence of information about non-heterosexual practices was, not surprisingly, less directly concerning to cisgender heterosexual respondents than their LGBQ + counterparts. Thus, their experiences diverged quite significantly. LGBQ + youth in particular recall the heteronormative bent of their school-based sex education as rendering it at best unhelpful to their understanding of sexual identities and practices. As Ana Luisa put it, at the time she already knew that heterosexual dynamics were “just not something I would have encountered,” so sex ed “was just useless to me personally.” She and her similarly positioned peers simply did not find much material from the cultural scripts offered by formal sex education with which to develop interpersonal scripts for their sexual interactions, or that affected the shape of their intrapsychic scripts of sexual desire.

Another absence is worth noting: although we did not query them about it directly, none of our respondents reported themes of love, care, and affection for others as a prominent theme in their formal sex education. Hints of such a framework in which to place sex occasionally came through in, for instance, lessons on consent, which tied sexual behavior to a kind of ethics of care for the other, and in lessons on sexual safety and health, which tied sexual behavior to a care of oneself and others. Yet, the notion that love is a necessary component of sex (or a precursor for sexual activity) appears to have been weak enough in the curriculum to not emerge organically in our respondents’ memories.

LGBQ  +  Youth and School-Based Sex Ed: Absences, Improvisations, and Memory

While all youth reported that there was limited information that was useful for first sexual encounters, LGBQ + youth felt particularly unprepared for sexual experiences and health hygiene. As Karl, who identifies as a cisgender gay man and Latinx, and went to public schools in the Northeast, put it, “They never really went over things like mouth guards or finger ones. For other people who do not practice actual intercourse, how are they going to know how to protect themselves?” Marlie, who went to private school in California and identifies as Latinx, bisexual/queer and a cisgender woman, similarly noted:

I don’t think there was any information that prepared me for my first sexual encounters, which started actually that year when I was 15 years old. In the classes, there wasn’t as much of an emphasis on the actual act of sex and what that is like and what happens. It is not that they emphasized heterosexual sex, it is that they did not talk about queer sex…. We definitely did not talk about what fingering is, what vulva on vulva sex is like, what penis on penis sex is like, any of that. My first sexual encounters were not with somebody with a penis, so I didn’t feel prepared to know about proper hygiene regarding fingering or dental dams or any of that stuff.

Other respondents found ways to translate—or perhaps more accurately, to hack—the heterosexually-directed information they encountered. For instance, Rhonda, age 22, Native American and white, cisgender lesbian woman, reported that in her public school in Kansas teachers focused a lot on preventing STDs and “keeping safe” through condom use, but “we never learned about LGBQ sex ed at all.”

So when a lot of us started coming out, we were like, “Well, what do we do now?” We knew condoms, in heterosexual relations, could help prevent STDs, but we didn’t know how that worked if we were having sex with women or AFAB [assigned female at birth] people. One thing that was very novel to us was that you could cut open a condom and make a dental dam – because you couldn’t buy dental dams where we lived, they just weren’t available anywhere. So, we just compared what we needed to use with what we had learned from our health classes. And whenever one of our friends was going to meet someone new, we would tell them, ”Hey, don’t forget about this cool trick you can use, because you don’t want to get an STD.”

In effect, through efforts such as these condom displays, queer youth found it necessary and possible to create new “interpersonal scripts”: The “disjunctures of meaning between distinct spheres of life,” as Simon and Gagnon pointed out ( 1986 , 99, 102, 106) created moments of “ad hoc improvisation” at the interpersonal level.

While a few respondents reported seeking support from queer-friendly teachers outside of sex ed classes, still others internalized the notion that their sexual desires and curiosities were irrelevant. Emily, for example, who identifies as a white, asexual, cis-gender woman, who went to a public school in the Northeast, noted that.

just one mention of there being other sexualities than straight, gay and bi, would’ve been useful for me, just off-hand, in a context that conveys authority would have been helpful…. I just figured I was wired differently and just left it at that.

She reached the conclusion, she said, that “I was an outlier and did not count.”

Interestingly, LGBQ+ youth also were less likely than their straight counterparts to recall a framing of sex as dangerous (39% of LGBQ+ youth vs. 71% of heterosexual youth). Queer identifying youth reported more often that their sex education classes framed sex scientifically, as a heterosexual biological process (21% of LGBQ+ youth vs. 9.5% of heterosexual youth). Furthermore, while no heterosexual youth recalled receiving sex education through a moral frame, LGBQ+ youth were more likely to recall a moral frame in the curriculum, either one that treated certain kinds of sex as immoral (15%) or all sex as morally acceptable (12%) (see Fig. 1 ). Finally, heterosexual youth recalled feeling in high school that the curriculum included material relevant to them (77%), but only 30% of the LGBQ+ youth felt the same way. Those who felt included or even partly included often recalled that same sex relationships were briefly mentioned, and that this mention made them feel included. However, at the time of the interview, and now in college, regardless of sexual identity, the majority did not feel that the curriculum was inclusive of them or of their LGBQ+ friends (see Fig.  2 ).

Inclusion in the Curriculum

While at first glance these findings seem counterintuitive, we suggest that they are outcomes of a nascent or developed identity difference that shapes the reception and memory of sex education. The broader range of sex ed frames LGBQ + respondents recall may have to do with their heightened sensitivity to the cultural frames surrounding non-normative sexualities and genders (Weeks 2023 ), the “paradigmatic” scripting of sexuality (Simon and Gagnon 1986 , 102)—as morally questionable, unnatural, or scientifically explicable deviations—that have less personal resonance for heterosexual respondents. The greater inclusivity that almost a third of LGBQ + students recall may have to do with the identity needs through which they filtered the curriculum, in which any mention of non-normative sexualities, and of ways to manage heterosexual situations as an outsider to them, stood out as memorable. Their overall irrelevance and invisibility within the curriculum—and within the cultural scenario scripting more broadly—we suggest, made moments of relevance and visibility particularly memorable.

Pleasure, Identity, and Online Sexual Learning: Convergent and Divergent Experiences

Online sexual explorations started early for the youth we interviewed, and were both constant and extensive. The Internet and its myriad platforms—including not just websites but interactive social media and online communities—was robust by the time all of our interviewees entered middle school. Our oldest interviewees at age 22 were 12–14 years old in 2011–2013; while our youngest interviewees at age 18 were 12–14 years old in 2015–2017.

Internet searches for almost two-thirds of our respondents began in middle school between the ages of 12–14, with just over a quarter searching the Internet even earlier (See Table 1 ). Although parents rarely monitored their children’s Internet searches, many of our respondents told us that they would sneak down early in the morning or late at night to the family computer or iPad hoping that their parents would not discover their activities. By high school all of our respondents, who completed high school between 2017 and 2020, had their own devices (phones, iPads, computers) in their rooms. Still, they were careful to hide their Internet Web search history.

Online Explorations: Finding and Making New Sexual Scripts

Our respondents used a variety of online platforms, each facilitating different kinds of activity, to seek out information, explore identities, compare themselves to their peers, and for entertainment and fun, regardless of their sexual identity. Online space—whether social network, content, or media-sharing platforms—of course, offers significant communication changes not readily found offline, serving as “a massive expert database,” providing easy access to the kind of credentialed expertise found in formal sex education; as a “global broker, a way for individuals with special concerns to find each other,” allowing for the dissemination of alternative and sometimes counter-normative sexual expertise, as well as sexuality-based community formation; and as a “global collective memory, allowing people to contribute, store, and annotate comments” (Radin 2006 , 593), facilitating alternative sexual storytelling. Accordingly, our respondents’ explorations ranged from information on how to “do sex,” to how people think about and label themselves sexually, to how to get sexual pleasure or give it to others, to topics like consent, disease, and activism; many also reported using online explorations to assess where they stood in terms of “normal” physical and sexual development.

Unlike school-based sexual learning, online explorations were not dominated by any “master” script, but involved a youth’s transformation from “being exclusively an actor trained in his or her role(s)” to “being a partial scriptwriter or adaptor,” as Simon and Gagnon ( 1986 , 99) describe interpersonal scripting. Respondents went all over the Internet for sex- and sexuality-related content. In Fig.  3 we have grouped these sites into various categories that our respondents used for learning online. We asked our interviewees what websites they accessed and what they remembered learning online; the answers showed widely ranging exploration. They reported taking online sex quizzes on Buzzfeed (“15 Things You Need to Know About Your Sex Life”), looking at medical sites (for “information about asexuality and attraction”) and sexuality education sites (such as Scarleteen, “a one-stop shop for LGBQ youth”), consulting Wikipedia and Google (for instance, for articles on “how to make out or give a blow job,”) watching porn sites (such as PornHub); enjoying fan fiction (Wattpad) and “smut” fan fiction (“it’s just like porn but it’s words”) on user-generated story sites; watching video sites (such as You Tube videos on sex positions, “the arousal of the vulva,” and masturbation, and TED Talks about the effects of porn), spending time on social networking sites (such as Grindr), in video chat rooms, on microblogging and networking sites (such as Tumbir), and in large online forums like Yahoo and Autostraddle.

Websites Used

Julia, quoted earlier, who identified as queer in middle school, described their explorations in a way that echoed throughout our interviews: secretive, exciting, voracious, and curiosity-driven.

I would look up information in the middle of the night. I would pull a blanket over my head and I’m looking at Tumblr, which was the fountainhead for the LGBTQ people in general. That’s a lot of my childhood experiences, trying to find information and then learning it. It was exciting. Now I understand that it was me taking agency over my own conceptualization of what sex can be, what sexual identity can be, what gender can be. It was like putting little puzzle pieces together which made me feel better. But I did it in a secretive way.

These wide-ranging, relatively unfettered explorations often began with pleasure-seeking but led to unexpected places. For instance, Bryan (age 21, white, cisgender male) grew up bisexual in a Southern town and school where the message was “very much sex is taboo.” He began his online explorations at age 12, sometimes Googling particular questions, but mostly “just looking for pleasure, or pictures, or browsing material, it would pretty much be Pornhub.” Over time, he dove into sub-Reddits—also initially for arousal—where he eventually discovered that “people were also having very intelligent and mature discussions about pleasure.”

Many of our respondents, in fact, turned to other online platforms for information about sexual pleasure and practices that were missing from their formal sex education. For instance, Summer, who identifies as  Latina/white, a cisgender woman, and bisexual, spent much of her time on Wattpad, where she read “books that people write on there that are not very good,” but whose quality she overlooked when she “stumbled across a few smutty books – and by smut I mean like books with like sexual content – and that’s where I got my basic knowledge of sexual pleasure.” Similarly, Jessica (age 20, white, bisexual, cisgender woman) sought information about queer sexual practices that were unavailable in her public-school education:

I would sometimes seek out Cosmopolitan or Buzzfeed or Autostraddle articles to ease any anxiety I felt or to get ideas about what to do, and I think about both anatomy and pleasure, for sure, because I feel like that wasn’t really talked about in my middle school sex ed…. Whenever I was looking in high school, and now, whenever I have looked at Autostraddle, it’s a lot of little graphics, like little silhouette positions, with descriptions of what’s going on, like, “Oh, here’s different positions to try.”

These online sites, that is, became something of an alternative how-to manual.

Given the mix of types of expertise available on online platforms—credentialed in a traditional sense or staking a claim to be so, lay and crowd-sourced expertise—the question or what information could be relied upon was often unresolved. While the majority of our respondents presumed that the Internet provided accurate information, 30% of our respondents told us they thought the Internet was a mix of accurate and inaccurate information. Many of our respondents looked to triangulate information from the websites they frequented; others reported that they were relieved to find answers to their questions regardless of the source and accuracy. Moreover, when our interviewees were skeptical about information their teacher discussed in their sex education class they turned to the Internet for answers. During middle school in 2014, Angie, who is currently age 19, Asian, and identified as queer prior to coming to college, described how her use of the Internet hastened her growing up as she tried to figure out which source was accurate:

So Tumblr was a thing, that’s where all the cool kids learned how to be adults. We were learning about sexually transmitted diseases and infections and I was listening. But I remember thinking like, “Some of this is a little weird.” And then slowly after the fact, I started looking up more and more things on Tumblr to try and figure out like, “Was what they were telling me true? Is this actually how I would get a sexually transmitted infection? Is this actually how I would get AIDS or get HIV? Is this actually how sex works?”

While most respondents reported using the Internet as a source of “basic knowledge about sexual pleasure” and “ideas about what to do,” the explorations of straight and queer youth were quite divergent (see Fig.  4 ). Heterosexual youth tended to be primarily focused on sexual pleasure and entertainment, with sexual learning as a byproduct. In particular, straight youth—especially but not only young men—who more readily saw themselves in the sex ed curriculum, were more likely than their queer counterparts to initially turn to online platforms seeking pleasure (23.5%) and sexual practices (23.5%), usually on porn sites. Through this process, they continued to experience online sexual sites as instructional, even if that was an indirect result of their porn consumption, and even if they were skeptical—as many were or became over time—of porn’s reality and impact.

Internet Searches Over Time

As John (21, white, straight, cisgender male) described his own quite typical experience, he recalled going on his mother’s computer in elementary school to “look up ‘big boobs’ or something.” In seventh grade, entering puberty, a friend showed him porn videos. “I was thinking about it all the time,” he recalls. “‘Wow. I really want to have sex with someone.’”

Such online explorations often interacted with offline ones through a back-and-forth in which youth tested out in one arena what they had learned in the other. Particularly as they got older, youth often tried out what they saw online in their own relationships, adapting the cultural material into interpersonal sexual scripts, and then returned online with those experiences in mind. Juan (19, Latino, straight, cisgender male who grew up in Puerto Rico) described it this way:

What did I look for in porn? At first it was pretty basic stuff – well, not basic at the time, but today I’d consider it to be a little bit basic in terms of sexual experimentation. I looked at hand jobs or stuff like that. And I think as I started to experiment more... What I looked for in porn kind of was the same as what I was experimenting with. When I had my first girlfriend in 10 th grade, we started to kind of experiment, and that’s when I started to look [online] for fingering and blowjobs.

For many respondents, pornography consumption itself set in motion a process at the intrapsychic level, in which they attempted to distinguish their own fantasies and desires from those contained in the cultural scripts of porn, an “internal dialogue” in which sexual desires experienced as “originating in the deepest recesses of the self” in relation to social meanings and expectations encountered in cultural scenarios (Simon and Gagnon 1986 , 99). For instance, RJ, a 21-year-old white cisgender male who identified as straight until college, realized at a certain point not only that porn presented “very unrealistic expectations of stuff that I had to unlearn,” and unhelpful sexual models such as the fact that “there is not a lot of foreplay in porn, or any female-centric pleasure,” but also that it had taken over his sexual desires such that “I couldn’t pleasure myself without porn, And I was like, ‘This is probably bad.’” Similarly, Max, a 21-year-old white cisgender male, came to believe—through offline conversations with women friends and his mother, as well as online viewings of TED talks on the subject—that pornography was not only unhealthy due to the unrealistic view of sex it generates but also because of its impact on his sexual desires. “When I was watching a lot of porn, when I would have sex, it would be kind of harder to enjoy it or be in the moment,” he said. “I’d be thinking about something that I’d seen in a video.” Both RJ and Max moved back and forth at an intrapsychic level distinguishing between a manufactured fantasy life and the realities of interpersonal sexual relations..

Offline conversations also lead to online sexual explorations. For instance, Mila (21, Latinx/white, cisgender woman, identified as straight in high school and in college), recalled a phone call with her boyfriend, in which he suggested that she watch porn and learn to masturbate. She followed up. “That is how I watched my first porn video,” she said. “I was like, ‘Damn, that’s hot.’ I could probably still tell you who was in that video. I remember it so distinctly.” Encouraged to explore her relationship to her sexual body—her self-desire—in the context of a sexual partnership, she turns to an online platform, bridging the intrapsychic, interpersonal, and cultural levels of sexual scripts.

LGBQ+ Youth Online: Information and Identity Work

Despite some overall similarities, LGBQ + and heterosexual youth differed quite a bit in their uses of online platforms. Although all youth reported initially turning to the Internet for specific sex-educational information, queer youth were more likely to do so. The LGBQ + youth we spoke to also tended to have more varied uses than the heterosexual ones (see Fig.  3 ). The latter turned mainly to sexual entertainment sites (22.9%) or large Internet forums (31.3%); the former turned less frequently to those and accessed a wider range of types of websites from micro-blogging sites (15.8%) to user-generated sites such as Wattpad (12.3%). Over time, LGBQ + youth were likely to search for information about LGBQ + identities (28%), followed by searches for information about safe sex/contraception (14%), sexual practices (13%) and information related to their own or someone else’s pleasure (15%).

In contrast to the primarily pleasure- and entertainment-driven explorations of straight youth, queer youth took to filling in knowledge gaps about non-conforming sexualities. Most significantly, they often reported using digital platforms for what scholars refer to as “identity work” (Bernstein 1997 ; Beech et al. 2008 ). This work took several, often overlapping, forms. One form of identity work came when youth, curious about an inchoate feeling of difference, discovered a sexual identity through their online explorations that they then developed in their daily lives and interactions. Another type of identity work turned to digital spaces to firm up and further develop a sexual identity that was forming offline. Lastly, youth used online spaces for validation of a stigmatized sexual identity, seeking out others with similar experiences in a lower-risk online environment.

The theme of online discovery and exploration of identity, entirely absent among heterosexually-identified respondents, was common among queer ones. These identity explorations online were typically conditioned on both the absence of information about queerness in face-to-face settings and the safe anonymity of the Internet. For instance, Ana Luisa, a Latinx, cisgender lesbian, described being “scared of being looked at differently because I was curious about this stuff.” Online, people would “know me but they didn’t really know me. They didn’t see me in the halls every single day. They didn’t cook my dinner every day. So, I felt like the Internet was really the only place I could go.” Similarly, Ruby—African American, who identified as non-binary and bisexual in high school and currently identifies as non-binary and pansexual—went online at first primarily to absorb information, learning “gay vernacular” and exploring “freely and without barriers” topics that were taboo at home and not addressed in school. The Internet, they said, was like “an elder” they could turn to that neither protected them from information their family deemed dangerous nor judged. In effect, they were engaged in “an internal rehearsal” (Simon and Gagnon 1986 , 99) of their self-identities that could be imagined and fantasized without the intervention of others. Their intrapsychic scripting became a “significant part of the self-process” (Simon and Gagnon 1986 , 99) that they found difficult to explore offline or in conversation with peers, teachers or parents.

Once they began online explorations, identity shifts often evolved, whether born of accident or curiosity. Bryan, for example, whose explorations with heterosexual porn are recounted above, did not turn to online spaces to work through his sexual identity. He was “never into gay porn” as a young teenager—although he now considers that “part of the self-repressing”—and he considered himself “very straight” in high school despite a small inkling that he should be questioning his identity. Later, finding himself drawn to gay porn, he noticed TikToks on Instagram that indicated

a large community of people talking about, “Oh, I thought I was straight but then I had this experience.” And I would just scroll and scroll and scroll. After about 50 of those matched up with my experience, I started to think, “Okay, I need to start thinking about this a little more.”

Thus, his path to bisexual identity, which by college was fully formed, began with the online discovery of people whose experiences “matched up” with his own.

Like Bryan, Abby, age 20, who identifies as Latina and a cisgender woman, was questioning her sexual identity in high school, also began pursuing her curiosities online “before I realized my own identity as a queer person,” then became inspired by her reading of online fan fiction to think differently about her identity.

I was looking for representation, queer media. I was searching for media in some way that kind of represented what I was feeling. And so then I would search for media that would create that feeling in me again. Like, “Damn, I want to be them .” And that was always essentially men who are portrayed in a more feminine way.

Similarly, Sara, age 18, who identifies as Latinx and a cisgender woman, had begun wondering in her first year of high school in Puerto Rico whether she was lesbian. She happened on a thread on Twitter that was “like, ‘How to tell if you’re a lesbian versus just Sapphic in general,’” which led her to the “Lesbian Masterdoc,” a 30-page, 20-section document aimed at helping women consider the “am I a lesbian?” question. “That was a pretty big stepping stone in realizing that I was a lesbian,” they said, “because so much of it resonated, so much of it resembled what I was feeling, so much of it resembled my [offline] experiences.”

For others, identity was not so much discovered as developed and solidified online in relation to offline experiences. Michael’s path to queerness began with sexual explorations involving “watching porn for the sake of jacking off,” and also “learning about some different ways that sex could look or different forms sex could take.” Michael, who grew up in the Midwest and identifies as white, gay and a cisgender male, describes the impact of the Internet on his sexual identity as a process in which he first investigated a little bit to see “what it felt like to be looking at naked guys or whatnot,” but not as the place where he really discovered a queer identity. Instead, an actual crush on another guy moved him towards a queer identity: “Okay, I’m queer because I had this crush on this guy.” After he had already begun that movement toward a queer identity, he says, the Internet became more central to his identity as he began “seeking out and savoring the knowledge that I could get.”

Once I discovered that this is something that I could be, that’s when it opens up these things of exploring who I am. And after having this affirmation that I had these feelings for a guy, that’s when I have permission to be myself to be exploring what that means for me. What I find useful is just being, “Oh, there are possibilities for how I can be.” And seeing what feels good, seeing what feels good to imagine, and to hear people tell stories about things and to learn about things that I might want or that might feel good for me that I haven’t come across in my [offline] life…. Learning about my identity and what feels rich to me, what feels titillating to me, I think is still more what comes from the Internet, reading and hearing other people’s perspectives and whatnot.

Indeed, the discovery or confirmation of new possible identities was also often accompanied by the pursuit of their positive affirmation. Ruby described how “the Internet really exposed me to queerness in a way that was helpful for me to develop my own identity.” While they first turned to online sources to fill in gaps in their knowledge of sexuality, as time went on and their identity shifted, Ruby began to wonder, “What will happen if I come out as queer?” Like many respondents, Ruby turned to online platforms for possible answers, seeking out sites that affirmed that gay and lesbian life could be happy rather than tragic. Watching queer movies online, Ruby said,

there was always a bit of a tragedy to the gay romance. It’s like, all right, is this movie going to let this gay person live and be happy or are they going to die because they’ve been outed. That’s what I was looking to know: Will I perish if I come out and can I live happily ever after?

As they delved deeper, Ruby found themself gravitating to gay, non-binary, and trans YouTubers who “kind of led me through my self-discovery as like non-binary and pansexual.” Unlike the school, family, and peer spaces of their everyday life, the Internet was “a safe space to explore that for myself.” In college, these identity explorations became the basis for a crystallized identity as openly non-binary and pansexual. Like for many respondents, online sexual identity (and sometimes also gender identity) explorations—driven first by the absence of adult information sources about queerness and also often the pursuit of pleasure—took place over a long period of time, eventually becoming the basis for the claiming of a different identity in everyday life offline.

Operating at a time and place where sexuality is in many ways “post-paradigmatic,” with fewer shared meanings, the cultural scenario emerging from schooling has lost many of its “coercive powers” (Simon and Gagnon 1986 , 102–103). In the face of an endless and easily accessed world of online sexual content, along with its own significant institutional constraints, school-based sex education clearly has a greatly diminished role as a controlled source of information (Lindberg et al. 2016 ). School- based sex education, our research once again confirms, provides some students with a narrow swath of knowledge on a limited range of topics, typically related to biological reproduction, the avoidance of pregnancy and sexually transmitted infections, with very little on sex or sexual identity. For many of our respondents, this information was not just too little but also too late, as sexual activity and talk was part of the school culture, and some were already involved in sexual activity. Even those who were sexually curious but not active lacked strong memories of sex education, as they reported that most of the topics they were interested in, such as masturbation or other sexual practices, were simply not addressed. Such perceptions of deficient education existed even in “comprehensive” sex ed settings, where the emphasis was broader than abstinence and disease. Online sexual explorations, on the other hand, were wide-ranging and uncontrolled, often accessed in isolation and without adult guidance, and put to quite divergent uses by youth of different sexual identities.

Just as the experience of sexual learning itself tends to be bifurcated, existing research tends to focus on either school-based sex education or on the “intersection of sexuality and digital space” (Adams-Santos 2020 , 1; Waskul 2014 ); our research highlights the dynamic interaction between formal school curriculum, informal online sexual learning, and sexual identities and practices.

First, as its role as an information source is further diminished, sex education gains significance in a different way: The very absences of information about sexual pleasure and sexual identity further propels youth to seek information elsewhere. Our interviewees rarely talked to their parents about sexual activity, reporting that sex was a taboo topic. Similar to findings from research Elliott ( 2012 ) conducted with parents, our respondents believed that their parents did not recognize them as sexual beings; schools did not go much further. In this context, digital platforms were a place to get answers, without judgment or exposure, to pretty much any sexual question or curiosity, even when they did not know exactly what they were looking for. Online explorations felt exciting as they pieced together information not otherwise available to them, and a place in which youth experienced agency, arming themselves with information lacking in sex ed and in the home, and often countering the framings found in school and at home (abstinence, danger, heteronormativity, and the like). Nearly all the online information, they reported, was new – an indicator, again, that the vacuum left by school-based sex education is an important push towards the digital space.

Second, the push to and pull of the Internet accentuates an ambivalent relationship to the sources of sexual knowledge and how to assess their reliability, particularly as youth are simultaneously operating in at least two very different arenas of authority. Our respondents often reported having been uncertain about the accuracy and reliability of information sources, and looked for ways to triangulate and substantiate online sources; despite a certain eye-rolling skepticism about school-based sex education, they generally assumed that their teachers were reliable authorities, and rarely described a concern about substantiating school-based information. Information learned online was often shared with peers, and tested out practically in relationships. Youth were likely to share websites or make suggestions to friends from the sites they frequented, such as how to make a dental dam out of a condom, use lubricants, or locate erogenous zones even as they also often articulated concerns that the online pornography they consumed gave them a distorted view of sexual activities, bodies, and pleasures. The controlled information from school was seen as reliable but often without much value; the uncontrolled information from online spaces was seen as valuable but often suspect, sometimes even scary.

Third, we have seen a destabilization of the relatively rigid conventional cultural scripts contained in school-based sex ed curricula, displaced by the multifarious and messy cultural scripts circulating within online platforms. The former left little room for identity play and exploration, or for the elaboration of alternative sexual scripts at the interpersonal and intrapsychic levels. Our respondents, particularly those who are LGBQ + -identified, were regularly and actively engaged in identity work and interpersonal re-scripting facilitated by a decentralized, multi-platformed online environment in which no single set of sexual scripts prevails.

Finally, as one set of scholars put it simply, “Sexuality education is exclusive of young people of different sexual and gender orientations, and this exclusion can have various negative impacts” (Gowen and Winges-Yanez 2014 , 799). Much more therefore seems to be riding on self-generated online sexual learning for LGBQ + youth than for others, given the privileging of heteronormative identities in sex education and in school settings more generally, where queer students participated in what one respondent called a “code of silence” regarding queer identification or questioning. In the “post-paradigmatic” context, LGBQ + youth in particular seek not just information but new shared meanings, often improvising interpersonal scripts such that their identities can be made “congruent with desired expectations” (Simon and Gagnon 1986 , 99). One impact, though not an entirely negative one, is LGBQ + youths’ heavy reliance on the Internet for sexual knowledge, identity work, and community not supported in schools. While the classroom was not a safe environment in which students could discuss their discomfort with a heteronormative lens—and often the assumption of heterosexuality—online space was quite the opposite. For many, their digital communities, whether fleeting or more lasting, became critical support. Having found queer community online, the lack of queer community in school became even more evident. The Internet provided an unparalleled source of affirmation and identification that queer interviewees did not find in schools, homes, or local communities.

Our findings are suggestive and, given the data limitations, not nearly the end of the story. Certainly, the need “for relevant and inclusive information on sexual health” (Gowen and Winges-Yanez 2014 , 799), particularly for LGBTQ + youth, is plain; other have suggested, for instance, “directly discussing LGBTQ issues, emphasizing sexually transmitted infection (STI) prevention over pregnancy prevention, and addressing healthy relationships” (Gowen and Winges-Yanez 2014 , 788). One particular gap that future research might seek to fill is the unique sexuality education experiences of transgender and non-binary youth, which may or may not parallel those of LGBQ + youth, and their unique needs. Our research also offers a view on how sexual identity needs affect the consumption of school-based sex education, including how it is remembered—the relative invisibility and exclusion of LGBQ + youth means that the few moments of visibility and inclusion in school curricula carry outsized impact—as well as driving much of the online activity of LGBQ + youth. Future research could usefully develop this line of inquiry.

In the end, our findings shed a different kind of light on the common critiques and calls for reform that contemporary US sex education regularly and rightly receives. For all of their importance, political debates over sex education in schools (Luker 2006 ), and political fights for school board control, may be less relevant for those seeking to understand and advocate for the sexual wellbeing of youth than they appear. Given the institutional constraints on school-based sex education, its role as a driver towards online sexual exploration is likely to continue; in democratic political settings, the digital space will continue serving as a primary setting for sexual learning. Unless schools are willing and institutionally able to recognize and tap into the dynamic interaction between sex education, online sexual explorations, and offline relationships, their role as relevant sources of sexual learning is likely to continue to recede.

Change history

06 december 2023.

A Correction to this paper has been published: https://doi.org/10.1007/s11133-023-09554-6

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Acknowledgements

We are very grateful to our research team, who substantially contributed to the design, interviewing and coding for this article, as well as providing input on drafts of the paper: Nathaly Andrade, Juliana Juarbe, Genesis Vasquez, and Ella Warburg. We also want to acknowledge Ella Warburg for assistance in creating the Figures presented in this paper. We appreciate the support of the Knapp Center at Wellesley College, which in 2020-21 provided funding for research assistance; and the College or Arts & Sciences Dean’s Office at the University of San Francisco, which supported interview transcription.

Open access funding provided by SCELC, Statewide California Electronic Library Consortium

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Gamson, J., Hertz, R. “But Everything Else, I Learned Online”: School-Based and Internet-Based Sexual Learning Experiences of Heterosexual and LGBQ + Youth. Qual Sociol 46 , 461–485 (2023). https://doi.org/10.1007/s11133-023-09550-w

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Three Decades of Research: The Case for Comprehensive Sex Education

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Purpose: School-based sex education plays a vital role in the sexual health and well-being of young people. Little is known, however, about the effectiveness of efforts beyond pregnancy and sexually transmitted disease prevention. The authors conducted a systematic literature review of three decades of research on school-based programs to find evidence for the effectiveness of comprehensive sex education. Methods: Researchers searched the ERIC, PsycINFO, and MEDLINE. The research team identified papers meeting the systematic literature review criteria. Of 8,058 relevant articles, 218 met specific review criteria. More than 80% focused solely on pregnancy and disease prevention and were excluded, leaving 39. In the next phase, researchers expanded criteria to studies outside the U.S. to identify evidence reflecting the full range of topic areas. Eighty articles constituted the final review. Results: Outcomes include appreciation of sexual diversity, dating and intimate partner violence prevention, development of healthy relationships, prevention of child sex abuse, improved social/emotional learning, and increased media literacy. Substantial evidence supports sex education beginning in elementary school, that is scaffolded and of longer duration, as well as LGBTQ–inclusive education across the school curriculum and a social justice approach to healthy sexuality. Conclusions: Review of the literature of the past three decades provides strong support for comprehensive sex education across a range of topics and grade levels. Results provide evidence for the effectiveness of approaches that address a broad definition of sexual health and take positive, affirming, inclusive approaches to human sexuality. Findings strengthen justification for the widespread adoption of the National Sex Education Standards.

• National Sex Education Standards
• National Sexuality Education Standards
• Sex education
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T1 - Three Decades of Research

T2 - The Case for Comprehensive Sex Education

AU - Goldfarb, Eva S.

AU - Lieberman, Lisa D.

N1 - Publisher Copyright: © 2020 Society for Adolescent Health and Medicine Copyright: Copyright 2020 Elsevier B.V., All rights reserved.

PY - 2021/1

Y1 - 2021/1

N2 - Purpose: School-based sex education plays a vital role in the sexual health and well-being of young people. Little is known, however, about the effectiveness of efforts beyond pregnancy and sexually transmitted disease prevention. The authors conducted a systematic literature review of three decades of research on school-based programs to find evidence for the effectiveness of comprehensive sex education. Methods: Researchers searched the ERIC, PsycINFO, and MEDLINE. The research team identified papers meeting the systematic literature review criteria. Of 8,058 relevant articles, 218 met specific review criteria. More than 80% focused solely on pregnancy and disease prevention and were excluded, leaving 39. In the next phase, researchers expanded criteria to studies outside the U.S. to identify evidence reflecting the full range of topic areas. Eighty articles constituted the final review. Results: Outcomes include appreciation of sexual diversity, dating and intimate partner violence prevention, development of healthy relationships, prevention of child sex abuse, improved social/emotional learning, and increased media literacy. Substantial evidence supports sex education beginning in elementary school, that is scaffolded and of longer duration, as well as LGBTQ–inclusive education across the school curriculum and a social justice approach to healthy sexuality. Conclusions: Review of the literature of the past three decades provides strong support for comprehensive sex education across a range of topics and grade levels. Results provide evidence for the effectiveness of approaches that address a broad definition of sexual health and take positive, affirming, inclusive approaches to human sexuality. Findings strengthen justification for the widespread adoption of the National Sex Education Standards.

AB - Purpose: School-based sex education plays a vital role in the sexual health and well-being of young people. Little is known, however, about the effectiveness of efforts beyond pregnancy and sexually transmitted disease prevention. The authors conducted a systematic literature review of three decades of research on school-based programs to find evidence for the effectiveness of comprehensive sex education. Methods: Researchers searched the ERIC, PsycINFO, and MEDLINE. The research team identified papers meeting the systematic literature review criteria. Of 8,058 relevant articles, 218 met specific review criteria. More than 80% focused solely on pregnancy and disease prevention and were excluded, leaving 39. In the next phase, researchers expanded criteria to studies outside the U.S. to identify evidence reflecting the full range of topic areas. Eighty articles constituted the final review. Results: Outcomes include appreciation of sexual diversity, dating and intimate partner violence prevention, development of healthy relationships, prevention of child sex abuse, improved social/emotional learning, and increased media literacy. Substantial evidence supports sex education beginning in elementary school, that is scaffolded and of longer duration, as well as LGBTQ–inclusive education across the school curriculum and a social justice approach to healthy sexuality. Conclusions: Review of the literature of the past three decades provides strong support for comprehensive sex education across a range of topics and grade levels. Results provide evidence for the effectiveness of approaches that address a broad definition of sexual health and take positive, affirming, inclusive approaches to human sexuality. Findings strengthen justification for the widespread adoption of the National Sex Education Standards.

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Three Decades of Research: The Case for Comprehensive Sex Education

Affiliations.

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

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

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

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

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

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

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

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• Sex Education*
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• Sexually Transmitted Diseases*

Sex Education that Goes Beyond Sex

• Posted November 28, 2018
• By Grace Tatter

Historically, the measure of a good sex education program has been in the numbers: marked decreases in the rates of sexually transmitted diseases, teen pregnancies, and pregnancy-related drop-outs. But, increasingly, researchers, educators, and advocates are emphasizing that sex ed should focus on more than physical health. Sex education, they say, should also be about relationships.

Giving students a foundation in relationship-building and centering the notion of care for others can enhance wellbeing and pave the way for healthy intimacy in the future, experts say. It can prevent or counter gender stereotyping and bias. And it could minimize instances of sexual harassment and assault in middle and high school — instances that may range from cyberbullying and stalking to unwanted touching and nonconsensual sex. A recent study from Columbia University's Sexual Health Initative to Foster Transformation (SHIFT) project suggests that comprehensive sex education protects students from sexual assault even after high school.

If students become more well-practiced in thinking about caring for one another, they’ll be less likely to commit — and be less vulnerable to — sexual violence, according to this new approach to sex ed. And they’ll be better prepared to engage in and support one another in relationships, romantic and otherwise, going forward. 

Giving students a foundation in relationship-building can enhance wellbeing and pave the way for healthy intimacy in the future, experts say. It can also prevent or counter gender stereotyping, and it could minimize instances of sexual harassment and assault in middle and high school.

Introducing Ethics Into Sex Ed

Diving into a conversation even tangentially related to sex with a group of 20 or so high school students isn’t easy. Renee Randazzo helped researcher Sharon Lamb pilot the Sexual Ethics and Caring Curriculum while a graduate student at the University of Massachusetts Boston. She recalls boys snickering during discussions about pornography and objectification. At first, it was hard for students to be vulnerable.

But the idea behind the curriculum is that tough conversations are worth having. Simply teaching students how to ask for consent isn’t enough, says Lamb, a professor of counseling psychology at UMass Boston, who has been researching the intersection between caring relationships, sex, and education for decades. Students also to have understand why consent is important and think about consent in a variety of contexts. At the heart of that understanding are questions about human morality, how we relate to one another, and what we owe to one another. In other words, ethics.

“When I looked at what sex ed was doing, it wasn’t only a problem that kids weren’t getting the right facts,” Lamb says. “It was a problem that they weren’t getting the sex education that would make them treat others in a caring and just way.”

She became aware that when schools were talking about consent — if they were at all — it was in terms of self-protection. The message was: Get consent so you don’t get in trouble.

But there’s more at play, Lamb insists. Students should also understand the concept of mutuality — making decisions with a partner and understanding and addressing other people’s concerns or wishes — and spend time developing their own sense of right and wrong. 

“If a young person is not in a healthy relationship, they can’t negotiate sex in a meaningful way. Even if they’re not having sex yet, they’re grappling with the idea of what a healthy relationship is.”

The curriculum she developed invites students to engage in frank discussions about topics like objectification in the media and sexting. If a woman is shamed for being in a sexy video, but she consented to it, does she deserve the criticism? Regardless of what you think, can you justify your position?

“How do they want to treat people, what kind of partner do they want to be? That takes discussion,” Lamb says. “It’s not a skill-training thing.”

The idea behind the curriculum isn’t that anything goes, so long as students can discuss their reasoning. Instead, the goal is that students develop the critical-reasoning skills to do the right thing in tricky situations. 

After Randazzo’s students got over their cases of the giggles, the conversations were eye-opening, she says. “You give them the opportunity unpack their ideas and form their own opinions,” she says.

Healthy Relationships — and Prevention

Most sexual assault and violence in schools is committed by people who know their victims — they’re either dating, friends, or classmates. Regardless, they have a relationship of some sort, which is why a focus on relationships and empathy is crucial to reducing violence and preparing students for more meaningful lives.

And while it might seem uncomfortable to move beyond the cut-and-dried facts of contraception into the murkier waters of relationships, students are hungry for it. A survey by researchers at the Harvard Graduate School of Education's  Making Caring Common  initiative found that 65 percent of young-adult respondents wished they had talked about relationships at school.

“It’s so critical that kids are able to undertake this work of learning to love somebody else,” says developmental psychologist Richard Weissbourd , the director of Making Caring Common and lead author of a groundbreaking report called The Talk: How Adults Can Promote Young People’s Healthy Relationships and Prevent Misogyny and Sexual Harassment . “They’re not going to be able to do it unless we get them on the road and are willing to engage in thoughtful conversations.”

Nicole Daley works with OneLove , a nonprofit focused on teen violence prevention. She previously worked extensively with Boston Public Schools on violence prevention. She echoes Lamb and Weissbourd: A focus on relationships is key to keeping students safe.

“If a young person is not in a healthy relationship, they can’t negotiate sex in a meaningful way,” she says. “Really discussing healthy relationships and building that foundation is important. Even if they’re not having sex yet, they’re grappling with the idea of what healthy relationship is.”

And it’s critical to start that work before college.

Shael Norris spent the first two decades of her career focusing on college campuses, but now is focused on younger students with her work through Safe BAE . By college, many people’s ideas about how to act when it comes to sex or romance are entrenched, she says. The earlier young people can start interrogating what they know about sex and relationships, the better.

Safe BAE is led by Norris and young survivors of sexual assault. The organization works to educate students about healthy relationships, sexual violence, students’ rights under Title IX, and other related topics.

Movement to change middle and high school curricula to include a focus on healthy relationships and consent has been slow, Norris notes. In 2015, Senators Tim Kaine (D-Va.) and Claire McCaskill (D-Mo.) introduced the Teach Safe Relationships Act, which would have mandated secondary schools teach about safe relationships, including asking for consent, in health education courses. It didn’t go anywhere. And while eight states now mandate some sort of sexual consent education , there’s no consensus about what that should entail.

Instead, the momentum for a more comprehensive sexual education that considers relationships and violence prevention is coming from individual teachers, students and parents.

“We don’t have to wait for politicians to start having conversations about this,” Norris says.

A New Approach to Sex Ed

• Develop an ethical approach to sex ed. Place emphasis on helping students learn how to care for and support one another. This will reduce the chance they’ll commit, or be vulnerable to, sexual violence.
• Don’t just tell students how to ask for consent; prompt them to consider why concepts like consent are important. It’s not just about staying out of legal trouble — it’s also about respecting and caring for others.
• Respect students’ intelligence and engage them in discussions about who they want to be as people. Serious dialogue about complicated topics will hone their critical-thinking skills and help them be prepared to do the right thing.
• Even without access to a curriculum, students, parents and educators can work together to facilitate conversations around sexual violence prevention through clubs, with help from organizations like Safe BAE.

Additional Resource

• National Sexuality Education Standards: Core Content and Skills, K–12

Part of a special series about preventing sexual harassment at school.  Read the whole series .

Illustration by Wilhelmina Peragine

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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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A qualitative assessment of the sexual-health education, training and service needs of young adults in Tehran

Narges sheikhansari.

1 Medical School, University of Exeter, Exeter, UK

Charles Abraham

2 School of Psychology, Deakin University, Melbourne, Australia

Sarah Denford

3 Research Fellow Health Protection Research Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

Mehrdad Eftekhar

4 Chair of department of psychiatry, Director of coordination of research centers, Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran

Associated Data

Data available in article supplementary material : The detailed data that supports the findings of the thematic analyses are available in the supplementary material of this article.

Sexual Health and Relationships Education (SHRE) provides individuals with knowledge and skills to manage risky behaviors and take informed decisions to protect themselves against STIs, and unintended pregnancy. Only minimal SHRE is provided in Iranian schools and universities and previous research has highlighted needs and demands for improved SHRE and sexual services in Iran. This study explored young, Iranian adults’ experience of, and need for sexual health education, sexual skills training and sexual healthcare services, as well their views on how to augment and improve existing provision.

Design and methods

Semi-structured interviews were conducted with a sample of 25 young adults who lived in Tehran, Iran and had volunteered to participate in the study. Transcripts were analyzed using thematic analysis.

Participants explained their needs and demands for sexual health education and sexual healthcare. They unanimously expressed their dissatisfaction with available SHRE and sexual health care provision. They highlighted barriers to gaining sexual health information and seeking advice and healthcare, including a lack of reliable resources, taboo and cultural barriers, lack of trust and protected confidentiality. This has resulted in ambiguities and misconceptions, including those regarding the cause and transmission of STIs and correct use of contraceptives. Participants recommended improvements, including holding mixed-gender extracurricular workshops with a comprehensive approach to sexual health and relationships education.

Conclusions

There is a clear need and demand for provision of relevant and reliable sexual health and relationships education for young adults in Tehran. This should be addressed to empower young people to make informed choices and avoid risky sexual behavior.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11371-x.

Tehran is the most populous city in Iran with a population of 8.5 million, including approximately 1.04 million people aged 18–25. Young people in Iran complete schooling at 18 and this is the legal age at which they can get married. Approximately 500,000 students are admitted into university courses in across the 10 universities in Tehran. So almost half of 18–25-year-old Tehranians attend university [ 12 , 13 ]. There are, therefore, considerable opportunities to reach this age group with extra-curricular education and preventive services.

Sexual health and relationship education (SHRE) can provide knowledge, motivation and skills to help people to, (i) understand the potential consequences of their sexual behavior, (ii) make informed decisions about sexual relationships, (iii) more comfortably communicate about sex, sexuality and sexual health and (iv) protect themselves against sexually transmitted infections [ 1 , 8 ].

SHRE is effective and does not promote earlier sexual debut. A review of reviews incorporating 37 systematic reviews (and 224 primary trials) indicated that comprehensive school based SHRE is effective in increasing knowledge, changing attitudes, and reducing risky sexual behavior [ 8 ]. Similarly, a review of 85 SHRE interventions for young people aged 15–24, delivered in schools, community centers and health clinics in the United States of America (USA) as well as developing countries, concluded that these interventions were effective and that there was no evidence indicating that SHRE is associated with earlier or more frequent sexual encounters [ 28 ]. Ideally, SHRE should promote “a state of physical, mental and social well-being in relation to sexuality… requiring a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” (World Health Organization, n, d) [ 21 ].

SHRE has never been included in Iranian school curricula so sexual health knowledge is based on less regulated media and discussions with other young people [ 15 ]. Consequently, young adults can have poor sexual health knowledge [ 18 , 23 ]. Many universities including those in Tehran, offer a single SHRE module (“Science of Family and Population”) which is a 20-h course taught by a lecturer specializing in religious and spiritual studies [ 14 ]. This module targets heterosexual people and does not include information relating to many elements of SHRE considered important by the World Health Organization (WHO) such as sexual consent, prevention of sexually transmitted infections, correct use of available contraception options and safer sexual practices across sexual orientations [ 29 ]. There are also pre-marriage classes teaching similar content and are compulsory for people getting married [ 19 ]. However, it is unclear how often such courses are run.

Free condoms are provided to sex workers and drug users in Tehran [ 17 ]. Other citizens can purchase contraceptives, including condoms, from pharmacies. However, because healthcare is predominantly privatized, such purchases are considered costly by middle class citizens and, especially by working class citizens, including young people. Thus, condoms can be purchased but the cost can be prohibitive [ 3 ]. There are a limited number of clinics across Tehran, referred to as “Centers for Behavioral Diseases”, that offer free and confidential testing for sexually transmitted infections (STIs) [ 2 , 11 ]. However, these facilities are not publicly advertised and are used primarily by “high risk” groups such as drug users and sex workers, so attendance tends to be stigmatized.

A series of insightful studies have highlighted a need and demand, for, SHRE in Iran. For example, Shahhosseini and Hamzegardeshi [ 27 ] interviewed 77 young women, aged 11–19 and concluded that there is a strong demand for SHRE and that, in its absence from school curricula, young adults have turned to unreliable internet sources. Mosavi, Babazadeh, Mirzaii Najmabadi & Shariati [ 22 ] drew similar conclusions, based on interviews with adolescent girls and their mothers. These authors highlighted a lack of knowledge regarding sexual health, ease of access to unreliable and inaccurate information through the Internet, and evidence of increased risky, sexual behavior patterns among adolescents.

Mahmodi and Valiee [ 16 ] and Rahmati Najarkolaei, Niknami, Aminshokravi & Tavafian, [ 26 ] designed and delivered sexual health and STIs awareness programs aimed at Muslim women and university students, respectively. These studies recruited small and unrepresentative samples (60 married Muslim women and 109 female law or literature students at the University of Tehran, respectively) and used only pre-post-evaluations. The results are, nonetheless, encouraging because participants who completed these programs showed significant improvements in knowledge about HIV/STIs, although we do not know if this translated into changes to their sexual health protection.

Despite these encouraging findings, there is a lack of research into what exactly young Iranians know about sex and sexual health and what they want and need in terms of SHRE and sexual services. Moreover, research to date has not applied theoretically driven analyses to identify particular gaps in knowledge, motivation and skills which might be expected to shape population-level behavior patterns and could identify key SHRE targets. Such theoretical analysis could clarify exactly how improved services could impact perceptions, attitudes, motivations and behaviors relevant to improved sexual health among young people in Iran.

The Information-Motivation Behavioral skills model (IMB [ 9 ];), proposes that people need to be well informed, motivated and to have prerequisite skills to successfully change behavior patterns. The model was developed as a framework to improve interventions designed to promote HIV-preventive behavior and can be used to identify key targets for health promotion including, for example, accurate risk assessments, positive attitudes towards performing preventive actions, the perception that important others’ (e.g., partners)’ approve of protective actions and self-efficacy and skills relevant to protective actions. The model has been applied in the design and evaluation of effective HIV-preventive behavior [ 10 ].

The present study

We aimed to clarify sexual health needs of young Tehranians by conducting needs-assessment interviews with young Tehranians, as recommended by the Intervention Mapping framework, [ 1 , 4 ].

Applying the IMB, we sought to understand what these young people know, the cognitive bases of their motivation, what skills and training they might need and what services they valued and wanted. We defined four research aims.

• To assess young people’s sexual health knowledge, and to identify their sources of sexual health information and available advice, as well as their recommended sources.
• To explore young people’s beliefs, attitudes, norms and motivations in relation to sexual health protection.
• To investigate the availability and accessibility of sexual health services for these young people.
• To explore what additional sexual health services would be most valued by this group.

Semi-structured, face-to-face interviews were conducted in person with 18–25-year-old Tehranians in a convenient location in Greater Tehran with one interviewer and one interviewee present. Participation was voluntary, and no incentives were provided to these key informants. Interviews took approximately 45 min and were conducted by the first author; a female doctoral candidate who has received training for interviewing young adults on sexual health. No relationship was established between the interviewer and the interviewees prior to interviews. The research was conducted in accordance with the Standards for Reporting Qualitative Research [ 24 ]. The study, and all data collection procedures, were approved by ethics committees of The University of Exeter Medical School and Iran University of Medical Sciences.

Sampling and data collection

Convenience sampling involved placing advertisements in health clinics and university health centers in Tehran. Interested people were asked to contact the research team and were provided with a participant information sheet. Those who consented to participate were given details of the interview time and location by telephone. Interviews were conducted in quiet, private rooms in a hospital or university setting most convenient to the participant. Interviewees were made aware that they could withdraw at any time without giving a reason. Verbal consent (rather than written consent) was obtained from every participant to protect the interviewees’ anonymity. All participants consented to interviews being recorded and for quotations to be reported anonymously.

The semi-structured topic guide is provided as document 1 in Supplementary Materials . The guide included questions on (1) sexual health knowledge (2) perception of personal knowledge (3) content of any sexual health education (4) source of sexual and sexual health information (5) confidence in preventing STIs and protecting oneself in sexual relationships and (6) perceived accessibility of sexual healthcare and contraceptives. The topic guide was developed in accordance with the research questions and was pilot tested on 5 young adults. Interviews were conducted in Persian except for one, in which the interviewee requested use of English. Recorded interviews were transcribed verbatim, anonymized and translated, where necessary.

Participants

One hundred and forty-five people responded to recruitment advertisements, of whom, 60 met the inclusion criteria of being Iranian and aged 18–25, speaking Persian as a first language and living in Greater Tehran. Thirty-five people declined to be interviewed when contacted or were not available during the data collection period. Twenty-five young women ( N  = 18) and men ( N  = 7) from various educational backgrounds, including those with high school diplomas (4), Bachelors degrees (13) and Masters degrees (8) were interviewed. Participants were from mixed socioeconomic backgrounds (high Income (9), middle Income (4) and lower Income (12). They identified as agnostic (11), atheist (1), theist (only believing in God) (10) and religious (identifying with a religion, including Islam and Christianity) (3). They were 18–25 years old, with the mean age of 23.

Data analysis

NVivo was used to store transcripts and allocate excerpts to categories. A thematic analysis was conducted employing guidelines provided by Braun & Clark (2006) [ 7 ]. This involved 6 stages of analysis applied to anonymized interview transcripts. These included (1) establishing familiarity with the data (reading, re-reading and note taking) and (2) generating initial category definitions (sketching definitions and identifying content examples and recurring categories). Step 3 involved a more systematic search for themes and overlapping/corresponding content categories (checking if emerging definitions are applicable across interviews or are too general/specific). During step 4 the emergent categories were reviewed (checking that defined categories are distinct and correspond to multiple examples from interviews). Steps 3–5 involved multiple meetings between the first three authors to critically discuss each of the category definitions, the differences between categories and the appropriateness of each excerpt allocation to the category definition. The fifth step was to finalize the category definitions and the conceptual tree to which they belonged. Finally, interviews were re-read to ensure selection of all excerpts were relevant to the final category definitions and the results report written, was illustrative of the category tree, category definitions and the overall coding of transcripts [ 6 ].

To ensure validity, two researchers coded five interviews separately and reviewed themes. Many meetings were held in which the first three authors discussed transcript excerpts and identified appropriate thematic definitions. This resulted in collaborative interpretation and validation of textual categorization and facilitated detailed consideration of any differences of interpretation. The final themes and sub-themes were defined and reviewed by the first three researchers who discussed all selected quotes and their thematic allocations. The results of this coding are provided in document 2 of the Supplementary materials . The first author recorded reflective notes during data collection and revisited these through data analysis to ascertain inclusion and explanation of details expressed by participants.

Thematic analyses generated 12 themes, incorporating 32 sub-themes which are listed in document 2 in the Supplementary Materials . In total, 505 quotations were extracted from 25 interviews. Table  1 lists the main themes and numbers of quotations allocated to each theme. Approximately 80% of the interview transcript text was extracted as relevant quotations. All participants contributed multiple quotations across themes. Documents 3 and 4 provide the thematic map and all extracted quotations by theme and sub theme in the supplementary materials , respectively. These data show recurring content across interviews. It was notable that, in later interviews, little semantic refinement of the emerging thematic structure was added, suggesting that data saturation had been achieved. We concluded data collection after 25 interviews.

12 Main Themes

Below we present a subset of illustrative quotations that highlight the core meaning of the 12 themes and highlight sub-thematic structure. We recorded demographic data including age, socioeconomic status and self-expressed religious beliefs, but we did not find differences in themes attributable to these individual characteristics.

Theme 1 sexual health knowledge and perceptions of personal understanding

Most participants expressed a good knowledge of sexual organs and could name and describe male and female sexual organs, in contrast to their knowledge of STIs, symptoms and transmission methods. Although HIV and HPV were named, their symptoms and transmission methods were often unclear. Other STIs were sometimes named but again there was a lack of understanding of transmission routes (sub-theme 1i and 1ii).

Participants reflected on their level of sexual health knowledge compared to their peers. These assessments were categorized as similar to others (sub-theme 1iii), not as good as others (1iv) or superior to others (1v). While a few felt they knew more, most felt their level of knowledge was equal to their peers. Interviewees also noted that socioeconomic deprivation was likely to be associated with less sexual health knowledge (1vi).

Theme 2. Used and recommended sources of sexual health information

The lack of official SHRE is likely to encourage self-education. Interviewees highlighted various sources of sexual health information and sources of sexual health information they would recommend to their friends. These overlapped considerably.

Six source categories were identified as sub-themes. The internet and social media (2i) were the most used and recommended sources of information. Interviewees mentioned popular social media apps like Instagram and Telegram along with Google as their source of sexual health information. By contrast, parents (2ii) were criticized for not discussing sexual health, although participants accepted that discussing sex was a taboo in their culture. Perhaps worryingly, pornography was identified as a learning tool by some male and female participants; with potential harms and informational benefits highlighted.

Porn really did help me, because there wasn ’ t anything else that would show everything as real as it was. It helped me to see, understand and discover things. However, watching porn is not healthy as it might make you have unrealistic expectations from yourself or your partner.

A few participants mentioned books (2iv) as a source of sexual health information, including general knowledge books (e.g., encyclopedias).

Some participants described their own sexual experiences as key learning opportunities (2v), and many trusted their friends’ descriptions and advice. Contrary to normative expectations, we found that some young women, but not men, mentioned experimenting with sexual relationships, in order to learn more about sex. Finally, although “doctors” were recommended as a useful source of information our interviewees did not report learning form this source (2vi).

Theme 3. Availability and quality / content of sexual health education

Interviewees highlighted the very limited sexual health education provided in school, university and / or pre-marriage classes.

We’ve never had an official sex education class.

I ’ ve learned everything I know through experience. No one has taught me anything.

Theme 4. Understanding and negotiation of sexual relationships

Interviewees discussed how young adults would manage sexual relationships. Quotes were categorized into four sub-themes (4i) Familiarity implies health in sexual partners, (4ii) Confidence and power in managing sexual relationships and (4iii) Communication in Sexual Relationships. These often highlight confidence in managing relationships despite lack of formal SHRE and developed self-management and behavioral skills.

I usually try to talk about these kind of stuff before starting any relationship and would tell him about what I want before sex.

[Young people are] rarely … concerned about STIs because they trust their partners and believe that they haven ’ t been with unhealthy people.

Theme 5. Concerns about sexually transmitted infections (STIs)

Participants explained their concerns about STIs including (5i) Ambiguity and lack of education on STIs, (5ii) Invisibility of STIs, (5iii) Fear and worry about STIs and (5iv) Perception of other groups’ lack of concern. Some were not concerned because of their perceived skills while others expressed quite serious fears about STIs. Many interviewees acknowledged lack of reliable information and STIs invisibility as reasons for misconceptions and, at times, poor motivation to prevent STIs.

We haven’t been educated for it and this can be as harmful as the diseases itself. We don’t consider STIs [to be] serious diseases.

The fact that you can hide your STI from others makes them not to be concerned about.

Theme 6. Concerns about pregnancy

Interviewees were more concerned about pregnancy than STIs, because pregnancy was visible and could lead to more serious life consequences. This was attributed to (6i) Fear and worry about pregnancy outside marriage and (6ii) Visibility of pregnancy leading to social and personal issues, especially because sex outside of marriage is not legal in Iran.

I remember that it was around 1 or 2 years ago that we were in a gathering and one of my closest friends came by and she was like 100% sure that [she was] pregnant and we were all scared as hell, not because of the pregnancy itself but because of the consequences …

Theme 7. Contraception and condoms

Condoms were the most frequently mentioned contraception method with only a few participants identifying contraceptive pills as their preferred option. Interviewees discussed (7i) Condom availability and accessibility, (7ii) Condom cost, (7iii) Quality of Iranian condoms (7iv), Ease of condom use and (7v) Inconsistent use.

[Condoms are] accessible everywhere. You can find them in both pharmacies and supermarkets. Therefore, the accessibility and availability are good.

In my opinion you ’ re better off not using condoms because you might be risking with a low quality one, maybe this way you would pull out because you don ’ t have that trust.

I think they are expensive. … For foreign condoms as imports are getting more complicated due to sanctions the prices are getting higher so they are more expensive.

Theme 8. Barriers to using sexual health services

Although there are government-funded sexual health centers in Tehran, our participants were not aware of them or how to access them. Participants also identified barriers in approaching doctors, including (8i) Cost of visiting doctors and sexual health care, and (8ii) Trust in doctors.

I don’t know any sexual health clinics in Tehran … part of [the problem] is the lack of information on where to go, who to trust and spend … money on.

I have so many questions … and I can’t afford to visit a doctor to ask them.

Interviewees reported reluctance to discuss their private lives, even when seeking advice or medical attention because they feared that these issues will be shared with their families or even law enforcement officials. Better relationships between young people and medical professionals might be facilitated by youth-friendly clinics in which confidentiality was explicitly guaranteed.

“ We are scared to tell the doctor about our issues, for example to tell them we’ve had sex out of marriage and they would let our families know about it. I ’ m absolutely terrified about that”

Further personal and social barriers to seeking sexual healthcare in Tehran, include (8iv) Embarrassment as a barrier to sexual protection, (9v) Taboo shame and social disapproval as barriers, (9vi) Health motivation, and (9vii) Denial / fear.

Some people are embarrassed to go and ask for condoms in a pharmacy because it ’ s usually out of hand reach and you should ask someone to give it to you. If it ’ s a lady selling it, it ’ s even worse for men, they would be even more embarrassed.

Theme 9. Sexual prohibition

Consistent with the identification of fear of social judgement as a barrier to seeking sexual health care, participants acknowledged that existing laws support social and cultural norms that portray sex as shameful or unacceptable for unmarried people and sanctify virginity in women.

I know girls who give in to any form of sexual relationship other than the vaginal intercourse only to protect their virginity, it’s a huge concern for so many people to the extent they put themselves in painful positions to please the guy … to stay virgin.

Theme 10. Socioeconomic sexual health inequalities in Tehran

Interviewees highlighted socioeconomic inequalities in sexual health, highlighting that citizens from lower socioeconomic backgrounds face challenges in accessing and paying for sexual healthcare and contraception methods.

And poor areas don’t have much of a choice, both with doctors, contraceptives and condoms.

Theme 11. Gender power inequalities in sexual relationships

Women interviewees indicated that they could not control heterosexual sexual encounters, including condom use, highlighting power inequalities and prioritization of male partners’ preferences; even when these young women were highly motivated to avoid STIs and pregnancy.

There is this need to please guys in girls, and they tend to agree with whatever guys tell them, like not using condoms or having rough sex. I ’ ve seen this in my friends ’ relationships.

Theme 12. Recommendations for improved sexual health education and services

All participants thought SHRE provision necessary and believed sexual health education would have optimal results if started from an early age. They suggested subjects such as contraception and condom use, sexual organs, pregnancy and relationship management skills to be included in short courses or workshops. Participants had varying opinions on the gender mix and delivery method of such programs.

It should be started from the beginning of elementary school with teaching about sexual organs, then they should carry it on with sexual health in middle school.

In my opinion it would be better for the classes to be mixed gender, so that we all benefit from it equally.

To our knowledge, this is the first qualitative assessment exploring sexual health education, training and service provision needs of 18–25-year-olds living in Tehran.

Participants expressed their demand for SHRE and shared recommendations for a potential intervention. Twelve themes and 32 sub-themes were identified from our thematic analyses of 25 interviews. These highlighted the demand for, and lack of SHRE, and provided in depth insight to existing sexual healthcare provision and needs. Interviewees also shared their understanding of SHRE and elaborated their unofficial sources of information. The interviews illustrated the negative consequences of poor SHRE, in a lack of understanding of sexual relationships, STIs and contraceptives and illustrated how inadequate knowledge influences sexual behavior.

We found that poor sexual health knowledge has caused misconceptions, and young adults have turned to unreliable sources, including their friends and social media, to find answers. This can deepen misconceptions and ambiguities regarding the threat, cause and treatment of STIs, the effectiveness of contraception methods, and the importance of consistent condom use. These findings correspond to those of Bostani Khalesi et al. [ 5 ].

Moreover, young adults deemed the quality and content of existing SHRE programs insufficient and ineffective and provided recommendations on ways to improve or augment current provision, which indicated their need and demand for comprehensive SHRE and mirrors the conclusions of Pourmarzi et al. [ 25 ].

Interviewees were unaware of existing government-funded sexual healthcare clinics and deemed visits to private doctors as limited by cost. They were concerned about confidentiality of their private information and the potential damage to their social image, even in conversations with doctors. Cultural barriers such as sexual prohibition and associated taboo and shame also discouraged visits to doctors.

Overall, the findings suggest a need for improved, well-advertised, accessible, confidential and reasonably priced sexual healthcare. Additionally, introduction of policies supporting patient confidentiality and pre-marriage sexual relationships would facilitate the removal of mistrust in current government-funded sexual healthcare services. Currently, contraceptives and condoms are not available for free, and long-acting reversible contraception (LARC) methods are only accessible through expensive, private clinics.

The information and skills foundation needed for effective STIs and pregnancy prevention was found to be underdeveloped in these young people. Interviewees acknowledged inconsistent condom use and, especially young women shared problems in negotiating protection. We concur with Mirzaee et al. [ 20 ] that such findings highlight a need for healthy, mutual relationship and sexual relations education and training for young Iranians. Our findings indicate that this should include, basic biology of STIs transmission, self-management skills (e.g., setting goals and priorities), relationship management skills and protection skills, including condom-acquisition, negotiation and use skills. Given the widespread use of internet sources, the creation of online training materials in Persian seems like an obvious first step to bridging this educational gap. This would also allow self-selection of short courses according to the needs of the users.

Young women expressed their lack of empowerment in managing sexual relationships, emphasizing the need for materials particularly addressing these issues. Our findings also suggest that presentations by young Iranians, similar to the target audience for such SHRE classes could optimize trust.

Our findings represent a novel needs assessment generating recommendations for improvement of health services and health education. Nonetheless, there are limitations to this research. We used a small sample and the applicability of our findings to other groups, including those who live in suburbs of Tehran, remains unclear. In addition, our sample may reflect selection bias because those who agreed to be interviewed may have been more confident, than average, in their sexual health knowledge and skills. Moreover, since the interviewees appeared to be predominantly heterosexual, our findings may not adequately reflect the needs, demands and experiences of individuals with other sexual orientations and preferences.

A large-scale quantitative study with quotas set for respondent types could generate a more representative portrayal, including participants from diverse socioeconomic and sexual backgrounds and those with special requirements (e.g., those with physical disabilities and learning difficulties and physical, limiting conditions). Such large-scale work could underpin tailored versions of SHRE and service provision for identified sub-groups. We found no discernible patterns, indicating differences in views across educational, socioeconomic and religious backgrounds, perhaps due to the almost universal reliance on internet and social media sources.

Notwithstanding these limitations, our study presents insights and recommendations for the development of sexual health services and education for young people in Tehran and provides a good basis for developing and testing preliminary materials, incorporating learning from international developments. Additionally, our findings could provide guidance to policy makers about service and educational gaps that could prompt revision of SHRE and sexual healthcare provision for young Iranians, as recommended above. It would be interesting to explore young people’s reflections and recommendations in relation to service provision with policy makers and health care practitioners.

C onclusions

In conclusion, sexual health knowledge is poor amongst young Tehranians and they do not perceive sexual healthcare as available and accessible. Young adults want comprehensive SHRE to understand and manage sexual health risks and conduct their sexual relationships safely. They requested non-judgmental, confidential, accessible, and reasonably priced sexual healthcare. This study (including findings reported in the supplementary document ) highlights the problems young Tehranians face daily in managing their sexual health. These findings provide a blueprint for sexual health educational and service enhancement that would meet these needs.

Acknowledgements

We would like to thank young adults who participated in this study.

Abbreviations

Authors’ contributions.

NS conceived of the study, carried out recruitment, data collection, data analysis and drafted the manuscript. CA co-created the study design and development with NS, and participated in its design, analysis and coordination and co-wrote the manuscript. SD participated in the design and data analysis and commented on the manuscript. ME provided local support and cooperated with the recruitment and coordination of the study. All authors read and approved the final manuscript.

This study was part of a self-funded PhD project and has not received external funding.

Availability of data and materials

Declarations.

Interviewees were made aware that they could withdraw at any time without giving a reason. Verbal consent (rather than written consent) was obtained from every participant to protect the interviewees’ anonymity. All participants consented to interviews being recorded and for quotations to be reported anonymously. They provided their verbal consent for their anonymous comments to be used following an audio-recorded interview. This was provided before the interviews were conducted. Details of consent questions are provided in document 1 of the supplementary materials . This procedure was approved by ethics committees of The University of Exeter Medical School and the Iran University of Medical Sciences, as stated in the Methods section of the manuscript.

Not Applicable.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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• 01 May 2024

Why it’s essential to study sex and gender, even as tensions rise

You have full access to this article via your institution.

In 2023, students protested against a new policy in Texas, where parents would be notified if their child asks to be identified as transgender. Credit: Brett Coomer/Houston Chronicle/Getty

This week, Nature is launching a collection of opinion articles on sex and gender in research. Further articles will be published in the coming months. The series will highlight the necessity and challenges of studying a topic that is both hugely under-researched and, increasingly, the focus of arguments worldwide — many of which are neither healthy nor constructive.

Some scientists have been warned off studying sex differences by colleagues. Others, who are already working on sex or gender-related topics, are hesitant to publish their views. Such a climate of fear and reticence serves no one. To find a way forward we need more knowledge, not less.

Collection: Sex and gender in science

Nearly 20 researchers from diverse fields, including neuroscience, psychology, immunology and cancer, have contributed to the series, which provides a snapshot of where scholars studying sex and gender are aligned — and where they are not. In time, we hope this collection will help to shape research, and provide a reference point for moderating often-intemperate debates.

In practice, people use sex and gender to mean different things. But researchers studying animals typically use sex to refer to male and female individuals , as defined by various anatomical and other biological features. In studies involving humans, participants are generally asked to identify their own sex and/or gender category. Here, gender usually encompasses social and environmental factors , including gender roles, expectations and identity.

For as long as scientific inquiry has existed, people have mainly studied men or male animals. Even as recently as 2009, only 26% of studies using animals included both female and male individuals, according to a review of 10 fields in the biological sciences 1 . This bias has had serious consequences. Between 1997 and 2000, for instance, eight prescription drugs were removed from the US market, because clinical testing had not revealed women’s greater risk of developing health problems after taking the drugs.

Male–female comparisons are powerful in biomedical research — don’t abandon them

The tide, however, is turning. Many journals, including those in the Nature Portfolio , and funders, such as the US National Institutes of Health, have developed guidelines and mandates to encourage scientists to consider sex and, where appropriate, gender in their work.

These efforts are reaping benefits 2 . Studies, for example, are showing that a person’s sex and/or gender can influence their risk of disease and chances of survival when it comes to many common causes of death — including cardiovascular conditions and cancer.

Despite this, many researchers remain unconvinced that the inclusion of sex and gender information is important in their field. Others, who are already doing so, have told Nature that they’re afraid of how their work is perceived and of how it could be misunderstood, or misused.

Podcast: Sex and gender discussions don't need to be toxic

Because researchers who are exploring the effects of sex and gender come from many disciplines, there will be disagreements. An often-raised and valid concern, for example, is that when researchers compare responses between female and male animals, or between men and women, they exclude those whose sex and/or gender doesn’t fall into a binary categorization scheme. Another is that variability between individuals of the same sex could be more important than that between sexes.

Sometimes sense does seem to get lost in the debates. That the term sex refers to a lot of interacting factors, which are not fully understood, does not invalidate its usefulness as a concept 3 . That some people misinterpret and misuse findings concerning differences between sexes, particularly in relation to the human brain, should not mean denying that any differences exist.

Tempering the debate

Many of the questions being raised, however, are important to ask, especially given concerns about how best to investigate biological differences between groups of humans , and the continued — and, in some regions, worsening — marginalization of people whose sex and/or gender identity doesn’t fall into narrowly defined norms. Often, such questions and concerns can be addressed through research. For example, studies might find that variability between individuals of the same sex in diet, or body weight, say, are more important predictors of how likely they are to develop anaemia than whether they are male or female.

We need more-nuanced approaches to exploring sex and gender in research

The problem, then is not the discussions alone: science exists to examine and interrogate disagreements. Rather, the problem is that debates — and work on sex and gender, in general — are being used to polarize opinions about gender identity. As Arthur Arnold, a biologist at the University of California, Los Angeles, and his colleagues describe in their Comment article , last September, legislation banning gender-affirming medical care for people under 18 years old was introduced in Texas on the basis of claims that everyone belongs to one of two gender groups, and that this reality is settled by science. It isn’t. Scientists are reluctant to study sex and gender, not just because of concerns about the complexity and costs of the research, but also because of current tensions.

But it is crucial that scholars do not refrain from considering the effects of sex and gender if such analyses are relevant to their field. Improved knowledge will help to resolve concerns and allow a scholarly consensus to be reached, where possible. Where disagreements persist, our hope is that Nature ’s collection of opinion articles will equip researchers with the tools needed to help them persuade others that going back to assuming that male individuals represent everyone is no longer an option.

Nature 629 , 7-8 (2024)

doi: https://doi.org/10.1038/d41586-024-01207-0

Beery, A. K. & Zucker, I. Neurosci. Biobehav. Rev. 35 , 565–572 (2011).

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Velocci, B. Cell 187 , 1343–1346 (2024).

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Menstrual health isn’t part of California sex education. Why that needs to change

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Guest Commentary written by

Sriya Srinivasan

Sriya Srinivasan is a high school student based in Solano County. She’s also a member of Advocates for Youth’s Young Womxn of Color for Reproductive Justice Leadership Council.

When I was 12, I lost my period. Though I’d attended sex education classes in middle school, nobody taught me what a period was, how to regulate one, how to care for one and, especially, how to notice irregularities and when or how to seek medical care.

Many young people don’t have a parent, guardian or trusted adult they can ask. I turned to online sources, where I encountered misinformation that only increased my anxiety. Disreputable health websites told me I could have cancer or a terminal disease. It took months before a doctor finally helped identify the treatable underlying health issue causing my irregular menstrual cycle.

I could have avoided so much silent suffering and stress if I’d been taught to understand my period.

California is a progressive state with a robust sex education curriculum, but there is still a lot of work to be done to ensure young people understand our bodies. Our state isn’t alone: Nearly every state lacks curricular requirements about menstruation.

That’s an even bigger problem since young people are starting puberty earlier than previous generations.

Armed with this information about the urgent need for sex ed that includes menstruation, my peers and I at the Solano Reproductive Health Club have joined hundreds of young people across California to launch the  Know Your Period Campaign , in support of  Assembly Bill 2229 , which we wrote and introduced in partnership with Assemblymember Lori Wilson . 

Learn more about legislators mentioned in this story.

Lori Wilson

Democrat, State Assembly, District 11 (Suisun City)

The first-of-its-kind proposal would update 2016’s California Healthy Youth Act  to include age-appropriate facts about periods, giving young people the tools we need to understand our bodies and our development. It addresses period stigma, premenstrual syndrome and pain management, menstrual hygiene, disorders, irregularities and more.

As a young girl growing up in Solano County, I never thought I’d be at the Capitol asking lawmakers to pass a bill I helped draft. After passing the Assembly’s Education Committee, it’s in the Appropriations Committee’s suspense file , but we expect it to move forward.

The legislative process felt distant and murky – something I’d definitely learned about in school, but had little to do with my daily life. That all changed when I realized my state’s sex ed curriculum had failed me, and I needed to step up and become an advocate for young people like me.

This work has brought me to places I never imagined I could belong. As a 16-year-old, I can’t vote yet but I can use my voice. A few weeks ago, I joined over a hundred young women in Sacramento for an “ Ignite the Capitol ” event, where we called on our representatives to take action on the issues impacting our lives the most.

Young women and girls in California and around the country should understand that, when we advocate on issues that matter to us, it’s possible to cut through society’s divides and make progress. I know I’m young, but I’ve learned to use my voice, and now I’m calling on my peers and the adults in our lives to use theirs, too, and embrace the Know Your Period campaign.

Being a young person is isolating enough. Nobody should suffer shame, confusion or pain related to their period. That starts with education – and today, with advocacy.

Despite Newsom veto, California should still provide free condoms to public school students

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