Sexual education, training, and advocacy: Cross-cultural comparisons progress of sexual education in formal and informal sectors

As they grow up, adolescents need and require age-appropriate and culturally sensitive sexuality education in order to provide them with the knowledge and skills that make them able to navigate safely through the critical phase of adolescence. However, many young people in many parts of the world are inadequately prepared to make proper decisions and choices. A large number of them lack the accurate knowledge and proper skills that help them adopt safe and healthy lifestyles and sexual practices.

Findings from a desk review of a number of sexuality education programs across the globe indicate that there has been persistent and wide debate around this issue in many communities around the globe. The controversy is mainly due to socio-cultural sensitivity or lack of political will.

The Arab World has distinctive conservative trends and attitudes dictated by deeply engraved cultural beliefs. For centuries, the issue of sexuality has been considered a taboo, shameful, “haram”, and sore issue. It is not to be discussed in public, with young people, and in the media. This attitude is adopted by all members of the community whether policy-makers or the public. Consequently, many young Arabs are kept in the dark and do not receive accurate information that would help protect them and make them able to make responsible decisions and choices

Certain actions are suggested to be taken during the design and implementation of the sexual education programs that could ease out the sensitivities around the issue, make them more appealing to all stakeholders, and ensure that no one is left behind.

Sexual education: Are we reading on the same page?

Some researchers and programmatic officers in the Arab World and some other developing countries may have limited acquaintance with the merits and format of the domain of sex education. We have not also reached a consensus and understanding of its scope and limits that could be applicable and appropriate to our cultural norms. For those living in a country where sex education is formally taught to young people, they can easily obtain these details as it is well documented. Parents get a fully detailed curriculum and they are aware and informed about what their children learn.

We should also accept another fact. We, as Arabs, are different in many ways from other communities. So are our almost 80 million adolescents. We have our own identity and should be proud of that. Our conservative traditions and culture impose a peculiar way of life, regardless of religion. These societal norms are usually protective, but in certain ways may constitute challenges. In many parts of our own world, sex is a taboo issue and cannot be discussed in public. It is Ayb (shameful). Sex should only be practiced within the frame of sanctioned marriage. Girls are required to keep their “hymen” intact until the wedding night. Losing virginity is a grave issue for girls and a disgrace for their families.

Most policymakers, many community leaders, and the media in almost all Arab countries do not currently tolerate the term “sex education”. Once, this word is mentioned; it will be the end of the conversation. The meaning, the idea, and the thought are absolutely rejected without discussion or explanation. This is also another fact that needs to be fully understood by all program designers, developers, and managers in the region where political and community support is fundamental to the success of any developmental initiatives.

However, is the term “sex education” all about “teaching doing it”? This meaning is usually what comes to the minds of many people in our region once the term is mentioned. The Arabic translation of “sex education” denotes such meaning. This misunderstanding is the core of the problem. However, the term “reproductive health education” sounds more acceptable, covers a larger scope, and usually responds to all that our young people need to know. It can be tailored to any particular cultural norms.

If we actually look at what our young people want to know and need to know, we will definitely develop an educational curriculum that is completely different from what is being taught in liberal countries. Working with young people in Egypt for almost 20 years helped us reach this understanding. Moreover, the curriculum will never be utilized if it does not follow and observe our societal norms and cultural beliefs.

Using the term “reproductive health education” has proved to be universally accepted in Egypt and helped us conduct a national school-based initiative for many years.

Sex education across the globe: Persona non grata

Sex education is also a controversial issue in other parts of the world. The content and principles that form the basis of this education have also changed over time and differ widely across the countries of Europe, the USA, and the rest of the world.

The term itself has evolved over the years; family life education, sex education, sexuality education, and finally Comprehensive Sexuality Education (CSE). Moreover, there is still no agreement on common standards of sexuality education across Europe and the different States of America.

The World Health Organization (WHO) has not committed to a universal definition for sex education and recommends that SRH education be provided within the context of school programs and activities that promote health [1].The United Nations Population Fund (UNFPA) on the other hand, is extremely interested in promoting comprehensive sexuality education all over the globe and strongly believes that it enables young people to make informed decisions about their sexuality, enabling them to protect their health, well-being and dignity. UNFPA defines CSE as: “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. It goes beyond information, to encourage confidence and improve communication skills. Curricula should address the social issues surrounding sexuality and reproduction, including cultural norms, family life, and interpersonal relationships” [2]. Many other organizations are strongly backing CSE either worldwide or in the USA. The list includes the International Planned Parenthood Federation (IPPF), Sexuality Information and Education Council of the US (SIECUS), Advocates for Youth, Guttmacher Institute, and American Civil Liberties Union (ACLU) [3].

For the last 50 years, battles have raged between conservatives and health advocates over the contents and format of sexuality education in public schools in the USA and the debate is still going on. The first wave of opposition took the form of attacks aimed at barring any form of sex education in schools. Sex education programs were described by the Christian Crusade and other conservative groups as “smut” and “raw sex” [4]. The John Birch Society termed the effort to teach about sexuality “a filthy Communist plot”. Phyllis Schlafly, leader of the far-right Eagle Forum, argued that sexuality education resulted in an increase in sexual activity among teens. Other opponents include the American Family Association, Concerned Women of America, Eagle Forum, Heritage Foundation, and Medical Institute of Sexual Health [5].

At present, only 24 states in the USA require that schools provide sexuality education, and 33 states require instruction about sexually transmitted diseases and/or HIV/AIDS [6].

Moreover, in some schools, teachers of sexuality education are prohibited from mentioning topics such as intercourse, masturbation, abortion, homosexuality, or condoms. Only five percent of American students receive truly comprehensive sexuality education [7].

By contrast, sexuality education is mandatory by law in nearly all the countries of the European Union. Nordic countries (Denmark, Finland, Greenland, Iceland, Norway, and Sweden) as well as Belgium, Netherlands, and Luxembourg are known for having the highest quality of sexuality education, while Eastern and Southern European States have deficient or inexistent sexuality education programs. In Austria, parents are included in the sexuality education lessons. In Denmark, external “experts” such as prostitutes, homosexuals, or HIV-positive persons are invited to speak in schools about their experiences. Sexuality education begins in the Netherlands at the age of four. However, in Poland, sexuality is taboo at school as well as at home. In Spain, the subject is hardly ever taught in schools in rural areas. France and Germany provide their students with well-designed sex education lessons [8].

Sex education is a controversial topic on the Chinese mainland and is almost nonexistent [9]. Many schools avoid the issue completely. Instead, students are taught only the basic anatomical differences between males and females [10]. Some sex educators, frustrated at the lack of official action, are taking it upon themselves to spread the message via apps and social media such as Buzz and Bloom launched in 2015. A recent series of primary school textbooks about sex has triggered debate and parents’ anger on the Chinese mainland over what sort of content is appropriate to teach the subject to children. The explicit series, called Cherish Life, is published by Beijing Normal University and intended for children aged from six to 12 [11].

In India, the second most populous country which is fast becoming one of the world’s superpowers, sex education remains a taboo topic in most areas in the country [12]. In his “vision” document for Delhi schools in 2014, the Indian Minister of Health said, “So-called ‘sex education’ should be banned.” However, there are growing numbers of supporters.

Russian students currently do not receive any sex education in schools and it seems that they will not be getting it for some time. The immediate-past Russian Children’s Rights Commissioner stated in 2015 that: “Russian school children will never receive sex education classes.” He added that introducing such classes would go against the country’s morals and traditions. “I am often asked: when will you have sex education? I say never “[13].

Going back to our Arab world; gifted with almost 80 million adolescents, very few of them have the opportunity to get reproductive health information that they direly need and have the right to obtain. These young people are even different from their peers living in more liberal societies. They have to follow and adopt conservative societal norms. They are usually caught between biology and traditions. Although these factors are protective; they impose obligations to provide supportive reproductive health care. Providing these young people with accurate information and emphatic counseling constitutes a fundamental need.

However, such service is seldom available to young Arab people. Tunisia and Algeria may be considered an exception to a certain degree as sexuality education has been provided there for some years in public schools. Similar efforts to introduce a form of sex education in school curriculum has been exerted recently in Bahrain. In Lebanon, the battle to introduce a “conservative” form of sex education in school curricula has been going on for years. In Egypt, the 17 million young people in public schools receive little information about their reproductive health and usually have no other reliable source of such information. Some non-governmental organizations conduct extra-curricular reproductive health activities that are highly valued by students and teachers.

Listening to young people in Egypt

Egypt has the largest cohort of young people in the Arab world. The Central Agency for Public Mobilization and Statistics (CAPMAS) estimates that there were 26.6 million Egyptians aged 10 to 24 years in the year 2017 constituting 27.6% of the total population [14].

Like any other emerging adults, Egyptian adolescents and youth need and are required to be provided with sexual and reproductive health knowledge and skills that would respond to their questions and concerns and make them able to make well-informed and responsible decisions and choices. Reproductive health awareness has a profound impact on acquiring healthy attitudes and practices needed to protect from illness and risky behaviors.

Several studies [15] and field observations [16] have concluded that young Egyptians have limited access to accurate sexual and reproductive health information. These young people are kept in the dark. Parents are usually not able or willing to provide such information. Many of them do not even have the time to do so. Young people receive very limited SRH education through the formal school system. Current school curricula contain only one lesson about human reproduction within the science book for grade 8th. The lesson is usually skipped by the teachers who are either unprepared or unwilling to discuss it in classes and ask students to read it at home or discuss it with their parents. The information in this lesson is never tested in any examination. Public media has no interest in providing health education; physicians or organizations willing to do so on the National Egyptian Television must pay for the airtime. There are recent efforts to allocate free time to messages targeting national issues such as the population problem and Hepatitis. Young Egyptians are left to seek information from their peers and the internet. What they get is not always right and is often misleading [17].

Efforts to provide young Egyptians with SRH information started in the year 1995 following the International Conference of Population and Development (ICPD) held in Cairo. A number of national and international organizations started several small-scale initiatives either in schools or in rural areas. The Egyptian Family Health Society (EFHS) was the leading organization in providing reproductive health awareness rallies for university students all over the country. The program started in 1999 and was maintained until 2015. The program covered almost all universities and reached more than 65000 students. The rallies concentrated on issues of interest for those preparing to get married. Sufficient time was allocated to respond to written questions from the audience. This seemed to be the most interesting part of the rallies as it covered a larger scope of issues reflecting the real interest of the students, their concerns, and misinformation. The questions touched on many sensitive issues such as masturbation, virginity, and reproduction. Senior university staff attending the rallies never objected that the trainer would respond to these “sensitive” questions.

EFHS has also conducted a national school-based health education project. This ambitious project was implemented during the period 2009 to 2016 and covered schools in 22 Governorates. During these years, well-trained young physicians; both males and females conducted a series of seminars to groups of students from preparatory and secondary schools (12 years - 18 years old). The interactive and participatory seminars covered general and reproductive health issues and allocated enough time to respond to questions. A pretest used to be conducted at the beginning of the series of seminars and repeated at the end of the last seminar so as to evaluate the impact on knowledge. The project managed to reach more than 450,000 students during these 7 years.

The Society evaluated its program at the end of the 2010 - 2011 school year. The study involved a sample of almost 7,000 students (nearly half female) who attended the seminars held during that period. The evaluation showed a clear initial deficiency in knowledge of SRH among the studied adolescents and also a marked improvement after they attended the seminars. The boys answered 28% of questions correctly before the training and 76% correctly after the seminars. The girls scored 35% before the training and 80% after. Both boys and girls had numerous misconceptions. Before the training, for example, 76% of male students believed that acne is a result of sexual frustration, while 73% of girls thought that the hymen is formed at the time of puberty and 85% believed that menstrual blood is “rotten” blood released from the body every month. To probe beliefs and attitudes, 25 focus group discussions were held with 161 students—some had attended the education sessions and some had not—and 45 parents. The students who had attended the seminars remembered most of the topics discussed and reported that they had been interested and attentive. “We were attentive because we were listening to information we did not know anything about,” said a female student. Another female student said, “We were not shy because the female physician was nice and explained the subject well.” A boy said, “At the beginning, we took it lightly but gradually we were more serious and benefited much.” Most of those who attended thought that the seminars were very useful and needed to be offered to more students. They said that they talked to their parents, relatives, and friends about the topics discussed. They also asked that similar educational activities be conducted for their parents. Parents mentioned that they would encourage their children to attend such educational activities. “Of course, we agree that they get information from a reliable source,” said one parent. “There are certain difficult issues to be discussed by parents, it is better that they know about it from the seminars,” said another. “I do agree about sex education for boys and girls, it is protection for them,” said one mother when asked about seminar topics. Another mother said, “Topics should be suitable for their age.” Almost all students and parents agreed that physicians are more acceptable than teachers for providing such information. “Physicians know how to answer any question,” said one student. Another said, “They (physicians) present the subject in an interesting way.” However, there were mixed opinions about the best way for SRH information to be given in school, whether through seminars or as part of the school curriculum. “Seminars give us the opportunity to discuss our questions,” said one student. Another added, “If it were in the curriculum, it means studying and forgetting it after the examination.” A parent said, “Seminars should be compulsory and taught to all students” [11].

EFHS has also produced a book that contains 3650 questions received from students during the seminars. This very interesting publication entitled; “Questions of Adolescents” [13] records only the questions without any answer. It aims to highlight the topics of interest and concern of Egyptian young people and reflect the prevailing myths and misconceptions. Going through the questions in the book is exactly like “listening to these young people”.

Looking at the future

Given the current confusion and misunderstanding of labelling the process of family life education to our teens in the Arab region, it is mandatory that we develop our own vision and agenda based on the real need for such information and in consideration of our cultural values and norms. We should define precisely what information our young people need to know and what skills they should acquire. We will then be capable of developing our own program that would be acceptable and applicable.

Until that happens, it will always be presumed that the term “sex education” refers to what is happening in other more liberal communities and the debate will continue. Therefore, we may not insist on using the term “sex education” as long as it is not tolerated or accepted and will be a major barrier to providing essential information to young people. It also seems that the term is inappropriate for many nations around the globe.

Conclusion

Reflecting on the findings from the present study and on the identified gaps and realities, a number of observations and suggestions can be concluded to help enhance programs aiming at providing school-based sexual and reproductive health information at the global level.

1. We need to choose whatever title would be suitable and acceptable to describe the program;
2. The wording of the definitions set for the SRH education program needs to be clear and articulate precisely what they mean;
3. The contents of the program should be culturally appropriate and respect contextual norms.
4. Contents should be tailored to address the prevailing sexual and reproductive health problems in the targeted population and should utilize the most culturally appropriate approaches during implementation.
5. A needs assessment study should be conducted during the initial stages of program design In order to identify both the “needs” and the “wants”.
6. Parents need to be consulted during program design and should be aware of the objectives of the program and the role they have to play.
7. The educational process should ensure the allocation of adequate time and space for young people to discuss their questions and concerns. Actually, the issues that would be labelled “sensitive” may not need to be included in the contents of the program as they are usually raised by the young people themselves once they feel comfortable expressing themselves.

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2. UNFPA. Advancing Comprehensive Sexuality Education to Achieve the 2030 Agenda for Sustainable Development. 2017. https://www.unfpa.org/press/advancing-comprehensive-sexuality-education-achieve-2030-agenda-sustainable-development
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5. Sexuality Information and Education Council of the United States. State Profile. 2010. https://siecus.org/state-profiles/
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11. UNESCO and UNFPA. Implementation of Sexuality Education in Middle Schools in China. Beijing, China. 2018. https://china.unfpa.org/sites/default/files/pub-pdf/Implementation%20of%20CSE%20in%20middle%20schools%20report_final_eng.pdf
12. Uzagare A. Sex education: Important for psychological growth or overhyped. 2017. http://indiatoday.intoday.in/education/story/sex-education-importance/1/960127.html
13. BBC News. Russia: Sex education will ‘Never’ be Taught - Official - BBC News. 2014. https://www.bbc.com/news/blogs-news-from-elsewhere-30293808.
14. Arab Republic of Egypt, CAPMAS. General Census for Population, Housing and Establishments. 2017. Reference ID, EGY-CAPMAS-CENSUS-2017
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