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Comprehensive Sex Education Addressing Gender and Power: A Systematic Review to Investigate Implementation and Mechanisms of Impact

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• Published: 16 December 2021
• Volume 20 , pages 58–74, ( 2023 )

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• Kerstin Sell   ORCID: orcid.org/0000-0003-2481-7237 1 , 2 , 3 ,
• Kathryn Oliver 3 &
• Rebecca Meiksin 3  

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Delivered globally to promote adolescents’ sexual and reproductive health, comprehensive sex education (CSE) is rights-based, holistic, and seeks to enhance young people’s skills to foster respectful and healthy relationships. Previous research has demonstrated that CSE programmes that incorporate critical content on gender and power in relationships are more effective in achieving positive sexual and reproductive health outcomes than programmes without this content. However, it is not well understood how these programmes ultimately affect behavioural and biological outcomes. We therefore sought to investigate underlying mechanisms of impact and factors affecting implementation and undertook a systematic review of process evaluation studies reporting on school-based sex education programmes with a gender and power component.

We searched six scientific databases in June 2019 and screened 9375 titles and abstracts and 261 full-text articles. Two distinct analyses and syntheses were conducted: a narrative review of implementation studies and a thematic synthesis of qualitative studies that examined programme characteristics and mechanisms of impact.

Nineteen articles met the inclusion criteria of which eleven were implementation studies. These studies highlighted the critical role of the skill and training of the facilitator, flexibility to adapt programmes to students’ needs, and a supportive school/community environment in which to deliver CSE to aid successful implementation. In the second set of studies ( n  = 8), student participation, student-facilitator relationship-building, and open discussions integrating student reflection and experience-sharing with critical content on gender and power were identified as important programme characteristics. These were linked to empowerment, transformation of gender norms, and meaningful contextualisation of students’ experiences as underlying mechanisms of impact.

Conclusion and policy implications

Our findings emphasise the need for CSE programming addressing gender and power that engages students in a meaningful, relatable manner. Our findings can inform theories of change and intervention development for such programmes.

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Introduction

School-based comprehensive sexuality education (CSE) constitutes a public health intervention, promoted globally, to improve young people’s sexual and reproductive health and well-being. CSE, described by UNESCO as ‘a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality’ (UNESCO, 2018a , p. 16), seeks to equip children and young people with a set of skills, attitudes, and scientifically accurate knowledge to nourish respectful social and sexual relationships (UNESCO, 2018a ). It commonly incorporates a positive notion of sexuality, a holistic understanding of sexual health, and emphasises the sexual rights of young people as a human right (Berglas, 2016 ; Haberland & Rogow, 2015 ; UNFPA, 2015 ). CSE is therefore increasingly considered best practice in sexuality education (Vanwesenbeeck, 2020 ). Footnote 1

CSE is recognised to impact positively on a range of adolescent sexual and reproductive health (SRH) outcomes, including but not limited to the following: knowledge of SRH and human rights, communication skills, sexual and emotional well-being, and attitudes supporting gender equity (Goldfarb & Lieberman, 2021 ; Ketting et al., 2016 ; UNFPA, 2015 ). Systematic reviews have demonstrated that CSE programmes also tend to have positive impacts on knowledge, attitudes, and skills although they often demonstrate weak or inconsistent effects on behavioural outcomes such as sexual risk-taking, number of partners, age at initiation of sex, and condom use (Denford et al., 2017 ; Kirby, Laris, & Rolleri, 2007 ; UNESCO, 2018b ).

CSE is also considered an important tool in efforts to promote gender equality, reduce gender-based violence (GBV) (Miller, 2018 ; UNESCO, 2018a ), including intimate partner violence (Kantor et al., 2021 ; Makleff et al., 2019 ), and in achieving the Sustainable Development Goals (Starrs et al., 2018 ). These efforts are rooted in an understanding that gender inequality, gender norms, and SRH are closely intertwined, with gender inequality and restrictive gender norms contributing substantially to adverse health outcomes, including in the area of SRH (Heise et al., 2019 ). Conceptualising gender as a hierarchical social system differentiating between women and men and commonly ascribing higher power, resources, and status to men and things masculine, Heise et al. argue that gender norms uphold this social system via unwritten rules that define acceptable behaviour for women, men, and gender minorities (Heise et al., 2019 ). These norms act as a powerful determinant of adolescent SRH (Pulerwitz et al., 2019 ). Gender inequality places girls and women at higher risk of gender-based violence, STIs, biological, social and behavioural vulnerability to HIV, and unintended pregnancy (Dellar et al., 2015 ; Heise et al., 2019 ; Park et al., 2018 ; Wingood & DiClemente, 2000 ). Traditional gender norms place adolescents at higher risk of unsafe sex as it affects their ability to negotiate safe sex (Wood et al., 2015 ), whilst masculinity norms can drive risky sexual behaviour in men, including avoiding condom use and contraception (Heise et al., 2019 ).

As adolescence is considered a key developmental phase during which gender norms and attitudes intensify, this period presents a window of opportunity for intervention (Amin et al., 2018 ; Buller & Schulte, 2018 ; Kågesten et al., 2016 ). Therefore, schools and school-based CSE have been argued to constitute key sites to promote healthier gender norms and gender equality at scale (Jamal et al., 2015 ). Whilst the focus of our work is on adolescents, it is increasingly recognised that school-based interventions geared towards younger children and continued through the school trajectory may be very effective in addressing gender norms and roles (Goldfarb & Lieberman, 2021 ).

A systematic review of randomised controlled trials of sexuality education programmes that were not abstinence-only and focused on the prevention of HIV, other STIs, and unintended pregnancies as primary outcomes showed that interventions were more likely to have a positive effect on these three biological outcomes if they explicitly addressed ‘gender and power’ in relationships as compared to interventions that did not include this component Footnote 2 (Haberland, 2015 ). In the review, the gender and power content constituted ‘at least one explicit lesson, topic or activity covering an aspect of gender or power in sexual relationships, for example, how harmful notions of masculinity and femininity affect behaviors, are perpetuated and can be transformed; rights and coercion; gender inequality in society; unequal power in intimate relationships; fostering young women’s empowerment; or gender and power dynamics of condom use’ (Haberland, 2015 , p. 3). In addition to demonstrating the effectiveness of the programmes with gender and power content, Haberland identified four common characteristics of effective programmes: ‘Fostering critical thinking’, ‘explicit attention to gender or power in relationships’, ‘fostering personal reflection’, and ‘valuing oneself and recognising one’s own power’ (ibid, pages 6–7).

As a result of the work of Haberland and others, explicit attention to gender and gender-related power has been incorporated into many CSE programmes, e.g. by incorporating gender norms and power dynamics into the theory of change in CSE programmes (Berglas, 2016 ). Such ‘gender-transformative’ programming considers the roots of gender-based health inequities, incorporates strategies to address these, and ultimately seeks to shift gender relations and norms that contribute to these inequities (Ruane-McAteer et al., 2019 ; World Health Organization, 2011 ). However, whilst there is both a strong rationale and great emphasis on incorporating gender and power content in CSE (UNESCO, 2018a ) and evaluating gender- and power-related outcomes (Haberland & Rogow, 2015 ; UNFPA, 2015 ), these programmes’ pathways of change remain under-researched (Ketting et al., 2016 ; Kippax & Stephenson, 2005 ; Ruane-McAteer et al., 2019 ). In complex public health interventions such as CSE, gender and power components are likely to interact with context and impact on intervention effects in a non-linear manner (Petticrew et al., 2013 ; Rutter et al., 2017 ). Evaluation studies exploring these processes can therefore contribute to understanding how interventions work by elucidating mechanisms of impact, effective implementation strategies, and contextual factors shaping programme outcomes (MRC, 2015 ).

Building on Haberland’s work, we undertook a systematic review of process evaluations of school-based CSE and other sex education programmes with gender and power components targeting adolescents. By sex education, we mean interventions which seek to promote healthy sexual and relationship behaviours, excluding abstinence-only interventions. We sought to gain an in-depth understanding of how inclusion of gender and power content shapes programme implementation and outcomes with the ultimate goal of informing CSE programming by delineating effective implementation strategies and programme characteristics, as well as mechanisms of impact. We synthesised evidence on (i) implementation, (ii) programme characteristics, and (iii) mechanisms of impact.

Search Strategy

Searches for this review were conducted in six scientific databases: Medline, EMBASE, PsycINFO, Web of Science, ERIC, and the Cochrane Library of Systematic Reviews. The search strategy was developed iteratively based on repeated scoping searches and employed the following four concepts: programmes and interventions; sexuality education/schools; gender; power and rights (full search strategy available in online supplementary material ). Synonyms and proximity operators were used to enable identification of studies that were not explicitly labelled as addressing gender and power or as evaluation studies. Additionally, we screened articles referencing the seminal Haberland review ( 2015 ) and its sibling publication (Haberland & Rogow, 2015 ).

Inclusion and Exclusion Criteria

The following inclusion criteria were applied for screening:

Publication date : Studies published from 2013 onwards, as this was the cut-off date for the searches of the seminal review that informed our work.

Population: Adolescents aged 10 to 18.

Intervention: Employing a broad definition of sexuality education, studies were included when reporting on CSE or other programmes with sex education content that included a relevant ‘gender and power’ component according to three criteria: Programmes (a) were labelled as gender-transformative programmes, (b) addressed the social construction of gender, and/or (c) highlighted problems related to gender inequality as structural and not as individual problems.

Setting: Interventions based in schools. Activities set in middle or high schools or reporting on a school curriculum, including after-school programmes.

Study design : Process evaluations and other primary studies that reported data on implementation, context, or mechanisms of impact but were not labelled process evaluations. Thus, we included all kinds of quantitative, qualitative, and mixed methods empirical studies reporting on process.

Programme outcomes : Studies on interventions that were designed to improve biological outcomes (e.g. reduction in unwanted pregnancy, reduction of STIs and HIV), behavioural outcomes (e.g. condom use, age at sexual debut, number of sexual partners, self-efficacy), social outcomes (e.g. equitable attitudes and norms with respect to gender, gender and sexual diversity; communication skills and emotional skills), or knowledge-related outcomes related to SRH were included. This included GBV-related outcomes (e.g. bystander intentions and behaviour, GBV victimisation and perpetration).

Previous work identified ‘gender and power’ content as an important working component in sex education (Haberland, 2015 ). Thus, even if our ultimate aim was to inform CSE programming, we included studies about sex education programmes that were not explicitly labelled as ‘CSE’, as well as other school-based interventions, as long as they included gender and power content meeting the above definition. As it has been demonstrated that a wider range of interventions in the school environment may affect (sexual) health (Shackleton et al., 2016 ), we expected to improve our understanding of the wider social context of the intervention by including a broader set of studies.

The following exclusion criteria were applied:

Publication date : Studies published before 2013 were excluded.

Population: Studies reporting primarily on children in primary school, young adults, and adults were excluded.

Intervention: Studies were excluded when they reported on interventions which did not seek to challenge traditional gender roles and norms and when they demonstrated an understanding of gender as a biological determinant or as a marker of sexual reproductive categories, as opposed to a social construct amenable to change.

Setting: Interventions based outside of schools such as community-based interventions without a school component were excluded.

Study design : Non-peer-reviewed reports, editorials, conference abstracts, study protocols, baseline surveys, opinion papers, dissertations, book chapters, and reviews were excluded. Outcome evaluations were initially included but a decision to exclude these studies was made post hoc in order to focus the scope of this review.

Programme outcomes : Studies reporting on interventions that were targeting educational attainment outcomes or socio-emotional skills only were excluded.

Screening Process

The systematic review software EPPI-reviewer was used for screening (University College London, 2017 ). After piloting and refinement of the screening criteria including double screening of a subset of studies, the first author conducted title and abstract and then full text screening. Items coded as ambiguous were discussed with a second author to reach a consensus.

A cluster-search was performed for evaluation studies of five programmes that were referred to multiple times in screened full-texts but were not represented among included records. Additionally, reference lists of articles included in our review were cluster-searched for sibling publications reporting on the same programmes and a Google and Google Scholar search for the programmes and lead authors of all included articles was performed to identify further relevant process-focused articles (Booth et al., 2013 ).

Assessment of Study Quality

For assessment of study quality, the Critical Appraisal Skills Programme (CASP) checklist for qualitative research was used (Critical Appraisal Skills Programme, 2018 ). It comprises 10 questions that prompt the user to consider potential for bias, along with methodological and ethical issues. We derived scores from these questions to indicate study quality, with a 10 out of 10 indicating high quality. As we were primarily interested in qualitative results, mixed-methods implementation studies were assessed with the CASP checklist for qualitative research as well.

Data Extraction

Data from included studies was extracted into a Microsoft Excel–based data extraction sheet. Study and intervention details, qualitative outcomes, and large sections of text covering process-related aspects (mechanisms of change, context, and implementation (MRC, 2015 )) were extracted comprehensively. Data on process was extracted from the introduction, methods, results, and discussion sections of included studies and it was noted which of these sections the respective data originated from.

Data Analysis and Synthesis

Based on the respective research question asked, the study design, and methods, the included studies were categorised into two mutually exclusive types. One group of studies examined programme implementation, employing quantitative and/or qualitative methods. These studies were reporting data explicitly about intervention implementation, which was defined as ‘the structures, resources and processes through which delivery is achieved, and the quantity and quality of what is delivered’ (MRC, 2015 , p. 10), including contextual factors (Pfadenhauer et al., 2017 ). The second set of studies investigated the impacts on social and behavioural outcomes and underlying processes, employing qualitative methods. These studies had a focus on exploring the links between programme outcomes, programme characteristics, and/or mechanisms of impact. We subsequently refer to the first group of studies as ‘implementation studies’ and to the second group of studies as ‘studies exploring mechanisms of impact’. We conducted two distinct syntheses, one of each of these study types.

Synthesis 1: Data Analysis and Narrative Synthesis of Implementation Studies

The synthesis of implementation studies was informed by the Context and Implementation of Complex interventions (CICI) framework (Pfadenhauer et al., 2017 ). Categories within this framework comprise the implementation agents (individuals concerned with running or receiving an intervention), implementation process, implementation strategies, and context (Pfadenhauer et al., 2017 ). Results from implementation studies were organised into the distinct implementation categories and summarised narratively.

Synthesis 2: Data Analysis and Thematic Synthesis of Studies Exploring Mechanisms of Impact

We conducted a thematic synthesis of qualitative studies exploring programme outcomes, characteristics, and mechanisms of impact (Thomas & Harden, 2008 ). We conceptualised mechanisms of impact as the link between intervention activities and outcomes including ‘[p]articipant responses to, and interactions with, the intervention’ as well as mediators (MRC, 2015 , p. 24).

Data analysis was undertaken at the level of the extracted data: the sections of the data extraction sheet containing data on qualitative outcomes and process from the results and discussion sections of included qualitative studies were analysed thematically. Data excerpts served as the unit of analysis for coding. Codes were developed inductively and subsequently compared across studies and grouped and regrouped together in an iterative process to develop themes, resulting in the development of an initial mindmap. This process was informed by key findings from the preceding synthesis of implementation studies and by the four programme characteristics previously identified by Haberland ( 2015 , textbox 1 ), which shaped our initial understanding of relevant programme aspects of sex education with gender and power content.

Programme Characteristics of Effective Sex Education Programmes Addressing Gender and Power as Identified and Defined By Haberland ( 2015 )

These four previously identified characteristics were compared, contrasted, and linked with the newly developed themes to facilitate differentiation of the new themes as programme characteristics or potential mechanisms of impact. The themes and respective links are visualised in Fig.  2 .

Where we encountered data that was not sufficiently rich to describe mechanisms of impact, we made inferences about potential mechanisms, which are identified as hypothesised mechanisms in the results section.

Searches were run on June 22–23, 2019. Database searches yielded 14,571 records and citation searches yielded 127 records, resulting in a total of 14,698 records (Fig.  1 ). After deletion of duplicates, 9375 records were screened on title and abstract and one additional record was added via intervention-specific searches, yielding 261 records which were screened on full-text. Nineteen reports on 18 studies were included in this review, with two implementation reports addressing the same study.

PRISMA flowchart

Characteristics of Included Studies and Programmes

Eleven studies were process evaluations that focused on programme implementation and employed qualitative or mixed methods. Eight studies were qualitative studies exploring qualitative intervention outcomes, programme characteristics, and mechanisms of impact. Only four of these eight studies were explicitly referred to as evaluation studies. For the majority of included studies ( n  = 17), there was very little concern with study quality (Table 1 ).

The 19 included primary studies were conducted in 15 countries (Table 1 ). Most evidence was from Europe ( n  = 6 countries, 3 studies) and Africa ( n  = 6 studies from six countries), followed by North America ( n  = 4 studies) and Australia ( n  = 4). Most articles reported evaluations of locally implemented programmes targeting boys and girls.

Only five programmes were labelled by the authors as CSE or holistic sex education programmes (Boonmongkon et al., 2019 ; Browes, 2015 ; Chandra-Mouli et al., 2018 ; Rijsdijk et al., 2014 ; Wood et al., 2015 ). Other programmes exhibited key CSE characteristics but were not labelled as such: five articles reported on school-based interventions labelled violence prevention programmes (including dating, domestic, and gender-based violence) (Jaime et al., 2016 ; Joyce et al., 2019 ; Kearney et al., 2016 ; Ollis, 2017 ; Williams & Neville, 2017 ). Four programmes were explicitly called gender-transformative (Jaime et al., 2016 ; Sánchez-Hernández et al.,, 2018 ) or ‘healthy’ or ‘positive masculinities’ programmes (Claussen, 2019 ; Namy et al., 2015 ). Three programmes were sports- or PE-based (Jaime et al., 2016 ; Merrill et al., 2018 ; Sánchez-Hernández et al., 2018 ) and three were focused on critical media literacy or critical thinking related to gender (Berman & White, 2013 ; Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ). In three of these programmes, the gender and power content constituted the only sex education component of the programme (Berman & White, 2013 ; Jacobs, 2016 ; Sánchez-Hernández et al., 2018 ).

Programmers incorporated creative, non-conventional, and innovative teaching methods: participatory methods like role-plays and discussions were utilised in most included studies. Further methods included the following: artwork, dance, drama, film and media production (Berman & White, 2013 ; Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ). Beyond classroom-based intervention components, six studies included activities at the school (Joyce et al., 2019 ; Kearney et al., 2016 ; Namy et al., 2015 ; Williams & Neville, 2017 ) and/or community level (Chandra-Mouli et al., 2018 ; Robertson-James et al., 2017 ).

The gender and power content was delivered across a range of different school subjects, i.e. social studies, PE, home economics, health, science, language, and religious education classes (Boonmongkon et al., 2019 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ; Wood et al., 2015 ). In addition to teacher or facilitator-led programmes, some included peer mentors and student-led initiatives outside of the classroom (Berman & White, 2013 ; Namy et al., 2015 ; Williams & Neville, 2017 ).

Gender and Power Content

Gender and power content was covered at different degrees of depth in included interventions. Whilst addressing gender stereotypes was a common curricular topic, notably fewer interventions included in-depth discussions of gendered relationship power: two addressed the links between gender inequality, relationship power, and GBV (Ollis, 2017 ; Williams & Neville, 2017 ). In addition to discussing gendered power, some programmes included the exploration of other dimensions of power, such as power relationships between students and teachers (Claussen, 2019 ), power in the family context (Chandra-Mouli et al., 2018 ), power in an intersectional framework (Jacobs, 2016 ), and how gender-related power is apparent in the media (Jacobs, 2016 ; Ollis, 2017 ). In most programmes, gender and power content was linked with exercises to encourage personal reflection and critical discussions.

Synthesis 1: Narrative Synthesis of Implementation Studies

Included implementation studies stressed the critical role of the implementation agent and their skill set in delivering sex education. Programmes reported in the implementation studies were delivered by teachers (Boonmongkon et al., 2019 ; Browes, 2015 ; Rijsdijk et al., 2014 ; Wood et al., 2015 ), sports coaches (Jaime et al., 2016 ; Merrill et al., 2018 ), and external facilitators (Claussen, 2019 ). Whole-school approaches were further supported by an external project implementer (Joyce et al., 2019 ; Kearney et al., 2016 ; Robertson-James et al., 2017 ). Whilst reports suggest that teacher-delivered CSE was implemented as intended when teachers participated in high-quality training focused on gender and human rights (Wood et al., 2015 ), teachers who were unprepared to deliver CSE were found to omit relevant programme topics and frame adolescent sexuality as a risk or problem (Boonmongkon et al., 2019 ), reflecting teachers’ values (Browes, 2015 ; Rijsdijk et al., 2014 ). Teacher training for CSE was thus recommended to address both teachers’ knowledge and teachers’ gender attitudes (Browes, 2015 ; Wood et al., 2015 ).

Implementation support from an external change agent was described as instrumental in mainstreaming programme content beyond the classroom, e.g. by addressing gender in school policies, providing gender training to teachers, and undertaking a gender-focused audit and staff surveys (Joyce et al., 2019 ; Kearney et al., 2016 ; Robertson-James et al., 2017 ). The latter were fed back to schools as part of the intervention in one study, thus serving as feedback loops enhancing an overall change process (Kearney et al., 2016 ).

Implementation strategies : In programmes delivered by sports coaches and other external facilitators, non-hierarchical participatory teaching strategies promoted student engagement with intervention content and supported implementation. Engagement was reportedly fostered by creating a safe space and building student-facilitator relationships, with facilitators acting in a non-authoritative, non-judgemental, approachable manner and sharing personal experiences whilst addressing real-life issues (Claussen, 2019 ; Jaime et al., 2016 ; Merrill et al., 2018 ). Programmes facilitated by these ‘adult allies’ (Jaime et al., 2016 ) were often delivered in same-sex groups by same-sex facilitators acting as role-models that encouraged student engagement (Claussen, 2019 ; Jaime et al., 2016 ; Merrill et al., 2018 ). Other implementation strategies included a strong focus on interaction, reflection, and discussion (Claussen, 2019 ; Jaime et al., 2016 ; Merrill et al., 2018 ; Wood et al., 2015 ) and allowing for curricular flexibility to adapt programmes to students’ needs and knowledge (Claussen, 2019 ; Rijsdijk et al., 2014 ). One report suggested that the ‘dose delivered’ in process evaluations of these programmes should consider the degree of student engagement and their relating of programme content to their experiences (Jaime et al., 2016 ).

In terms of implementation context , included studies suggest that CSE programming is likely to be met with contradictory messages from schools, families, and communities (Browes, 2015 ) and sometimes with resistance from diverse actors in these settings (Chandra-Mouli et al., 2018 ), especially in conservative contexts, which could impact on programme implementation. While this may restrain programme effectiveness or may lead to programme adaptations (Browes, 2015 ; Chandra-Mouli et al., 2018 ; Wood et al., 2015 ), studies suggested that the implementation process can be tailored to build support for these programmes: successful approaches included framing the programmes around healthy skills instead of sexuality (Chandra-Mouli et al., 2018 ; Wood et al., 2015 ), getting stakeholder and community buy-in during the programme development phase (Chandra-Mouli et al., 2018 ), and building support networks or enhancing pre-existing networks for the programmes in schools and communities (Joyce et al., 2019 ; Kearney et al., 2016 ; Rijsdijk et al., 2014 ; Robertson-James et al., 2017 ), including with other initiatives that promote gender equality, such as non-governmental organisations providing teacher training (Wood et al., 2015 ).

Synthesis 2: Thematic Synthesis of Studies Exploring Mechanisms of Impact

The qualitative studies reporting on programme outcomes, characteristics, and/or mechanisms of impact primarily reported what happened in the classroom during delivery of eligible sex education interventions, focusing on the learning methods employed, the role of facilitators, and students’ reactions to the sessions. The reported outcomes predominantly constituted observations of students’ classroom behaviour and their comments about the programme and content whilst data on programme impact on SRH outcomes beyond the classroom were limited due to the nature of the included studies. However, our findings identify likely mechanisms of impact on SRH outcomes.

Six themes emerged in our analysis. Three constitute key programme characteristics: (i) student-facilitator relationship-building, (ii) student participation, and (iii) open discussions or ‘dialogues’ integrating student reflection and experience-sharing with critical content on gender and power. Three additional themes represented potential mechanisms of impact: empowerment , meaningful contextualisation of students’ experiences, and transformation of gender norms . Figure  2 depicts the themes and crosslinks, including further relevant programme characteristics identified in a previous review (Haberland, 2015 ).

Overview of programme characteristics (blue boxes) and potential mechanisms of impact (green boxes); light blue boxes represent programme characteristics that were identified in Haberland’s review ( 2015 ); dark blue boxes represent characteristics that were identified in our review

Programme Characteristics

Student-facilitator relationship-building.

Evidence from our thematic synthesis highlighted the importance of the facilitator’s role in building (egalitarian) relationships with students and enabling a teaching atmosphere where open discussions could take place, with codes echoing the factors that facilitated implementation described in the narrative synthesis above, in particular the relevance of safe spaces and facilitators as potential ‘allies’ (Jacobs, 2016 ; Namy et al., 2015 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ). Other important facilitator skills included emotional awareness and a ‘strong awareness of the socially constructed nature of gender’ (Jearey-Graham & Macleod, 2017 ). Across studies, a trusting atmosphere in the class and a confidential, safe space were highlighted as both a result of facilitators’ efforts to build relationships with students and as a prerequisite to successful programming and to the open discussions that emerged as another key theme (Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ; Sánchez-Hernández et al., 2018 ).

Student Participation

Our findings suggest there was a high degree of student participation in included interventions. This included students co-creating the curriculum (Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ) or taking on leadership roles in student initiatives that were linked to the programme, e.g. mentoring of younger students or participation in after-school clubs (Namy et al., 2015 ; Williams & Neville, 2017 ). Programmers noted students’ sense of shared responsibility and their ownership of programme messages (Berman & White, 2013 ; Jacobs, 2016 ; Williams & Neville, 2017 ), whilst students appreciated the opportunity to practice leadership and transferable skills and benefitted from supportive peer networks (Berman & White, 2013 ; Jacobs, 2016 ; Namy et al., 2015 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ).

Open Discussions to Discuss Gender and Power

All programmes but one (Ngabaza et al., 2016 ) were characterised by use of participatory methods, in particular open discussions where gender and power content was discussed critically and where students shared their experiences. The open discussions or ‘dialogues’ (Jearey-Graham & Macleod, 2017 ) served as a venue for students to exercise their curiosity and ask questions about sensitive topics, to be heard and share personal stories, to feel that their experience was validated, and to take on others’ perspectives (Jacobs, 2016 ; Jearey-Graham & Macleod, 2017 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ). In one sports-based programme, ‘boys listening to girls’ enabled participants to recognise gender stereotypes (Sánchez-Hernández et al., 2018 ). Topics invoking emotional responses such as pornography or cheating on a partner were observed as instrumental in fostering students’ critical thinking about gender and power and creating awareness of gender norms and stereotypes (Jearey-Graham & Macleod, 2017 ; Ollis, 2017 ). The use of these open discussions thus went along with course content paying ‘explicit attention to gender and power in relationships’ and content ‘fostering critical thinking’, alongside ‘personal reflection’, the programme characteristics Haberland ( 2015 ) had previously described and which informed our analysis. In addition to critical examination of the status quo, some programmes explored alternative discourses to dominant gender narratives (Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ), including from an intersectional perspective (Jacobs, 2016 ).

Themes Representing Potential Mechanisms of Impact

Empowerment.

Empowerment emerged as a theme that was linked to the three programme characteristics described above, all of which contributed to a shift of power in the classroom: Facilitators’ emphasis on building egalitarian relationships with students, student leadership, enhanced peer support, and open discussions where students make their voices heard are empowering and rebalance otherwise hierarchical relations between students and teachers, representing a disruption of ‘traditional power dynamics’ (Jacobs, 2016 ). In three programmes, students who were involved as student mentors or participated in optional programme retreats displayed the strongest ownership of programme messages and experienced the greatest programme effects (Berman & White, 2013 ; Namy et al., 2015 ; Williams & Neville, 2017 ), demonstrating the link between enhanced student participation, empowerment, and outcomes. This resonates with the synthesis of implementation studies, which demonstrated that intervention activities taking place outside of the classroom, such as whole-school approaches, and interventions including the wider community, were found to enhance implementation. These interventions may lead to a change of hierarchies and relationships at a broader contextual level and further strengthening of student empowerment.

The empowerment theme corresponds with what Haberland coined ‘valuing oneself and one’s own power’, the acknowledgement of students’ own power as change agents (Haberland, 2015 ). We therefore hypothesise that student empowerment constitutes one mechanism of impact: sex education taught in an egalitarian, participatory manner may empower students to adapt attitudes and norms, enhance self-efficacy, and ultimately influence behaviour and SRH outcomes beyond the classroom.

Meaningful Contextualisation of Students’ Experiences and Transformation of Gender Norms

Across most included studies, open discussions and other participatory methods were utilised by facilitators to connect students’ reports of their own experiences with broader societal topics, including gender and power. Authors report that these participatory methods increased critical thinking and critical awareness of harmful gender norms, gender inequality, and GBV (Berman & White, 2013 ; Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ; Ollis, 2017 ; Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ). Enhanced non-violent attitudes, willingness to change (Namy et al., 2015 ), and improved class climate (Sánchez-Hernández et al., 2018 ; Williams & Neville, 2017 ) were described as further outcomes of the programmes.

In addition to reporting positive outcomes attributed to the participatory methods and critical discussions of gender and power content, authors also reported that the personalisation of programme content resonated strongly with students (Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ; Ollis, 2017 ) and that students identified the questioning of dominant beliefs as a crucial step towards behaviour change (Namy et al., 2015 ).

The open discussions thus served as a forum in which personal reflection and sharing of personal experiences made the sex education content more relevant and relatable for students, while programmes’ explicit focus on gender and power enabled critical examination of the patriarchal societal context of those experiences, especially unequal power in relationships, rigid gender norms, and gender stereotypes. Thus, evidence from our review points towards two interlinking mechanisms of impact: The first is meaningful contextualisation of students’ experiences, which highlights the importance of personalisation of programme messages to support students in developing an understanding of the societal context of their sexual and romantic relationships. This is closely linked with the second mechanism, transformation of gender norms. As Namy et al. ( 2015 ) observed, intervention participants showed an increased appreciation of ‘multiple masculinities’ and demonstrated willingness to change when they recognised personal identification with harmful masculinities. This shows an initial shift in gender norms and illustrates its link with the contextualisation of students’ experiences, as well as empowerment. It further suggests that discussing alternatives to dominant norms may expand the range of possible behaviours beyond traditionally gendered behaviours (Jearey-Graham & Macleod, 2017 ), enabling behaviour change that ultimately affects SRH outcomes.

Interaction of Mechanisms of Impact

At the same time, the use of participatory learning methods, in particular open discussions, encouragement of student participation, and egalitarian relationships of students and facilitators lead to a palpable shift in power in hierarchical school environments, complementing students’ theoretical discussions and reflections with a lived and embodied experience of empowerment. Based on this link and other connections between mechanisms as outlined above, we hypothesise that the mechanisms empowerment, meaningful contextualisation of students’ experiences, and transformation of gender norms act synergistically, build upon each other, and influence one another in affecting students’ behaviours and ultimately SRH outcomes (Fig.  2 ).

Unintended Effects

Included studies also highlighted that sex education with gender and power content may leave entrenched norms unchanged, in particular when student exposure to the programme was limited to only a few classroom sessions (Jearey-Graham & Macleod, 2017 ; Namy et al., 2015 ), and that teachers at times reinforced gender stereotypes (Ngabaza et al., 2016 ), resonating with similar findings from the implementation studies.

Nineteen studies met the inclusion criteria of this process-focused systematic review of school-based sex education programmes addressing gender and power. The review found that gender and power content was incorporated and operationalised differently in a diverse range of programmes. Implementation studies highlighted the importance of high-quality facilitator training, flexibility to adapt programmes to students’ needs, and building support for sex education programmes among school and local communities. We found that (i) student participation, (ii) student-facilitator relationship-building, and (iii) open discussions integrating student reflection and experience-sharing with critical content on gender and power constituted important programme characteristics that data suggest contribute to programme effectiveness. Evidence from our thematic synthesis suggests that linked to these intervention characteristics meaningful contextualisation of students’ experiences, empowerment, and transformation of gender norms may constitute mechanisms of impact that ultimately affect SRH outcomes.

Results in Context

Focusing on both CSE and other sex education interventions that include critical content on gender and power enabled comparisons across studies to enhance our understanding of how sex education with this component works. To place these results in context, we draw on the broader literature of CSE evaluation and the theoretical literature on sex education theory, empowerment, and critical pedagogy.

• Implementation

Our narrative synthesis of findings from implementation studies largely corresponds with other summaries of aspects that facilitate intervention implementation and engagement with CSE, e.g. regarding the importance of educator training and skill, support from external facilitators, non-hierarchical participatory teaching methods to engage students in intervention activities, and a supportive school and community context (Kirby et al., 2007 ; UNESCO, 2018a ; Vanwesenbeeck, 2020 ). These other reviews have further emphasised the critical role of an enabling school environment and multicomponent approaches for CSE implementation (UNESCO, 2018a ; Vanwesenbeeck, 2020 ).

Whether teachers or external facilitators are best placed to deliver CSE is an area of active debate. For example, in a UK-focused overview of best-practices in sex and relationships education (SRE), students deemed teachers unsuitable to deliver SRE whilst teachers and SRE professionals considered teacher-led SRE to be the most sustainable model long-term (Pound et al., 2017 ). This is reflected in our review where studies involving outside facilitators appeared to be pilot or one-off projects, or required substantial resources (e.g. Jaime et al., 2016 ; Joyce et al., 2019 ; Kearney et al., 2016 ; Williams & Neville, 2017 ). However, our results suggest that programmes were generally more successful in empowering students and engaging them in a meaningful way when implemented by an outside facilitator. Pound et al. argue that one of the challenges of teachers implementing SRE is the breeching of boundaries between teachers and students, which may be less of a problem when outside facilitators are involved (Pound et al., 2016 ). Given that the overall importance of the skill level of the teacher or facilitator for achieving positive programme effects has been strongly emphasised, it remains somewhat unclear to which extent programme ‘success’ can be attributed to the programme content as opposed to the skill level of the implementing agent, in particular with respect to addressing gender and power and facilitating participatory sessions. Whilst this may present an avenue for further research work, it is promising that authors in one implementation study included in our review argued that high-quality teacher training would enable teachers with previously limited CSE teaching skills to implement progressive sex education programmes as intended (Wood et al., 2015 ).

Hypothesised Mechanisms of Impact

In our thematic synthesis, empowerment of students emerged as a likely mechanism of impact on SRH outcomes. This is not unexpected, as empowerment is central to many CSE programmes (UNFPA, 2015 ; Vanwesenbeeck, 2020 ) and constitutes a key strategy in health promotion more generally (Laverack, 2004 ). In sex education, student empowerment is theorised to expand the range of ‘sexual or gendered subject positions’ (Jearey-Graham & Macleod, 2017 ), thus enabling health-promoting attitudes, practices, and behaviours, including sexual agency (Fields, 2008 ; Jearey-Graham & Macleod, 2017 ). Our findings suggest that fostering student engagement and egalitarian relationships in the classroom, as well as open discussions allowing students to share experiences and feel validated, led to a shift of power in classrooms and contributed to this mechanism. However, empowerment may be easier envisioned than enacted. Jessica Fields argues that even staunch CSE advocates tend to fall short of embracing the transformative and empowering potential of CSE. By resorting to narratives of danger, they eschew positive messaging that builds on students’ existing sexual knowledge, encourages sexual agency, and equips them to deal with the social challenges that are intertwined with sexuality (Fields, 2008 ). This is echoed by other authors who observe that even in the most progressive contexts sex education teachers fail to achieve a shift in power hierarchies that would enable student empowerment (Naezer et al., 2017 ; Sanjakdar, 2019 ). Thus, while our findings suggest student empowerment is a mechanism of impact that may ultimately affect adolescent SRH, this mechanism likely requires a very facilitative context and skilled implementer.

The second potential mechanism of impact we identified was meaningful contextualisation of students’ experiences, facilitated by open discussions that provided a forum for critical thinking on gender and power and personal reflection. Open discussions as interactive learner-centred approaches are emphasised in CSE guidance (UNESCO, 2018a ), desired by students (Pound et al., 2017 ), and theorised to make CSE relevant for the diverse and heterogeneous SRH needs of adolescents (Engel et al., 2019 ). Similarly, our analyses highlight their central role in CSE programming with gender and power content. Beyond ensuring that programmes are relevant for individual students, open discussions that include critical content on gender and power also address the societal dimensions of sex and relationships, enabling meaningful contextualisation of students’ experiences in particular in relation to gender inequality, and harmful gender norms. As Jessica Fields powerfully states, ‘Sex education offers students an opportunity to grasp sexuality’s place in the context of gender, racial and class inequalities […]’ (Fields, 2008 ). Ensuring that programmes are linked to the social environment of participants’ lived realities is understood to make SRH interventions more effective (Wingood & DiClemente, 2000 ).

The power of the interactive discussions led one group of authors in our review to conclude that students needed these open ‘sexuality dialogues’ more than what’s conventionally understood as sexuality education (Jearey-Graham & Macleod, 2017 ). The term ‘dialogues’ originates from critical pedagogy (Sanjakdar et al., 2015 ). In this framework, schools are understood as sites that reinforce existing social systems and power structures—which critical pedagogy seeks to counter (Sanjakdar et al., 2015 ). This approach is a democratic, joint process of knowledge creation that drives on student voice and curiosity, with teachers encouraging questioning and critical thinking via ‘dialogic teaching’ (Sanjakdar, 2019 ; Sanjakdar et al., 2015 ). The critical pedagogy framework thus incorporates the programme characteristics and mechanisms we identified, including the disruption of traditional power dynamics which was linked to our empowerment mechanism. A critical pedagogy approach in CSE may therefore facilitate a better understanding of the operationalisation of these mechanisms in educational systems and improve programme implementation.

Systematic review evidence suggests that gender-transformative programmes seeking to improve diverse SRH outcomes impact behaviour more effectively than programmes without this approach (Barker et al., 2010 ). Interventions addressing gender norms were identified as most promising in addressing a multitude of risk factors to reduce violence against women and girls (VAWG) (Jewkes et al., 2015 ). In our review, whilst transformation of gender norms emerged as a potential mechanism in our thematic analysis, only few included studies reported using an explicit gender transformative approach, defined as approaches including ‘strategies to foster progressive changes in power relationships between women and men’ by WHO ( 2011 ). This reflects findings from a systematic review of reviews on engaging boys and men in SRH programming that reported an overall dearth of gender transformative programmes (Ruane-McAteer et al., 2019 ). Programmes to prevent VAWG and those set in low- and middle-income countries were most likely to be gender transformative compared to programmes targeting other SRH outcomes (Ruane-McAteer et al., 2019 ), suggesting that the potential of a gender transformative approach has not yet been harnessed across the educational programming seeking to improve adolescent SRH. Our findings also highlight a barrier to implementation of gender transformative programming: programme implementation is highly dependent on implementation agents whose values and skills influence implementation and may reproduce gender stereotypes, thus maintaining gender relations (Boonmongkon et al., 2019 ; Browes, 2015 ; Ngabaza et al., 2016 ; Rijsdijk et al., 2014 ).

Strengths and Limitations

This review employed a broad and comprehensive search strategy across six databases and supplemental searches to include a wide range of studies. Inclusion of studies from 15 countries across diverse world regions may support transferability of our findings across contexts. Whilst we were interested in understanding how gender and power content would work in CSE, which is considered best practice in sexuality education, we included other sex education and school-based programmes with relevant gender and power components to broaden our understanding, in particular on potential mechanisms of impact. Since all included studies still contained relevant CSE content, we are confident that our conclusions are applicable for CSE programming. Similarly, we included studies that reported relevant data on the intervention process but were not strictly process evaluations in order to draw on a larger body of evidence. These decisions led to some ambiguity at the screening stage and heterogeneity among included studies but ultimately enhanced the findings in this work, especially the thematic synthesis.

This review also has limitations. Additional cluster-searching, repeated iterative searches, snowballing, inclusion of grey literature (Booth et al., 2013 ), and inclusion of studies published in languages other than English may have identified additional eligible studies but were beyond the scope of this review. Relevant studies may have been excluded based on programme descriptions, which were often limited in screened reports (Ruane-McAteer et al., 2019 ). Nevertheless, included studies reported a wide range of observations and reinforced key findings across studies, suggesting that included studies provide reliable insights to support implementation of CSE programmes with gender and power content among adolescents.

Implications for Policy, Practice, and Research

Whilst our synthesis does not allow for causal inference on mechanisms of impact that describe how school-based CSE interventions with a gender and power component ultimately impact adolescents’ SRH outcomes, the evidence suggesting empowerment, meaningful contextualisation of students’ experiences, and transformation of gender norms as relevant mechanisms correspond with the theoretical literature and existing empirical evidence. These mechanisms are facilitated by student participation, open discussions, and student-facilitator relationship-building and rely on skills of facilitators and a supportive context for effective intervention delivery.

This research can thus contribute to the growing body of literature to inform programme design, adaptation, transferability, and the evaluation of interventions to improve adolescent SRH. The mechanisms identified in this review can inform future research in which they are empirically tested and refined, for example through linked, rigorous outcome and process evaluations investigating the pathways to change of how sex education programme content impacts on the multiplicity of SRH outcomes, which constitutes a gap in the current literature. Furthermore, as it is considered best practice to guide intervention design, implementation, and the evaluation of complex interventions such as CSE by a relevant theory of change (De Silva et al., 2014 ; Moore & Evans, 2017 ), our results can inform the evaluation of ongoing programmes and inform the theory of change of future programmes—which is currently not often made explicit in interventions to improve SRH (Ruane-McAteer et al., 2019 ). Our review identified only one study which incorporated an explicit focus on complexity into the evaluation of school-based CSE (Joyce et al., 2019 ; Kearney et al., 2016 ). Their results suggest that feedback loops and the evaluation itself may have an important effect on programme implementation and outcomes and should be considered in future intervention planning and theories of change (Kearney et al., 2016 ).

In the field of knowledge co-production in public health research, co-produced (research) knowledge has long been argued to be more relevant to research users, empower communities, increase the chance of research uptake, and to ultimately affect health outcomes, but evidence supporting this has been scarce (Oliver et al., 2019 ). Whilst preliminary, our findings elucidate how the non-hierarchical, discussion-based co-production of knowledge on gender, sex, and relationships in sex education interventions makes this knowledge more relevant to participants, which may inform other interventions employing co-production approaches as part of an intervention in SRH and other public health fields.

Whilst not discussed in depth, our results also show that sex education with gender and power content does leave some entrenched norms unchanged (Namy et al., 2015 ; Ngabaza et al., 2016 ), calling for wider efforts targeting these norms. This should include interventions starting at a much younger age, that is before gender norms and roles become ingrained, continuing through childhood and adolescence (Goldfarb & Lieberman, 2021 ), and reaching beyond the classroom, including components targeting the broader school environment (Denford et al., 2017 ; Vanwesenbeeck, 2020 ). Further evidence suggests that school-based interventions should be coupled with interventions targeting social contexts outside of school, where both policies and community-wide interventions are needed to improve access to youth-friendly SRH services, address discriminatory practices, and support equitable gender norms at scale (Denford et al., 2017 ; DFID PPA Learning Partnership Gender Group, 2015 ; Starrs et al., 2018 ).

Data Availability

Search strategies are available as online supplementary material .

Code Availability

Not applicable.

Whilst CSE may be considered best practice in sex education, this label is not consistently used (Haberland, 2015 ). We therefore consider literature on sex education programmes without the CSE label as potentially relevant to inform CSE programming, as long as programmes are not abstinence-only.

We consider content on ‘gender and power’ as defined by Haberland as one component of sex education interventions and will use the terms content and component interchangeably throughout this article.

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Sell, K., Oliver, K. & Meiksin, R. Comprehensive Sex Education Addressing Gender and Power: A Systematic Review to Investigate Implementation and Mechanisms of Impact. Sex Res Soc Policy 20 , 58–74 (2023). https://doi.org/10.1007/s13178-021-00674-8

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Article Contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Description of moderator variables

Effect sizes of studies

Tests of categorical moderators for abstinence

Weighted least-squares regression and test of model specification

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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.

Reviewed by:

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]

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Sex Education: Level of Knowledge and Its Effects on the Sexual Behavior and Opinions Among the Government Senior High School Students of Vigan City SY 2018-2019

James Alexander Gordon on 6th November 2019

The Philippines, being a Christian country, finds Sex Education a sensitive topic to discuss with. But, with the increasing cases of pregnancies, sexually-transmitted diseases and other forms of sexually-related violence, the Philippine government raised their vote to integrate and teach sex education in the curriculum. After recognizing the vital role of education on the rising incidences of early pregnancy, sexual violence and human immunodeficiency virus (HIV) infection among youth, a DepEd Order was passed to include sexuality education in order to mandate the provision of an age appropriate reproductive health education for adolescents. The main objective is to elicit the baseline information of students on Sex Education and to give a background on their current sexual knowledge, behaviors and opinions. This study used quantitative method specifically, non-experimental descriptive-correlational research design. A questionnaire that underwent validation and reliability testing was utilized as a form of instrumentation. Out of the 846 respondents, 19.15% already tried engaging in sexual intercourse, most of which having 1-2 sexual partners (10.99%), with the usual age of 16 years old (6.74%). Respondents prefer masturbation over vaginal, oral or anal sex and those who had sexual experience are embarrassed buying contraceptives. The extent of Cumulative Sexual Education information gained by the students is generally “low” and their Sexual Knowledge and Sexual Opinion are at “average” level. The extent of Sexual Behaviors of those who don’t have sexual experience is “low” but “average” among those who already had experience. However, gender orientation shows significant difference in their sexual behavior.

This paper is part of the SEACE2020 Conference Proceedings ( View ) Full Paper View / Download the full paper in a new tab/window