thesis statement for sex education in schools

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Article Contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Description of moderator variables

Effect sizes of studies

Tests of categorical moderators for abstinence

Weighted least-squares regression and test of model specification

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• least-squares analysis
• sex education

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

Associated data.

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

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

1. Introduction

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

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

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

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

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

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

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

2. Methodology

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

(2) To summarize evidence relating to effectiveness.

2.2. Methods

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

2.3. Search Strategy

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

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

2.4. Inclusion Criteria

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

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

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

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

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

2.5. Exclusion Criteria

Reviews were excluded if:

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

2.6. Risk of Bias and Assessment of Study Quality

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

2.7. Data Synthesis

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

3.1. Results of Search

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

3.2. Risk of Bias in Included Studies

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

3.3. Reviews Included

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

3.3.1. Setting

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

3.3.2. Population

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

3.3.3. Interventions/Types of Study

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

3.3.4. Outcomes

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

3.3.5. Country of Review

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

3.3.6. Year of Last Paper Included

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

3.3.7. Search Tools

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

3.3.8. Multicenter Studies and Number of Studies Included

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

3.3.9. Number of Reviews Covered That Include Meta-Analysis

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

3.4. Effectiveness

3.4.1. school settings.

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

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

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

3.4.2. Online Platforms

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

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

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

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

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

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

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

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

3.4.3. Blended Learning

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

4. Discussion

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

4.1. Interventions Reviewed

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

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

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

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

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

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

4.2. Effectiveness

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

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

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

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

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

4.3. Limitations

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

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

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

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

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

5. Conclusions

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

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

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

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

Search Terms Used.

Description of studies.

Characteristics and main results of the studies included.

Evaluation of the studies included (AMSTAR II).

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

Author Contributions

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

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare that they have no conflicts of interest.

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

Home > Student Work > Honors Theses > 2711

Honors Theses

Should sex education be taught in schools sex education within the united states: analyzing social and political factors of sex education within the united states.

Elena Gerrato , Union College - Schenectady, NY Follow

Date of Award

Document type.

Open Access

First Advisor

David Cotter

political affiliation in relation to sex education conservative liberal sexual orientation sexual identity

Sex education has been a prominent topic among society since the 1800s, coinciding with the prevention and relevance of current social issues. As years have passed, sex education has continued to evolve through the prevailing social situations. However, within the 21st century, sex education started to lack improvement and inclusion of social topics and issues that are prevalent in today's society. This thesis analyzes the history behind sex education among the United States, and defines what it is that shapes sex education in today's society. With society ever changing, and social and political concepts becoming a more central topic in today's society, the issue of sex education has become more of an issue. This thesis addresses the development of sex education among schools within the United States, and emphasizes the difference between each district and state perspective on sex education. This thesis looks at sex education in not only a social light, but also a political standpoint. Sex education started as a solution to social circumstances, however, with legislation evolving and many social topics coming into play, there are many other factors that shape sex education. By researching eight different states with different political affiliations, this thesis was able to come to a conclusion as to what characteristics of a state or district shape that community's sex education, but also how exactly a state's political background influences and shapes their perspective on sex education. With sex education everchanging, and becoming more of a significant social issue in today's society, it is important to understand why sex education is the way it is around the country, and how the structure of sex education impacts society and individuals as a whole. The result of the analysis and comparison of eight different states indicates how the political standpoint and authority of each state generalizes what type of stance that specific state has on sex education, and sex education within schools.

Recommended Citation

Gerrato, Elena, "Should Sex Education Be Taught in Schools? Sex Education Within the United States: Analyzing Social and Political Factors of Sex Education Within The United States" (2023). Honors Theses . 2711. https://digitalworks.union.edu/theses/2711

Since August 22, 2023

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