The scientific literature is replete with evidence that quality, comprehensive, and rights-based sexuality education delays the commencement of sexual activity and unprotected intercourse.

YOUNG people account for a disproportionate burden of global sexual and reproductive ill health, viz: the number one killer of young women is pregnancy and childbirth related causes; 45% of all new HIV infections occur in those aged between 15 and 24 years; and there are about 500,000 new curable sexually transmitted infections occurring in young people every day.

The Malaysian data is nothing to shout about. It has been reported that statistics from the Registration Department between 2000 and 2008 showed that there were 257,411 newborns without fathers, i.e. the birth certificates did not have their fathers’ names. This translates to an average of 78 babies born out of wedlock daily during the last nine years.

The number of abandoned babies appears to be increasing as well. The Social Welfare Department recorded 407 abandoned babies in the past five years. Police statistics reveal an average of 100 cases annually. Recent media reports that some of the newborns have been left to die are distressing.

Some policymakers and regulators need to recognise and accept that sexuality education is based on scientific evidence and promotes a positive approach to sexuality that has been proven to be effective in the making of safe and healthy sexual choices by young people in many countries.

The percentage of females infected by HIV increased from 1.2% of the total number in 1990 to 19.1% in 2008. No female had AIDS in 1990 but 15.5% of AIDS victims in 2008 were female. Heterosexual transmission increased from 4.8% in 1990 to 16.6% in 2008 for HIV infections and 29.6% for AIDS. Vertical transmission, i.e. mother to newborn, was first reported in 1991. By 2008, the number of vertical transmission cases totalled 742 (0.9%) for HIV and 186 (1.3%) for AIDS.

Various local data also indicate that many young and unmarried Malaysians are already having sex. The decrease in the age of menarche and the increase in the age of marriage, together with socioeconomic changes, may have contributed to this trend.

There has been much public debate recently about the social ills affecting young people, particularly in relation to unintended pregnancies. This has resulted in the dumping of, and also injuries to, newborns, some to the extent of causing death. However, there has been little mention of abuse, violence, and sexually transmitted infections, including HIV/AIDS in this debate.

The debate about sexuality education is one that I have heard almost all my adult life. Denial and fear are the common threads running through much of the debate. There have also been several occasions when pious and emotional statements have been made. It appears from the many statements made that the onus of responsibility of providing sexuality education to our young rests with someone else.

The young bear a disproportionate burden of sexual and reproductive ill health because they have not received adequate preparation, leaving them vulnerable to coercion, abuse, exploitation, unintended pregnancy, and sexually transmitted infections, including HIV/AIDS.

The scientific literature is replete with evidence that quality, comprehensive and rights-based sexuality education delays the commencement of sexual activity and unprotected intercourse, decrease the number of sexual partners, and increase the use of contraceptives and condoms, all of which contribute to a decrease in the incidence of unintended pregnancies and sexually transmitted infections in young people.

This article was written from a doctor’s perspective, one who has been in active medical practice encountering enormous challenges in managing the consequences of society’s failure in providing sexuality education for the young.

Sexual development

The sexual development of an individual starts in infancy. When infants develop control of their upper limbs, many males can be observed touching their genitalia, before they can talk! Many toddlers learn and recognise the differences between male and female.

An individual’s sexual development is a complex process that involves physical, psychological, social, and cultural dimensions. It is also linked to the development of one’s individual identity. Parents or caregivers inculcate the growing child with values, including that of gender and sexuality. The growing child asks many innocent questions about gender and sexuality, which many parents are often reluctant to answer or discuss because of a variety of factors, including ignorance, discomfort, or cultural norms.

There are physical and social changes at the time of puberty for males and females. Many thirst for knowledge about gender and sexuality. If parents do not provide the information and values, these are acquired from alternative sources, e.g. from teachers, peers, and the print and electronic media.

Values that are the foundations for healthy and safe sexual and social relationships in adult life like respect, responsibility, and reciprocity are acquired and developed in childhood and at puberty. For these values to take root, they need reinforcement.

Schools play a vital role in preparing children and young people for their roles and responsibilities as adults. Young people have to be equipped with the necessary knowledge and skills to make responsible choices in their social and sexual lives.

Young people who do not possess the skills and knowledge face threats to their lives and health. They include health risks associated with unintended pregnancy, sexually transmitted infections including HIV/AIDS, abusive relationships, and domestic violence. In this respect, comprehensive sexuality education has a crucial role to play.

Defining sexuality education

There is more than one definition of comprehensive sexuality education (CSE). The definition by the International Planned Parenthood Federation (IPPF) is succinct and simple. It states that “A rights-based approach to CSE seeks to equip young people with the knowledge, skills, attitudes, and values they need to determine and enjoy their sexuality – physically and emotionally, individually, and in relationships”. It views “sexuality” holistically and within the context of emotional and social development. It recognises that information alone is not enough. Young people need to be given the opportunity to acquire essential life skills and develop positive attitudes and values.

CSE must help young people to:

·Acquire accurate information on sexual and reproductive rights; information to dispel myths; references to resources and services.

·Develop life skills such as critical thinking, communication, and negotiation skills, self-development skills, decision making skills; sense of self; confidence; assertiveness; ability to take responsibility; ability to ask questions and seek help; empathy.

·Nurture positive attitudes and values open-mindedness; respect for self and others; positive self worth/esteem; comfort; non-judgmental attitude; sense of responsibility; positive attitude toward their sexual and reproductive health.

CSE covers a broad range of issues relating to both the physical and biological aspects of sexuality, and the emotional and social aspects. It recognises and accepts all people as sexual beings and is concerned with more than just the prevention of disease or pregnancy. CSE programmes should be adapted to the age and stage of development of the target group.

In short, CSE have objectives that are mutually reinforcing, i.e. it increases knowledge, explains feelings, values, and attitudes, develops skills, and promotes and sustains behaviour that reduces risk.

The content of sexuality education has to be based on the principle of age-appropriateness. Sexuality education includes a variety of relationships, and not just sexual relationships.

Components

The United Nations Educational, Scientific and Cultural Organisation (UNESCO) and the Joint UN Programme on HIV/AIDS (UNAIDS) have issued an evidence-informed international technical guidance on sexuality education. The learning objectives are to “provide accurate information about topics that children and young people are curious about and about which they have a need to know; provide children and young people with opportunities to explore values, attitudes, and norms concerning sexual and social relationships; promote the acquisition of skills; and encourage children and young people to assume responsibility for their own behaviour and to respect the rights of others”.

The learning process has four components, i.e. information; values, attitudes, and social norms; interpersonal and relationship skills; and responsibility. The topics are organised around six key concepts, i.e. relationships; values, attitudes, and skills; culture, society and human rights; human development; sexual behaviour; and sexual and reproductive health.

The topics in the concept of relationships are families; friendship, lovem and romantic relationships; tolerance and respect; and long-term commitment, marriage, and parenting.

The topics in the concept of values, attitudes, and skills are values, attitudes, and sources of sexual learning; norms and peer influence on sexual behaviour; decision-making; communication, refusal, and negotiation skills; and finding help and support.

The topics in the concept of culture, society, and human rights are sexuality, culture, and human rights; sexuality and the media; the social construction of gender; and gender-based violence including sexual abuse, exploitation, and harmful practices.

The topics in the concept of human development are sexual and reproductive anatomy and physiology; reproduction; puberty; body image; and privacy and bodily integrity.

The topics in the concept of sexual behaviour are sex, sexuality, and the sexual life cycle; and sexual behaviour and sexual response.

The topics in the concept of sexual and reproductive health are pregnancy prevention; understanding, recognising, and reducing the risk of STIs, including HIV; and HIV and AIDS stigma, care, treatment, and support.

Needless to say, the content of the various topics are age-appropriate and in tandem with the evolving learning capacity of the child, i.e. basic information provided to children in primary school is expanded and built upon when the children advance to secondary school.

Concerns

Concerns raised about comprehensive sexuality education have to be addressed and there is no better way than with research evidence. Some of the major concerns are addressed below.

·Sexuality education leads to early sex – The evidence clearly indicate that it is rare, if ever, that sexuality education leads to early sexual initiation. Sexuality education leads to more responsible sexual behaviour and later sexual initiation, or it may have no discernible impact on sexual behaviour.

·Sexuality education is against certain cultures or religions – All guidelines emphasise the need for cultural relevance and local adaptations. The major stakeholders, including parents and religious leaders, have to be involved in the development of the form of sexuality education.

However, social norms and harmful practices which are not in consonance with human rights and increase vulnerability and risk of young people, especially girls and young women, have to be reviewed and changed.

·Sexuality education may be good for young people, but not for young children – The content of sexuality education has to be based on the principle of age-appropriateness. Sexuality education includes a variety of relationships, and not just sexual relationships.

Young children are aware of and recognise these relationships years before they act on their sexuality. They need the skills to understand their bodies, relationshipss and feelings.

Sexuality education prepares the foundations, e.g. by learning the correct names for parts of the body, exploring family and interpersonal relationships, and learning about safety, which can then be built upon progressively as the child develops and grows.

·Parental objection to sexuality education being taught in schools – Parents and caregivers have a pivotal role in the shaping of their children’s sexual identity and their social and sexual responsibilities. Schools can complement and supplement the parents’ role. In addition, it can fill in the gaps and address any misperceptions and misinformation learnt from parents and caregivers.

The objective of sexuality education is to enable young people to develop the values, skills, and knowledge to make informed and responsible choices in their social and sexual lives.

·Teachers may be willing to teach but are uncomfortable or lack the skills to do so – Well-trained, supported, and motivated teachers play a key role in the delivery of good quality sexuality education.

Abstinence

It is usual for the detractors of sexuality education to advocate abstinence as the only appropriate approach for young people. The reality is that there are many sexually active young people. An abstinence approach would deny them of knowledge and skills, leaving them exposed to the consequences of risky sexual behaviour, i.e. unintended pregnancies and sexually transmitted infections including HIV/AIDS and its consequences.

In addition, an abstinence-only approach would undermine and deny young people of their right to enjoy the highest attainable health, including sexual and reproductive health.

The majority of young people who choose abstinence would, in due course, become sexually active. They will still need the knowledge and skills provided in sexuality education programmes. As abstinence means different things to different individuals, young people may engage in other sexual practices that may expose them to sexually transmitted infections, including HIV/AIDS, e.g. anal sex. Furthermore, abstinence is not an option for young people who are married.

The results of the abstinence messages are obvious in many countries in sub-Saharan Africa, where there are many households that comprise and grandparents and children, with the parents having succumbed to HIV/AIDS.

Parents and caregivers

Parents and caregivers are in a unique position to provide sexuality education to children and young people. They have a golden opportunity to impart to children and young people the values that are the foundations for healthy and safe sexual and social relationships in adult life like respect, responsibility, and reciprocity.

If parents do not fulfill their responsibilities, children and young people acquired the information and values from alternative sources, e.g. from teachers, peers and the print and electronic media.

There is a need for some parents to realise that sexuality education does not promote sexual promiscuity.

The global evidence is that it delays sexual activity and promotes safer sexual behaviour. Sexuality education prepares children and young people to become healthy and sexually responsible adults.

There may be situations when difficult and sensitive issues about sexual and reproductive health and sexual relationships are raised by children and young people. Sexuality education would provide the necessary support when parents discuss such issues with their children.

Teachers

Some teachers need to recognise that sexuality education has a vital role in the promotion of sexual and reproductive health and rights and the prevention of sexually transmitted infections, including HIV/AIDS and unwanted pregnancies. Age-appropriate information helps in the development of values that supports self development and self esteem, which in turn, contributes to a positive approach to health. Children and young people need knowledge and skills to make healthy and positive choices in their sexual and reproductive health.

There has to be clearly defined minimum standards and teaching objectives with the necessary resources provided. The implementation of sexuality education has to be continually monitored and evaluated.

Policymakers

Some policymakers and regulators need to recognise and accept that sexuality education is based on scientific evidence and promotes a positive approach to sexuality that has been proven to be effective in the making of safe and healthy sexual choices by young people in many countries. It integrates health, cultural, moral and social issues which contribute to the positive sexual development of children and young people.

There are few fundamental questions that society has to address. How many more abandoned babies and fatherless children do we want to read about? What is the acceptable number of young people with HIV/AIDS?

When will positive and firm action be taken? Will there be action when the disease burden of HIV/AIDS and unintended pregnancies reach epidemic proportions?

The technology is there, but is there a will to address a pressing issue before it becomes overwhelming?

Source: Dr Milton Lum