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

Associated data.

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

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

1. Introduction

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

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

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

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

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

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

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

2. Methodology

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

(2) To summarize evidence relating to effectiveness.

2.2. Methods

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

2.3. Search Strategy

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

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

2.4. Inclusion Criteria

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

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

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

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

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

2.5. Exclusion Criteria

Reviews were excluded if:

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

2.6. Risk of Bias and Assessment of Study Quality

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

2.7. Data Synthesis

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

3.1. Results of Search

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

3.2. Risk of Bias in Included Studies

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

3.3. Reviews Included

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

3.3.1. Setting

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

3.3.2. Population

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

3.3.3. Interventions/Types of Study

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

3.3.4. Outcomes

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

3.3.5. Country of Review

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

3.3.6. Year of Last Paper Included

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

3.3.7. Search Tools

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

3.3.8. Multicenter Studies and Number of Studies Included

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

3.3.9. Number of Reviews Covered That Include Meta-Analysis

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

3.4. Effectiveness

3.4.1. school settings.

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

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

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

3.4.2. Online Platforms

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

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

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

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

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

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

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

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

3.4.3. Blended Learning

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

4. Discussion

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

4.1. Interventions Reviewed

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

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

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

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

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

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

4.2. Effectiveness

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

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

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

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

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

4.3. Limitations

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

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

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

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

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

5. Conclusions

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

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

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

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

Search Terms Used.

Description of studies.

Characteristics and main results of the studies included.

Evaluation of the studies included (AMSTAR II).

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

Author Contributions

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

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare that they have no conflicts of interest.

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

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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.

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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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• least-squares analysis
• sex education

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“But Everything Else, I Learned Online”: School-Based and Internet-Based Sexual Learning Experiences of Heterosexual and LGBQ + Youth

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• Volume 46 , pages 461–485, ( 2023 )

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A Correction to this article was published on 06 December 2023

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Building upon scholarship on sex education, our research aims to understand how youth with a range of sexual identities have experienced school-based sex education, how they have explored sexual content online, and how they see the two in relation to each other. We thus ask: (1) How do youth with varied sexual identities recall experiencing formal school-based sex education from elementary through high school offerings? (2) How do heterosexual and LGBQ + youth utilize the Internet and social media sites for sexual learning? Through in-depth interviews with college students, we find that heterosexual and LGBQ + youth report that formal sex education was both limited and heteronormative; LGBQ + youth felt particularly unprepared for sexual experiences and health hygiene, and sometimes found ways to translate the information provided for their own needs. Despite some overall similarities in online sexual explorations, experiences of online sexual learning proved quite divergent for youth of different sexual identities. Heterosexual youth were likely to search for information on sexual pleasure and entertainment; in contrast, LGBQ + youth sought information to fill in knowledge gaps about non-conforming sexualities, and often used the digital space for identity discovery, confirmation, and affirmation. For both groups, online explorations interacted with offline ones through a back-and-forth in which youth tested out in one arena what they had learned in the other. These findings highlight the dynamic interaction between formal school curriculum, informal online sexual learning, and sexual scripts, identities and practices.

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Contraceptives and stuff like that I think I learned mostly through sex ed class. But everything else, I learned online. Anal sex, learned online. Oral sex and the details about that, learned online. Self-pleasure, masturbation, learned that online. Histories of queer communities, different sexualities and gender identities, learned online. Different ways that queer communities engage in sex, learned it online. Everything except penis-penetration type of sex, I learned everything else online. Everything. – Abby (age 20, Latinx, queer, non-binary)

Our research aims to understand how youth with a range of sexual identities have experienced school-based sex education, how they have explored sexual content online and how they see the two in relation to each other. It emerges from a recognition that while the existing literature on sex education is well developed, the research on sexual learning online is less robust. In particular, we know little about how school-based and Web-based sexual learning experiences differ for youth with non-normative sexual and gender identities and those who identify as straight. We also know little about the interaction between school-based and online sexual learning.

In this study, based on in-depth interviews with 56 college students from a variety of backgrounds and identities, we ask: (1) How do youth with varied sexual identities recall experiencing formal school-based sex education from elementary through high school offerings? (2) How do heterosexually-identified and LGBQ + -identified youth utilize the Internet and social media sites for self-discovery and for acquiring information not offered in their formal sex education curriculum, and how do they assess that information?

Bridging and building upon the scholarship on LGBQ + student experiences (Beattie et al. 2021 ) and on formal and informal sex education, we find that while both heterosexual and LGBQ + youth report that formal sex education was both limited and heteronormative, their experiences of online sexual learning are quite divergent. Largely excluded from their school’s sex education curriculum, LGBQ + youth often seek online content related to their identity or imagined partners and practices—in ways that may be both affirming and confusing. This dynamic points to ways the reform of school-based sex education remains significant, despite its diminished role as an information source (Lindberg et al. 2016 ), and highlights the interaction between formal school curriculum, informal online learning, and sexual “scripts” (Simon and Gagnon 1986 ), identities and practices.

Sex Education and Online Sexual Learning

Decades of research have established three clear characteristics of formal sex education in the USA: (1) governed largely at the local and state level, it varies widely from place to place; (2) it is usually both narrow in scope and short in duration; and (3) it is almost exclusively heteronormative.

Informed by competing sex education policy frameworks—one advocating “comprehensive” sex education and the other “abstinence” education (Fields 2012 ; Fine and McClelland 2006 ; Irvine 2002 ; Luker 2006 )—the curriculum runs the gamut from conservative just-say-no to liberal here’s-how-it-works to total silence (Kramer 2019 ). Regardless of ideological bent, American sex education tends to reinforce dominant understandings of race, class, gender, and sexuality (Connell and Elliott 2009 ; Fields 2005 , 2008 ; McNeill 2013 ). In particular, sex education in the USA has been almost exclusively focused on heterosexual identities and practices (Hirst 2004 ; Irvine 2002 ; Luker 2006 ; Fine and McClelland 2006 ; Pascoe 2007 ) and at times outright hostile towards non-normative ones (McNeil 2013; Gowen and Winges-Yanez 2014 ).

Formal sex education has been one major institutional source of sexual scripts at what Simon and Gagnon ( 1986 , 105) call the “cultural scenario” level, a kind of collective “instructional guide” specifying the “appropriate objects, aims, and desirable qualities of self-other relations,” instructing the “times, places, sequences of gesture and utterance and… what the actor and his or her coparticipants (real or imagined) are assumed to be feeling,” which are then “rehearsed at the time of our initial sexual encounters.” These cultural scripts are then adapted and molded by individuals into “interpersonal scripts” that shape “the materials of relevant cultural scenarios into scripts for behavior in particular contexts,” and brought into the self as “intrapsychic scripts,” the “private world of wishes and desires that are experienced as originating in the deepest recesses of the self” (Simon and Gagnon 1986 , 99–100).

Formal sex education, of course, is not the only source of sexual information, scripts, and learning. Young people also learn about sex and sexuality outside of schools from people around them (family, peers, community, and religious leaders) and, though often passively, through the consumption of popular culture. Since the inception of popular media in the early twentieth century, generally speaking, “depictions of sexual content and imagery abound in popular film, television, and advertising”; in centralized, risk-averse, commercial cultural industries, the sexual content was typically characterized by “regressive and often objectifying portrayals of sex and sexuality,” routinely rendering non-normative sexualities invisible or stigmatizing them, if still open to “queer readings” (Grossman 2020 , 281). That is, the cultural scripts and sexual content provided by popular culture was—until more recent structural changes such as the expansion of cable and then streaming outlets—quite a thin and narrow source for sexual learning, particularly for people experiencing desires and identities outside of the sexual and gender mainstream. Digital technologies have plainly altered that, rendering new popular culture far more diverse, more individualized, and more emphemeral, not only “personal, mass, and global but also decentralized” (Grossman 2020 , 286). This is, of course, a very different cultural environment for sexual learning.

While the relevance of school-based sex ed is in decline (Lindberg et al. 2016 ), in recent years social media and online spaces, and the popular culture circulating within them, have become a crucial informal curriculum through which young people learn about sexuality (Adams-Santos 2020 ; Boyd 2015 ; Fields 2012 ; Orenstein 2016 ; Orenstein 2020 ; Simon and Daneback 2013 ) and “craft and articulate their sexualities” (Adams-Santos 2020 , 2)—what some have called “the new sex ed” (Orenstein 2020 , 52). The Internet’s “availability, acceptability, affordability, anonymity, and aloneness” make it “unique in the delivery of sexual information in the digital age” (Simon and Daneback 2013 , 315, 306). For youth with non-normative sexual desires and identities, some researchers have found, the various available online platforms hold a particular draw, interacting with offline experiences “in ways that shape their emerging identities, social lives, romantic relationships, sexual behaviors, and physical and sexual health” (DeHaan et al. 2013 ). The prevalence of “techno-sexuality” (Waskul 2014 ), which allows youth to explore and experience sexuality beyond adult control, combined with the continued heteronormative emphasis of school-based sex education, points to the questions that animate our research.

While research on online sexual learning is increasing, and has established that “online sex education plays a role in adolescents’ lives,” just what sort of role, and how, and for whom, remains more poorly understood. Scholars have suggested, for instance, that “there is little knowledge on adolescents’ use of online sexual information for sexuality education in particular” (Nikkelen et al. 2020 , 190); that “the qualitative experiences of adolescents who engage with sex information online, from their initial interest in information to the effects such information could have on their lives,” the “process of applying online information offline” and “demographic differences” all remain understudied (Simon and Daneback 2013 , 312–314). Furthermore, the dynamic relationship between formal sex education—what it does and does not provide to youth—and online sexual explorations, the decentering of traditional sexual scripts (at the cultural, interpersonal, and intrapsychic levels) and the impact of this destabilization, have received scant scholarly attention (for an exception, see DeHaan et al. 2013 ). Our research addresses these gaps.

Methods and Data

We recruited college-age students between the ages of 18 and 22 years. Given national differences in sex education, we limited our respondents to the USA and territories. We found respondents primarily through posting flyers (online due to COVID restrictions) on websites affiliated with Boston-area colleges. These colleges attracted students from varied geographic locations in the USA and Puerto Rico, types of schooling, sexual identities, race and social class backgrounds (see Table 1 ).

On the flyers we indicated that we were interested in learning about sex education programs in their schools and also their use of digital spaces. We restricted the recruitment to young people enrolled in college because we wanted to understand how these youth made sense of the “sexual scripts” (Simon and Gagnon 1986 ), or social underpinnings of sexuality and sexual identity taught in high school sex ed programs and augmented or challenged by private Internet searches and social media interactions, once they were away from home. Given our particular interest in the experiences of lesbian, gay, bisexual, asexual (LGBQ +) youth, we indicated on organization posts that we were particularly interested in LGBQ + youth and their experiences. In total we conducted 56 in-depth interviews with college students.

This paper compares college age youth who currently identify as heterosexual or straight (39.3%) with the experiences of those who identify as LGBQ + or queer (60.7%) youth. While we distinguish between straight and queer respondents on the basis of their current self-reported identities, many of our respondents described experiences of fluid or changing sexual practices and desires. While youth are coming out as lesbian, gay, queer, questioning, bisexual at younger ages than in the past, data indicates that most reveal their sexual identity to family and friends in college (Beattie et al. 2021 ; Dunlap 2016 ). For instance, 20% reported that in high school they either identified as heterosexual or were questioning their sexual or gender identities but currently identify as LGBQ + . In the sections that follow we capture this fluidity in their descriptions of identify shifts and discoveries, both in the context of sex education in schools and in online explorations, which we note when we introduce quotes from our respondents.

Online flyers included a link to a Google form that college students from 18 to 22 years old completed in order to volunteer. On the form we asked for contact information and background information (age, pronouns, race, sexual identity in high school and currently, gender identity, region of the country where they grew up). We re-checked this information at the time of the interview and used it for coding purposes. When we reached out to our respondents, we also sent then a consent form that included information on audio and video recording and confidentiality. Interviews lasted between 1.5 and 2 hours, were audio recorded and videotaped, and transcribed verbatim. Since Zoom allows us to record with simultaneous transcription, we destroyed the video recording within a week after checking the accuracy of the transcript. To protect our respondents’ confidentiality, we informed them that we would use pseudonyms in any publications and presentations.

The study protocol was approved by the Institutional Review Boards for the protection of human subjects at the University of San Francisco and Wellesley College (for Zoom interviews only because of pandemic restrictions on in-person interviewing in 2021). All interviews were conducted between March and November 2021.

We chose qualitative interviews as the most effective method to access interviewees’ opinions and recollections, within their social context, and for understanding multiple aspects of the same experience (Gerson and Damaske 2021 ). We developed a semi-structured interview guide that asked questions related to experiences of sex education both in their schools as well as in digital spaces, including what students recalled learning from elementary school through high school; what material was taught, for how long and by whom; the major messaging frameworks they encountered; how useful and inclusive they thought the curriculum was at the time and in retrospect; whether and how students sought information online, and if so what types of information; where they searched; and how they evaluated the information they found. We also asked for what they discussed with parents, other family members and their peers.

In the convention of interview data analysis, we developed a detailed coding scheme in order to discern patterns across interviews. Both inductive and deductive codes were developed. Construction of the codes was guided by the principles of grounded theory, with emerging themes identified and then reanalyzed for consistency and completeness (Charmaz 2006 ; Gerson and Damaske 2021 ; Glaser and Strauss 1967 ). We coded interviews to reveal the topics interviewees recalled learning in schools; how they were presented, where, for how long, and by whom; the frames through which the sexual information was presented; school-based learning outside of classroom settings; feelings and perceptions of inclusion in the curriculum; when they began consuming online content and what kinds of information or activities they sought; what sites they most frequently visited; whether they also created online content; with whom they discussed sex education content or online learnings; and how accurate and reliable they took sexually-related information to be both at schools and online. This allowed us to quantify the content, generating the figures and tables referred to in this paper.

In addition, we generated a related qualitative coding document in which interviewees’ quotes were gathered according to thematic content, in order to more deeply understand their accounts of their own learning and how they made sense of their experiences of school-based and online sexual learning, with particular attention to the divergent circumstances that led our interviewees to turn to the various online platforms available to them. Each interview was coded by at least two researchers to facilitate intercoder reliability. Coders met weekly to discuss their individual coding, referring back to the original interviews to reach consensus.

Since our respondents were in college at the time of the interviews the summer provided a natural break in interviewing. We used the summer to code the interviews conducted in the first round (March–June 2021). This allowed us to discuss where we had achieved “conceptual depth” (Nelson 2017 , 556) both with regard to the open-ended questions we were asking and also with regard to understanding the interplay between schools and online learning, and how they might differ for our two groups.

Our interviews were retrospective by necessity, and retrospective accounts hit up against the “limitations of chronological memory, the potential for hindsight-based rationalizations, as well as people’s tendencies to construct stories that place themselves in a favorable light” (Langley and Meziani 2020 , 373). People look back through the filters of the present, and details become fuzzy or distorted, and that was certainly the case in our research. Our investigations, however, are not so much aimed at a factual account of what took place in classrooms or online as at what stands out in participants’ memories, and the related “imagined meanings of their activities, their self-concepts, their fantasies about themselves” (Lamont and Swidler 2014 , 159); that is, how participants remember their sex education and online explorations, and how they understand those in relation to their life paths and identities.

Formal Sex Education: Experiences of a Limited and Heteronormative Curriculum

Most of our respondents recalled having some version of sex education, particularly in the latter parts of their schooling (see Table 1 ), though not a lot of it; what they did receive they report finding quite limited in scope and heterosexually focused. In elementary school, almost two thirds of the respondents (61.4%) had sex education, and most (77.1%) reported that it was for one class on puberty and hygiene. Almost three quarters recalled having sex education in middle school; of these, the majority (72%) said that the class was a module or a brief part of another course (such as health or biology). The largest portion of respondents (85.9%) reported having sex education in high school, again typically as a module of a course (60.4%), though a third (33.3%) recounted having a full sex education course for half a year.

Generally speaking, our respondents recall elementary school sex education focused on puberty and menstruation, typically in class meetings segregated by sex. Despite often having some exposure to this sort of information through parents (usually mothers), and finding the emphasis on bodily changes and hygiene “embarrassing,” many respondents recalled being excited for their first sex education class. As one respondent, Erika (21, Asian, cisgender woman, lesbian, attended public school in the Northeast) put it, “It was a really highly anticipated conversation. Everyone in the class knew the day we were going to talk about it and people were talking about it, like, ‘Wait, do you know this, this and this about [puberty]?’” Interestingly, our respondents recalled only learning information related to their sex assigned at birth.

By middle and high school, class content became more varied, in part to cover state-mandated material, and all students were in classes together. In some school districts these classes were supplemented by professionals from the community. In other schools, students could elect a human development course or a section of a biology course that presented information on reproduction. Respondents recalled putting condoms on bananas, learning about sexually transmitted infections (STIs), watching videos about birth, sometimes discussing consent and sexual assault and mostly being told not to have intercourse. Many noted that no answer to the central question “What is sex?” was provided.

Few of the respondents recalled learning much novel or in depth in school, regardless of whether they went to private or public schools. Some respondents told us that the sex education came too late: they had already learned quite a bit about sex from peers and other sources, and some were already involved in sexual activity. Others reported that they did not pay a lot of attention because the topics they were interested in, such as sexual pleasure and sexual practices, were not covered. All agreed that in addition to pleasures and practices, a vast range of sex- and sexuality-related topics were almost entirely absent from the curriculum, including cultural representations of sexuality, pornography, relationships and dating, non-cisgender and non-heterosexual identities, and abortion.

Overarching Cultural Scripts: Abstinence, Danger, Gender, and Heterosexuality

Our respondents articulated, looking back, the cultural scripting their school-based education provided, in terms of the appropriate “objects, aims, and desirable qualities,” as well as the appropriate “times, places, sequences” and emotional content, for sexual encounters (Simon and Gagnon 1986 , 105). The focus, they reported, was most often on the dangers of sex (disease, unplanned pregnancy) and ways to avert them (condoms, occasionally sexual consent tools), often with a fear or abstinence message, and often from a male perspective. (While we expected that secular private schools would be more progressive in sex education content, the evidence from our interviews suggested that this was not the case.)

For instance, John, a 21-year-old white, cisgender, straight man from rural Colorado, received minimal sex education from his private school. He recalled,

I don’t think I learned anything new. I think all I got out of it is like, “Oh that’s how you have heterosexual sex, this is what a penis looks like going into a vagina,” from a cheesy video – and I already kind of knew this… It was the biology of how it works. I wouldn’t say I remember anything about pleasure or things like that. It was mainly just the scientific aspects of it.

As Jessica, a 20-year-old, white, cisgender woman from the Northeast who came out as bisexual in her junior year of high school, put it, “teachers had to walk a fine line between informing us and not seeming like they were encouraging us to have sex.” Even so, she recalls, the focus was on male pleasure. “Male ejaculation was discussed. Why was there no discussion of oral sex or lube or that women could have an orgasm?” Elena, age 20, Latinx, non-binary, queer and asexual, who attended public school in southeast LA, echoed this view. Her elementary school sex education was brief (“a one-time, thirty-minute to an hour class”) and focused on puberty, and her middle school offered one session in seventh grade (“how to put a condom on a banana”). Recalling her “penis-heavy” 9 th grade health class, she said:

The biggest thing I remember was just abstinence. “Don't have sex. The best contraceptive is never have sex, so just don't have sex." Which is not helpful at all, because most people engage in sexual activity. I don't remember anything about other forms of sex ed, like how to have sex or different forms of pleasure or anything like that. The knowledge about how to apply a condom and what you can catch is not really helpful because then you don't even know how to engage in sex…. So then, well, I know that I can catch chlamydia, for example, but what are ways that I can prevent it? None of that. What ways can I engage in sex? Never taught. So were they ever that helpful? Not really.

As another respondent put it, “Abstinence is [presented as] the gold standard.”

The majority of our respondents, regardless of identity, understood the focus on abstinence to be tied to the primary framing of sex as risky, dangerous, and fearful; their classes focused primarily on disease and pregnancy (See Fig.  1 ). As Jocelyn (African American, cisgender, straight woman, from an urban, East Coast public school) recalled, the message was: “If you want to avoid STI, don’t have sex. If you don’t want to get pregnant, don’t have sex.” Similarly, Shenita, a 21-year-old, African American, cisgender, straight woman who attended a public school in the mid-Atlantic suburbs, recalled her teacher comparing sex to “operating heavy machinery, dangerous” and telling the class of 13-year-olds that “none of us should be having sex within the next ten years.”

Primary Framing of the Sex Ed Curriculum

We also found a general consensus—again in line with most popular and academic accounts of American sex education (Gowen and Winges-Yanez 2014 ; McNeill 2013 ) —that the sex ed curriculum youth encountered generally assumed everyone in the room was heterosexual, implicitly or explicitly equated heterosexuality with sexual normalcy, and treated non-heterosexual sexualities as rare, a side note, or nonexistent. Youth repeatedly recalled that teachers “very much emphasized that heterosexual dynamic” (Ana Luisa, 18, Latinx, cisgender woman, lesbian and educated in public school), with a “very heterosexual” take on pregnancy and an “overall emphasis on heterosexual couples” in discussions of and videos about sexually transmitted infections (Lizzie, 19, white, cisgender woman, asexual, queer, public school-educated). Nearly three-quarters of the LGBQ + youth, and more than nine-tenths of the heterosexual youth, said that only heterosexual relationships were discussed in their sex ed classes; four-fifths of the LGBQ + youth and all of their heterosexual counterparts indicated that non-cisgender identities were never discussed. LGBQ + youth rarely asked for information that might be more applicable to their lives because, some reported, they felt they would be “flagged” in school peer cultures that emphasized heteronormativity.

When non-normative sexualities were discussed, a few respondents noted, it was often in the context of HIV. For instance, Julia, a 19-year-old, Latinx/white, nonbinary, lesbian, educated in public school in rural Georgia, recalls:

I knew I was queer in middle school and I was hoping to hear something. The only time I ever heard about queer people in sex ed was when they were talking about HIV and AIDS. So that was a scary thing because I had just figured out I was queer, and then the gym teacher comes in and says, “This is a bunch of dead gay people, and you can be like them, too,” and I was like, “I could be like them too?”

The absence of information about non-heterosexual practices was, not surprisingly, less directly concerning to cisgender heterosexual respondents than their LGBQ + counterparts. Thus, their experiences diverged quite significantly. LGBQ + youth in particular recall the heteronormative bent of their school-based sex education as rendering it at best unhelpful to their understanding of sexual identities and practices. As Ana Luisa put it, at the time she already knew that heterosexual dynamics were “just not something I would have encountered,” so sex ed “was just useless to me personally.” She and her similarly positioned peers simply did not find much material from the cultural scripts offered by formal sex education with which to develop interpersonal scripts for their sexual interactions, or that affected the shape of their intrapsychic scripts of sexual desire.

Another absence is worth noting: although we did not query them about it directly, none of our respondents reported themes of love, care, and affection for others as a prominent theme in their formal sex education. Hints of such a framework in which to place sex occasionally came through in, for instance, lessons on consent, which tied sexual behavior to a kind of ethics of care for the other, and in lessons on sexual safety and health, which tied sexual behavior to a care of oneself and others. Yet, the notion that love is a necessary component of sex (or a precursor for sexual activity) appears to have been weak enough in the curriculum to not emerge organically in our respondents’ memories.

LGBQ  +  Youth and School-Based Sex Ed: Absences, Improvisations, and Memory

While all youth reported that there was limited information that was useful for first sexual encounters, LGBQ + youth felt particularly unprepared for sexual experiences and health hygiene. As Karl, who identifies as a cisgender gay man and Latinx, and went to public schools in the Northeast, put it, “They never really went over things like mouth guards or finger ones. For other people who do not practice actual intercourse, how are they going to know how to protect themselves?” Marlie, who went to private school in California and identifies as Latinx, bisexual/queer and a cisgender woman, similarly noted:

I don’t think there was any information that prepared me for my first sexual encounters, which started actually that year when I was 15 years old. In the classes, there wasn’t as much of an emphasis on the actual act of sex and what that is like and what happens. It is not that they emphasized heterosexual sex, it is that they did not talk about queer sex…. We definitely did not talk about what fingering is, what vulva on vulva sex is like, what penis on penis sex is like, any of that. My first sexual encounters were not with somebody with a penis, so I didn’t feel prepared to know about proper hygiene regarding fingering or dental dams or any of that stuff.

Other respondents found ways to translate—or perhaps more accurately, to hack—the heterosexually-directed information they encountered. For instance, Rhonda, age 22, Native American and white, cisgender lesbian woman, reported that in her public school in Kansas teachers focused a lot on preventing STDs and “keeping safe” through condom use, but “we never learned about LGBQ sex ed at all.”

So when a lot of us started coming out, we were like, “Well, what do we do now?” We knew condoms, in heterosexual relations, could help prevent STDs, but we didn’t know how that worked if we were having sex with women or AFAB [assigned female at birth] people. One thing that was very novel to us was that you could cut open a condom and make a dental dam – because you couldn’t buy dental dams where we lived, they just weren’t available anywhere. So, we just compared what we needed to use with what we had learned from our health classes. And whenever one of our friends was going to meet someone new, we would tell them, ”Hey, don’t forget about this cool trick you can use, because you don’t want to get an STD.”

In effect, through efforts such as these condom displays, queer youth found it necessary and possible to create new “interpersonal scripts”: The “disjunctures of meaning between distinct spheres of life,” as Simon and Gagnon pointed out ( 1986 , 99, 102, 106) created moments of “ad hoc improvisation” at the interpersonal level.

While a few respondents reported seeking support from queer-friendly teachers outside of sex ed classes, still others internalized the notion that their sexual desires and curiosities were irrelevant. Emily, for example, who identifies as a white, asexual, cis-gender woman, who went to a public school in the Northeast, noted that.

just one mention of there being other sexualities than straight, gay and bi, would’ve been useful for me, just off-hand, in a context that conveys authority would have been helpful…. I just figured I was wired differently and just left it at that.

She reached the conclusion, she said, that “I was an outlier and did not count.”

Interestingly, LGBQ+ youth also were less likely than their straight counterparts to recall a framing of sex as dangerous (39% of LGBQ+ youth vs. 71% of heterosexual youth). Queer identifying youth reported more often that their sex education classes framed sex scientifically, as a heterosexual biological process (21% of LGBQ+ youth vs. 9.5% of heterosexual youth). Furthermore, while no heterosexual youth recalled receiving sex education through a moral frame, LGBQ+ youth were more likely to recall a moral frame in the curriculum, either one that treated certain kinds of sex as immoral (15%) or all sex as morally acceptable (12%) (see Fig. 1 ). Finally, heterosexual youth recalled feeling in high school that the curriculum included material relevant to them (77%), but only 30% of the LGBQ+ youth felt the same way. Those who felt included or even partly included often recalled that same sex relationships were briefly mentioned, and that this mention made them feel included. However, at the time of the interview, and now in college, regardless of sexual identity, the majority did not feel that the curriculum was inclusive of them or of their LGBQ+ friends (see Fig.  2 ).

Inclusion in the Curriculum

While at first glance these findings seem counterintuitive, we suggest that they are outcomes of a nascent or developed identity difference that shapes the reception and memory of sex education. The broader range of sex ed frames LGBQ + respondents recall may have to do with their heightened sensitivity to the cultural frames surrounding non-normative sexualities and genders (Weeks 2023 ), the “paradigmatic” scripting of sexuality (Simon and Gagnon 1986 , 102)—as morally questionable, unnatural, or scientifically explicable deviations—that have less personal resonance for heterosexual respondents. The greater inclusivity that almost a third of LGBQ + students recall may have to do with the identity needs through which they filtered the curriculum, in which any mention of non-normative sexualities, and of ways to manage heterosexual situations as an outsider to them, stood out as memorable. Their overall irrelevance and invisibility within the curriculum—and within the cultural scenario scripting more broadly—we suggest, made moments of relevance and visibility particularly memorable.

Pleasure, Identity, and Online Sexual Learning: Convergent and Divergent Experiences

Online sexual explorations started early for the youth we interviewed, and were both constant and extensive. The Internet and its myriad platforms—including not just websites but interactive social media and online communities—was robust by the time all of our interviewees entered middle school. Our oldest interviewees at age 22 were 12–14 years old in 2011–2013; while our youngest interviewees at age 18 were 12–14 years old in 2015–2017.

Internet searches for almost two-thirds of our respondents began in middle school between the ages of 12–14, with just over a quarter searching the Internet even earlier (See Table 1 ). Although parents rarely monitored their children’s Internet searches, many of our respondents told us that they would sneak down early in the morning or late at night to the family computer or iPad hoping that their parents would not discover their activities. By high school all of our respondents, who completed high school between 2017 and 2020, had their own devices (phones, iPads, computers) in their rooms. Still, they were careful to hide their Internet Web search history.

Online Explorations: Finding and Making New Sexual Scripts

Our respondents used a variety of online platforms, each facilitating different kinds of activity, to seek out information, explore identities, compare themselves to their peers, and for entertainment and fun, regardless of their sexual identity. Online space—whether social network, content, or media-sharing platforms—of course, offers significant communication changes not readily found offline, serving as “a massive expert database,” providing easy access to the kind of credentialed expertise found in formal sex education; as a “global broker, a way for individuals with special concerns to find each other,” allowing for the dissemination of alternative and sometimes counter-normative sexual expertise, as well as sexuality-based community formation; and as a “global collective memory, allowing people to contribute, store, and annotate comments” (Radin 2006 , 593), facilitating alternative sexual storytelling. Accordingly, our respondents’ explorations ranged from information on how to “do sex,” to how people think about and label themselves sexually, to how to get sexual pleasure or give it to others, to topics like consent, disease, and activism; many also reported using online explorations to assess where they stood in terms of “normal” physical and sexual development.

Unlike school-based sexual learning, online explorations were not dominated by any “master” script, but involved a youth’s transformation from “being exclusively an actor trained in his or her role(s)” to “being a partial scriptwriter or adaptor,” as Simon and Gagnon ( 1986 , 99) describe interpersonal scripting. Respondents went all over the Internet for sex- and sexuality-related content. In Fig.  3 we have grouped these sites into various categories that our respondents used for learning online. We asked our interviewees what websites they accessed and what they remembered learning online; the answers showed widely ranging exploration. They reported taking online sex quizzes on Buzzfeed (“15 Things You Need to Know About Your Sex Life”), looking at medical sites (for “information about asexuality and attraction”) and sexuality education sites (such as Scarleteen, “a one-stop shop for LGBQ youth”), consulting Wikipedia and Google (for instance, for articles on “how to make out or give a blow job,”) watching porn sites (such as PornHub); enjoying fan fiction (Wattpad) and “smut” fan fiction (“it’s just like porn but it’s words”) on user-generated story sites; watching video sites (such as You Tube videos on sex positions, “the arousal of the vulva,” and masturbation, and TED Talks about the effects of porn), spending time on social networking sites (such as Grindr), in video chat rooms, on microblogging and networking sites (such as Tumbir), and in large online forums like Yahoo and Autostraddle.

Websites Used

Julia, quoted earlier, who identified as queer in middle school, described their explorations in a way that echoed throughout our interviews: secretive, exciting, voracious, and curiosity-driven.

I would look up information in the middle of the night. I would pull a blanket over my head and I’m looking at Tumblr, which was the fountainhead for the LGBTQ people in general. That’s a lot of my childhood experiences, trying to find information and then learning it. It was exciting. Now I understand that it was me taking agency over my own conceptualization of what sex can be, what sexual identity can be, what gender can be. It was like putting little puzzle pieces together which made me feel better. But I did it in a secretive way.

These wide-ranging, relatively unfettered explorations often began with pleasure-seeking but led to unexpected places. For instance, Bryan (age 21, white, cisgender male) grew up bisexual in a Southern town and school where the message was “very much sex is taboo.” He began his online explorations at age 12, sometimes Googling particular questions, but mostly “just looking for pleasure, or pictures, or browsing material, it would pretty much be Pornhub.” Over time, he dove into sub-Reddits—also initially for arousal—where he eventually discovered that “people were also having very intelligent and mature discussions about pleasure.”

Many of our respondents, in fact, turned to other online platforms for information about sexual pleasure and practices that were missing from their formal sex education. For instance, Summer, who identifies as  Latina/white, a cisgender woman, and bisexual, spent much of her time on Wattpad, where she read “books that people write on there that are not very good,” but whose quality she overlooked when she “stumbled across a few smutty books – and by smut I mean like books with like sexual content – and that’s where I got my basic knowledge of sexual pleasure.” Similarly, Jessica (age 20, white, bisexual, cisgender woman) sought information about queer sexual practices that were unavailable in her public-school education:

I would sometimes seek out Cosmopolitan or Buzzfeed or Autostraddle articles to ease any anxiety I felt or to get ideas about what to do, and I think about both anatomy and pleasure, for sure, because I feel like that wasn’t really talked about in my middle school sex ed…. Whenever I was looking in high school, and now, whenever I have looked at Autostraddle, it’s a lot of little graphics, like little silhouette positions, with descriptions of what’s going on, like, “Oh, here’s different positions to try.”

These online sites, that is, became something of an alternative how-to manual.

Given the mix of types of expertise available on online platforms—credentialed in a traditional sense or staking a claim to be so, lay and crowd-sourced expertise—the question or what information could be relied upon was often unresolved. While the majority of our respondents presumed that the Internet provided accurate information, 30% of our respondents told us they thought the Internet was a mix of accurate and inaccurate information. Many of our respondents looked to triangulate information from the websites they frequented; others reported that they were relieved to find answers to their questions regardless of the source and accuracy. Moreover, when our interviewees were skeptical about information their teacher discussed in their sex education class they turned to the Internet for answers. During middle school in 2014, Angie, who is currently age 19, Asian, and identified as queer prior to coming to college, described how her use of the Internet hastened her growing up as she tried to figure out which source was accurate:

So Tumblr was a thing, that’s where all the cool kids learned how to be adults. We were learning about sexually transmitted diseases and infections and I was listening. But I remember thinking like, “Some of this is a little weird.” And then slowly after the fact, I started looking up more and more things on Tumblr to try and figure out like, “Was what they were telling me true? Is this actually how I would get a sexually transmitted infection? Is this actually how I would get AIDS or get HIV? Is this actually how sex works?”

While most respondents reported using the Internet as a source of “basic knowledge about sexual pleasure” and “ideas about what to do,” the explorations of straight and queer youth were quite divergent (see Fig.  4 ). Heterosexual youth tended to be primarily focused on sexual pleasure and entertainment, with sexual learning as a byproduct. In particular, straight youth—especially but not only young men—who more readily saw themselves in the sex ed curriculum, were more likely than their queer counterparts to initially turn to online platforms seeking pleasure (23.5%) and sexual practices (23.5%), usually on porn sites. Through this process, they continued to experience online sexual sites as instructional, even if that was an indirect result of their porn consumption, and even if they were skeptical—as many were or became over time—of porn’s reality and impact.

Internet Searches Over Time

As John (21, white, straight, cisgender male) described his own quite typical experience, he recalled going on his mother’s computer in elementary school to “look up ‘big boobs’ or something.” In seventh grade, entering puberty, a friend showed him porn videos. “I was thinking about it all the time,” he recalls. “‘Wow. I really want to have sex with someone.’”

Such online explorations often interacted with offline ones through a back-and-forth in which youth tested out in one arena what they had learned in the other. Particularly as they got older, youth often tried out what they saw online in their own relationships, adapting the cultural material into interpersonal sexual scripts, and then returned online with those experiences in mind. Juan (19, Latino, straight, cisgender male who grew up in Puerto Rico) described it this way:

What did I look for in porn? At first it was pretty basic stuff – well, not basic at the time, but today I’d consider it to be a little bit basic in terms of sexual experimentation. I looked at hand jobs or stuff like that. And I think as I started to experiment more... What I looked for in porn kind of was the same as what I was experimenting with. When I had my first girlfriend in 10 th grade, we started to kind of experiment, and that’s when I started to look [online] for fingering and blowjobs.

For many respondents, pornography consumption itself set in motion a process at the intrapsychic level, in which they attempted to distinguish their own fantasies and desires from those contained in the cultural scripts of porn, an “internal dialogue” in which sexual desires experienced as “originating in the deepest recesses of the self” in relation to social meanings and expectations encountered in cultural scenarios (Simon and Gagnon 1986 , 99). For instance, RJ, a 21-year-old white cisgender male who identified as straight until college, realized at a certain point not only that porn presented “very unrealistic expectations of stuff that I had to unlearn,” and unhelpful sexual models such as the fact that “there is not a lot of foreplay in porn, or any female-centric pleasure,” but also that it had taken over his sexual desires such that “I couldn’t pleasure myself without porn, And I was like, ‘This is probably bad.’” Similarly, Max, a 21-year-old white cisgender male, came to believe—through offline conversations with women friends and his mother, as well as online viewings of TED talks on the subject—that pornography was not only unhealthy due to the unrealistic view of sex it generates but also because of its impact on his sexual desires. “When I was watching a lot of porn, when I would have sex, it would be kind of harder to enjoy it or be in the moment,” he said. “I’d be thinking about something that I’d seen in a video.” Both RJ and Max moved back and forth at an intrapsychic level distinguishing between a manufactured fantasy life and the realities of interpersonal sexual relations..

Offline conversations also lead to online sexual explorations. For instance, Mila (21, Latinx/white, cisgender woman, identified as straight in high school and in college), recalled a phone call with her boyfriend, in which he suggested that she watch porn and learn to masturbate. She followed up. “That is how I watched my first porn video,” she said. “I was like, ‘Damn, that’s hot.’ I could probably still tell you who was in that video. I remember it so distinctly.” Encouraged to explore her relationship to her sexual body—her self-desire—in the context of a sexual partnership, she turns to an online platform, bridging the intrapsychic, interpersonal, and cultural levels of sexual scripts.

LGBQ+ Youth Online: Information and Identity Work

Despite some overall similarities, LGBQ + and heterosexual youth differed quite a bit in their uses of online platforms. Although all youth reported initially turning to the Internet for specific sex-educational information, queer youth were more likely to do so. The LGBQ + youth we spoke to also tended to have more varied uses than the heterosexual ones (see Fig.  3 ). The latter turned mainly to sexual entertainment sites (22.9%) or large Internet forums (31.3%); the former turned less frequently to those and accessed a wider range of types of websites from micro-blogging sites (15.8%) to user-generated sites such as Wattpad (12.3%). Over time, LGBQ + youth were likely to search for information about LGBQ + identities (28%), followed by searches for information about safe sex/contraception (14%), sexual practices (13%) and information related to their own or someone else’s pleasure (15%).

In contrast to the primarily pleasure- and entertainment-driven explorations of straight youth, queer youth took to filling in knowledge gaps about non-conforming sexualities. Most significantly, they often reported using digital platforms for what scholars refer to as “identity work” (Bernstein 1997 ; Beech et al. 2008 ). This work took several, often overlapping, forms. One form of identity work came when youth, curious about an inchoate feeling of difference, discovered a sexual identity through their online explorations that they then developed in their daily lives and interactions. Another type of identity work turned to digital spaces to firm up and further develop a sexual identity that was forming offline. Lastly, youth used online spaces for validation of a stigmatized sexual identity, seeking out others with similar experiences in a lower-risk online environment.

The theme of online discovery and exploration of identity, entirely absent among heterosexually-identified respondents, was common among queer ones. These identity explorations online were typically conditioned on both the absence of information about queerness in face-to-face settings and the safe anonymity of the Internet. For instance, Ana Luisa, a Latinx, cisgender lesbian, described being “scared of being looked at differently because I was curious about this stuff.” Online, people would “know me but they didn’t really know me. They didn’t see me in the halls every single day. They didn’t cook my dinner every day. So, I felt like the Internet was really the only place I could go.” Similarly, Ruby—African American, who identified as non-binary and bisexual in high school and currently identifies as non-binary and pansexual—went online at first primarily to absorb information, learning “gay vernacular” and exploring “freely and without barriers” topics that were taboo at home and not addressed in school. The Internet, they said, was like “an elder” they could turn to that neither protected them from information their family deemed dangerous nor judged. In effect, they were engaged in “an internal rehearsal” (Simon and Gagnon 1986 , 99) of their self-identities that could be imagined and fantasized without the intervention of others. Their intrapsychic scripting became a “significant part of the self-process” (Simon and Gagnon 1986 , 99) that they found difficult to explore offline or in conversation with peers, teachers or parents.

Once they began online explorations, identity shifts often evolved, whether born of accident or curiosity. Bryan, for example, whose explorations with heterosexual porn are recounted above, did not turn to online spaces to work through his sexual identity. He was “never into gay porn” as a young teenager—although he now considers that “part of the self-repressing”—and he considered himself “very straight” in high school despite a small inkling that he should be questioning his identity. Later, finding himself drawn to gay porn, he noticed TikToks on Instagram that indicated

a large community of people talking about, “Oh, I thought I was straight but then I had this experience.” And I would just scroll and scroll and scroll. After about 50 of those matched up with my experience, I started to think, “Okay, I need to start thinking about this a little more.”

Thus, his path to bisexual identity, which by college was fully formed, began with the online discovery of people whose experiences “matched up” with his own.

Like Bryan, Abby, age 20, who identifies as Latina and a cisgender woman, was questioning her sexual identity in high school, also began pursuing her curiosities online “before I realized my own identity as a queer person,” then became inspired by her reading of online fan fiction to think differently about her identity.

I was looking for representation, queer media. I was searching for media in some way that kind of represented what I was feeling. And so then I would search for media that would create that feeling in me again. Like, “Damn, I want to be them .” And that was always essentially men who are portrayed in a more feminine way.

Similarly, Sara, age 18, who identifies as Latinx and a cisgender woman, had begun wondering in her first year of high school in Puerto Rico whether she was lesbian. She happened on a thread on Twitter that was “like, ‘How to tell if you’re a lesbian versus just Sapphic in general,’” which led her to the “Lesbian Masterdoc,” a 30-page, 20-section document aimed at helping women consider the “am I a lesbian?” question. “That was a pretty big stepping stone in realizing that I was a lesbian,” they said, “because so much of it resonated, so much of it resembled what I was feeling, so much of it resembled my [offline] experiences.”

For others, identity was not so much discovered as developed and solidified online in relation to offline experiences. Michael’s path to queerness began with sexual explorations involving “watching porn for the sake of jacking off,” and also “learning about some different ways that sex could look or different forms sex could take.” Michael, who grew up in the Midwest and identifies as white, gay and a cisgender male, describes the impact of the Internet on his sexual identity as a process in which he first investigated a little bit to see “what it felt like to be looking at naked guys or whatnot,” but not as the place where he really discovered a queer identity. Instead, an actual crush on another guy moved him towards a queer identity: “Okay, I’m queer because I had this crush on this guy.” After he had already begun that movement toward a queer identity, he says, the Internet became more central to his identity as he began “seeking out and savoring the knowledge that I could get.”

Once I discovered that this is something that I could be, that’s when it opens up these things of exploring who I am. And after having this affirmation that I had these feelings for a guy, that’s when I have permission to be myself to be exploring what that means for me. What I find useful is just being, “Oh, there are possibilities for how I can be.” And seeing what feels good, seeing what feels good to imagine, and to hear people tell stories about things and to learn about things that I might want or that might feel good for me that I haven’t come across in my [offline] life…. Learning about my identity and what feels rich to me, what feels titillating to me, I think is still more what comes from the Internet, reading and hearing other people’s perspectives and whatnot.

Indeed, the discovery or confirmation of new possible identities was also often accompanied by the pursuit of their positive affirmation. Ruby described how “the Internet really exposed me to queerness in a way that was helpful for me to develop my own identity.” While they first turned to online sources to fill in gaps in their knowledge of sexuality, as time went on and their identity shifted, Ruby began to wonder, “What will happen if I come out as queer?” Like many respondents, Ruby turned to online platforms for possible answers, seeking out sites that affirmed that gay and lesbian life could be happy rather than tragic. Watching queer movies online, Ruby said,

there was always a bit of a tragedy to the gay romance. It’s like, all right, is this movie going to let this gay person live and be happy or are they going to die because they’ve been outed. That’s what I was looking to know: Will I perish if I come out and can I live happily ever after?

As they delved deeper, Ruby found themself gravitating to gay, non-binary, and trans YouTubers who “kind of led me through my self-discovery as like non-binary and pansexual.” Unlike the school, family, and peer spaces of their everyday life, the Internet was “a safe space to explore that for myself.” In college, these identity explorations became the basis for a crystallized identity as openly non-binary and pansexual. Like for many respondents, online sexual identity (and sometimes also gender identity) explorations—driven first by the absence of adult information sources about queerness and also often the pursuit of pleasure—took place over a long period of time, eventually becoming the basis for the claiming of a different identity in everyday life offline.

Operating at a time and place where sexuality is in many ways “post-paradigmatic,” with fewer shared meanings, the cultural scenario emerging from schooling has lost many of its “coercive powers” (Simon and Gagnon 1986 , 102–103). In the face of an endless and easily accessed world of online sexual content, along with its own significant institutional constraints, school-based sex education clearly has a greatly diminished role as a controlled source of information (Lindberg et al. 2016 ). School- based sex education, our research once again confirms, provides some students with a narrow swath of knowledge on a limited range of topics, typically related to biological reproduction, the avoidance of pregnancy and sexually transmitted infections, with very little on sex or sexual identity. For many of our respondents, this information was not just too little but also too late, as sexual activity and talk was part of the school culture, and some were already involved in sexual activity. Even those who were sexually curious but not active lacked strong memories of sex education, as they reported that most of the topics they were interested in, such as masturbation or other sexual practices, were simply not addressed. Such perceptions of deficient education existed even in “comprehensive” sex ed settings, where the emphasis was broader than abstinence and disease. Online sexual explorations, on the other hand, were wide-ranging and uncontrolled, often accessed in isolation and without adult guidance, and put to quite divergent uses by youth of different sexual identities.

Just as the experience of sexual learning itself tends to be bifurcated, existing research tends to focus on either school-based sex education or on the “intersection of sexuality and digital space” (Adams-Santos 2020 , 1; Waskul 2014 ); our research highlights the dynamic interaction between formal school curriculum, informal online sexual learning, and sexual identities and practices.

First, as its role as an information source is further diminished, sex education gains significance in a different way: The very absences of information about sexual pleasure and sexual identity further propels youth to seek information elsewhere. Our interviewees rarely talked to their parents about sexual activity, reporting that sex was a taboo topic. Similar to findings from research Elliott ( 2012 ) conducted with parents, our respondents believed that their parents did not recognize them as sexual beings; schools did not go much further. In this context, digital platforms were a place to get answers, without judgment or exposure, to pretty much any sexual question or curiosity, even when they did not know exactly what they were looking for. Online explorations felt exciting as they pieced together information not otherwise available to them, and a place in which youth experienced agency, arming themselves with information lacking in sex ed and in the home, and often countering the framings found in school and at home (abstinence, danger, heteronormativity, and the like). Nearly all the online information, they reported, was new – an indicator, again, that the vacuum left by school-based sex education is an important push towards the digital space.

Second, the push to and pull of the Internet accentuates an ambivalent relationship to the sources of sexual knowledge and how to assess their reliability, particularly as youth are simultaneously operating in at least two very different arenas of authority. Our respondents often reported having been uncertain about the accuracy and reliability of information sources, and looked for ways to triangulate and substantiate online sources; despite a certain eye-rolling skepticism about school-based sex education, they generally assumed that their teachers were reliable authorities, and rarely described a concern about substantiating school-based information. Information learned online was often shared with peers, and tested out practically in relationships. Youth were likely to share websites or make suggestions to friends from the sites they frequented, such as how to make a dental dam out of a condom, use lubricants, or locate erogenous zones even as they also often articulated concerns that the online pornography they consumed gave them a distorted view of sexual activities, bodies, and pleasures. The controlled information from school was seen as reliable but often without much value; the uncontrolled information from online spaces was seen as valuable but often suspect, sometimes even scary.

Third, we have seen a destabilization of the relatively rigid conventional cultural scripts contained in school-based sex ed curricula, displaced by the multifarious and messy cultural scripts circulating within online platforms. The former left little room for identity play and exploration, or for the elaboration of alternative sexual scripts at the interpersonal and intrapsychic levels. Our respondents, particularly those who are LGBQ + -identified, were regularly and actively engaged in identity work and interpersonal re-scripting facilitated by a decentralized, multi-platformed online environment in which no single set of sexual scripts prevails.

Finally, as one set of scholars put it simply, “Sexuality education is exclusive of young people of different sexual and gender orientations, and this exclusion can have various negative impacts” (Gowen and Winges-Yanez 2014 , 799). Much more therefore seems to be riding on self-generated online sexual learning for LGBQ + youth than for others, given the privileging of heteronormative identities in sex education and in school settings more generally, where queer students participated in what one respondent called a “code of silence” regarding queer identification or questioning. In the “post-paradigmatic” context, LGBQ + youth in particular seek not just information but new shared meanings, often improvising interpersonal scripts such that their identities can be made “congruent with desired expectations” (Simon and Gagnon 1986 , 99). One impact, though not an entirely negative one, is LGBQ + youths’ heavy reliance on the Internet for sexual knowledge, identity work, and community not supported in schools. While the classroom was not a safe environment in which students could discuss their discomfort with a heteronormative lens—and often the assumption of heterosexuality—online space was quite the opposite. For many, their digital communities, whether fleeting or more lasting, became critical support. Having found queer community online, the lack of queer community in school became even more evident. The Internet provided an unparalleled source of affirmation and identification that queer interviewees did not find in schools, homes, or local communities.

Our findings are suggestive and, given the data limitations, not nearly the end of the story. Certainly, the need “for relevant and inclusive information on sexual health” (Gowen and Winges-Yanez 2014 , 799), particularly for LGBTQ + youth, is plain; other have suggested, for instance, “directly discussing LGBTQ issues, emphasizing sexually transmitted infection (STI) prevention over pregnancy prevention, and addressing healthy relationships” (Gowen and Winges-Yanez 2014 , 788). One particular gap that future research might seek to fill is the unique sexuality education experiences of transgender and non-binary youth, which may or may not parallel those of LGBQ + youth, and their unique needs. Our research also offers a view on how sexual identity needs affect the consumption of school-based sex education, including how it is remembered—the relative invisibility and exclusion of LGBQ + youth means that the few moments of visibility and inclusion in school curricula carry outsized impact—as well as driving much of the online activity of LGBQ + youth. Future research could usefully develop this line of inquiry.

In the end, our findings shed a different kind of light on the common critiques and calls for reform that contemporary US sex education regularly and rightly receives. For all of their importance, political debates over sex education in schools (Luker 2006 ), and political fights for school board control, may be less relevant for those seeking to understand and advocate for the sexual wellbeing of youth than they appear. Given the institutional constraints on school-based sex education, its role as a driver towards online sexual exploration is likely to continue; in democratic political settings, the digital space will continue serving as a primary setting for sexual learning. Unless schools are willing and institutionally able to recognize and tap into the dynamic interaction between sex education, online sexual explorations, and offline relationships, their role as relevant sources of sexual learning is likely to continue to recede.

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06 december 2023.

A Correction to this paper has been published: https://doi.org/10.1007/s11133-023-09554-6

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Acknowledgements

We are very grateful to our research team, who substantially contributed to the design, interviewing and coding for this article, as well as providing input on drafts of the paper: Nathaly Andrade, Juliana Juarbe, Genesis Vasquez, and Ella Warburg. We also want to acknowledge Ella Warburg for assistance in creating the Figures presented in this paper. We appreciate the support of the Knapp Center at Wellesley College, which in 2020-21 provided funding for research assistance; and the College or Arts & Sciences Dean’s Office at the University of San Francisco, which supported interview transcription.

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Gamson, J., Hertz, R. “But Everything Else, I Learned Online”: School-Based and Internet-Based Sexual Learning Experiences of Heterosexual and LGBQ + Youth. Qual Sociol 46 , 461–485 (2023). https://doi.org/10.1007/s11133-023-09550-w

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Comprehensive sexuality education: For healthy, informed and empowered learners

Did you know that only 37% of young people in sub-Saharan Africa can demonstrate comprehensive knowledge about HIV prevention and transmission? And two out of three girls in many countries lack the knowledge they need as they enter puberty and begin menstruating? Early marriage and early and unintended pregnancy are global concerns for girls’ health and education: in East and Southern Africa pregnancy rates range 15-25%, some of the highest in the world. These are some of the reasons why quality comprehensive sexuality education (CSE) is essential for learners’ health, knowledge and empowerment. 

What is comprehensive sexuality education or CSE?

Comprehensive sexuality education - or the many other ways this may be referred to - is a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. It aims to equip children and young people with knowledge, skills, attitudes and values that empowers them to realize their health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and understand and ensure the protection of their rights throughout their lives.

CSE presents sexuality with a positive approach, emphasizing values such as respect, inclusion, non-discrimination, equality, empathy, responsibility and reciprocity. It reinforces healthy and positive values about bodies, puberty, relationships, sex and family life.

How can CSE transform young people’s lives?

Too many young people receive confusing and conflicting information about puberty, relationships, love and sex, as they make the transition from childhood to adulthood. A growing number of studies show that young people are turning to the digital environment as a key source of information about sexuality.

Applying a learner-centered approach, CSE is adapted to the age and developmental stage of the learner. Learners in lower grades are introduced to simple concepts such as family, respect and kindness, while older learners get to tackle more complex concepts such as gender-based violence, sexual consent, HIV testing, and pregnancy.

When delivered well and combined with access to necessary sexual and reproductive health services, CSE empowers young people to make informed decisions about relationships and sexuality and navigate a world where gender-based violence, gender inequality, early and unintended pregnancies, HIV and other sexually transmitted infections still pose serious risks to their health and well-being. It also helps to keep children safe from abuse by teaching them about their bodies and how to change practices that lead girls to become pregnant before they are ready.

Equally, a lack of high-quality, age-appropriate sexuality and relationship education may leave children and young people vulnerable to harmful sexual behaviours and sexual exploitation.

What does the evidence say about CSE?

The evidence on the impact of CSE is clear:

• Sexuality education has positive effects, including increasing young people’s knowledge and improving their attitudes related to sexual and reproductive health and behaviors.
• Sexuality education leads to learners delaying the age of sexual initiation, increasing the use of condoms and other contraceptives when they are sexually active, increasing their knowledge about their bodies and relationships, decreasing their risk-taking, and decreasing the frequency of unprotected sex.
• Programmes that promote abstinence as the only option have been found to be ineffective in delaying sexual initiation, reducing the frequency of sex or reducing the number of sexual partners. To achieve positive change and reduce early or unintended pregnancies, education about sexuality, reproductive health and contraception must be wide-ranging.
• CSE is five times more likely to be successful in preventing unintended pregnancy and sexually transmitted infections when it pays explicit attention to the topics of gender and power
• Parents and family members are a primary source of information, values formation, care and support for children. Sexuality education has the most impact when school-based programmes are complemented with the involvement of parents and teachers, training institutes and youth-friendly services .

How does UNESCO work to advance learners' health and education?

Countries have increasingly acknowledged the importance of equipping young people with the knowledge, skills and attitudes to develop and sustain positive, healthy relationships and protect themselves from unsafe situations.

UNESCO believes that with CSE, young people learn to treat each other with respect and dignity from an early age and gain skills for better decision making, communications, and critical analysis. They learn they can talk to an adult they trust when they are confused about their bodies, relationships and values. They learn to think about what is right and safe for them and how to avoid coercion, sexually transmitted infections including HIV, and early and unintended pregnancy, and where to go for help. They learn to identify what violence against children and women looks like, including sexual violence, and to understand injustice based on gender. They learn to uphold universal values of equality, love and kindness.

In its International Technical Guidance on Sexuality Education , UNESCO and other UN partners have laid out pathways for quality CSE to promote health and well-being, respect for human rights and gender equality, and empower children and young people to lead healthy, safe and productive lives. An online toolkit was developed by UNESCO to facilitate the design and implementation of CSE programmes at national level, as well as at local and school level. A tool for the review and assessment of national sexuality education programmes is also available. Governments, development partners or civil society organizations will find this useful. Guidance for delivering CSE in out-of-school settings is also available.

Through its flagship programme, Our rights, Our lives, Our future (O3) , UNESCO has reached over 30 million learners in 33 countries across sub-Saharan Africa with life skills and sexuality education, in safer learning environments. O3 Plus is now also reaching and supporting learners in higher education institutions.

To strengthen coordination among the UN community, development partners and civil society, UNESCO is co-convening the Global partnership forum on CSE together with UNFPA. With over 65 organizations in its fold, the partnership forum provides a structured platform for intensified collaboration, exchange of information and good practices, research, youth advocacy and leadership, and evidence-based policies and programmes.

Good quality CSE delivery demands up to date research and evidence to inform policy and implementation . UNESCO regularly conducts reviews of national policies and programmes – a report found that while 85% of countries have policies that are supportive of sexuality education, significant gaps remain between policy and curricula reviewed. Research on the quality of sexuality education has also been undertaken, including on CSE and persons with disabilities in Asia and East and Southern Africa .

How are young people and CSE faring in the digital space?

More young people than ever before are turning to digital spaces for information on bodies, relationships and sexuality, interested in the privacy and anonymity the online world can offer. UNESCO found that, in a year, 71% of youth aged 15-24 sought sexuality education and information online.

With the rapid expansion in digital information and education, the sexuality education landscape is changing . Children and young people are increasingly exposed to a broad range of content online some of which may be incomplete, poorly informed or harmful.

UNESCO and its Institute of Information Technologies in Education (IITE) work with young people and content creators to develop digital sexuality education tools that are of good quality, relevant and include appropriate content. More research and investment are needed to understand the effectiveness and impact of digital sexuality education, and how it can complement curriculum-based initiatives. Part of the solution is enabling young people themselves to take the lead on this, as they are no longer passive consumers and are thinking in sophisticated ways about digital technology.

A foundation for life and love

• Safe, seen and included: report on school-based sexuality education
• International Technical Guidance on Sexuality Education
• Safe, seen and included: inclusion and diversity within sexuality education; briefing note
• Comprehensive sexuality education (CSE) country profiles
• Evidence gaps and research needs in comprehensive sexuality education: technical brief
• The journey towards comprehensive sexuality education: global status report
• Definition of Sustainable Development Goal (SDG) thematic indicator 4.7.2: Percentage of schools that provided life skills-based HIV and sexuality education within the previous academic year
• From ideas to action: addressing barriers to comprehensive sexuality education in the classroom
• Facing the facts: the case for comprehensive sexuality education
• UNESCO strategy on education for health and well-being
• UNESCO Health and education resource centre
• Campaign: A foundation for life and love
• UNESCO’s work on health and education

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Sexually Transmitted Infections

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Older adults, patient handouts, what are sexually transmitted infections (stis).

Sexually transmitted infections (STIs), or sexually transmitted diseases (STDs), are infections that are passed from one person to another through sexual contact. They are usually spread during vaginal, oral, or anal sex. But sometimes they can spread through other sexual contact involving the penis, vagina, mouth, or anus. This is because some STIs, like herpes and HPV, are spread by skin-to-skin contact.

Some STIs can be passed from a pregnant person to the baby, either during pregnancy or when giving birth. Other ways that some STIs may be spread include during breastfeeding , through blood transfusions , or by sharing needles.

There are more than 20 types of STIs, including:

• Genital herpes
• Trichomoniasis

What causes sexually transmitted infections (STIs)?

STIs can be caused by bacteria , viruses , and parasites .

Who is affected by sexually transmitted infections (STIs)?

Most STIs affect both men and women, but in many cases the health problems they cause can be more severe for women. If an STI is passed to a baby, it can cause serious health problems.

What are the symptoms of sexually transmitted infections (STIs)?

STIs don't always cause symptoms or may only cause mild symptoms. So it is possible to have an infection and not know it. And even without symptoms, STIs can still be harmful and may be passed on during sex.

If there are symptoms, they could include:

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How are sexually transmitted infections (STIs) diagnosed?

If you are sexually active, you should talk to your health care provider about your risk for STIs and whether you need to be tested. This is especially important since many STIs do not usually cause symptoms.

Some STIs may be diagnosed during a physical exam or through STI testing . Some tests involve a microscopic examination of a sore or fluid swabbed from the vagina, penis, or anus. Blood tests can diagnose other types of STIs.

What are the treatments for sexually transmitted infections (STIs)?

Antibiotics can treat STIs that are caused by bacteria or parasites. There is no cure for STIs caused by viruses, but antiviral medicines can often help with the symptoms and lower your risk of spreading the infection.

It's important to get treatment if you have an STI. Some types of STIs can cause serious health problems if they are not treated.

Can sexually transmitted infections (STIs) be prevented?

The surest way to protect yourself against STIs is to not have sex.

If you do decide to have sex, you can lower your risk of getting an STI by:

• Having you and your partner tested for STIs before having sex.
• Using a condom every time you have sex. Correct usage of latex condoms greatly reduces, but does not completely eliminate, the risk of catching or spreading STIs. If your or your partner is allergic to latex , you can use polyurethane condoms.
• Reducing your number of sex partners. You might even consider "mutual monogamy" with just one partner. This means that you agree to be sexually active only with them, and they agree to be sexually active only with you. But first you should both get tested to make sure that you don't already have an STI.
• Getting vaccinated against HPV and hepatitis B .

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• Lymphogranuloma Venereum (LGV) (VisualDX)
• Molluscum Contagiosum (VisualDX)
• Pubic Lice (Pediculosis Pubis) (VisualDX)
• STI Myths & Facts Quiz (Medical Encyclopedia) Also in Spanish
• FastStats: Sexually Transmitted Diseases (STD) (National Center for Health Statistics)

Journal Articles References and abstracts from MEDLINE/PubMed (National Library of Medicine)

• Article: Enhancing routine HIV and STI testing among young men who have...
• Article: Associations between intravaginal practices and incidence of sexually transmitted infections and...
• Article: 2023 Korean sexually transmitted infections guidelines for non-gonococcal bacterial infection (chlamydia,...
• Sexually Transmitted Infections -- see more articles
• Centers for Disease Control and Prevention Also in Spanish
• Pubic Lice (Crabs) (Nemours Foundation) Also in Spanish
• STDs (Sexually Transmitted Diseases) (Nemours Foundation) Also in Spanish
• Talking to Your Kids About STDs (Nemours Foundation) Also in Spanish
• Talking to Your Partner about Condoms (Nemours Foundation) Also in Spanish
• Talking to Your Partner about STDs (Nemours Foundation) Also in Spanish
• Telling Your Partner You Have an STD (Nemours Foundation) Also in Spanish
• What Gay, Bisexual and Other Men Who Have Sex with Men Need to Know about Sexually Transmitted Diseases (Centers for Disease Control and Prevention) Also in Spanish
• Sexually Transmitted Infections (Department of Health and Human Services, Office on Women's Health) Also in Spanish
• Sexually Transmitted Infections, Pregnancy, and Breastfeeding (Department of Health and Human Services, Office on Women's Health) Also in Spanish
• STDs during Pregnancy (Centers for Disease Control and Prevention) Also in Spanish
• Safe Sex for Older Adults (AGS Health in Aging Foundation)
• Chancroid (Medical Encyclopedia) Also in Spanish
• Condom Fact Sheet in Brief (Centers for Disease Control and Prevention) - PDF
• Donovanosis (granuloma inguinale) (Medical Encyclopedia) Also in Spanish
• Genital sores - female (Medical Encyclopedia) Also in Spanish
• Genital sores - male (Medical Encyclopedia) Also in Spanish
• Safe sex (Medical Encyclopedia) Also in Spanish

The information on this site should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.