Sexual health education in the schools: Questions & Answers Updated 2015 Edition Sexual health education in the schools: Questions & Answers (Updated 2015 Ontario Edition)

A resource with answers to your questions about sexual health education in our schools

This resource document was prepared by the Sex Information and Education Council of (SIECCAN): www.sieccan.org

CONTENTS

INTRODUCTION ...... 3 9. What are the key ingredients of behaviourally QUESTIONS: effective sexual health education programs? ...... 10 1. Sexual health and youth: What are the key 10. Why is it important to integrate the educa- issues? ...... 3 tional needs of lesbian, gay, bisexual, and 2. Why do we need sexual health education in the transgender (LGBT) students into school- schools?...... 5 based sexual health education? ...... 13 3. Do parents want sexual health education taught 11. Why is it important to integrate the educa- in the schools? ...... 6 tional needs of students with physical or 4. Do young people want sexual health education developmental disabilities into school-based taught in the schools? ...... 7 sexual health education? ...... 14 5. What values are taught in school-based sexual 12. Should learning about the concept of consent health education? ...... 8 be integrated into school-based sexual health 6. Does providing youth with sexual health education? ...... 15 education lead to earlier or more frequent 13. Should learning about the risks of sexting and sexual activity? ...... 8 online pornography be integrated into school- 7. Is there clear evidence that sexual health based sexual health education? ...... 16 education can effectively help youth reduce 14. What are the social and economic benefits their risk of STI/HIV infection and of implementing broadly-based sexual health unintended pregnancy? ...... 9 education in the schools?...... 17 8. Are abstinence-only programs an appropriate and REFERENCES ...... 18 effective form of school-based sexual health education? ...... 9 ACKNOWLEDGEMENTS ...... 23

Suggested citation:

Sex Information and Education Council of Canada. (2015). Sexual health education in the schools: Questions and answers. Updated 2015 Ontario edition. , ON: Sex Information and Education Council of Canada (SIECCAN). www.sieccan.org

6 2015 Sex Information and Education Council of Canada Introduction

ccess to effective broadly-based sexual ’s (2008) Canadian Guidelines for Sexual A education that provides the necessary infor- Health Education. The Guidelines are based on mation and skills to enhance sexual health and the principle that sexual health education should avoid negative sexual health outcomes is an im- be accessible to all people and that it should be portant contributing factor to the health and provided in an age appropriate, culturally sensitive well-being of youth (Public Health Agency of manner that is respectful of an individual’s right to Canada, 2008; Society of Obstetricians and Gyne- make informed choices about sexual and repro- cologists of Canada, 2004). School-based pro- ductive health. This approach is aligned with The grams are an essential avenue for providing sexual Canadian Charter of Rights and Freedoms’ articula- health education to young people. Educators, tion of all ’ rights to personal liberty public health professionals, administrators, and and security of person, and freedom of thought, others who are committed to providing high quality belief, and opinion. Sexual health education in- sexual health education in the schools are often formed by democratic principles provides people asked to explain the rationale, philosophy, and with complete and accurate information so that content of proposed or existing sexual health edu- they have the capacity to make informed decisions cation programs. This document, prepared by that directly impact on their own health and well- SIECCAN, the Sex Information and Education being. As noted in Question 5 below, the Guide- Council of Canada (www.sieccan.org), is designed lines also specify that sexual health education to support the provision of high quality sexual should provide sexual health education program- health education in Ontario schools and across ing that does not discriminate based on character- Canada. It provides answers to some of the most istics such as sexual orientation and gender iden- common questions that parents, communities, tity which is consistent with the equality section 3 educators, program planners, school and health of the Charter of Rights and Freedoms and the administrators, and governments may have about Ontario Human Rights Code. The answers to com- sexual health education in the schools. mon questions about sexual health education pro- Canada is a pluralistic society in which people vided in this document are based upon and in- with differing philosophical, cultural, and religious formed by the findings of up-to-date and credible values live together with a mutual recognition and scientific research. An evidence-based approach respect for the basic rights and freedoms that all combined with a respect for individual rights people are entitled to in a democratic society. within a democratic society offers a strong founda- Philosophically, this document reflects the demo- tion for the development and implementation of cratic, principled approach to sexual health educa- high quality sexual health education programs in tion embodied in the Public Health Agency of schools.

1. Sexual health and youth: What are the key issues?

exual health is multidimensional and involves Canada, 2008). Trends in teen pregnancy, sexually S the achievement of positive outcomes such as transmitted infections, age of first intercourse, and mutually rewarding interpersonal relationships condom use, as well as challenges facing lesbian, and desired parenthood, as well as the avoidance gay, bisexual, and transgender (LGBT) youth, the of negative outcomes such as unwanted pregnancy impact of technology, and the need to address sex- and STI/HIV infection (Public Health Agency of ual coercion/assault are among the key sexual

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 1. SEXUAL HEALTH AND YOUTH: WHAT ARE THE KEY ISSUES? (CONTINUED)

health issues for youth in Ontario and across chlamydia annually is significant. The highest Canada. reported rates of chlamydia in Ontario are among It is likely that a large proportion of teen young women aged 20 to 24, followed by those pregnancies, particularly among younger teens, are aged 15 to 19 (Public Health Ontario, 2014). unintended. Teen pregnancy rates are therefore Although definitive age-specific prevalence data a reasonably direct indicator of young women’s for Ontarians or Canadians is not available, sur- opportunities and capacity to control this aspect veillance data from the United States indicates a of their sexual and reproductive health (McKay, chlamydia positivity rate of 8.4% among women 2012). In Canada, the pregnancy rate (i.e., live aged 15 to 24 attending family planning clinics births/induced abortions) for both younger (age (Centers for Disease Control and Prevention, 15-17) and older (age 18-19) teenage women has 2013). fallen significantly over the last several decades Other STIs are also common among youth (McKay, 2012). Between 2001 and 2010, the teen and young adults. A study of students at a Cana- pregnancy rate among young women aged 15 to dian university found a prevalence of human 19 in Ontario declined from 30.6 per 1,000 to papillomavirus (HPV) was over 50% in both 21.2, a decline of 30.7% and during the same females and males (Burchell, Tellier, Hanley, period the teen pregnancy rate for Canada fell Coutle´e, & Franco, 2010). Data from the Cana- less, (20.3%; McKay, 2012). Based on data from dian Health Measures Survey indicate that approxi- the Canadian Institute for Health Information mately 6% of people aged 14 to 34 have acquired and Statistics Canada, calculations indicate that genital herpes (HSV-2; Rotermann, Langlois, for the years 2007 to 2013, the teen abortion rate Severini, & Totten, 2013) and it is likely that a in Ontario declined from 13.0 per 1,000 to 7.8, a significant proportion of these infections were decline of 40.0% (Sex Information and Education acquired during adolescence or young adulthood. 4 Council of Canada, unpublished data). In order to There is also growing concern about the emer- maintain these positive trends, it is essential that gence of antibiotic resistant gonorrhea in Canada all young people in Ontario receive concise, up- (Public Health Agency of Canada, 2013). High to-date, and medically accurate information about rates of STIs among youth in Ontario result in contraception. significant preventable negative health outcomes Sexually transmitted infections (STI) pose a for young people and entail significant costs for significant threat to the health and well-being of the health care system. Sexual health education in Ontario youth. Chlamydia is of particular concern the schools can play an important role in ensuring because, if left untreated, it can result in numerous that youth have the necessary knowledge about negative health outcomes. Potential outcomes STIs and their prevention. from undiagnosed infection for women include For a majority of Canadians, first sexual inter- pelvic inflammatory disease (PID), chronic pelvic course occurs during the teenage years (Roter- pain, ectopic pregnancy, tubal infertility, and in- mann, 2008, 2012). Data from Statistics Canada’s creased susceptibility to HIV infection (Public Canadian Community Health Survey indicate that Health Agency of Canada, 2010a). Reported rates 35% of Canadian youth reported experiencing (the number of positive test reports made to pub- first sexual intercourse before age 17; over two lic health agencies) of chlamydia have been in- thirds (68%) reported having intercourse before creasing steadily in recent years in both Ontario age 20 (Rotermann, 2012). A survey of Ontario and Canada (Public Health Agency of Canada, youth found that among Grade 9-10 students, 2014; Public Health Ontario, 2014). While some 18% of females and 25% of males reported that or all of this increase may be explained by im- they had experienced sexual intercourse (Freeman, proved screening practices and testing methods, King, Al-Haque, & Picket, 2012). By the time the number of young people in Ontario acquiring they have reached their early 20’s, approximately

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 1. SEXUAL HEALTH AND YOUTH: WHAT ARE THE KEY ISSUES? (CONTINUED) three quarters of Canadian young people have condom use is a clear indication that many young become sexually active to some degree (Milhausen people in Canada underestimate their risk for STI et al., 2013; Rotermann, 2012). In addition, it (Reported rates of chlamydia and other STI are should be noted that the percentage of Canadian highest among 20-24 year-olds.). To reduce the youth who report that they have experienced burden of STI on young people and society gen- sexual intercourse has remained stable since the erally, it is necessary to provide sexual health edu- mid-1990s (Rotermann, 2008, 2012). It is im- cation that provides comprehensive information portant that sexual health education in schools on STIs and STI risk reduction. provide developmentally appropriate information As discussed in Question #10 of this docu- that addresses the reality of the timing of initiation ment, sexual health education in the schools is of partnered sexual behaviour among young people. often presented predominantly or entirely within This means, for example, that it is necessary and a heterosexual context and may therefore neglect appropriate to provide information on delaying the needs LGBT youth. In addition, LGBT youth sexual first intercourse, the importance of condom often face high levels of harassment and violence use to reduce risk for STI, and contraception to while in school (Taylor et al., 2011). prevent unwanted pregnancy before a sizable per- As discussed in Question #11 of this docu- centage of youth have become sexually active. ment, rates of sexual assault in Canada are highest Condom use among sexually active Canadian among young people aged 15 to 24 and young youth is relatively high. About 80% of sexually women are disproportionately the victims (Perreault active 15 to 17 year-olds report using a condom & Brennan, 2010). There is an increasing awareness at last intercourse (Rotermann, 2012). However, that to reduce the occurrence of sexual assault and there is also a persistent trend for high rates of coercion in Canada, sexual health education cur- condom use among sexually active teens to decline ricula must integrate the concept of consent. as they get older. Among the Canadian Community As discussed in Question #12 of this docu- 5 Health Survey participant’s, levels of condom use ment, technology (i.e., cell/smartphones and the at last intercourse declined to 74% among 18 to internet) have fundamentally altered the way young 19 year-olds and 63% among 20 to 24 year-olds people are exposed to and absorb sexuality related (Rotermann, 2012). A more recent study of Cana- imagery and information. Sexting and online por- dian university students found that less than half nography pose challenges to the sexual health of used a condom at last intercourse (Milhausen et young people and, as a result, these issues require al., 2013). The propensity for older sexually active attention within sexual health education curricula. teens and young adults in Canada to discontinue

2. Why do we need sexual health education in the schools?

exual health is a key aspect of personal In principle, all Canadians, including youth, ‘‘S health and social welfare that influences have a right to information and opportunities to individuals across their life span’’ (Public Health develop the motivation/personal insight and skills Agency of Canada, 2008, p. 2). Because sexual necessary to prevent negative sexual health out- health is a key component of overall health and comes (e.g., STIs including HIV, unintended well-being, ‘‘sexual health education should be pregnancy, sexual assault/coercion) and to enhance available to all Canadians as an important com- sexual health (e.g., positive self-image and self- ponent of health promotion and services’’ (Health worth, integration of sexuality into mutually satis- Canada, 2003, p. 1). fying relationships). In order to ensure that youth

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 2. WHY DO WE NEED SEXUAL HEALTH EDUCATION IN THE SCHOOLS? (CONTINUED)

are adequately equipped with the information, As a fundamental part of its contribution to motivation/personal insight, and skills to protect the development and well-being of youth, school- their sexual and reproductive health, ‘‘it is impera- based sexual health education can play an impor- tive that schools, in cooperation with parents, the tant role in the primary prevention of significant community, and health care professionals, play a sexual health problems. As documented in more major role in sexual health education and promo- detail elsewhere in this resource document, well- tion’’ (Society of Obstetricians and Gynecologists planned and implemented sexual health education of Canada, 2004, p. 596). As stated by the Public programs are effective in helping youth reduce Health Agency of Canada (2008), their risk of STI/HIV infection and unplanned pregnancy. In addition, it should be emphasized Since schools are the only formal edu- that an important goal of sexual health education cational institution to have meaningful is to provide education on broader aspects of (and mandatory) contact with nearly sexual health, including the development of a every young person, they are in a positive self-image and the integration of sexuality unique position to provide children, into rewarding and equitable interpersonal rela- adolescents and young adults with the tionships (Public Health Agency of Canada, 2008). knowledge, understanding, skills, and attitudes they will need to make and act upon decisions that promote sexual health throughout their lives (p. 19).

3. Do parents want sexual health education taught in the schools? 6

arents and guardians are an important and e Correct names for body parts, including P primary source of guidance for young people genitalia concerning sexual behaviour and values. Many e Physical, cognitive, emotional, and social youth look to their parents as a valuable source changes of sexuality information (Frappier et al., 2008). e Puberty Parents also recognize that the schools should play a key role in the sexual health education of e Reproduction their children. e Abstinence A series of surveys involving a total of 12,800 e Methods of contraception parents conducted in Ontario (McKay, Pietrusiak & Holowaty, 1998; McKay, Byers, Voyer, Hum- e Sexually transmitted infections phreys, & Markham, 2014) and other parts of e Skills for healthy relationships

Canada (Advisory Committee on Family Planning, e Decision-making skills 2008; Weaver, Byers, Sears, Cohen & Randall, e Self-esteem and personal development 2002) clearly demonstrate that a strong majority of parents support the teaching of sexual health e Communication skills education in the schools (See Figure 1). e Sexual orientation In the most recent Ontario survey (McKay et e Media literacy al., 2014), parents rated all 13 of the following potential topics as important for inclusion in the sexual health education curriculum:

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 3. DO PARENTS WANT SEXUAL HEALTH EDUCATION TAUGHT IN THE SCHOOLS? (CONTINUED)

Figure 1. Percentage of parents agreeing with the statement ‘‘Sexual health education should be provided in the schools’’

7 4. Do young people want sexual health education taught in the schools?

urveys of youth have clearly shown that young pating in the Toronto Teen Survey ranked healthy S people in Canada want sexual health educa- relationships, HIV/AIDS, pleasure, and com- tion to be taught in school (Byers, Sears, Voyer, munication highest (Causarano, Pole, Flicker, and Thurlow, Cohen & Weaver, 2003a; Byers, Sears, the Toronto Teen Survey Team, 2010). National Voyer, Thurlow, Cohen & Weaver, 2003b; McKay surveys of youth in Canada have found that & Holowaty, 1997). For example, a survey of high schools are the most frequently cited main source school youth found that 92% agreed that ‘‘Sexual of information on sexuality issues (human sexual- health education should be provided in the ity, puberty, birth control, HIV/AIDS) (Boyce, schools’’ and they rated the following topics as Doherty, Fortin & Mackinnon, 2003) and rank either ‘‘very important’’ or ‘‘extremely important’’: highest as the most useful/valuable source of puberty, reproduction, personal safety, sexual coer- sexual health information (Frappier et al., 2008). cion and sexual assault, sexual decision-making in However, when Ontario students were surveyed, dating relationships, birth control and safer sex 45% indicated that sexual health education classes practices, and STIs (Byers et al., 2003a). When did not address the concerns they had encoun- asked what topics they wanted to learn more tered or expected to encounter (Ontario Student about from sexual health education, youth partici- Trustees Association, 2011).

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 5. What values are taught in school-based sexual health education?

anada is a pluralistic society in which differ- e Helps individuals to become more sensitive C ent people have different values and perspec- and aware of the impact their behaviours tives towards human sexuality. At the same time, and actions may have on others and society;

Canadians are united by their respect for the basic e Does not discriminate on the basis of age, and fundamental values and principles of a demo- race, ethnicity, gender identity, sexual cratic society. An emphasis on democratic values orientation, socioeconomic background, (e.g., the right to make informed decisions about physical/cognitive abilities and religious health and well-being) provides the overall philo- background in terms of access to relevant, sophical framework for many school-based sexual appropriate, accurate and comprehensive health education programs in Canada. The Public information (Public Health Agency of Canada, Health Agency of Canada’s (2008) Canadian Guide- 2008, p. 11). lines for Sexual Health Education have been used by These statements acknowledge that sexual health communities as a basis for the development of a education programs should not be value free, but consensus on the fundamental values that should rather that: be reflected in school-based sexual health educa- tion. The Guidelines were formulated to embody e Effective sexual health education recognizes an educational philosophy that is inclusive, respects that responsible individuals may choose a diversity, and reflects the fundamental precepts of variety of paths to achieve sexual health;

education in a democratic society. Thus, the Cana- e Effective sexual health education supports dian Guidelines for Sexual Health Education are in- informed decision making by providing 8 tended to inform sexual health programming that: individuals with the knowledge, personal e Focuses on the self-worth, respect, and insight, motivation, and behavioural skills dignity of the individual; that are consistent with each individual’s personal values and choices (Public Health e Is provided in an age-appropriate, culturally Agency of Canada, 2008, p. 25). sensitive manner that is respectful of indi- vidual sexual diversity, abilities, and choices;

6. Does providing youth with sexual health education lead to earlier or more frequent sexual activity?

he impact of sexual health education on the measuring the behavioural impact of broadly- T sexual behaviour of youth has been exten- based sexual health education for youth that in- sively examined in a large number of evaluation cluded information on abstinence, contraception, research studies. A meta-analysis of 174 studies and STI/HIV prevention (e.g., condom use) con- examining the impact of different types of sexual cluded that such programs do not hasten or in- health promotion interventions found that these crease sexual behaviour but rather that they result programs do not inadvertently increase the fre- in ‘‘. . .reductions in both sexual activity and fre- quency of sexual behaviour or number of sexual quency of sexual activity among adolescents com- partners (Smoak, Scott-Sheldon, Johnson, & Carey, pared to adolescents not receiving the inter- 2006). More specifically, a review of 66 studies vention’’ (Chin et al., 2012, p. 286-287). Other

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 6. DOES PROVIDING YOUTH WITH SEXUAL HEALTH EDUCATION LEAD TO EARLIER OR MORE FREQUENT SEXUAL ACTIVITY? (CONTINUED) reviews of studies measuring the effects of sexual (Bennett & Assefi, 2005; Johnson, Scott-Sheldon, health education have reached the same conclu- Huedo-Medina, & Carey, 2011; Kirby, Laris, & sion: Sexual health education for youth does not Rolleri, 2007). result in earlier or more frequent sexual behaviour

7. Is there clear evidence that sexual health education can effectively help youth reduce their risk of STI/HIV infection and unintended pregnancy?

here is a large body of rigorous evidence in tion Interventions includes programs for adoles- T the form of peer-reviewed published studies cents that have been rigorously evaluated and measuring the behavioural impact of well-designed have demonstrated efficacy in reducing HIV/STI adolescent sexual health interventions that leads to incidence or sexual risk behaviors. For compre- the definitive conclusion that such programs can hensive reviews of the evaluation research litera- have a significant positive impact on sexual health ture demonstrating the positive behavioural im- behaviours (e.g., delaying first intercourse, in- pact of well-developed sexual health education, creasing use of condoms). For example, the U.S. see Bennett and Assefi (2005), Chin et al., (2012), Centers for Disease Control and Prevention’s Johnson et al., (2011), Kirby, Laris and Rolleri (2014) Compendium of Evidence-Based HIV Preven- (2007), and Protogerou and Johnson (2014).

9 8. Are abstinence-only programs an appropriate and effective form of school-based sexual health education?

n some parts of the United States, some com- sexually active? And second, do abstinence-only I munities and school boards receive federal gov- programs respect young people’s right to make ernment funding to teach abstinence-only sex edu- fully informed decisions in accordance with their cation programs. (Broadly-based/comprehensive own values about sexual and reproductive health? sexual health education programs are also eligible It should be noted that the term abstinence as it for U.S. federal government funding.) To receive applies to education for youth is commonly under- U.S. federal government funding, an abstinence stood to mean not engaging in sexual intercourse until program must have ‘‘. . .as its exclusive purpose, marriage but abstinence may be given a range of teaching the social, psychological, and health gains definitions including not having intercourse until to be realized by abstaining from sexual activity" some point in the future or not engaging in any and teach students ‘‘. . .that sexual activity outside form of partnered sexual activity (e.g., intercourse, the context of marriage is likely to have harmful oral sex, touching), and others may also include psychological and physical effects’’ (Social Security refraining from masturbation in their definition Administration, 2015). To assess the appropriate- of abstinence. In sum, the term abstinence can be ness of abstinence-only as a form of school-based highly ambiguous and should be used with cau- sexual health education, two key questions tion, if at all, in delineating the objectives of sexual emerge. First, are abstinence-only programs effec- health education for youth. tive in persuading young people not to become

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 8. ARE ABSTINENCE-ONLY PROGRAMS AN APPROPRIATE AND EFFECTIVE FORM OF SCHOOL-BASED SEXUAL HEALTH EDUCATION? (CONTINUED)

A substantial body of research evidence mained generally consistent over time (Rotermann, clearly indicates that most abstinence-only sex 2005, 2008, 2012). Young people have a right education programs are ineffective in reducing to receive sexual and reproductive health informa- adolescent sexual behaviour. For example, a multi- tion relevant to their needs, circumstances, and ple site randomized trial evaluation of abstinence- choices. For most Canadian youth, that includes only programs that were eligible for and received information on contraception for pregnancy pre- the U.S. Federal government abstinence educa- vention and safer sex practices (e.g., condom use) tion funding found that students who had partici- for HIV/STI risk reduction. According to the pated in these programs were not more likely to Public Health Agency of Canada’s (2008) Cana- be abstinent or to delay first intercourse or to dian Guidelines for Sexual Health Education, have fewer sexual partners than students who did Effective sexual health education not receive abstinence-only education (Trenholm supports informed decision-making et al., 2007). These findings, indicating that by providing individuals with the abstinence-only programs are not effective in re- opportunity to develop the knowledge, ducing the likelihood that youth will engage in personal insight, motivation and sexual intercourse, are consistent with the findings behavioural skills that are consistent of other large scale studies (e.g., Kohler, Manhart, with each individual’s personal values & Lafferty, 2008) and reviews of the program and choices. For example, some ado- evaluation literature indicating that abstinence- lescents engage in partnered sexual only education is ineffective (e.g., Bennett & Assefi, activities whereas others will make 2005; Hauser, 2004; Johnson et al., 2011; Kirby, an informed decision to delay these 2008; Protogerou & Johnson, 2014). In the few sexual activities. . . . Effective sexual cases where individual abstinence-based interven- health education recognizes that 10 tions aimed at younger youth (e.g., age 10-14) responsible individuals may choose a have resulted in reduced sexual activity, compared variety of paths to achieve sexual to youth who received no sex education, these health (p. 25). programs neglected to provide important health information on unintended pregnancy and HIV/ Educational programs that withhold informa- STI prevention for those students who become tion necessary for individuals to make voluntary, sexually active during the program or in the informed decisions about their sexual health are months or years afterwards (Chin et al., 2012). unethical (World Association for Sexual Health, As noted earlier in this document, over two- 2008). Abstinence-only policies may violate the thirds of Canadian youth will experience their first human rights of young people because they with- sexual intercourse before age 20, a sizable propor- hold potentially life-saving information on HIV tion become sexually active during the mid-teens, and other STI (Ott & Santelli, 2007). and these levels of teen sexual activity have re-

9. What are the key ingredients of behaviourally effective sexual health education programs?

he first and most important ingredients of and that the teachers/educators who provide it T effective sexual health education programs are adequately supported, trained, and motivated in the schools are that sufficient classroom time is to do so (Society of Obstetricians and Gynecolo- allocated to the teaching of this important topic gists of Canada, 2004). As stated by the Public

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 9. WHAT ARE THE KEY INGREDIENTS OF BEHAVIOURALLY EFFECTIVE SEXUAL HEALTH EDUCATION PROGRAMS? (CONTINUED)

Health Agency of Canada (2008), ‘‘Sexual health active and benefits of delaying first intercourse), education should be presented by confident, well- and teach the specific behavioural skills that are trained, knowledgeable and nonjudgmental indi- needed to protect and enhance sexual health (e.g., viduals who receive strong administrative support’’ learning to negotiate condom use and/or sexual (p. 18). limit-setting; See Figure 2). Support for utilizing It is clear from the research on sexual health the IMB model as a theoretical framework for the promotion that behaviourally effective programs development of behaviourally effective sexual are based and structured on theoretical models health education interventions with youth has been of behaviour change that enable educators to provided in several scientific evaluations (Fisher, understand and influence sexual health behaviour Fisher, Bryan, & Misovich, 2002; Morrison-Beedy (Albarracin et al., 2005; Kirby et al., 2007; Proto- et al., 2013). For information on the use of the gerou & Johnson, 2014; Public Health Agency of IMB model for the planning, implementation, Canada, 2008). The Public Health Agency of and evaluation of sexual health education pro- Canada’s (2008) Canadian Guidelines of Sexual grams, see the Canadian Guidelines for Sexual Health Health Education provide a framework for imple- Education (Public Health Agency of Canada, 2008). menting effective programming based on the There is an extensive body of research that Information-Motivation-Behavioural Skills (IMB) has identified the key ingredients of effective sexual model of sexual health enhancement and problem health promotion programming. (For a summary prevention (Albarracin et al., 2005; Fisher & and review of this literature see Albarracin et al., Fisher, 1998). For example, the IMB model speci- 2005; Fisher & Fisher, 1998; Kirby et al., 2007; fies that in order for sexual health education to Public Health Agency of Canada, 2008; Proto- be effective, it must provide information that is gerou & Johnson, 2014; World Association for directly relevant to sexual health (e.g., information Sexual Health, 2008.) This research has clearly on effective forms of birth control and where to demonstrated that effective sexual health educa- 11 access them), address motivational factors that tion programs will contain the following ingre- influence sexual health behaviour (e.g., discussion dients, listed in Table 1 below. of social pressures on youth to become sexually

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 9. WHAT ARE THE KEY INGREDIENTS OF BEHAVIOURALLY EFFECTIVE SEXUAL HEALTH EDUCATION PROGRAMS? (CONTINUED)

Table 1. The key ingredients of effective sexual health promotion programming

1. A realistic and sufficient allocation of classroom time to achieve program objectives. 2. Provide teachers/educators with the necessary training and administrative support to deliver program effectivly.

3. Employ sound teaching methods including the utilization of well-tested theoretical models to develop and implement programming (e.g., IMB Model, Social Cognative Theory, Trans- theoretical Model, Theory of Reasoned Action/Theory of Planned Behaviour). 4. Use elicitation research to identify student characteristics, needs, and optimal learning styles including tailoring instruction to student’s ethnocultural background, sexual orientation, and development stage.

5. Specifically target the behaviours that lead to negative sexual health outcomes such as STI/HIV infection and unintended pregnacy. 6. Deliver and consistently reinforce the prevention messages related to sexual limit-setting (e.g., delaying first intercourse, choosing not to have intercourse), consistent condom use and other forms of contraception.

7. Include program activities that address the individual’s environment and social context includ- ing peer and partner pressures related to adolescent sexuality.

12 8. Incorporate the necessary information, motivation and behavioural skills to effectively enact and maintain behaviours to promote sexual health.

9. Provide clear examples of and opportunities to practice (e.g., role plays) sexual limit setting, condom use negotiation, and other communication skills so that students are active participants in the program, not passive recipients. 10. Incorporate appropriate and effective evaluation tools to assess program strengths and weak- nesses in order to improve subsequent programming.

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 9. WHAT ARE THE KEY INGREDIENTS OF BEHAVIOURALLY EFFECTIVE SEXUAL HEALTH EDUCATION PROGRAMS? (CONTINUED)

Figure 2. The Information, Motivation, Behavioural Skills Model (IMB) for effective sexual health education

BEHAVIOURAL SKILLS INFORMATION MOTIVATION Development of Relevant sexual Motivation to use behavioural skills health information information to put information into practice

EXAMPLES EXAMPLES EXAMPLES e Knowledge about STI e Personal vulnerability to e Negotiating condom use transmisson negative sexual health e Negotiating sexual e How to use birth control outcomes limit-setting e Impact of social norms and peer pressure

13 10. Why is it important to integrate the educational needs of lesbian, gay, bisexual, and transgender (LGBT) students into school-based sexual health education?

n the past, sexual health education in schools gay, lesbian, bisexual, questioning or ‘‘mostly I tended to focus primarily, if not exclusively, on straight’’ in a large sample survey of high school providing information within a heterosexual con- students in (Smith et al., 2014). text and this often left lesbian, gay, bisexual, and Due to experiences of bullying, discrimination, transgender (LGBT) students without the relevant and stigmatization, LGBT youth often remain an and necessary information to make informed deci- invisible population in schools (Public Health sions to protect and enhance their sexual health Agency of Canada, 2010b; 2010c). The Public (Schalet et al., 2014). Most school classrooms will Health Agency of Canada’s (2008) Canadian have one or more students who are not hetero- Guidelines for Sexual Health Education suggest that sexual. In a demographic survey of junior and educational curricula should address the sexual high school students by the Toronto District health needs of all students, including those who School Board (2013), 8% of Grade 9 to 12 stu- are gay, lesbian, bisexual, transgender, or ques- dents identified themselves as non-heterosexual tioning. As well, the Guidelines note that an (e.g., lesbian, gay, bisexual, queer) or ‘‘not sure/ understanding of sexual diversity perspectives and questioning’’ in relation to their sexual orienta- issues is an important component of sexual health tion. Similar percentages of youth identified as education. Thus, the sexual health education needs

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 10. WHY IS IT IMPORTANT TO INTEGRATE THE EDUCATIONAL NEEDS OF LESBIAN, GAY, BISEXUAL, AND TRANSGENDER (LGBT) STUDENTS INTO SCHOOL-BASED SEXUAL HEALTH EDUCATION? (CONTINUED)

of LGBT students should be integrated within However, Egale Canada’s national survey of more broadly-based sexual health education in the than 3700 students on homophobia, biphobia, and schools. trans-phobia in Canadian schools found that 64% Surveys have repeatedly shown that a majority of LGBT students felt unsafe at school and 21% of Canadian parents (Advisory Committee on reported that they had been physically harassed Family Planning, 2008; Weaver, Byers, Sears, or assaulted because of their sexual orientation Cohen, & Randall, 2002) including Ontario (Taylor et al., 2011). In addition to the provision of parents (McKay et al., 2014; McKay, Pietrusiak, LGBT inclusive sexual health education, schools & Holowaty, 1998) want sexual orientation ad- can foster peer acceptance, school connectedness, dressed in school-based sexual health education and student safety by facilitating and supporting programs. the development of Gay-Straight Alliances (Public A supportive, non-threatening school envi- Health Agency of Canada, 2010b). An Ontario ronment has been recognized as being one protec- survey found that 79% of parents and 88% of stu- tive factor that can potentially reduce the risk of dents agreed that students should be allowed to set negative health and social outcomes among youth up a Gay-Straight Alliance at their school (Ontario (Public Health Agency of Canada, 2010b; 2010c). Student Trustees Association, 2011).

11. Why is it important to integrate the educational needs of students with physical or developmental disabilities into school-based sexual health education? 14 s noted in the Canadian Guidelines for Sexual more likely than their non-disabled peers to be A Health Education (Public Health Agency of the victims of sexual abuse and assault (McDonald, Canada, 2008), youth with physical and develop- Wobick, & Graham, 2004). mental disabilities have a right to broadly-based While sexual health education provided to sexual health education relevant to their needs. youth in schools should seek to be inclusive of Although sexuality and sexual health is as integral the needs of all students, including youth with dis- to the overall health and well-being of youth with abilities, in some instances educational opportuni- disabilities as it is for their non-disabled peers, the ties specific to the unique needs of students with provision of sexual health education for youth disabilities needs to be provided. For example, with disabilities that is specific to their needs youth with Autism Spectrum Disorder may need is often overlooked or lacking (DiGiulio, 2003; sexual health education curriculum materials East & Orchard, 2013; Public Health Agency of adapted to their specific learning styles and needs, Canada, 2013a; Sex Information and Education youth with other types of developmental disabil- Council of Canada, 2015a). Failure to provide ities may require education tailored to their spe- sexual health education that is inclusive of youth cific developmental level, and youth with different with disabilities places them at increased risk for physical disabilities may require sexual health edu- STIs/HIV, sexual exploitation, lower self-esteem, cation specific to their disability so that they have social isolation, and lower quality of life (Public the information and skills to protect and enhance Health Agency of Canada, 2013). Of particular their sexual health (DiGiulio, 2003; Public Health concern is that in Canada, youth and adults with Agency of Canada, 2013a; Sex Information and developmental and physical disabilities are much Education Council of Canada, 2015a).

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 12. Should learning about the concept of consent be integrated into school-based sexual health education?

ithin a democratic society, sexual health old. However, a 15-year-old cannot legally con- W education reflects basic fundamental values sent to engage in sex with a 21 year-old and in of respect for others and informs young people of that case the 21 year-old could be charged with their moral and legal obligations towards other sexual interference. The Criminal Code of Canada people. Consistent with this approach, the Public states that a young person under the age of 18 Health Agency of Canada’s (2008) Canadian cannot legally consent to have sex with a person Guidelines for Sexual Health Education indicate that in a position of authority, such as a teacher, health sexual health education should address the impact care provider, coach, lawyer, or family member that behaviours and actions may have on others. (Government of Canada, 2015). Sexual health As such, the concept of consent, as it applies to education programs should provide age appro- sexual behaviour, is an appropriate and necessary priate information regarding the age of consent component of sexual health education in the to sexual activity so that young people are fully schools. Two key aspects of consent pertain to (1) aware of the circumstances in which they may the ages at which a young person can legally con- be the victims of sexual exploitation by an older sent to sexual activity and (2) the communication person or a person in a position of authority. Fur- of consent or non-consent to engage in sexual thermore, each young person should be aware of activity with another person (Sex Information and the potential circumstances in which their rela- Education Council of Canada, 2015). tionships with peers younger than themselves is Age of consent refers to the age at which in violation of age of consent laws. people are able to make their own decisions about In Canada, sexual assault, including unwanted sexual activity. In Canada, the age of consent was sexual touching, as well as violent sexual attacks, 15 raised from 14 to 16 in 2008. Effective sexual disproportionately affects young women with young health education should provide students with a people aged 15 to 24 almost twice as likely to be clear understanding of how age of consent is sexually assaulted as those aged 25 to 34 (Perreault interpreted under the law. Educators should make & Brennan, 2010). Canadian law specifies that youth aware that the intent of the legislation is sexual activity must involve ‘‘voluntary agreement’’ to protect children and youth from adult sexual and that when there is a ‘‘lack of agreement’’ ex- predators. It is also important for youth to know pressed either verbally or by physically resisting, that the law is directed at adult sexual predators, consent does not exist (Government of Canada, not youth themselves, and that this law does not 2015). Furthermore, the law specifies that a person affect the right of young people to access sexual cannot consent to engage in sexual activity if they health education or sexual and reproductive health are ‘‘incapable’’ of doing so (e.g., because of ex- services. treme alcohol or drug intoxication; Sex Informa- Although the age of consent to sexual activity tion and Education Council of Canada, 2015b). is 16, there are several close in age exceptions. One Broadly-based sexual health education in the close in age exception is that 12 and 13 year-olds schools ‘‘Helps individuals to become more sensi- can consent to sexual activity with peers who are tive and aware of the impact their behaviours and not more than 2 years older than themselves. The actions may have on others. . .’’ (Public Health other is that 14 and 15 year-olds are able to con- Agency of Canada, 2008, p. 11). In early elemen- sent to sex with partners who are not more than tary grade levels, sexual health education can pro- 5 years older than themselves (Government of vide foundational knowledge and skill develop- Canada, 2015). For example, a 14 year-old can ment opportunities regarding general concepts of legally consent to sexual activity with an 18-year- respect of self and others. This can include learn-

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 12. SHOULD LEARNING ABOUT THE CONCEPT OF CONSENT BE INTEGRATED INTO SCHOOL-BASED SEXUAL HEALTH EDUCATION? (CONTINUED)

ing verbal and non-verbal communication skills of Canada, 2015). In addition, sexual health educa- (e.g., to listen, show respect for themselves and tion should provide students with the information others, to advocate for personal needs). In later necessary to be able to identify when they have grade levels, it is important for sexual health edu- been sexually assaulted or abused. cation in the schools to provide students with a To contribute to a reduction in sexual assault clear understanding of the meaning of consent as among young people, sexual health education can it applies specifically to sexual activity. It is devel- promote the development of interpersonal and opmentally appropriate for educational programs social environments that are free of coercion. To to provide information on sexual consent to young do so, sexual health education programs can address people as they approach the ages at which a sizable gender norms within society that contribute to un- proportion of young people become sexually equal intimate relationships. Focusing on gender- active. To reduce the likelihood of sexual assault based inequality as it applies to sexuality in sexual and to promote equitable, healthy relationships, health education programs may not only reduce young people need to learn the communication the likelihood of non-consensual sexual activity, skills to express non-consent (i.e., refusal) to research indicates that sexual health education engage in sexual activity and to ensure that mutual programs that incorporate issues of gender and consent exists between partners if sexual activity power are more likely to be effective in reducing does occur through the expression of affirmative STIs and unintended pregnancy (Haberland, 2015). consent (Sex Information and Education Council

13. Should learning about the risks of sexting and online 16 pornography be integrated into school-based sexual health education?

odern communication technologies (i.e., within broadly-based sexual health education cur- M cell phones/smartphones and the Internet) ricula. have fundamentally altered the way young people A national study of Canadian school students are exposed to and absorb sexuality related imag- found that among Grade 10 and 11 students with ery and information. By the time they reach ado- a cell phone, 11% and 14% respectively reported lescence, virtually all Canadian young people have that they had sent a sext of themselves to someone access to the Internet and most own or have access (Steeves, 2014). Young people need to be aware of to cell phones (Steeves, 2014). The Internet pro- the social, psychological, and legal consequences vides nearly unlimited access to graphic sexual im- of sending sexts (Canadian Paediatric Society, agery and cell phones can be used for various 2014). In particular, young people need to be forms of sexual communication. These modern aware that it is a criminal offense to distribute or communication technologies can be beneficial in share a photo or video of a sexual nature or that enhancing young people’s ability to learn about depicts nudity without the consent of the person sexuality from credible sources but at the same in the photo or video (Government of Canada, time, sexting and online pornography may present 2015). challenges to young people’s sexual health and Research indicates that the percentage of well-being (Springate & Omar, 2013). As a result, Canadian young people accessing pornography it is important that these issues are addressed on the Internet is increasing: A recent national

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 13. SHOULD LEARNING ABOUT THE RISKS OF SEXTING AND ONLINE PORNOGRAPHY BE INTEGRATED INTO SCHOOL-BASED SEXUAL HEALTH EDUCATION? (CONTINUED) survey of Canadian youth found that about a third construct hidden and overt sexual messages and of Grade 10 and 11 students reported looking for stereotypes’’ (p. 25). To be relevant to young pornography online (Steeves, 2014) and smaller people’s current educational needs, it is increas- studies in Canada (Thompson, 2006) and the ingly important that school-based sexual health United States (Braun-Courville & Rojas, 2009) education programs assist young people in devel- have found higher percentages of adolescents re- oping the critical media skills to interpret and porting exposure to sexually explicit websites. assess the sexual imagery on the Internet that they The Canadian Guidelines for Sexual Health will inevitably be exposed to. In addition, youth Education (Public Health Agency of Canada, need to develop the skills to differentiate between 2008) suggests that sexual health education pro- credible and problematic sources of information grams provide students with training in media about sexuality sourced from the Internet. literacy ‘‘. . .to help individuals identify and de-

14. What are the social and economic benefits of implementing broadly-based sexual health education in the schools?

exual health is a major, positive part of result in substantial economic costs to the province ‘‘S personal health and healthy living’’ (Public in the form of health care and other expenditures. Health Agency of Canada, 2008, p. 8). According Based on statistics from the year 2010, ap- to the World Health Organization (2010), ‘‘Sexual proximately 9,000 young women under the age of health is fundamental to the physical and emo- 20 become pregnant in Ontario each year tional health and well-being of individuals, cou- (McKay, 2012). Over half result in abortion, in- 17 ples and families, and to the social and economic dicating that a substantial proportion of these development of communities and countries’’ (p. 1). pregnancies are unintended. For younger teens in In sum, there is a growing recognition that the particular, unintended pregnancy and childbearing attainment and maintenance of sexual health for can have social and economic consequences for individuals, couples, and families is an important the young woman, her family, and the community component of the overall well-being of the com- (Lavin & Cox, 2012). munity (World Association for Sexual Health, Sexually transmitted infections are prevent- 2008). Broadly-based sexual health education in able but continue to be a significant public health the schools can make a significant positive con- concern in Canada (Public Health Agency of tribution to the health and well-being of the com- Canada, 2013b). According to the Ontario Burden munity by equipping young people with broadly- of Infectious Disease Study, of the ten most burden- based sexual health education that enables them some infectious agents in Ontario in terms of to make informed choices about their sexual and morbidity and mortality, three are sexually trans- reproductive health. mitted (Human papillomavirus [HPV], Hepatitis Preventable sexual and reproductive health B virus [HBV], Human immunodeficiency virus problems constitute a significant threat to the [HIV/AIDS]; Ontario Agency for Health Protec- health and well-being of individuals and families tion and Promotion/Institute for Clinical Evalua- in Ontario. Many of these problems dispropor- tive Sciences, 2010). tionately affect youth and young adults. Beyond According to data from the Ontario Ministry the negative personal and social outcomes, pre- of Health and Long-Term Care, there were 781 ventable sexual and reproductive health problems newly diagnosed cases of HIV in the province in

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION) 14. WHAT ARE THE SOCIAL AND ECONOMIC BENEFITS OF IMPLEMENTING BROADLY-BASED SEXUAL HEALTH EDUCATION IN THE SCHOOLS? (CONTINUED)

2012 (Public Health Ontario, 2014). In addition to inflammatory disease, ectopic pregnancy, and/or the loss of life, personal suffering, and lost produc- infertility. In Ontario, the highest reported rates tivity, the Canadian AIDS Society (2011) esti- of Chlamydia occur among females aged 20-24 mates that each case of HIV infection results in and 15-19 (Public Health Ontario, 2014). $250,000 in health care costs. In sum, the burden of preventable sexual and Of cases of reportable disease in the province reproductive health problems on the people of of Ontario, nearly two thirds (64%) involve sexu- Ontario is significant. Given the negative health ally transmitted infections (2006 data: Ministry of and personal consequences of these problems, Health and Long-Term Care, 2009). Chlamydia, access to high quality sexual health education in which is transmitted through sexual contact in the schools is properly viewed as the right of all most cases, is the most frequently reported report- youth. Given the broader social and economic able disease in Ontario (Public Health Ontario, costs of these problems, the provision of sexual 2014). Individuals with a chlamydia infection often health education in the schools serves the public have no symptoms and left untreated, the in- interests of the people of Ontario. fection may lead to chronic pelvic pain, pelvic

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Acknowledgements 23

Funding for the development of this resource document was provided by the Government of Ontario. The opinions expressed in this document are those of the authors and do not necessarily reflect the official views of the Government of Ontario. This report was authored by Alexander McKay, Ph.D. and Jocelyn Wentland, Ph.D. of the Sex Information and Education Council of Canada (SIECCAN).

SEXUAL HEALTH EDUCATION IN THE SCHOOLS: QUESTIONS & ANSWERS (UPDATED 2015 ONTARIO EDITION)