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REVIEW article

A systematic review of the provision of sexuality education to student teachers in initial teacher education.

• 1 School of Languages, Law and Social Sciences, Technological University of Dublin, Dublin, Ireland
• 2 School of Human Development, Institute of Education, Dublin City University, Dublin, Ireland
• 3 Department of Psychology, Faculty of Science & Engineering, Maynooth University, Kildare, Ireland

Teachers, and their professional learning and development, have been identified as playing an integral role in enabling children and young people’s right to comprehensive sexuality education (CSE). The provision of sexuality education (SE) during initial teacher education (ITE) is upheld internationally, as playing a crucial role in relation to the implementation and quality of school-based SE. This systematic review reports on empirical studies published in English from 1990 to 2019. In accordance with the PRISMA guidelines, five databases were searched: ERIC, Education Research Complete, PsycINFO, Web of Science and MEDLINE. From a possible 1,153 titles and abstracts identified, 15 papers were selected for review. Findings are reported in relation to the WHO Regional Office for Europe and BZgA (2017) Training Matters: Framework of core competencies for sexuality educators . Results revealed that research on SE during ITE is limited and minimal research has focused on student teachers’ attitudes on SE. Findings indicate that SE provision received is varied and not reflective of comprehensive SE. Recommendations highlight the need for robust research to inform quality teacher professional development practices to support teachers to develop the knowledge, attitudes and skills necessary to teach comprehensive SE.

Introduction

Sexuality education.

Our understanding of sexuality education is ever evolving, and differences exist in the terminology, definitions and criteria employed across various international documentation relating to SE (cf. Iyer and Aggleton, 2015 ; European Expert Group on Sexuality Education, 2016 ). While the term comprehensive sexuality education (CSE) has, in the last decade or so, come to be widely employed ( WHO Regional Office for Europe and BZgA, 2017 ; United Nations Educational Scientific and Cultural Organisation [UNESCO], 2018 ), given its more recent common usage, for the purpose of this paper, sexuality education (SE) is the broader term employed.

An international qualitative review of studies which report on the views of students and experts/professionals working in the field of SE ( Pound et al., 2017 ) provides recommendations for effective SE provision. According to that review, effective SE provision should include: The adoption of a “sex positive,” culturally sensitive approach; education that reflects sexual and relationship diversity and challenges inequality and gender stereotyping; content on topics including consent, sexting, cyberbullying, online safety, sexual exploitation, and sexual coercion; a “whole-school” approach and provide content on life skills; non-judgmental content on contraception, safer sex, pregnancy and abortion; discussion on relationships and emotions; consideration of potentially risky sexual practices and not over-emphasize risk at the expense of positive and pleasurable aspects of sex; and the production of a curriculum in collaboration with young people. Similarly, Goldfarb and Lieberman’s (2021) systematic review provides support for the adoption of comprehensive SE that is positive, affirming, inclusive, begins early in life, is scaffolded and takes place over an extended period of time.

Teachers as Sexuality Educators

While there are a variety of sources from which students access information for SE, and diversity in respect of students expressed preferences with regards to SE sources ( Turnbull et al., 2010 ; Donaldson et al., 2013 ; Pound et al., 2016 ), the formal education system remains a significant site for universal, comprehensive, age-appropriate, effective SE. Teachers are particularly well-positioned to provide comprehensive SE and create a climate of trust and respect within the school ( World Health Organisation [WHO]/Regional Office for Europe & Federal Centre for Health Education BZgA, 2010 , 2017 ; Bourke et al., 2022 ). Qualities of the teacher and classroom environment are associated with increased knowledge of health education, including SE, for students. Murray et al. (2019) found that the teacher being certified to teach health education, having a dedicated classroom, and having attended professional development training were associated with greater student knowledge of this subject. Inadequate training, embarrassment and an inability to discuss SE topics in a non-judgmental way have been cited as explanations provided by students as to why they would not consider teachers suitable or desirable to teach SE ( Pound et al., 2017 ).

Walker et al. (2021) in their systematic review of qualitative research on teachers’ perspectives on sexuality and reproductive health (SRH) education in primary and secondary schools, reported that adequate training (pre-service and in-service) was a facilitator that positively impacted on teachers’ confidence to provide school-based SRH education. These findings highlight the importance of quality teacher professional development, commencing with initial teacher education (ITE), for the provision of comprehensive SE. Consequently, ITE has increasingly been proposed as key in addressing the global, societal challenge of ensuring the provision of high-quality SE.

Initial Teacher Education

Teacher education provides substantial affordances to respond to the opportunities and challenges presented in the area of SE ( WHO Regional Office for Europe and BZgA, 2017 ). Furthermore, a research-informed understanding of teacher education is emphasized to better support teacher educators in their work with student teachers ( Swennen and White, 2020 ).

Quality ITE provides a strong foundation for teachers’ delivery of comprehensive SE and the creation of safe and supportive school climates. Research has found that teacher professional development in SE is a significant factor associated with the subsequent implementation of school-based SE ( Ketting and Ivanova, 2018 ). A recent Ecuadorian study reported that student teachers held a relatively high level of confidence in terms of their perceived ability to implement SE and to address specific CSE topics. Furthermore, favourable attitudes toward CSE, strong self-efficacy beliefs to implement CSE, and increased confidence in the ability to implement CSE were significantly associated with positive intentions to teach CSE in the future. Insufficient mastery of CSE topics, however, may temper student teachers’ intentions to teach CSE ( Castillo Nuñez et al., 2019 ). Internationally, research suggests there is inconsistency in the provision of SE in ITE and that access to professional development in SE in ITE, and after qualification, needs substantial development ( United Nations Educational Scientific and Cultural Organisation [UNESCO] , 2009 , 2018 ; Ketting et al., 2018 ; O’Brien et al., 2020 ).

Research is thus warranted to explore aspects at the institutional, programmatic and student-teacher level at ITE to address issues regarding the provision, and barriers to SE provision during ITE. Contemporaneous to the current review, O’Brien et al. (2020) undertook a systematic review of teacher training organizations and their preparation of student teachers to teach CSE. They found that teacher training organizations are often strongly guided by national policies and their school curricula, as opposed to international guidelines. They also found that teachers are often inadequately prepared to teach CSE and that CSE provision during ITE is associated with greater self-efficacy and intent to teach CSE in schools. The importance of ITE with regards to the provision of SE cannot be underestimated. Teachers are in an optimal position to provide age-appropriate, comprehensive and developmentally relevant SE to all children and young people.

The current systematic review will assess the provision of SE to student teachers in ITE and how this relates to the relevant knowledge, attitudes and skills required of sexuality educators as proposed by the international guidelines produced by the WHO Regional Office for Europe and BZgA (2017) . The WHO Regional Office for Europe and BZgA (2017) Training Matters: Framework of core competencies for sexuality educators adopts a holistic definition of core competencies, espousing an understanding of teacher competencies as “…overarching complex action systems” and as multi-dimensional, made up of three components: attitudes, skills and knowledge ( WHO Regional Office for Europe and BZgA, 2017 , p. 20). This framework outlines a set of general competencies, together with more specific attitudes, skills and knowledge competencies for sexuality educators. Attitudes, which may be explicit or implicit, are understood as a factor pertaining to the influencing and guiding of personal behaviour. Skills are understood in terms of the abilities educators can acquire which enables them to provide high-quality education. While knowledge is understood as professional knowledge (pedagogical knowledge, content knowledge and pedagogical subject knowledge) in all relevant areas required to deliver high-quality education. Overall, the framework endorses a holistic and multi-dimensional approach which focuses on sexuality educators and the inter-related competencies, in relation to the knowledge, attitudes, and skills that they should have, or need to develop to become effective teachers of SE.

Aims and Objectives

The current study aimed to systematically review existing empirical evidence on the provision of SE for student teachers in the context of ITE.

The objectives were:

• To review the existing peer-reviewed, published literature on SE provision during ITE.

• To synthesize the research on SE provision at ITE institutional/programmatic level.

• To synthesize the research on individual level student teachers’ knowledge, attitudes, and skills in relation to SE during ITE.

Materials and Methods

The systematic review was completed in accordance with PRISMA guidelines ( Liberati et al., 2009 ). A descriptive summary and categorization of the data is reported ( Khangura et al., 2012 ).

Eligibility Criteria

Articles were included in the review subject to adherence to specific inclusion criteria. An overview of inclusion criteria is outlined in Table 1 .

Table 1. Screening and selection tool.

Information Sources

A three-reviewer process was employed. Searches were conducted in August 2019 on five databases selected for their ability to provide a focused search within the disciplines of education (ERIC and Education Research Complete), psychology (PsycINFO), and multi-disciplinary research in the disciplines of health/public health (Web of Science and MEDLINE).

Screening and Study Selection

Reviewers’ selected keywords from two domains, namely ITE and SE as outlined in Table 2 , for the searches. Search terms for each domain were combined using the Boolean search function “AND.”

Table 2. Overview of Systematic Review search terms.

Where possible, limits were applied to include articles from peer reviewed journals as outlined in Table 3 .

Table 3. Overview of database searches and limits applied.

In accordance with Boland et al. (2017) , a pilot screening of a sample of titles and abstracts were completed by two reviewers to assess the inclusion and exclusion criteria. All titles and abstracts were then screened using Abstrackr software ( Abstrackr, 2010 , accessed 2019; Wallace et al., 2010 ). A selection of abstracts were then cross checked by two reviewers. The final selection involved a three reviewer process. Duplicates and references which did not meet the eligibility criteria were removed at this stage. Full text papers of the remaining articles were obtained, where possible. All three reviewers blindly screened the texts of the remaining articles. Consensus was reached that 15 articles met the criteria for this review. Two experts in the field of SE reviewed the list of 15 articles to ensure there were no outstanding papers for consideration within the parameters of the review. No additional papers were identified.

Data Collection Process

A data extraction template was devised in accordance with Boland et al.’s (2017) recommendations. Information was collected on each study regarding: participant characteristics (data on participant gender, age, programme and institution of study, ethnicity, socio-economic status and religion were extracted, where provided); whether the studies examined programmatic input and if so the duration/extent of input; theoretical and conceptualization of SE within the programme; topics covered; whether this was a compulsory or elective programme; and whether the study addressed the WHO-BZgA competencies of knowledge, attitudes and skills of student teachers during ITE ( WHO Regional Office for Europe and BZgA, 2017 ). One lead author was contacted for the purpose of data collection and provided further information regarding their study.

Synthesis of Results

A qualitative synthesis was conducted; the purpose of which was to provide an overview of the evidence identified regarding research on the provision of SE in the ITE context. The findings of the reviewed studies were synthesized following consideration of the key learnings and recommendations from the studies and consideration of the WHO Regional Office for Europe and BZgA (2017) competencies of knowledge, attitudes, and skills necessary for the provision of SE at ITE. The WHO Regional Office for Europe and BZgA (2017) framework was selected to support the categorization and analysis of findings as it was developed by global experts in the field and is thus, an international standard for SE. While there are limitations to the use of this framework, it offered the ability to categorize and analyze findings through a multi- dimensional lens of knowledge, attitudes, and skills.

Quality Appraisal

The Mixed Methods Appraisal Tool (MMAT) ( Pluye et al., 2009 ; Hong et al., 2018 ) was used to appraise the quality of papers by two reviewers. This tool has been found to be reliable for the appraisal of qualitative, quantitative and mixed methods studies ( Pace et al., 2012 ; Taylor and Hignett, 2014 ) and has been successfully used in previous systematic reviews (e.g., McNicholl et al., 2019 ). For each paper, the appropriate study design was selected (i.e., 1. Qualitative, 2. Quantitative randomized controlled trials, 3. Quantitative non-randomized, 4. Quantitative descriptive, and 5. Mixed methods). Next, the paper was assessed using the checklist associated with the study design (see Appendix A for overview of checklist). For example, if the study was categorized as 4. Quantitative descriptive, the study was assessed against the five criteria (4.1–4.5) associated with this study design. An example of a question on the checklist includes “Are the measurements appropriate?” criteria were reported as “met,” “not met,” “cannot tell if criteria were met” or “criteria not applicable.” The results of the quality appraisal are presented in Table 4 . The same numbering as the methodological quality criteria of Hong et al.’s (2018) study was used.

Table 4. MMAT quality appraisal.*

Study Selection

Fifteen articles reporting on thirteen empirical studies were included in the review (see Figure 1 ). Harrison and Ollis (2015) and Ollis (2016) articles are derived from the same dataset, as are Sinkinson and Hughes (2008) and Sinkinson (2009) articles. Given, however, that these articles refer to unique aspects of the particular studies, they have been described and discussed as separate studies in this review. An overview of the process of screening and study selection is outlined in Figure 1 .

Figure 1. Flow diagram of systematic review process.

Study Characteristics

Six qualitative, five quantitative, and four mixed methods studies were reviewed. Where information was available, the research studies were identified as having been conducted predominantly in Australia, New Zealand, and South Africa. The studies were published between 1996 and 2016. Data was most frequently collected from one source; student teachers ( n = 10) and teacher educators/course providers ( n = 3). One study collected data from both student teachers and teacher educators/course providers ( Johnson, 2014 ). The samples size of studies varied from three to 478 participants but were generally small (eight of the studies had fewer than 90 participants: Vavrus, 2009 ; Carman et al., 2011 ; Goldman and Coleman, 2013 ; Johnson, 2014 ; Harrison and Ollis, 2015 ; Brown, 2016 ; MacEntee, 2016 ; Ollis, 2016 ).

Seven studies assessed SE educational inputs at ITE, and three conducted content analysis of content covered on SE educational input at ITE. As the studies were predominantly descriptive and explorative in design, specific outcome variables were often neither defined nor addressed. Educational input studies were classified as examples of research which assessed a particular course, module, or lecture on SE at ITE. With regards to theoretical approaches that may have informed the educational input studies reviewed, three did not report a specific theoretical approach ( Sinkinson, 2009 ; Gursimsek, 2010 ; MacEntee, 2016 ), and the remaining four reported that a critical approach was adopted ( Vavrus, 2009 ; Harrison and Ollis, 2015 ; Brown, 2016 ; Ollis, 2016 ). An overview of study characteristics are presented in Table 5 .

Table 5. Overview of characteristics of reviewed studies.

Quality Appraisal Results

An overview of the results of the MMAT are presented in Table 4 . All the papers in the review were empirical studies and therefore could be appraised using the MMAT. Predominantly the studies reviewed employed the use of qualitative methods, and of the mixed methods studies there was often an emphasis on the qualitative data. Generally, the quality of the mixed methods studies was varied with only a minority of these studies providing a rationale for the use of mixed methods and reporting on divergences between the qualitative and quantitative findings.

The rigour and quality of the qualitative research was also varied. An explicit statement of the epistemological stance adopted and detail of the analytical process were reported in a minority of studies. With regards to educational input studies, data was often collected only after the educational input was completed and thus behavioral change as a result of engagement in the educational input could not be ascertained (e.g., Harrison and Ollis, 2015 ; MacEntee, 2016 ; Ollis, 2016 ). Only one study employed a quasi-experimental design ( Gursimsek, 2010 ), and in this case a purposive sample of student teachers who did not complete the SE course was selected as the control group. Within the remaining 14 studies there were no control groups, randomization, or concealment.

Findings are reported in relation to (a) institutional/programme level and (b) individual student teacher level aligned with the World Health Organisation ( WHO Regional Office for Europe and BZgA, 2017 ) Training Matters: Framework of Core Competencies for Sexuality Educators . An awareness of the interaction of these aspects of student teachers’ development was informative in terms of structuring the findings.

The research studies reviewed predominantly focused on examining a particular educational input on SE during ITE ( Sinkinson, 2009 ; Vavrus, 2009 ; Gursimsek, 2010 ; Harrison and Ollis, 2015 ; Brown, 2016 ; MacEntee, 2016 ; Ollis, 2016 ) or investigating the SE content covered during ITE ( Rodriguez et al., 1997 ; McKay and Barrett, 1999 ; Carman et al., 2011 ). Fewer of the reviewed studies focused on student teachers’ skills to teach SE (e.g., Sinkinson, 2009 ; Vavrus, 2009 ; Harrison and Ollis, 2015 ; Goldman and Grimbeek, 2016 ; MacEntee, 2016 ) or student teachers’ attitudes regarding SE (e.g., Sinkinson and Hughes, 2008 ; Sinkinson, 2009 ; Vavrus, 2009 ; Gursimsek, 2010 ; Johnson, 2014 ; Brown, 2016 ). The findings of the studies were synthesized and categorized in relation to institutional/programmatic level or individual student teacher level. Findings which reflected responses and perceptions of student teachers were categorized as individual student teacher level. Institutional/Programme level related to studies assessing particular modules or comparing course content across programmes, and institutional level studies were categorized as studies where data was collected from multiple institutions. Individual student teacher level findings were reported in relation to the knowledge, attitudes, and skills competency areas required of sexuality educators. These competency domains, however, are not discrete entities or mutually exclusive. In taking a systemic approach, it is, therefore, acknowledged that they are dynamically interconnected, and influence and interact.

Institutional/Programme Level Findings

At a programmatic level, studies revealed variance in the type of SE provision (core/mandatory and elective), student teachers receive during ITE. May and Kundert (1996) found that coursework on SE was reported as part of a mandatory course by 66% of respondents and as part of an elective course by 14% of respondents. While McKay and Barrett (1999) reported that only 15% of the health education programmes in their study offered mandatory SE training with 26% of programmes offering an elective component. With regards to the provision of skill development and training for SE that student teachers received during ITE, Rodriguez et al. (1997) found that of a potential 169 undergraduate programmes, the majority (i.e., 72%) offered some training to student teachers in health education: A minority offered teaching methods courses in SE (i.e., 12%) and HIV/AIDS prevention education (i.e., 4%). Two of the reviewed studies also investigated programme time allocated to SE and found that time spent on SE varied from 3.6 hours ( May and Kundert, 1996 ) to between 9.6 and 36.2 hours ( McKay and Barrett, 1999 ). While at an institutional level, Carman et al. (2011) found that eight of 45 teacher training institutions did not offer any training in SE and of those that did, 62% offered mandatory, and 38% elective inputs.

Findings indicate the paucity of SE topics covered across ITE programme curricula. Rodriguez et al. (1997) reported that 90% of the courses they reviewed listed a maximum of three SE topic areas. The top three SE topics reported in terms of coverage were human development, relationships, and society and culture. Somewhat consistently, McKay and Barrett (1999) found that the topics least emphasized on courses were masturbation, sexual orientation, human sexual response, and methods of sexually transmitted disease prevention. Johnson (2014) sought to examine coverage of, what they defined as, “lesbian, gay, bisexual, transsexual and intersexual (LGBTI)” (p. 1249) issues on ITE courses and reported that of the three ITE institutions examined, none specifically reference LGBTI issues. Finally, one study reported that the provision of SE was found to be contingent on the interest and expertise of the university teacher educators ( Carman et al., 2011 ). Collectively, these findings bring to light the variance in mandatory and/or elective SE provision during ITE, as well as the diverse content covered and the role of teacher educators on its provision.

Individual Student Teacher Level Findings

Factors associated with student teachers’ attitudes regarding sexuality education topics.

Gender, geographical location, religious beliefs, and family background were identified as factors associated with student teachers’ attitudes regarding SE ( Sinkinson and Hughes, 2008 ; Gursimsek, 2010 ; Johnson, 2014 ). Attending a SE course may have positive implications for student teachers’ attitudes as Gursimsek (2010) found that students who had not attended the SE course reported more conservative and prejudiced views toward sexuality than those who had attended the SE course. Given that this was an elective course, however, it is important to consider self-selection bias regarding those who may have opted to take the course.

Student teachers in Johnson’s (2014) study reported that, through engagement in educational inputs which discussed sexuality issues in an open and inclusive way, greater awareness of student teachers’ own and others’ biases was developed. So, too, was knowledge to better understand sexuality issues. Student teachers did, however, acknowledge difficulty integrating these new learnings with their family backgrounds, and belief systems. MacEntee’s (2016) study also brought to light tensions between student teachers’ intentions to teach, and their own attitudes to SE topics and norms within schools. Since the educational input, however, none had used the participatory visual methods when teaching about HIV and AIDS during their teaching practice. Student teachers’ responses indicated that external factors made it difficult to independently continue to integrate participatory visual methods and HIV and AIDS topics into their teaching practice experiences in schools. The findings from Johnson (2014) , and MacEntee (2016) studies indicate that student teachers’ intentions and the realities of teaching subjects and using pedagogical approaches in schools do not always align.

Critical Consciousness

The WHO Regional Office for Europe and BZgA (2017) Training Matters: Framework outlines the objectives of SE, including “open-mindedness and respect for others” (p.26). Although SE courses during ITE may be student teachers’ first exposure to issues of sexual and gender equality, for example, critiques of hetero-normativity ( Vavrus, 2009 ) and introductions to critical feminist discourses ( Harrison and Ollis, 2015 ), findings from several of the studies ( Sinkinson, 2009 ; Vavrus, 2009 ; Harrison and Ollis, 2015 ), indicated that the SE programmes offered during ITE may be insufficient in developing student teachers’ critical consciousness—the ability to recognize and analyze wider social and cultural systems of inequality and the commitment to take action to address such inequalities.

Vavrus (2009) found student teachers expressed varying degrees of critical consciousness as a result of completing a multi-cultural curriculum and assignment. While Harrison and Ollis’s (2015) examination of micro-teaching lessons indicated that completion of an educational input on SE from a feminist, post-structuralist perspective did not suffice in increasing student teachers’ understanding of gender/power relations but rather brought to light the challenges of employing such a perspective. Similarly, Sinkinson (2009) reported a noticeable lack of development of criticality regarding socio-cultural perspectives of SE from the completion of an introductory health education course (2004, first year) to the completion of a specialist health education course (2006, third year). Finally, albeit difficult to generalize given the study’s small sample size, Brown (2016) reported that experiential pedagogical approaches, through inclusion of a guest speaker living with HIV, and employment of a critical, creative arts-based pedagogical strategy offered a critical lens through which student teachers moved from a position of stigmatization toward one of understanding and compassion.

Factors Associated With Student Teachers’ Skills Regarding Sexuality Education Topics

With regards to student teachers’ skills, or potential skill development during ITE, several aspects of ITE were identified as significant in relation to the acquisition of the required skills to teach SE. These included the pedagogical approaches adopted during ITE; the learning environment; opportunities for practical teaching experience, and critical self- reflection.

Pedagogical Approaches and Practical Teaching Experiences

Seven of the studies reviewed examined aspects of pedagogical approaches to teaching SE ( Rodriguez et al., 1997 ; Sinkinson and Hughes, 2008 ; Sinkinson, 2009 ; Carman et al., 2011 ; Goldman and Coleman, 2013 ; Johnson, 2014 ; Goldman and Grimbeek, 2016 ). Goldman and Coleman (2013) reported that their small sample of six student teachers indicated that they learned very little regarding knowledge and pedagogical approaches specific to SE during ITE. Sinkinson (2009) , however, found that student teachers identified co- constructivist pedagogical approaches as being important when teaching SE. Student teacher participants in MacEntee’s (2016) study indicated that the use of participatory visual methods was a novel and thought-provoking way to learn about HIV and AIDS.

Several of the studies indicated the need for opportunities for student teachers to teach and develop the skills to teach SE. Harrison and Ollis (2015) article was the sole study to report on the evaluation of the potential pedagogical skills student teachers had acquired following the completion of SE input. Their examination of micro-teaching lessons indicated the value in examining student teachers teaching of SE. Through this experience, they identified that the educational input had been insufficient in providing student teachers with the opportunity to reflect on a critical approach to gender and sexuality, and to develop the pedagogical skills to teach SE from a critical perspective.

Vavrus (2009) suggested that, given the level of fear acknowledged by student teachers around teaching SE, interventions and programmes should provide structured opportunities for student teachers to construct lesson plans that critically address gender identity and sexuality in developmentally appropriate ways. Vavrus (2009) further suggests that instruction on conducting discussions related to gender identity and sexuality, and strategies to respond to homophobic and sexist discourse should also be provided. Participants in Brown’s (2016) study similarly reported that they would have liked to have had more opportunities to familiarize themselves with facilitating visual participatory methods when teaching about SE topics such as HIV and AIDS.

Learning Environment

MacEntee’s (2016) study provides provisional support for the use of workshops in learning about HIV and AIDS. Student teachers ( Goldman and Grimbeek, 2016 ) and course providers ( Johnson, 2014 ), indicated preferences for the use of tutorial groups, small group face-to-face discussion, and case studies when teaching about SE. In both studies, these approaches were associated with creating less threatening, and more comfortable environments for student teachers to engage with topics on a personal level. Across studies, student teachers remarked that respect and acceptance of other people’s views and opinions were critical to ensure that the environment in which SE provision takes place is safe. These views are aligned with two of the overarching skills outlined by the WHO Regional Office for Europe and BZgA (2017) ; the “ability to use interactive teaching and learning approaches” and the “ability to create and maintain a safe, inclusive and enabling environment” (p. 28). In relation to assessment of SE at ITE, Goldman and Grimbeek (2016) found that student teachers had a preference for group-based assessments, independent research, and self-assessment.

Consistent with the WHO Regional Office for Europe and BZgA (2017) Training Matters: Framework of Core Competencies for Sexuality Educators , sexuality educators should “be able to use a wide range of interactive and participatory student-centered approaches” (p. 28). These findings indicate that the creation of interactive and participatory learning environments is conducive to SE at ITE level. The opportunity to engage in these types of learning environments and student teachers’ positive perceptions of these learning environments may have consequences for the classroom environment which student teachers subsequently create.

Critical Self-Reflection

The ability of sexuality educators to reflect on beliefs and values is a vital skill, according to WHO Regional Office for Europe and BZgA (2017) . The reviewed studies consistently cited the importance of self-reflection in SE provision during ITE. Vavrus (2009) found that self-reflection was critical to the development of a more understanding, and empathetic, approach to teaching. Harrison and Ollis (2015) emphasized the need to support teachers in the development of reflective practices. Ollis (2016) concluded that the opportunity for self-reflection would impact on student teachers’ intention to include pedagogies of pleasure in their practice. Johnson’s (2014) study indicated that engagement in reflection regarding the self and others, helped students to develop a better understanding of their own beliefs and assumptions. The findings from Johnson’s study, however, also show that increased opportunity for self-reflection, and exposure to critical interpretations of content, do not necessarily transfer to teaching behaviours. Gursimsek (2010) recommended the inclusion of critical self-reflection components on future SE courses as it was suggested that components would assist student teachers in clarifying their own social and sexual values, life experiences, and learning histories. This clarification then assists, and supports, maturation in terms of attitudes, beliefs, knowledge as they relate to sexuality. Collectively, these findings indicate that teaching in ITE needs to provide safe spaces for self-reflection on the part of student teachers—and honest engagement with others.

Factors Associated With Student Teachers’ Knowledge Regarding Sexuality Education Topics

Two of the reviewed studies explored the topics student teachers perceived as important for school students to learn about, and the topics they themselves would like to study during ITE. Sinkinson and Hughes (2008) found that, of the aspects of health education student teachers prioritized for school students, the most important were mental health (62%); aspects of sexuality (61.2%); and drugs and alcohol (46.8%). Mental health included “personal development, relationships, emotional health and essential skill development such as decision making” (p. 1079). Student teachers’ responses indicate that they saw personal and interpersonal topics as important aspects of health education. Goldman and Grimbeek (2016) reported that, during ITE on SE, student teachers would most prefer to have social, psychological, and developmental factors associated with student/learner puberty and sexuality addressed. Older student teachers—those in the 22–48 year-old age range—were significantly more likely than their younger student teachers to strongly rate preferences for knowledge about wider socio-cultural contextual factors.

Student Teachers’ Confidence and Comfort to Teach Sexuality Education

Four of the studies reviewed reported student teachers’ comfort and confidence in teaching SE ( Sinkinson, 2009 ; Vavrus, 2009 ; Johnson, 2014 ; Ollis, 2016 ). Student teachers in Sinkinson’s (2009) study suggested that increases in knowledge and learning about SE topics increased comfort levels and intention to teach SE. Student teachers suggested that the opportunity to listen, learn, and discuss topics in an open environment reduced their embarrassment in discussing SE issues. These opportunities increased their comfort for answering pupils’ questions, and using language that they had previously considered taboo ( Sinkinson, 2009 ). Vavrus (2009) reported that having completed the educational input on SE, all student teachers felt they would create an open and safe space for students. Some student teachers reported confidence in their ability to create content, and think of topics to cover, relating to sexuality and gender identity. Responses also indicated challenges for student teachers regarding empathy; fears on how to respond to issues of sexuality and gender identity; lack of experience; feeling unprepared; and fear of reprisal for working outside traditional norms. Cognitive dissonance between the knowledge student teachers acquired about sexuality issues during ITE, and their personal and familial belief system in Johnson’s (2014) study was associated with discomfort for student teachers. Thus, findings from Vavrus’s (2009) and Johnson’s (2014) studies indicate that, although ITE had provided student teachers with knowledge on SE topics, wider socio-cultural/systemic factors may influence student teachers’ confidence or comfort to integrate or apply this knowledge outside of the ITE context.

A lack of student teacher knowledge about SE topics, especially with regards to “non- normative” areas, such as HIV/AIDS, was reported by Brown (2016) as associated with “othering” and discomfort regarding teaching SE content. Ollis (2016) reported the discomfort student teachers’ experience with topics on sexual pleasure and observed that engagement in teaching a 20-minute lesson on a positive sexual development theme—such as pleasure—resulted in increased confidence and skill to discuss sexual pleasure, orgasm, and ethical sex. The topic of student teachers’ comfort and confidence provides a prime example of the interaction of all three competency areas; knowledge, attitudes, and skills in relation to SE. Furthermore, the findings highlight that a more systemic consideration of these competency areas and teachers’ comfort and confidence to teach SE beyond the ITE context to the lived experience of school contexts, is warranted.

Overview of Findings

This systematic review sought to investigate the empirical literature on SE provision with student teachers during ITE. Fifteen articles, reporting on thirteen studies, from predominantly Western, English-speaking contexts met the criteria for review. The findings reveal the varied nature of the provision of SE during ITE for student teachers ( Rodriguez et al., 1997 ; McKay and Barrett, 1999 ; Carman et al., 2011 ). This is consistent with the findings of O’Brien et al.’s (2020) systematic review which similarly found variability in the provision of SE for student teachers. The current reviewed studies document an examination of SE provision at institutional/programme level, and individual student teacher level. The latter studies, in the main, reflected student teachers’ experiences regarding a particular educational input on SE, and to a lesser extent related to an examination of student teachers’ general knowledge, attitudes, or skills regarding SE.

Along with the acknowledged need to provide educational input on SE in ITE, the findings reflect that SE is perceived of as more than a stand-alone curriculum subject. Recommendations from the reviewed studies in respect of educational input provide some support for a more embedded and intersectional approach to SE provision during ITE. Similarly, O’Brien et al.’s (2020) systematic review emphasized the need for greater collaboration, integration and consistency in provision of SE at ITE. ITE in SE is typically seen within the realm of student teachers who are going to qualify as health educators, however, there is a strong argument to make that all pre-service teachers require a fundamental understanding of SE. With regards to the current review, for example, Vavrus (2009) concluded that there is a need for teacher education programmes that extend curricular attention to gender identity formation and sexuality, beyond specific SE modules, as it was suggested that this will help student teachers better understand socio-cultural factors that influence their teacher identities. Harrison and Ollis (2015) acknowledged that—as student teachers may not have engaged with critical approaches to material previously and may not have been provided with adequate time to consider these interpretations of gender and power—programmes over an extended period of time and engagement with these topics across the curriculum may facilitate increased engagement and reflection on this content. The findings provide some support that more time invested in educational input programmes may be beneficial. Courses covered over a semester ( Sinkinson, 2009 ; Gursimsek, 2010 ), for example, may be more beneficial than those covered over much shorter periods ( Harrison and Ollis, 2015 ; Ollis, 2016 ).

The WHO Regional Office for Europe and BZgA (2017) states that an important pre-requisite to teaching SE is the ability and willingness of teachers to reflect on their own attitudes toward sexuality, and social norms of sexuality. Sexual Attitudes Reassessment or values clarification has been an integral part of sexology education and training since the 1990s ( Sitron and Dyson, 2009 ). Indeed, many accreditation bodies set a minimum number of hours in this process-orientated exploration as a requirement for sexology or sexuality education work ( Areskoug-Josefsson and Lindroth, 2022 ). This involves a highly personal internal exploration that is directed toward helping participants to clarify their personal values and provides opportunities for participants to explore their attitudes, values, feelings and beliefs about sexuality and how these impact on their professional interactions ( Sitron and Dyson, 2009 ). This type of input would be valuable in the ITE space. The current findings indicate that educational inputs which facilitate self-reflection and the development of critical consciousness may be particularly beneficial and necessary in supporting student teachers to teach SE. Having the space and time to engage with one’s own belief systems, and experiences, can provide student teachers with insights regarding factors that shape identity and human interaction, which are fundamental to comprehensive SE. This is an important task for teachers and previously has been identified as a gap within existing teacher education programmes ( Kincheloe, 2005 , as cited in Vavrus, 2009 ).

With regards to pedagogical approaches for teaching SE during ITE, the findings indicate that the use of tutorial groups, small group face-to-face discussions, case studies, participatory visual methods, and the inclusion of guest speakers sharing their lived experiences may create less threatening, and more comfortable, environments for student teachers to engage with SE topics on a personal level ( Johnson, 2014 ; Brown, 2016 ; Goldman and Grimbeek, 2016 ; MacEntee, 2016 ). These findings are somewhat consistent with existing evidence that supports experiential and participatory learning techniques for SE (e.g., United Nations Educational Scientific and Cultural Organisation [UNESCO], 2018 ; Begley et al., 2022 ). A lack of practical teaching experience was acknowledged by student teachers as a barrier to teaching SE topics (e.g., Vavrus, 2009 ; MacEntee, 2016 ). Given the reported ( Ollis, 2016 ), and potential ( Vavrus, 2009 ) benefits from engaging in the practice of teaching SE the inclusion of skills-based and practical teaching experience of SE or its proxy as a minimum, within the ITE context may be warranted.

There were some notable absences from the literature reviewed. Although there are examples of research in this review which refer to positive SE topics such as pleasure, sexual orientation, and gender identity, the studies in the main do not reflect an examination of topics fundamental to a CSE curriculum. Studies did not consider or examine the impact of the Internet and social media in relation to SE. Apart from May and Kundert’s (1996) study, the research did not reflect consideration of the provision of SE for students with diverse learning abilities and needs. Some studies considered correlational factors pertaining to student teachers’ attitudes regarding SE. These included gender, geographical location of upbringing ( Gursimsek, 2010 ), and student teachers’ previous school experiences of SE ( Sinkinson and Hughes, 2008 ; Vavrus, 2009 ). Overall, in the studies reviewed there was a dearth of research on student teachers’ attitudes about SE, and the inter-dependence of factors that may influence student teachers’ attitudes.

Given that this field of research is in its relative infancy, the findings which may be inferred from the educational input studies ( Sinkinson, 2009 ; Vavrus, 2009 ; Gursimsek, 2010 ; Harrison and Ollis, 2015 ; Brown, 2016 ; MacEntee, 2016 ; Ollis, 2016 ), are tentative. These studies are generally informative regarding a particular topic or educational input but tend not to shed light on student teachers’ experiences. Furthermore, the findings from Carman et al.’s (2011) and Johnson’s (2014) studies, highlight the role of teacher educators in relation to SE provision being taught during ITE. Teacher educators provide vital support and facilitate new understandings and guidance in the context of SE and teacher professional development. Consistent with O’Brien et al. (2020) , this review highlights the need to promote greater shared learning and evidence-based resources among teacher educators and ITE institutions.

Limitations

This systematic review should be considered in light of its limitations. There is inherent risk of bias across studies given that only peer reviewed articles written in English were reported on. Consequently, a wealth of potential research may have been precluded from review and the findings of the studies will pertain to and potentially reflect the experiences of those in the global north and/or a Westernized view. The exclusion of grey literature such as dissertations and theoretical papers is indicative of publication bias. The very process of selecting inclusion and exclusion criteria is subjective and may facilitate the exclusion of minority voices, or creative methodologies for conducting and or presenting research. Through the exclusion of position papers or articles that do not make reference to empirical data, important voices to this conversation may have been limited/excluded.

Findings were discussed in relation to the competencies outlined by the WHO Regional Office for Europe and BZgA (2017) . Although an international standard for SE, there are limitations to these guidelines. Our understanding of the provision of SE is continuously developing. In 2019, the Sex Information and Education Council of Canada (SIECCAN) updated their guidelines to include an emphasis on changing demographics in relation to sexual health, the need for sexual health educators to demonstrate awareness of the impact of colonialism on the sexual health and well-being of indigenous people, to recognize the impact of technology on sexual health education, to meet the needs of young people of all identities and sexual orientations, and the need to address the topic of consent within sex education. These aspects of SE are not reflected in the WHO Regional Office for Europe and BZgA (2017) guidelines, nor are they reflected in the studies reviewed. This is indicative of the dynamic and complex nature of the field of SE and specifically in ITE.

Given the design of the studies we cannot conclude that ITE experiences translate to teachers’ SE teaching practice. Some studies provided examples of the barriers student teachers can face in the translation of ITE experiences to classroom experiences (e.g., MacEntee, 2016 ). However, other than MacEntee (2016) , examples of research with both student teachers and in-service teachers were not identified nor were longitudinal studies examining the progression from ITE to classroom experiences. Notably, upon screening the abstracts, the literature tended to assess SE received by medical and health care professionals, and there were far less examples regarding research with teachers in general and as may be garnered from this systematic review, a very limited amount of research conducted with student teachers in ITE. As ITE programmes do not routinely publish their course content, there is also a chance that such professional learning and development is being provided but not being reported. Furthermore, given that research on SE within an ITE context is a relatively novel field, diverse methodological approaches have been adopted and there appears to be limited reporting of the theoretical basis informing on this work which has implications for cross-study synthesis of findings. The studies included in this systematic review, predominantly employed qualitative designs and consequently were more idiosyncratic in their selected methodological approach.

Recommendations

Drawing on the findings from the systematic review the overarching recommendation is for more quality research on teacher professional development in the context of SE during ITE. Aspects which require further research attention are outlined below.

Along with the provision of educational input on SE at ITE, an embedded and intersectional approach to SE at ITE programme-level requires further exploration. If student teachers are to meet their future school students’ SE needs, a foundational element of teacher preparation must involve actively addressing issues that are linked to teacher confidence and comfort for delivering SE. The reviewed studies broadly indicate that opportunities for critical self-reflection, practice-oriented and small-group, dialogical, inclusive and participatory pedagogical approaches may be beneficial to adopt with regards to the provision of SE during ITE, however, further robust research is required to support this.

Larger scale, multi-dimensional, integrative studies employing rigorous methodologies to assess inter alia student teachers’ knowledge, attitudes, and skills, regarding sexuality during ITE including student teachers’ knowledge, comfort, confidence and preparedness to teach sexuality are warranted. Furthermore, research which is inclusive of both student teachers’ and teacher educators’ voices, is needed.

Adoption of a systemic approach examining individual-level and contextual factors relating to SE provision during ITE is needed to develop theoretically derived, research-informed, and evidence-based SE programmes at ITE. In order to improve the provision of SE at ITE an evaluation of provision must be in place for best practice to be achieved.

ITE provision needs to adopt a holistic approach when supporting teacher development. As documented by the WHO Regional Office for Europe and BZgA (2017) guidelines, this involves supporting the development and acquisition of relevant knowledge, attitudes and skills pertaining to SE. Although ITE in SE often focuses on student teachers who will qualify as health educators, it can be argued that all pre-service teachers require a fundamental understanding of SE. Furthermore, the SE provided during ITE should be nuanced to support LGBTI students, students with special educational needs and/or from diverse racial and cultural backgrounds ( Whitten and Sethna, 2014 ; Ellis and Bentham, 2021 ; Michielsen and Brockschmidt, 2021 ). A series of indicators to assess the relevant factors pertaining to SE provision and how these indicators relate to the knowledge, attitudes, and skills required for sexuality educators would be helpful. Monitoring and evaluation of structural indicators such as the designated SE components of course programmes, whether courses are elective or core, whether practice elements are provided etc. would provide a baseline from which system change and improvements could be measured. This systematic review has provided tentative suggestions as to what may work to ensure best practice of SE during ITE. Further research is required to evaluate the outcomes associated with their implementation.

Author Contributions

AC, CM, CC, and AB were responsible for the development and design of the study and final decisions regarding the reviewed articles. AC and CM completed the initial pilot searches. AC completed the final searches and wrote the first draft of the manuscript. AC, CM, and CC reviewed the articles. AC and AB developed the data extraction template. All authors contributed to manuscript revision, read, and approved the submitted version.

This work was supported by the Irish Research Council IRC Coalesce Research Award (Strand 1E—HSE—Sexual Health and Crisis Pregnancy Programme) for the research study TEACH-RSE Teacher Professional Development and Relationships and Sexuality Education: Realizing Optimal Sexual Health and Wellbeing Across the Lifespan (Grant No. IRC COALESCE 2019/147).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords : systematic review, sexuality education, student teacher, initial teacher education, comprehensive sexuality education, sex education

Citation: Costello A, Maunsell C, Cullen C and Bourke A (2022) A Systematic Review of the Provision of Sexuality Education to Student Teachers in Initial Teacher Education. Front. Educ. 7:787966. doi: 10.3389/feduc.2022.787966

Received: 01 October 2021; Accepted: 08 February 2022; Published: 07 April 2022.

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Copyright © 2022 Costello, Maunsell, Cullen and Bourke. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Aisling Costello, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

SEX EDUCATION REVISITED: SCHOOL-BASED SEX EDUCATION

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Sex Education in the Spotlight: What Is Working? Systematic Review

Associated data.

The data presented in this study are available from the corresponding author on reasonable request.

Adolescence, a period of physical, social, cognitive and emotional development, represents a target population for sexual health promotion and education when it comes to achieving the 2030 Agenda goals for sustainable and equitable societies. The aim of this study is to provide an overview of what is known about the dissemination and effectiveness of sex education programs and thereby to inform better public policy making in this area. Methodology : We carried out a systematic review based on international scientific literature, in which only peer-reviewed papers were included. To identify reviews, we carried out an electronic search of the Cochrane Database Reviews, ERIC, Web of Science, PubMed, Medline, Scopus and PsycINFO. This paper provides a narrative review of reviews of the literature from 2015 to 2020. Results : 20 reviews met the inclusion criteria (10 in school settings, 9 using digital platforms and 1 blended learning program): they focused mainly on reducing risk behaviors (e.g., VIH/STIs and unwanted pregnancies), whilst obviating themes such as desire and pleasure, which were not included in outcome evaluations. The reviews with the lowest risk of bias are those carried out in school settings and are the ones that most question the effectiveness of sex education programs. Whilst the reviews of digital platforms and blended learning show greater effectiveness in terms of promoting sexual and reproductive health in adolescents (ASRH), they nevertheless also include greater risks of bias. Conclusion : A more rigorous assessment of the effectiveness of sexual education programs is necessary, especially regarding the opportunities offered by new technologies, which may lead to more cost-effective interventions than with in-person programs. Moreover, blended learning programs offer a promising way forward, as they combine the best of face-to-face and digital interventions, and may provide an excellent tool in the new context of the COVID-19 pandemic.

1. Introduction

Adolescence is a period of transition, growth, exploration and opportunities that the World Health Organization defines as referring to individuals between 10 years and 19 years of age [ 1 ]. During this life phase, adolescents undergo physical, psychological and sexual maturation and tend to develop an increased interest in sex and relationships, with positive relationships becoming strongly linked to sexual and reproductive health as well as overall wellbeing [ 2 ]. Sexual health is understood as a state of wellness comprising physical, emotional, mental, and social dimensions [ 3 ]: it represents one of the necessary requirements to achieve the general objective of sustainable and equitable societies in terms of the 2030 Agenda [ 4 ], which advocates the need for a sexual education that is anchored in a gender- and human rights-oriented perspective.

In high-income countries, sexual debut usually occurs during adolescence [ 5 ], though research suggests that sexual initiation is increasingly occurring at earlier ages [ 6 ]. Adolescents have to deal with the results of unhealthy sexual behaviors, including unplanned pregnancies and sexually transmitted infections [ 7 ], as well as experiences of sexual violence [ 8 , 9 ]. Adolescents are aware that they need more knowledge in order to enjoy healthy relationships [ 10 ], yet do not receive enough of the kind of information from parents or other formal sources that would allow them to develop a more positive, respectful experience of sexuality and sexual relationships [ 11 ].

Sexual education can be defined as any combination of learning experiences aimed at facilitating voluntary behavior conducive to sexual health. Sex education during adolescence has centered on the delivery of content (abstinence-only vs. comprehensive instruction) by teachers, parents, health professionals or community educators, and on the context (within school and beyond) of such delivery [ 12 ]. As regards content, the proponents of abstinence-only programs aim to help young adults avoid unintended pregnancies and sexually transmitted diseases (STDs), working on the assumption that while contraceptive use merely reduces the risk, abstinence will eliminate it entirely [ 13 ]. Nevertheless, an overwhelming majority of studies in this field have shown that programs advocating abstinence-only-until-marriage (AOUM) are neither effective in delaying sexual debut nor in changing other sexual risk behaviors [ 14 , 15 ], and participants in abstinence-only sex education programs consider that these had only a low impact in their lives [ 16 ]. On the other hand, holistic and comprehensive approaches to sex education go beyond risk behaviors and acknowledge other important aspects, as for example love, relationships, pleasure, sexuality, desire, gender diversity and rights, in accordance with internationally established guidelines [ 17 ], and with the 2030 Agenda [ 4 ]. Comprehensive Sexuality Education (CSE) “plays a central role in the preparation of young people for a safe, productive, fulfilling life” (p. 12) [ 17 ] and adolescents who receive comprehensive sex education are more likely to delay their sexual debut, as well as to use contraception during sexual initiation [ 18 ]. Comprehensive sexual education initiatives thereby promote sexual health in a way that involves not only the biological aspects of sexuality but also its psychological and emotional aspects, allowing young people to have enjoyable and safe sexual experiences.

With regard to context, sexual education may occur in different settings. School settings are key sites for implementing sexual education and for promoting adolescent sexual health [ 19 ], but today internet is becoming an increasingly important source of information and advice on these topics [ 20 ]. Access to the internet by adolescents is almost universal in high-income countries. The ubiquity and accessibility of digital platforms result in adolescents spending a great deal of time on the internet, and the search for information is the primary purpose of health-related internet use [ 21 ]. At the same time, this widespread use of technology by young people offers interesting possibilities for sexual health education programs, given the ease of access, availability, low cost, and the possibility of participating remotely [ 22 ]. The topics that young people search for online include information on everyday health-related issues, physical well-being and sexual health [ 23 ]. The majority of internet users of all ages in the US (80%) search online for health information including sexual health information [ 24 ], and among adolescents social media platforms are the most frequent means of obtaining information about health, especially regarding sexuality [ 25 ].

Thanks to the ubiquity and popularity of technologies, digital media interventions for sexual education offer a promising way forward, both via the internet (eHealth) and via mobile phones (mHealth, a specific way of promoting eHealth), given the privacy and anonymity they afford, especially for young people. Digital interventions in school—both inside and outside the classroom—offer interesting possibilities, because of their greater flexibility with regard to a variety of learning needs and benefits in comparison with traditional, face-to-face interventions, and because they offer ample opportunities for customization, interactivity as well as a safe, controlled, and familiar environment for transmitting sexual health knowledge and skills [ 26 ]. As Garzón-Orjuela et al. [ 27 ] argues, contemporary adolescents’ needs are mediated by their digital and technological environment, making it important to adapt interventions in the light of these realities. Online searches for sexual health information are likely to become increasingly important for young people with diminishing access to information from schools or health care providers in the midst of the lockdowns and widespread school closures during the COVID-19 pandemic [ 28 ], with more than two million deaths and 94 million people infected around the world [ 29 ]. Specifically, blended learning programs, consisting of internet-based educational interventions complemented by face-to-face interventions, may prove a significant addition to regular secondary school sex education programs [ 30 , 31 ]. Blended learning programs can be especially helpful in promoting sexual and reproductive health in the context of the COVID-19 pandemic, which is challenging the way we have so far approached formal education, with its focus on face to face interventions, given the need, now more than ever, to “develop and disseminate online sex education curricula, and ensure the availability of both in-person and online instruction in response to school closures caused by the pandemic” [ 28 ].

The present study sets out to research the dissemination and effectiveness in different settings (school, digital and blended learning) of sex education programs that promote healthy and positive relationships and the reduction of risk behaviors, so as to make current sexual health interventions more effective [ 32 ]. Numerous researchers have carried out trials and systematic reviews so as to evaluate the effectiveness of school-based sexual health and relationship education [ 19 , 27 , 33 , 34 , 35 ], as well as that of digital platform programs [ 36 , 37 , 38 , 39 ]. However, there has not been a review that is representative of the literature as a whole. Furthermore, in the reviews that have been carried out, differing aims and inclusion criteria have led to differences in the sampling of available primary studies [ 19 ]. As Garzón-Orjuela et al. [ 27 ] asserts, the field of adolescent sex education is continuously evolving and in need of evaluation and improvement. Better assessments are necessary in order to clarify whether they offer a viable and effective strategy for influencing adolescents, especially with respect to improved ASRH behaviors. Hence, given the need for an up-to-date revision so as to consider more recent emerging evidence in this field, in this study we carry out a review of reviews that includes reviews of interventions both in school settings and via digital platforms, as well as, for the first time, those that combine both formats (blended learning).

The decision to conduct a review of reviews (RoR), assessing the quality and summarizing the findings of existing systematic reviews, rather than working directly with primary intervention studies, addresses the need to include as wide a range of topics covered within the field of sex education as possible [ 40 ]. As Schackleton et al. [ 35 ] (p. 383) point out, in order to provide overviews of research evidence that are relevant to policy making, it is important “to bring together evidence on different forms of intervention and on different outcomes because it is useful for policy makers to know what is the range of approaches previously evaluated and whether these have consistent effects across different outcomes.” Carrying out and publicly sharing reviews of reviews such as the present study constitutes one way of better providing practitioners with evidence they can then carry over into their interventions [ 32 ].

2. Methodology

(1) To systematically review existing reviews of Sex Education (SE) of school-based (face-to-face), digital platforms and blended learning programs for adolescent populations in high-income countries.

(2) To summarize evidence relating to effectiveness.

2.2. Methods

The review is structured in accordance with the PRISMA checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) (see Figure A1 ), and the systematic review protocol has previously been published on the PROSPERO International Prospective Registry of Technical Reviews (CRD42021224537).

2.3. Search Strategy

This systematic review is based on international scientific literature and only peer- reviewed papers have been included. Only meta-analyses (publications that combine results from different studies) and systematic reviews (literature reviews that synthesize high-quality research evidence) were used for this review. Findings from reviews of reviews were not analyzed. To identify reviews, we electronically searched the Cochrane Database Reviews, ERIC, Web of Science, PubMed, Medline, Scopus and PsycINFO. After the list was completed the duplicated papers were automatically removed. Two reviewers working independently applied inclusion criteria in screening citations by titles, abstracts, and keywords to identify records for full-text review. A third reviewer reconciled any disagreement. The same procedure was carried out in screening the full text of studies selected after the title and abstract screening phase. Two reviewers then examined the full text of each article to determine which satisfied inclusion criteria. Data extraction was carried out independently by the first and second reviewer. The extracted data included specific details about the interventions, populations, study methods and outcomes significant to the review question and objective. Any discrepancies were discussed until consensus was reached. Search terms are included in Table A1 .

This RoR included the reviews published since 2015, when the United Nations decided on new Global Sustainable Development Goals, until December 2020. The 2030 Agenda for Sustainable Development [ 4 ] takes into account the relevance of Sexual Health to achieve peace and prosperity.

2.4. Inclusion Criteria

We extracted data using a “Population, Intervention, Comparison, Outcome” structure, PICO [ 41 ].

Population: Reviews of interventions targeting adolescents (aged 10–19 years), school-setting, digital platforms or blended learning education were eligible for inclusion. Reviews in which studies of interventions targeted youth and adults were eligible if the primary studies included people between the ages of 10–19 years.

Intervention: Reviews of interventions developed in school-setting (school-based), digital (digital platforms) or blended learning programs were included. Interventions based on multiple settings or targeted multiple health-related issues were only considered for inclusion if any primary studies were linked to school-based, digital or blended learning interventions, as well as targeting Sexual and Reproductive Health (SRH).

Comparison groups: Randomized controlled trials (RCTs) and studies using a quasi-experimental design (including non-randomized trials—nRCTs). Single group, pre- and post-test research designs, group exposed to sexual education (SE) program (school-based, digital platforms or blended learning) compared with non-exposed control group or another intervention.

Outcomes: Primary outcomes: (1) Sexual behavior and (2) Health and social outcomes related to sexual health. Secondary outcomes: (1) Knowledge and understanding of sexual health and relationship issues and (2) Attitudes, values and skills.

2.5. Exclusion Criteria

Reviews were excluded if:

• Their primary focus was adult people and adolescents were not included.
• Their primary focus was sexual-health screening, sexual abuse or assault or prevention of sexual abuse or rape.
• The studies targeted specific populations (e.g., pre-pubertal children, children with developmental disorders, migrant and refugee, or sexual minorities).
• The interventions focused on low- and middle-income countries or if high income countries were not included in the study.
• Recipients were professionals, teachers, parents or a combination of the latter.

2.6. Risk of Bias and Assessment of Study Quality

Review quality was assessed by the first author using the AMSTAR II checklist [ 42 ]. This is an updating and adaptation of AMSTAR [ 43 , 44 ] which allows a more detailed assessment of systematic reviews that include randomized or non-randomized studies of healthcare interventions, or both. It consists of a 16-item tool (including 5 critical domains) assessing the quality of a review’s design, its search strategy, inclusion and exclusion criteria, quality assessment of included studies, methods used to combine the findings, likelihood of publication bias and statements of conflict of interest. The maximum quality score is 16.

2.7. Data Synthesis

After manually coding the papers and extracting relevant data, we used a narrative/descriptive approach for data synthesis to summarize characteristics of the studies included. Considering the heterogeneity of outcomes, their measures and research designs, meta-analysis of all the studies included was not carried out. Two researchers were involved in data synthesis. Discrepancies were resolved through discussion, and a third researcher was consulted to resolve any remaining discrepancies. For the classification of the information and presentation of the effects of the interventions reported, data was separated (school setting, digital platforms or blended learning) and structured around population, intervention, comparison, and outcome. To address the main review questions, data was synthesized in two phases. Phase 1 addressed the first question, the description of sex education/sexual health interventions. Phase 2 addressed the second question, the effectiveness and benefit of the interventions; studies with a low risk of bias were highlighted, so as to strengthen the reliability of findings (AMSTAR II) [ 42 ].

3.1. Results of Search

Our searches yielded 1476 unique citations. After excluding 776 records based on title and abstract screening, we reviewed 217 full-text articles for eligibility, of which 20 ultimately met inclusion criteria, and proceeded to data extraction. Of the 197 studies that we excluded after full-text review, 82 were carried out in low- and middle-income countries, 47 targeted exclusively adults, 56 dealt with minority groups, and 12 targeted exclusively pre-teen students.

3.2. Risk of Bias in Included Studies

According to the AMSTAR II quality assessment tool’s developers [ 42 ] scores may range from 1 to 16: in this case only 2 reviews scored 16 out of 16: 1 in a school setting [ 45 ], and 1 on a digital platform [ 46 ]. 6 of the 20 systematic reviews were of high quality: 5 in school settings [ 45 , 47 , 48 , 49 , 50 ], and 1 in digital platforms [ 46 ]; there was one study of medium quality in a school setting [ 51 ]. The remaining studies were of low or very low quality (N = 13). It is possible that low quality reviews may not provide reliable evidence, so those scoring in low and critically low quality should be regarded skeptically.

3.3. Reviews Included

Key information regarding the 20 reviews included is shown in Table A2 and Table A3 .

3.3.1. Setting

Ten studies (50%) dealt with school-based interventions [ 45 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ], 9 (45%) referred to online interventions [ 46 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 ] and 1 (5%) was a review of blended learning programs [ 64 ]. In total 491 studies were included in the 20 reviews covered by the present RoR. The 10 reviews of school setting interventions include a total of 266 studies (54%), the 9 reviews of online interventions cover a total of 216 (44%) studies, and the only review of blended learning interventions includes a total of 9 studies (2%). All studies were conducted in high-income economies following the World Bank classification [ 65 ], including US samples in 16 of the 20 studies, although there are two studies in which the country of the sample is not identified [ 51 , 52 ]. Most of the studies evaluating interventions in school settings also include developing countries (low- and middle-income economies) [ 45 , 47 , 50 , 52 , 53 , 55 ], as is also the case in three reviews of online interventions [ 46 , 61 , 62 ] (see Table A2 ).

3.3.2. Population

The targeted age for reviews in school settings, as shown in Table A2 , is the period of adolescence, from 10 to 19 years of age, though one of the studies covers ages from 7 to 19 years [ 53 ]. All the online studies also include young adults (20–24 years old), alongside the adolescent sample [ 46 , 56 , 57 , 59 , 60 , 61 , 62 , 63 ], whilst the review by DeSmet et al. [ 58 ] extends the upper limit to 29 years of age. Along with the sample of adolescents and young adults, the blended learning studies review also incorporates adults of over 25 years of age [ 64 ].

3.3.3. Interventions/Types of Study

All the studies included in this review of reviews used randomized controlled trials (RCTs), non-randomized controlled trials (non-RCT), and a quasi-experimental design or a pre-test/post-test design to examine program effects.

3.3.4. Outcomes

The term “sexual outcomes” refers to the attitudes, behaviors, and experiences of adolescents consequent to their sex education [ 14 ] (p. 1), and an extensive range of variables was included (see Table A2 ): knowledge (e.g., knowledge of contraceptive effectiveness or effective method use); attitudes (e.g., about sex and reproductive health); beliefs (e.g., self-efficacy); skills (e.g., condom skills); intentions/motivation (e.g., use of birth control methods; condom use); behaviors (e.g., sexual debut; condom use; contraception use; intercourse; initiation of sexual activity) and; other outcomes related to sexual behavior (e.g., pregnancy prevalence; number of partners; rates of sexually transmissible infections (STIs); cervical screening; appreciation of sexual diversity; dating and intimate partner violence prevention; sexual violence).

3.3.5. Country of Review

Of the 10 reviews of interventions in school settings, the authors are from the USA in 7 reviews [ 47 , 48 , 49 , 50 , 53 , 54 , 55 ], from the United Kingdom in 1 [ 45 ], from Australia in 1 [ 51 ], and from Thailand in 1 [ 52 ]. Of the 9 reviews of interventions in digital settings, the authors are from the United States in 3 reviews [ 59 , 60 , 63 ], from the United Kingdom in 2 [ 46 , 56 ], from Australia in 1 [ 62 ], from Belgium in 1 [ 58 ], from France in 1 [ 61 ] and from Turkey in 1 [ 57 ]. The authors of the blended learning review are from the USA [ 64 ].

3.3.6. Year of Last Paper Included

The studies cited in the reviews that met the inclusion criteria for this review were published over a wide range of years (between 1981–2019), although only one [ 61 ], with articles published up to and including 2019 was published later than 2017. Of these, 3 were carried out in school settings [ 49 , 51 , 53 ], and 1 on digital platforms [ 46 ].

3.3.7. Search Tools

All reviews include more than 2 tools to carry out the search, in a range of 3–12, and in 7 of them the review of gray literature was included.

3.3.8. Multicenter Studies and Number of Studies Included

All reviews from school settings are multicenter, except that of Mirzazadeh et al. [ 49 ], which includes only one North American sample. The same is true for the blended learning review [ 64 ] and for the reviews of digital platforms, except for the reviews by Bailey et al. [ 56 ], L´Engle et al. [ 60 ], and Widman et al. [ 63 ]. Regarding the number of countries included in the reviews, the range in the school-setting reviews is from 1 to 11, in digital platforms reviews from 1 to 16, and in the only review of blended learning, 3. As for the range of studies included, in the reviews in school setting the range is between 8 and 80, in digital platforms, between 5 and 60, and in the only review of reviews of blended learning 9 studies were included.

3.3.9. Number of Reviews Covered That Include Meta-Analysis

As for the number of reviews that carry out a meta-analysis, there are 8 in total: 4 in school settings [ 45 , 48 , 49 , 55 ] and 4 on digital platforms [ 43 , 46 , 56 , 58 ], while in the only review of blended learning there is no meta- analysis.

3.4. Effectiveness

3.4.1. school settings.

Half of the reviews conclude that interventions are not effective in promoting healthy sexual behaviors and/or reducing risks [ 45 , 47 , 48 , 49 , 50 ]. These reviews are of high quality and with a reduced risk of bias (see Table A4 ), so that the results are highly reliable, even though in most of the studies cited the risk of bias was judged to be high and the quality of evidence was low or very low. These reviews include those of the Marseille et al. [ 48 ] and Mirzazadeh et al. [ 49 ] team, who in two studies—each led by one of the two authors—analyze, on the one hand, the effectiveness of school-based teen pregnancy prevention programs [ 48 ], and, on the other hand, the effectiveness of school-based programs prevent HIV and other sexually transmitted infections in North America [ 49 ]. The results of the studies question the usefulness of interventions carried out in schools to prevent both unwanted pregnancies and the incidence of HIV and other sexual transmitted infections in adolescents in North America. In addition to these results, those of Lopez et al. [ 47 ] focus on analyzing the effectiveness of programs implemented in schools to promote the use of contraceptive methods and conclude that many trials reported contraceptive use as an outcome but did not take into consideration whether contraceptive methods and their relative effectiveness were part of the content. For its part, the review by Mason-Jones et al. [ 45 ] also concludes that the educational programs covered had no significant effect as regards the prevalence of HIV or other STIs (herpes simplex virus, moderate evidence and syphilis, low evidence), nor was there any apparent effect in terms of the number of pregnancies at the end of the trial (moderate evidence). Finally, the review by Oringanje et al. [ 50 ] finds only limited evidence for program effects on biological measures, and inconsistent results for behavioral (secondary) outcomes across trials and concludes that it was only the interventions which combined education and contraception promotion (multiple interventions) that led to a significant reduction in unintended pregnancies over the medium- and long-term follow-up period.

In contrast to these negative results in terms of the effectiveness of the programs implemented in the school environment (identified in 5 of the 10 reviews included), 3 of the 10 reviews concluded that the programs evaluated were mostly effective in promoting knowledge, attitudes and/or in reducing risk behaviors [ 51 , 52 , 53 ] whilst programs were effective in terms of some of the primary outcomes in the reviews by Haberland et al., [ 54 ], and Peterson et al. [ 55 ]. However, these data must be taken with caution since the level of bias in these reviews—excepting that of Kedzior et al. [ 51 ] with a medium quality level—is at a low or critically low-quality level. In the review by Chokprajakchad et al. [ 52 ], 22 programs reviewed were effective in changing targeted adolescent psychosocial and/or behavioral outcomes, in 12 of 17 studies evaluating delay in the initiation of sexual intercourse, the programs were effective and many of the reviewed studies demonstrated impacts on short-term outcomes, such as knowledge, attitudes, perception and intention. The review by Goldfarb et al. [ 53 ] identifies changes in appreciation of sexual diversity, dating and intimate partner violence prevention, healthy relationships, child sex abuse prevention and additional outcomes. According to the review by Kedzior et al. [ 51 ], focused on studies promoting social connectedness with regard to sexual and reproductive sexual health, the programs reviewed improved condom use, delayed initiation of sex, and reduced pregnancy rates. Additionally, in this review, program effectiveness was influenced by ethnicity and gender: greater improvements in condom use were often reported among African American students. For its part, in the study by Peterson et al. [ 55 ] the meta-analysis of three randomized trials provided some evidence that school-environment interventions may contribute to a later sexual debut while their narrative synthesis of other outcomes offered only mixed results.

Finally, the review by Haberland et al. [ 54 ], which focused on studies analyzing whether addressing gender and power in sexuality education curricula is associated with better outcomes, concluded that where interventions addressed gender or power (N = 10/22) there was a fivefold greater likelihood of effectiveness than in those that did not.

3.4.2. Online Platforms

The reviews included show a very diverse panorama of digital platforms used to carry out educational interventions (e.g., websites, social media, gaming, apps or text messaging and mailing), which makes it difficult to compare the results. Of the 9 reviews of studies included, only one—in which the effects of TCCMD (Targeted Client Communication delivered via Mobile Devices) are evaluated [ 46 ]—meets the quality criteria according to the AMSTAR II quality assessment tool [ 42 ] (see Table A4 ); the rest include biases that limit the reliability of the results so that these must be taken with caution. In the studies reviewed by Palmer et al. [ 46 ] among adolescents nine programs were delivered only via text messages; four programs used text messages in combination with other media (for example, emails, multimedia messaging, or voice calls); and one program used only voice calls.

When compared with more conventional approaches, interventions that use TCCMD may increase sexual health knowledge (low certainty evidence), and may modestly increase contraception use (low certainty evidence) while the effect on condom use remains unclear given the very low certainty evidence. Additionally, when compared with digital non-targeted communication, the effects TCCMD on sexual health knowledge, condom and contraceptive use are also unclear, again given the very low-certainty evidence. The review finds evidence of a modest beneficial intervention effect on contraceptive use among adolescent (and adult) populations, but that there was insufficient evidence to demonstrate that this translated into a reduction in contraception.

Most of the reviews included refer to changes to a greater or lesser extent [ 56 , 57 , 59 , 60 , 62 , 63 ], while no changes determined by the intervention were identified in the study by DeSmet et al. [ 58 ]. Finally, the review by Martin et al. [ 61 ] does not include details about changes as a result of the programs.

The review by L´Engle et al. [ 60 ] assesses mHealth mobile phone interventions for ASRH (almost all of which were carried out via SMS platforms, with the notable exception of only four of the programs covered which used other media formats instead of or as well as SMS). The interventions reviewed set out to foster positive and preventive SRH behaviors, augment take-up and continued use of contraception, support medication adherence for HIV-positive young people, support teenage parents, and encourage use of health screening and treatment services. Results from the studies covered in the review offer support for diverse uses of mobile phones in order to help further ASRH. The health promotion programs that made use of text messaging demonstrated robust acceptability and relevance for young people globally and contributed to improved SRH awareness, less unprotected sex, and more testing for STIs. However, the review also found that improved reporting on essential mHealth criteria is necessary in order to understand, replicate, and scale up mHealth interventions. Holstrom’s [ 59 ] review, focused on evaluations of internet-based sexual health interventions, finds that these were associated with greater sexual health knowledge and awareness, lower rates of unprotected sex and higher rates of condom use, as well as increased STI testing. Moreover, the review explores young people’s continuing use of and trust in internet as a source of information about sexual health, as well as the particular themes that interest them. Specifically, the study finds that young people want to know not only about STIs, but also about sexual pleasure, about how to talk with partners about their sexual desires, as well as about techniques to better pleasure their partners.

The review by Widman et al. [ 63 ] reveals a significant weighted mean effect of technology-based interventions on condom use and abstinence, the effects of which were not affected by age, gender, country, intervention, dose, interactivity, or program tailoring. The effects were more significant when evaluated with short-term (one to five months) follow-ups than with longer term (over six months) ones. Moreover, digital programs were more effective than control programs in contributing to sexual health knowledge and safer sex norms and attitudes. This meta-analysis, drawing on fifteen years of research into youth-oriented digital interventions, is clear evidence of their ability to contribute to safer sex behavior and awareness. In the review by Wadham et al. [ 62 ] the majority of studies used a web-based platform for their programs (16 out of 25). These web-based programs varied between complex, bespoke multimedia interventions to more simplified educational modules. Five studies employed SMS platforms both via mobile phone messaging and web-based instant message services. Three of the programs used social networking sites, either for live chat purposes or alongside a web-based platform. Several studies showed that variety in terms of media and platforms was associated with stronger positive responses among participants and improved outcomes. Eleven of the twenty-five studies focused specifically on HIV prevention, with seven finding a statistically significant effect of the program with regard to knowledge levels about prevention of HIV and other STIs, as well as about general sexual health knowledge. However, only twenty percent of the programs that assessed intended use of condoms reported significant effects due to the intervention.

The review by Bailey et al. [ 56 ] (p. 5) assesses interactive digital interventions (IDIs), defined as “digital media programs that provide health information and tailored decision support, behavioral-change support and/or emotional support” and focuses on the sexual well-being of young people between the ages of thirteen and twenty four in the United Kingdom. IDIs have significant though small effects on self-efficacy and sexual behavior, although there is not sufficient evidence to ascertain the effects on biological outcomes or other longer-term impacts. When comparing IDIs with in-person sexual health programs, the former demonstrate significant, moderate positive effects on sexual health knowledge, significant small effects on intention but no demonstrable effects on self-efficacy. The review by Celik et al. [ 57 ] looks at digital programs (the majority internet- and computer-based with only six making use of mobile phone-based applications) and sets out to understand their effectiveness in changing adolescents’ health behaviors. Findings from the studies ( n = 9) suggest that the digital interventions carried out with the adolescents generally had a positive effect on health-promoting behaviors. However, in another study focused on fostering HIV prevention [ 66 ], there was a statistically significant increase in health-promoting behavior in only one of the four studies reviewed.

In the review by DeSmet et al. [ 58 ], no significant behavioral changes as a result of the interventions for sexual health promotion using serious digital games are identified, although the interventions did have significant though small positive effects on outcomes. The fact that so few studies both met the inclusion criteria and also analyzed behavioral effects suggests the need to further investigate the effectiveness of this kind of game-based approach.

Finally, in the review by Martin et al. [ 61 ] 60 studies were covered, detailing a total of 37 interventions, though only 23 of the reviews included effectiveness results. A majority of the interventions were delivered via websites ( n = 20) while online social networks were the second most favored medium ( n = 13), mostly via Facebook ( n = 8). The programs under review favored online interaction, principally amongst peers ( n = 23) but also with professionals ( n = 16). The review concludes that ASHR programs promoting these kinds of online participation interventions have demonstrated feasibility, practical interest, and attractiveness, though their effectiveness has yet to be determined, given that they are still in the early stages of design and evaluation.

3.4.3. Blended Learning

In the only blended learning review included in our study [ 64 ], the authors conclude that blended learning approaches are being successfully applied in ASHR interventions, including in school-based programs, and have led to positive behavioral and psychosocial changes. However, these results should be treated with caution as the review does not follow the guidelines recommended in the AMSTAR II quality assessment tool [ 44 ] (see Table A4 ) and only includes nine studies.

4. Discussion

The present review of reviews assesses, for the first time jointly to our knowledge, the effectiveness of sexual education programs for the adolescent population (ASRH) developed in school settings, digital platforms and blended learning. Of the twenty reviews included (comprising a total of 491 programs, mostly from the USA), ten correspond to reviews of programs implemented in school settings, nine to those dealing with interventions via digital platforms and only one deals with studies relating to blended learning. Twelve (60%) of the reviews included (6 out of 10 in school settings, 5 out of 9 on digital platforms, and the only blended learning review) have been published in the last 3 years (between 2018 and 2020). Thus, the present study constitutes the most up-to-date and recent review of reviews incorporating several contemporary studies not covered by earlier reviews [ 19 , 27 , 33 , 35 , 36 , 37 , 38 , 39 ].

4.1. Interventions Reviewed

The interventions included in the reviews covered by our study were largely focused on reducing risk behaviors (e.g., VIH/STIs and unwanted pregnancies), and envisaging sex as a problem behavior. Programs reviewed often focused on the physical and biological aspects of sex, including pregnancy, STIs, frequency of sexual intercourse, use of condom, and reducing adolescents´ number of sexual partners. One exception is Golfard’s et al. [ 53 ] review about comprehensive sex education, which is centered on healthy relationships and sexual diversity, though it also makes reference to prevention of violence (dating and intimate partner violence prevention and sex abuse prevention). However, Golfard’s et al.’s [ 53 ] rejects more than 80% of the studies initially reviewed because they were focused solely on pregnancy and disease prevention. In the reviews of interventions on digital platforms and via blended learning all the outcomes focused on behaviors related to sexual health (focused on the prevention of risk behaviors), and in several cases also addressed perceived satisfaction and usability. These results are in line with other studies that confirm the over-attention given to risk behaviors, to the detriment of other more positive aspects of sexuality [ 67 , 68 ]. Teachers continue to perceive their responsibility as combating sexual risk, whilst viewing young people as immature and oversexualized [ 69 ], even as adolescents themselves express a preference for sex education with less emphasis on strictly negative sexual outcomes [ 16 ], and more emphasis on peer education [ 70 ].

As for more positive views of sexuality, only on rare occasions do interventions address issues such as sexual pleasure, desire and healthy relationships. Desire and pleasure were not included in the outcome evaluations for school settings, nor for digital and blended learning programs included in this review: again this is in line with the position of other authors cited in the present study, who advocate the need to also embrace the more positive aspects of sexuality [ 53 , 56 ]. Specifically, Bailey and colleagues [ 56 ] (p. 73) suggest as “optimal outcomes” social and emotional well-being in sexual health. Young people want to know about more than STIs, they also “want information about sexual pleasure, how to communicate with partners about what they want sexually and specific techniques to better pleasure their partners” [ 59 ] (p. 282). Similarly, Kedzior et al. [ 51 ] also argue for the need to move beyond a risk-aversion approach and towards one that places more emphasis on positive adolescent sexual and reproductive health.

Pleasure and desire are largely absent within sex and relationship education [ 71 ] and, when they are included, they are often proposed as part of a discourse on safe practice, where pleasure continues to be equated with danger [ 72 ]. The persistent absence of a “discourse of desire” in sex education [ 73 , 74 ] is especially problematic for women, for whom desire is still mediated by (positive) male attention, and for whom pleasure is derived from being found desirable and not from sexual self-expression or from their own desires [ 75 ]. Receiving sexualized attention from men makes women “feel good” by increasing their self-esteem and self-confidence [ 76 ]. However, it is still men who decide what is sexy and what is not, based on the attention they pay to women “girl watching”, [ 77 ] (p. 386), which leads the latter to self-objectify [ 78 ] with all the attendant negative consequences for their overall and sexual health [ 79 ]. In fact, women experience “pushes” and “pulls” [ 80 ] (p.393) with regard to sexualized culture. In one sense, the sexualization of culture has placed women in the position of subjects who desire, not just that of subjects who are desired, but at the same time it becomes a form of regulation in which young women are forced to assume the current sexualized ideal [ 81 , 82 ] in order to position themselves as “modern, liberated and feminine,” and avoid being seen as “outdated or prudish” [ 83 ] (p. 16). Koepsel [ 84 ] provides a holistic definition of pleasure as well as clear recommendations for how educators can overcome these deficits by incorporating pleasure into their existing curricula. At present, sexual education is still largely centered on questions of public health, and there is as yet no consensus on criteria for defining sexual well-being and other aspects of positive sexuality [ 85 ]. Patterson et al. [ 86 ] argue for the need to mandate “comprehensive, positive, inclusive and skills-based learning” to enhance people´s ability to develop healthy positive relationships throughout their lives.

The absence of desire and pleasure in the outcomes of the evaluated reviews is connected with the absence of gender-related outcomes. Only one of the reviews addresses the issue of gender and power in sexuality programs [ 54 ], illustrating how their inclusion can bring about a five-fold increase in the effectiveness of risk behavior prevention. Nonetheless, men are far less likely than women to sign up for a sexuality course, and as a result of masculine ideologies many young males experience negative attitudes towards sex education [ 87 ]. To date we still have little idea as to what are the “active ingredients” that can contribute to successfully encouraging men to challenge gender inequalities, male privilege and harmful or restrictive masculinities so as to help improve sexual and reproductive health for all [ 88 ] (p.16). Schmidt et al.’s [ 89 ] review looks at 10 evidence-based sexual education programs in schools: the majority discuss sexually transmitted diseases and unplanned pregnancy, abstinence, and contraceptive use, while very few address components related to healthy dating relationships, discussion of interpersonal violence or an understanding of gender roles.

The International Guidance on Sexuality Education [ 90 ], and the International Technical Guidance on Sexuality Education [ 17 ] promote the delivery of sexual education within a framework of human rights and gender equality to support children and adolescents in questioning social and cultural norms. The year 2020 marked the anniversaries of several path breaking policies, laws and events for women’s rights: the 100th anniversary of women´s suffrage in the United States; the 25th anniversary of the Beijing Platform for Action, a global roadmap for women´s empowerment; and, the 20th anniversary of the United Nations Security Council Resolution for a Women, Peace and Security agenda. Although there have been important advances in recent years in research relating to the inclusion of gender equality and human rights interventions in ASRH policies and programming still “fundamental gaps remain” [ 40 ] (p.14). Gender equality, and to an even greater extent human rights, have had very little presence in sexual and reproductive health programs and policies, and there is a pressing need to do more to address these issues systematically. Specifically, issues such as abortion and female genital mutilation, with clear repercussions in terms of gender equality and human rights, are rarely dealt with [ 40 ].

Furthermore, sexual education that privileges heterosexuality reinforces hegemonic attributes of femininity and masculinity, and ignores identities that distance themselves from these patterns. Our collective heteronormative legacy marginalizes and harms LGB families [ 91 ] and LGBTQ+-related information about healthy relationships is largely absent from sexual and reproductive health programs [ 92 ]. Students want a more LGBTQ+ inclusive curriculum [ 92 ]: in the present RoR one review [ 53 ] addresses the issue of non-heteronormative identity in sexuality programs with significant results; and other authors are exploring promising initiatives which are also challenging this lack of inclusivity [ 93 ] and rectifying heterosexual bias [ 94 ]. However, unfortunately, the underlying neoliberal focus of the majority of contemporary sexuality education militates to assimilate LGBTQ+ people into existing economic and social normative frameworks rather than helping disrupt them [ 95 ].

4.2. Effectiveness

This present review of reviews shows a variety of types of sexual health promotion initiatives across the three settings (school-based, digital and blended learning), with inconsistent results. The reviews with lower risk of bias are those carried out in school settings and those that are most critical regarding the effectiveness of programs promoting ASRH, both in the prevention of pregnancies and of HIV/STIs. Reviews dealing with digital platforms and blended learning show greater effectiveness in terms of promoting adolescent sexual health: however, these are also the studies that incorporate the highest risks of bias. Specifically, in digital platforms programs the great variety of alternatives makes comparability difficult. Moreover, these programs, along with blended learning, are in a more incipient state of evaluation, compared to school-setting evaluations, and present greater risks of lower quality than reviews in school settings.

The results of the present RoR are in line with those of previous RoRs [ 19 , 32 ]. The review of reviews by Denford et al.s´ [ 19 ] RoR covered 37 reviews up to 2016 and summarized 224 primary randomized controlled trials: whilst it concludes that school-based programs addressing risky sexual behavior can be effective, its reviews of exclusively school-based studies offer mixed results as to effectiveness in relation to attitudes, skills and behavioral change. Some of those studies report positive effects while others find there are no effects, if not even negative effects, in terms of the aforementioned outcomes [ 19 ]. As regards pregnancy, programs appear to be effective at increasing awareness regarding STIs and contraception but overall the findings suggest that the impact of these interventions on attitudes, behaviors and skills variables are mixed, with some studies leading to improvements whilst others show no change. Moreover, the fact that community-based programs were also taken into consideration might have led to the effectiveness of school-based programs being exaggerated [ 19 ].

However, although in our RoR the higher quality/lower bias studies—in keeping with the findings of previous reviews [ 19 , 33 ]—fail to show a clear pattern of effectiveness, the interventions could nevertheless be generating changes as Denford et al. [ 19 ] suggest, though not in the measured outcomes, bearing in mind the low incidence of sexual intercourse and pregnancy in school-going adolescents.

With regard to school settings, Peterson et al. [ 55 ] conclude that further, more rigorous evidence is necessary to evaluate the extent to which interventions addressing school-related factors are effective and to help better understand the mechanisms by which they may contribute to improving adolescent sexual health. With regard to digital platform programs, Wadham et al. [ 62 ] (p. 101) argue that “although new media has the capacity to expand efficiencies and coverage, the technology itself does not guarantee success.” An interesting observation in their review was that interventions which were either web-based adaptations of prior prevention programs, or were theory-based or had been developed from models of behavioral change appeared effective independently of the chosen digital media mode. However, digital programs are still in the early stages of design and evaluation, especially in terms of the effects of peer interaction and often diverge from existing theoretical models [ 61 ] (p. 13). The expert opinion-based proposal of the European Society for Sexual Medicine [ 96 ] argues that e-sexual health education can contribute to improving the sexual health of the population it seems the future of CSHE is moving towards smartphone apps [ 97 ].

However, “despite clear and compelling evidence for the benefits of high-quality curriculum-based CSE, few children and young people receive preparation for their lives that empowers them to take control and make informed decisions about their sexuality and relationships freely and responsibly” [ 17 ] (p. 12), and during “the current public health crisis, the sexual and reproductive health of adolescents and young adults must not be overlooked, as it is integral to both their and the larger society’s well-being” [ 28 ] (p. 9). In the light of these challenges, Coyle et al.’s [ 64 ] suggestion that the blended learning model may end up achieving a far more dominant role in the future of sexual education acquires even more relevance.

4.3. Limitations

This study represents the first review of reviews, as far as we are aware, in which the effectiveness of sex education programs in different settings (school-based, digital and blended learning) is evaluated, using a rich methodology and providing interesting conclusions. However, the present review of reviews is not without its limitations.

While systematic reviews and reviews of reviews can offer a way synthesizing large amounts of data, the great heterogeneity and diversity of measured outcomes make it difficult to establish a synthesis of the results, even more so in cases where it is not possible to apply meta-analysis. Furthermore, the quality of reviews of reviews is limited by that of the reviews they include and RoRs do not necessarily represent the leading edge research in the field.

In addition, although we searched for a wide range of keywords on the most commonly used databases in the field of health (namely ERIC, Web of Science, PubMed, and PsycINFO) to identify relevant papers, it is possible that the choice of keywords and database may have resulted in our omitting some relevant studies. Moreover, our review has focused on articles in international journals published in English, allowing us access to the most rigorous peer-reviewed studies and to those with greater international diffusion, given that English is the most frequently used language in the scientific environment: notwithstanding, this has also limited the scope of our review by precluding research published in other languages and contexts. Nor have documents that could have been found in the gray literature been included, given that only peer-reviewed studies have been considered for inclusion.

It is worth remembering moreover that most of the data on the outcomes of the studies included are self-reported, with mention of only occasional biological outcomes, which may limit the reliability of the effectiveness results. This represents another interesting reflection on the way in which the evaluation of the effectiveness of programs on sexual education is being carried out, and alerts us to the need for change.

Finally, it should be noted that this review of reviews is focused on adolescents from high-income countries, and our results show that studies carried out in the United States are largely overrepresented, since it is the country that provides the highest number of samples, especially in school settings: this may give rise to bias when it comes to generalizing from these results. Once again, this raises another necessary reflection on the capitalization that studies focused on American samples are having in the construction of the body of scientific knowledge on sexual and reproductive behavior, when in reality sexuality is conditioned by socio-economic variables that require a far-more multicultural and world-centric approach.

5. Conclusions

This review of reviews is the first to assess jointly the effectiveness of school-based, digital and blended learning interventions in ASRH in high-income countries. The effectiveness of the sex education programs reviewed mostly focused on the reduction of risky behaviors (e.g., STI or unwanted pregnancies) as public health outcomes; however, pleasure, desire and healthy relationships are outcomes that are mostly conspicuous by their absence in the reviews we have covered. Nonetheless, the broad range of studies included in this RoR, with their diversity of settings and methods, populations and objectives, precludes any easily drawn comparisons or conclusions. The inconsistent results and the high risk of bias reduce the conclusiveness of this review, so a more rigorous assessment of the effectivity of sexual education programs is pending and action needs to be taken to guarantee better and more rigorous evaluations, with sufficient human and financial resources. Schools and organizations need technical assistance to build the capacity for rigorous program planning, implementation and evaluation [ 98 ]. To this end, there are already examples of interesting proposals, such as that of the Working to Institutionalize Sex Education (WISE) Initiative, a privately funded effort to help public school districts develop and deliver comprehensive sexuality programs in the USA [ 99 ].

The extent of the risks of bias identified in the reviews and studies covered by this RoR points to an important conclusion, allowing us to highlight the precariousness that characterizes the evaluation of sexual education programs and the consequent undermining of public policy oriented to promoting ASRH. Public policies that promote ASRH are of vital importance when it comes to minimizing risks related to sexual behavior, and maximizing healthy relations and sexual well-being for the youngest members of our society.

Above all it is important to recognize the opportunities afforded by new technologies, so ubiquitous in the lives of young people, since they allow for programs that are far more cost-effective than traditional, in-person interventions. Finally, blended learning programs are perhaps even more promising, given their combination of the best of face-to-face and digital interventions, meaning they provide an excellent educative tool in the new context of the COVID-19 pandemic, and may even become the dominant teaching model in the future.

Flow diagram Preferred reporting items for systematic reviews and meta-analysis, PRISMA).

Search Terms Used.

Description of studies.

Characteristics and main results of the studies included.

Evaluation of the studies included (AMSTAR II).

1 1. Did the research questions and inclusion criteria for the review include the components of PCIO?; 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?; 3. Did the review authors explain their selection of the study designs for inclusion in the review?; 4. Did the review authors use a comprehensive literature search strategy?; 5. Did the review authors perform study selection in duplicate?; 6. Did the review authors perform data extraction in duplicate?; 7. Did the review authors provide a list of excluded studies and justify the exclusions?; 8. Did the review authors describe the included studies in adequate detail?; 9. Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?; 10. Did the review authors report on the sources of funding for the studies included in the review?; 11. If meta-analysis was performed, did the review authors use appropriate methods for statistical combination of results?; 12. If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?; 13. Did the review authors account for RoB in primary studies when interpreting/discussing the results of the review?; 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?; 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?; 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review? 2 H = Hight; M = Media; C = Low; CL = Critically Low. N = No; Y = Yes.

Author Contributions

Conceptualization, M.L.-F. and R.M.-R.; methodology, M.L.-F.; R.M.-R.; Y.R.-C. and M.V.C.-F.; formal analysis, M.L.-F.; R.M.-R.; Y.R.-C. and M.V.C.-F.; investigation, M.L.-F.; R.M.-R.; Y.R.-C. and M.V.C.-F.; writing—original draft preparation, M.L.-F. and R.M.-R.; writing—review and editing, M.L.-F.; R.M.-R., and Y.R.-C. and.; supervision, M.L.-F.; R.M.-R.; Y.R.-C. and M.V.C.-F. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare that they have no conflicts of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

US Adolescents’ Receipt of Formal Sex Education

Reproductive rights are under attack. Will you help us fight back with facts?

Sex education is vital to adolescents’ healthy sexual development, and young people have the right to information that is medically accurate, inclusive, and age- and culturally appropriate in order to make informed decisions about their sexual behavior, relationships and reproductive choices. 1–4 Numerous health organizations recommend comprehensive sex education that addresses a range of topics, 2–4 and support for this type of instruction is reflected in national public health goals. 5

Formal sex education for adolescents consists of instruction that generally takes place in a structured setting, such as a school, community center or church. The US Department of Health and Human Services’ Healthy People 2030 initiative includes objectives for formal sex education for adolescents based on a minimal set of topics that focus on delaying sex, using birth control methods and preventing STIs (including HIV). 6 However, not all states require sex education and any required content varies widely; there is further variation at both the district and school levels. 7,8 Understanding differences in the receipt of formal instruction is the first step toward ensuring that the needs of all youth are met.

The data in this fact sheet come from multiple rounds of the National Center for Health Statistics’ National Survey of Family Growth and apply to female and male respondents aged 15–19 at the time of the survey interview. (Self-reported gender at time of interview may differ from respondents’ gender assigned at birth.)

• Young people are not getting the sex education they need: About half of adolescents (53% of females and 54% of males) reported in 2015–2019 that they had received sex education that meets the minimum standard articulated in Healthy People 2030; among teens reporting penile-vaginal intercourse, fewer than half (43% of females and 47% of males) received this instruction before they first had sex. 9
• In 2015–2019, more adolescents reported that they had received instruction about saying no to sex (81% of females and 79% of males) or waiting until marriage (67% and 58%, respectively) than about where to obtain birth control (48% of females and 45% of males) or how to use a condom (55% and 60%, respectively). 9

that they had received instruction on where to get birth control before they had sex for the first time. 9

• More than 90% of adolescents reported receiving instruction on STIs, including HIV. 9
• Adolescents reported in 2015–2019 that they first received instruction about birth control methods, where to get birth control and how to use a condom primarily in grades nine and above. 9

Changes in receipt of sex education

Adolescents were less likely to report receiving sex education on key topics in 2015–2019 than they were in 1995. 9

• In 1995, 81% of adolescent males and 87% of adolescent females reported that they had received instruction on birth control methods, while in 2015–2019, 63% of males and 64% of females reported receiving instruction on this topic. 9
• Although the proportion of adolescent males reporting instruction on saying no to sex increased between 1995 and 2015–2019 (74% vs. 79%), this proportion decreased for adolescent females during the same time period (92% vs. 81%). 9

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Disparities in sex education received

Disparities in the receipt and timing of formal sex education by gender, race and ethnicity, and sexual orientation leave some young people without critical information for their sexual health and well-being, particularly when this instruction does not occur before they first have sex.

• In 2015–2019, adolescent females were more likely than males to report receipt of instruction on waiting until marriage to have sex (67% vs. 58%), while males were more likely to report instruction about condoms (60% vs. 55%). 9
• Adolescent males were more likely than females to report that, before they had sex for the first time, they had received condom instruction (64% vs. 50%), instruction about birth control methods (61% vs. 54%) and instruction on STIs or HIV (78% vs. 69%). 9

Race and ethnicity

• In 2015–2019, non-Hispanic Black adolescents were more likely than their peers of other races and ethnicities to report having received instruction about condoms (males, 67% vs. 58–62% and females, 65% vs. 50–56%). 9
• Non-Hispanic Black males and Hispanic males were less likely than non-Hispanic White males to report having received instruction on a range of topics before they first had sex: prevention of STIs or HIV (70% and 72%, respectively, vs. 84%), methods of birth control (41% and 54% vs. 75%) and where to get birth control (36% and 42% vs. 56%). 9
• In 2015–2019, 30% of non-Hispanic Black females reported that they had learned about where to get birth control before having sex for the first time; this was true for 45% of non-Hispanic White females and 49% of Hispanic females. 9

Sexual orientation

• Males who reported that they were homosexual, gay or something else were less likely than straight males to report in 2015–2019 that they had received instruction about STIs or HIV (83% vs. 93%) or where to get birth control (31% vs. 46%). 9

Sources of formal instruction

Young people receive sex education from multiple sources. Religious institutions were commonly reported in 2015–2019 as a source of sex education, but they rarely offered comprehensive information.

• In 2015–2019, adolescents who attended religious services at least once a week were more likely than their peers who attended services less frequently or not at all to report having received instruction about delaying sex until marriage and less likely to report having received instruction about birth control methods. 9
• Among adolescent females who reported in 2015–2019 that they had received instruction about waiting until marriage to have sex, 56% received this instruction in church; more than half (53%) received this instruction in school and 13% in a community setting. Among males, 49% reported that they received this instruction in church, 59% in school and 11% in a community setting. 9 (Some respondents received instruction in multiple locations.)
• Among adolescents who reported in 2015–2019 that they had received instruction about birth control methods, 92% of females and 98% of males received it in school. Only 2% and 3%, respectively, reported receiving instruction about birth control methods at church, and 14% and 4% reported receiving instruction in another community setting. 9

1. Santelli JS et al., Abstinence-only-until-marriage: an updated review of U.S. policies and programs and their impact, Journal of Adolescent Health , 2017, 61(3):273–280, doi:10.1016/j.jadohealth.2017.05.031.

2. Breuner CC et al., Sexuality education for children and adolescents, Pediatrics , 2016, 138(2):e20161348, doi:10.1542/peds.2016-1348.

3. American College of Obstetricians and Gynecologists, Comprehensive sexuality education, Committee Opinion No. 678, Obstetrics & Gynecology , 2016, 128(5):e227–e230, doi:10.1097/AOG.0000000000001769.

4. Society for Adolescent Health and Medicine, Abstinence-only-until-marriage policies and programs: an updated position paper of the Society for Adolescent Health and Medicine, Journal of Adolescent Health , 2017, 61(3):400–403, doi:10.1016/j.jadohealth.2017.06.001.

5. Office of Disease Prevention and Health Promotion (ODPHP), US Department of Health and Human Services (HHS), Healthy People 2030: Adolescents, no date, https://health.gov/healthypeople/objectives-and-data/browse-objectives/… .

6. ODPHP, HHS, Increase the proportion of adolescents who get formal sex education before age 18 years—FP‑08, no date, https://health.gov/healthypeople/objectives-and-data/browse-objectives/… .

7. Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, School Health Policies and Practices Study, Trends Over Time: 2000–2016 , 2019, https://www.cdc.gov/healthyyouth/data/shpps/results.htm .

8. Guttmacher Institute, Sex and HIV education, State Laws and Policies (as of January 1, 2022) , 2022, https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education .

9. Lindberg LD and Kantor L, Adolescents’ receipt of sex education in a nationally representative sample, 2011–2019, Journal of Adolescent Health , 2022, 70(2):290–297, doi:10.1016/j.jadohealth.2021.08.027.

Figure sources:

1995 and 2002: Lindberg LD et al., Changes in formal sex education: 1995–2002, Perspectives on Sexual and Reproductive Health , 2006, 38(4):182–189. 2006–2010: Lindberg LD et al., Changes in adolescents’ receipt of sex education, 2006–2013, Journal of Adolescent Health , 2016, 58(6):621–627. 2011–2015 and 2015–2019 : reference 9.

Federally Funded Abstinence-Only Programs: Harmful and Ineffective

Federally funded sex education: strengthening and expanding evidence-based programs, sex and hiv education, adolescents deserve better: what the biden-harris administration and congress can do to bolster young people’s sexual and reproductive health, united states.

• Northern America : United States