Comprehensive Sex Education—Why Should We Care?

Let us pause for a second and recollect our childhood memories.

If we ask ourselves, how did we learn about sex and sexual behavior during the early years of our life—what would be the answer?

For most people, perhaps, the source of such knowledge and discourse was friends, peer groups, books, and social/mass media. Only a few can claim that they have been introduced to the tenets of healthy sexual life by their parents, siblings, or teachers. Rather, many feel they were uncomfortable to discuss sexual matters within their family circles in childhood and adolescence.

Sex (sexuality) education is not just the activity of offering/gaining knowledge about sex and sexuality—it’s also about understanding sexual and reproductive rights, making healthy decisions about sexual life, and attaining high standards of sexual health. It is an effective health promotion tool.1 For most formal and informal curriculums across the world, sex education covers topics like “what, when and how” about intimacy and relationships, sexual identity, gender roles, body image, sexual decision-making, sexually transmitted infections (STI), reproductive health, and contraception. According to the handbook by Campos,2 sex education is

involving a comprehensive course of action by the school, calculated to bring about the socially desirable attitudes, practices and personal conduct on the part of children and adults, that will best protect the individual as a human and the family as a social institution.

It has a far richer scope and goal of helping children incorporate sex more meaningfully into their present and future life and to provide them with some basic understanding of sex by the time they reach maturity.

Thus, it also includes ideas about sexual orientation, pleasure, values, communication, and dating.3 It is also tailored based on sociocultural contexts and age of the students for better understanding.

However, in spite of the beneficial evidence related to sex education, it is still laden with stigma, cultural constraints, and overshadowed by a stereotyped public opinion which prohibits “sex from being incorporated in school curriculum.” This is perhaps one of the reasons why families and teachers are less involved in imparting knowledge about sexuality.

Comprehensive sex education (CSE) is preferred over abstinence-only sex education for obvious reasons. CSE is much more than just “how we have babies” and “birth control”; it focuses on healthy decision-making, respect for the opposite gender, safe sex, ability to consent, and sexual rights. The United Nations Educational, Scientific and Cultural Organization (UNESCO) has published International Technical Guidance on Sexuality Education, which “advocates for quality CSE to promote health and wellbeing, respect for human rights and gender equality, and empowers children and young people to lead healthy, safe and productive lives.”4

CSE entails a curriculum-driven teaching process about the physical, cognitive, emotional, and social aspects of sexuality. The core underlying factors are well-being and dignity as well as respectful sexual and social relationships. CSE has shown to prevent gender-based violence, unwanted pregnancies, HIV and other STIs, and sexual exploitative behaviors. Based on an age-appropriate learner-centered approach, CSE highlights inclusion, respect, equality, nondiscrimination, empathy, reciprocity, and responsibility with respect to sexual practices and relationships.5

Gender-focused CSE is more effective and most impactful when integrated into school-based curriculums advocated by teachers, parents, and other youth-health services. The technical guidance is based on stories, narratives, fables, and practical scenarios based on cultural connotations which are simple yet geared toward sexual health. Psychosexual well-being is also an invariable component of CSE. A meta-analysis that compared CSE programs with abstinence-only programs found that abstinence-only programs did not reduce the likelihood of pregnancy, but rather may have increased it.6 Of special mention is its ability to reduce STIs in vulnerable areas. Fonner et al7 conducted a systematic review and meta-analysis of the existing evidence for school-based sex education interventions in low- and-middle-income countries to understand the efficacy of these services in changing HIV-related risk behaviors and knowledge. CSE adapted based on the local milieu integrated into community and school-based curricula had the maximum impact. Starkman and Rajani5 strongly argue in favor of CSE over abstinence-only programs stressing that the former is rights-sensitive and is better suited for contraception, healthy sexuality, reducing sexual assault, and disease-prevention methods. Recently, a review of “three decades of research” related to CSE identified 80 articles. Sex education beginning in elementary school with a scaffolded approach and longer duration was shown to have significant impact on prevention of child abuse, social/emotional learning, better media literacy, fostering healthy sexual relationships, and decreased intimate partner violence.8 The authors recommended national standards of CSE based on inclusion, diversity, and human rights considerations.

The United Nations Population Fund (UNFPA) recommends comprehensive sexuality education, as it enables young people to make informed decisions about their sexuality. According to UNFPA,9

It is taught over several years, introducing age-appropriate information consistent with the evolving capacities of young people. It includes scientifically accurate, curriculum-based information about human development, anatomy and pregnancy. It also includes information about contraception and sexually transmitted infections (STIs), including HIV. And it goes beyond information, to encourage confidence and improved communication skills. Curricula should also address the social issues surrounding sexuality and reproduction, including cultural norms, family life and interpersonal relationships.

CSE helps an individual gain an optimistic view of sexuality and appropriate decision-making ability focused on a life-span approach. Early years of understanding also help in emotional and sociocognitive development related to sexuality. CSE has indirectly led to reduced depression scores and better self-esteem and quality of life. Healthy relationships are promoted and discrimination related to sexual orientation is reduced through CSE.4^,5^,10

While talking about CSE, it is also imperative that sexual and gender minorities as well as older people are taken into consideration. Pro-LGBTQIA+ (Lesbian Gay Bisexual Transgender Queer Intersex Asexual) safe sex practices need to be centered around sexual orientation and gender identity. It has been shown to reduce marginalization in these communities, promote safe men-with-men sex, and reduce homophobic bullying.7^,8 This unfortunately is still stigmatized and absent in many schools today. Proponents of LGBTQIA+ sex education argue that encompassing homosexuality into the curricula would provide LGBTQIA+ students with the sexual health information they need, and help to ameliorate problems such as low self-esteem and depression that research has shown can be present in LGBTQIA+ individuals.11 A qualitative study explored experiences of 30 young gay, bisexual, and questioning men (YGBQM) with school-based sex education.12 Most of them felt that same-sex sexuality was excluded in sex education lessons and they looked up to online resources for the same. They expressed the need for creation of a YGBQM friendly website and school-based sex education curricula tailored to their needs.

An example of LGBTQIA+ inclusive curriculum is introduced by the National Sexuality Education Standards set forth by the Future of Sex Education Initiative.13 These education standards outline 7 core topics that must be addressed in sex education; one of those core topics is identity. The identity topic presents lesbian, gay, bisexual, and transgender identities as possibilities for students as they progress through life and come to understand who they are.

Similarly, the traditional unhealthy stereotype of considering older people as “asexual” is propagated as they are often “invisible” in traditional CSE curricula. Strengthening intergenerational bonds is an evidence-based approach for upholding dignity in older persons and preventing elder abuse.14 Hence, sexual rights of older persons should be considered as a vital component of their human rights.

Tradition, culture, and society have a marked impact on sexuality and sexual health. Rao et al15 while discussing about “social determinants of sexual health” in India highlight the need to empower children and adolescents through sex education. Policies, education, culture, and health systems need to be sensitized toward CSE. To quote the authors, “Viewing sexuality as a moral failing, an individual choice, a private family matter, a religious issue, a social concern or a political problem is not an option for a modern, civilized, democratic and secular country.” Sex education has the potential to help generations with awareness and utilization of their sexual rights and promoting their sexual well-being. Research in India has unfortunately been sparse in this area.16 More evidence base is needed for the effects of CSE on sexual violence and gender equity in this country. In “Adolescent sex education in India: Current perspectives,” Shajahan et al17 call for a holistic approach. Sexuality education needs to be linked to other life-skills such as decision-making, communication, negotiation, and identification of sources of help. Parents, teachers, caregivers, and other stakeholders in health and welfare services can be involved. However, the authors also caution that “public discussion of topics of a sexual nature are widely considered as taboo in Indian society, therefore acting as a barrier to delivery of adequate and effective sexual education to Indian adolescents.” The wrong attribution of sex education to promiscuity, high-risk sexual behavior, and sexual experimentation makes it a “cultural challenge” to incorporate CSE into school curricula.

Notwithstanding these traditional and conservative views of the Indian society, the climate has indeed been changing. Healthy discussion of gender equality, gender equity, reproductive/sexual rights, and HIV prevention is being increasingly accepted in the mainstream societal discourse. The existing program of family life/sex education (FLE) was proposed by the National AIDS Control Organization and the Ministry of Human Resources and Development, Government of India.17 The objectives are to develop emotionally secure children/adolescents, sound knowledge of biopsychosocial aspects of sexual behavior, and adequate awareness about reproductive rights/responsibilities. However, the program is yet to improve in the aspects of LGBTQIA+ sensitivity, debunking sexual myths, and breaking traditionalism related to these aspects. The other criticism is that the existing curriculum is “directive” and imposes beliefs/values rather than empowering the existing belief systems with authentic information. Also, in many schools, there is limited implementation of such programs. The FLE provides a great promise, but there’s a long way to go for it to become a “true and effective” CSE.

Sex education is more than dos and don’ts. It is also much more than just birth control and sexual anatomy. Sex education is essentially sensitization, respect, appreciation, and healthy implementation of one’s sexuality that promotes a healthy sexual life, sound psychosexual health, and well-being. Every stakeholder involved in the life of a child needs to be involved in imparting CSE best integrated into the school-curriculum. This may go a long way in reduced intimate partner violence, sexual crimes and violence, and gender inequality. If we envisage a world free from gender-based discrimination, the taboo related to sex education must be abolished and policymakers need to be proactive about implementing CSE in schools (at all levels), much more than just a mere mention in a document. It is a collective responsibility and if we need to make a difference, we need to act now.

In the words of Albert Einstein, “Education is not just the learning of facts, but the training of the mind to think and react.” Sexuality education is NO exception!