A Review and a Report
15 March 2016 

Emerging Evidence, Lessons and Practice in Comprehensive Sexuality Education: A Global Review, 2015

Full report:
This new report from the UN Educational, Scientific and Cultural Organization (UNESCO) was developed in consultation with the UN Population Fund and UNAIDS.
The report provides an overview of the status of comprehensive sexuality education (CSE) implementation and coverage on a global level. It draws on specific information about the status of CSE in 48 countries, generated through analysis of existing resources and studies. The report examines the evidence base for CSE and its positive impact on health outcomes, takes stock of political support for CSE, and examines how the various global and regional commitments have had an impact at national levels on the delivery of CSE in practice. The current review represents the first in a series of periodic reports that aim to monitor the global implementation of CSE.
Comprehensive sexuality education is recognized as an ‘age-appropriate, culturally relevant approach to teaching about sexuality and relationships by providing scientifically accurate, realistic, non-judgmental information’ (UNESCO, 2009).
There is clear evidence that CSE has a positive impact on sexual and reproductive health (SRH), notably contributing towards reducing sexually transmitted infections (STIs), the Human Immunodeficiency Virus (HIV) and unintended pregnancy. CSE has demonstrated impact in terms of improving knowledge and self-esteem, changing attitudes and gender and social norms, and building self-efficacy. This is particularly critical during adolescence, as young people make the transition into adulthood.
Global momentum around CSE has resulted in increased political commitment worldwide. In 2008, ministers of education and health from Latin America and the Caribbean signed the Preventing through Education Declaration committing to delivering sexuality education and health services. Similarly, in 2013, 20 countries across Eastern and Southern Africa (ESA) endorsed a Ministerial Commitment on CSE and SRH services for adolescents and young people, setting specific targets to ensure access to high-quality, comprehensive life skills-based HIV and sexuality education and appropriate youth-friendly health services for all young people. UNAIDS and the African Union have recently cited comprehensive, age-appropriate sexuality education as one of five key recommendations to fast track the HIV response and end the AIDS epidemic among young women and girls across Africa. Many countries in the Asia-Pacific region, West Africa and Europe are also revising their policies and approaches to scale up sexuality education.
Young people are increasingly demanding their right to sexuality education, as evidenced by the 2011 Mali Call to Action; declarations at the 2011 International Conference on AIDS and STIs in Africa (ICASA); the 2012 Bali Global Youth Forum Declaration; the 2014 Colombo Declaration on Youth; youth delegates’ inputs to the post-2015 development agenda through the ‘Have you seen my Rights?’ coalition; as well as the advocacy efforts of the PACT coalition of youth organizations.
The political momentum has led many governments to scale up delivery of CSE and to seek guidance on best practice. Ministries of Education are working in collaboration with Ministries of Health and departments responsible for child protection and youth well-being. Partnerships with civil society and private institutions have been critical in key elements of scale-up such as teacher training and the development of teaching and learning resources.
Almost 80 per cent of the countries in this assessment have policies or strategies that support CSE. Despite this increased political will, however, a gap remains between the global and regional policies in place and the actual implementation and monitoring on the ground.
Across the world, sexuality education may be delivered as a stand-alone subject - with the advantages of providing opportunities for specialized teacher training and being easier to monitor. Alternatively, it may be integrated across relevant subjects within the school curriculum, making it less likely to be cut to reduce pressure on an overcrowded timetable. CSE may be mandatory or it may be delivered through optional courses. However, where sexuality education is non-compulsory, extra-curricular or only partially compulsory, a large number of students will not reap its benefits.

Key points
1. CSE content must respond appropriately to the specific context and needs of young people in order to be effective.
2. Recent assessments show that gender and rights should be consistently strengthened across curricula, and address the needs of young people living with HIV and other key populations. The lack of appropriate attention to gender in CSE curricula represents a stark disconnect from the reality for most adolescent girls and young women.
3. Delivering high-quality CSE requires adequate training and capacity. Teacher training remains limited in scope, and, if provided at all, is usually delivered only through in-service training. Consequently, teachers often feel uncomfortable and avoid discussing sensitive issues like sexual behaviour, sexuality, and how students can access contraception and obtain referrals for SRH services. They also do not consistently use participatory methodologies to engage pupils fully in health and life skills education. Without adequate training and sensitization to the issues, teachers may potentially re-enforce harmful messages to young people - sometimes backed by harmful and punitive national laws.
4. Engaging parents and communities in the implementation and scale-up of CSE is critical, both to ensure that there is support for the subject among the school community, and to enhance overall understanding of the issues facing adolescents and young people.
5. The report demonstrates that a majority of countries are now embracing the concept of CSE, informed by evidence and international guidance, and are engaged in strengthening its implementation at a national level. This includes specifically ongoing attention to curricula revision, integration of CSE into the national curriculum, investment in monitoring systems, the engagement of communities and the scale-up of effective teacher training. In concert with national governments and civil society, development partners – including the UNAIDS Joint Programme – are supporting countries in their efforts to develop age-appropriate, evidence-informed curricula that reflect the country context and that will have a direct, beneficial impact on the HIV response and more widely on adolescent and young people’s health.

The report contains nine case studies
Case Study 1: Strengthening the national provision of CSE in schools in Zambia
Case Study 2: Reducing unintended pregnancy in the United Kingdom
Case Study 3: A gender-focused approach in Bangladesh
Case Study 4: Cost effectiveness in Estonia
Case Study 5: Engaging parents in Pakistan
Case Study 6: Building teachers’ capacity to deliver quality sexuality education across Africa
Case Study 7: Building the evidence base with a strong evaluation framework in Colombia
Case Study 8: CSE reaches out-of-school children and young people
Case Study 9: Using mobile technologies to reach vulnerable young people in Nigeria 

Sociocultural and community determinants of unwanted pregnancies and abortion: DR Congo, Peru, Burkina Faso, Gaza

Four studies reveal the weight of the social repercussions from unwanted pregnancies and abortion

Discussion of these reports:
An interview with Magali Bouchon, by Isabelle Hanne, in Libération 
En français a
: Translation, Marge Berer

In 2015, Médecins du monde et le Laboratoire d’études et de recherches sur les dynamiques sociales et le développement local (Lasdel) carried out four anthropological studies in Burkina Faso, the Democratic Republic of Congo (DRC), Peru, and Gaza. The anthropologist Magali Bouchon participated in this work, which identifies the social, cultural and community determinants of unwanted pregnancies and abortions in the 15-24 age group.
"The abortion methods women were using were very violent, from introducing dangerous objects into the uterus through the vagina to the consumption of toxic mixtures by young women in Kinshasa. In general, the risks taken to cause an abortion are very high and act as a form of social constraint on the woman involved."
Why did you choose these four places for this study?
These are countries where abortion is illegal and where access to contraception is, at a minimum, complicated. They are urban spaces, where young women aged 15-24 years represent about 20% of the population - in densely populated cities with a lot of promiscuity, lack of access to basic services, and a lot of migration and conflict… Diverse spaces with a strong religious influence. Gaza, for example, is governed by Islamic law. And in these four places, a lot of gender-based violence exists. There is a lot of sexual violence in the DR Congo, and a profoundly deep machismo in Peru…

What cross-cutting lessons have you learned?
In theory, many contraceptive methods are available in these countries, free or otherwise. But in reality, a series of difficulties make contraception almost completely inaccessible. In Peru, the morning-after pill is available only in pharmacies with a prescription, and has to be paid for. In the DRC, the woman must have the permission of her husband, or her parents if she is a minor, in order to obtain a contraceptive. Our studies have also shown the lack of training for medical personnel, and health care structures that are too few and too remote… The structures of care are dysfunctional, with poor quality of care, and a lack of confidentiality… Overall, there are many obstacles.
Which methods of contraception are used in the four study areas?
There are traditional methods, such as the cyclic necklace, which allows women who don’t always have an accurate picture of how their bodies work, to visualise their menstrual cycles. One can actually find all the methods: hormonals, chemical, condoms… But in reality, the possibilities are often limited due to stock-outs. That forces women to go to the private sector, where they have to pay. Family planning, which means you anticipate what will happen and want to decide what comes next, is very remote from a practice that is controlled by precariousness.
The four studies cite numerous health professionals who convey the wrong information, such as which type of contraception makes one infertile, for example.
One sees this often in many subject areas, that a great many of the obstacles come from the health professionals themelves, not from a lack of knowledge among the women. Health care providers convey a lot of moral messages, they advocate abstinence, and they encourage pregnancy soon after marriage. These standards necessarily affect the quality of care. Health care providers are not aware of new techniques or of all the kinds of contraceptives or of post-abortion care, and they perpetuate the practice of curettage for abortions, even though the World Health Organization recommends manual vacuum aspiration. They themselves start a lot of the rumours and create negative perceptions of contraceptives.
How much latitude do girls and women actually have?
First, to get access to contraception, you really need to want it, in countries where fertility equals femininity. Then, it is necessary to know how/where to find it, in the face of a cruel lack of information. Finally, you must be powerful, when there is very strong inequality in gender relations. So even if women want to, they may not necessarily be able to. The power of men, health care providers, religion, all prevent women controlling their bodies. In addition, there is the reverse of the Western view of family planning, children are still seen as insurance for the future. In these societies, having a child remains an investment. So women do nothing to prevent a pregnancy, and they accept having another child even if they do not wish to have one, as it often appears to be the simplest solution.
What do the men say ?
This is the other great cross-determinant in our studies: these are countries where men have the freedom not to worry about the consequences of their sexuality. All of them reflected an ambivalence in their responses. They are not necessarily against contraception, but they do not want their wife to use it. They exercise a form of control over their wife’s sexuality through her fertility.
What are the consequences?
This situation pushes women to adopt strategies of circumvention, which can have enormous consequences, particularly for their health. Unwanted pregnancies result in a condemnation that is very strong in the family. Births outside marriage isolate the woman, who is no longer supported by her partner or by his family. This can lead to unsafe abortions in clandestine clinics, which can have dramatic consequences, including for the long-term health of the woman. Yet, our studies show that contraception is even less well accepted than abortion: abortion is seen as unplanned, an accident, while contraception is regarded as a form of planning, a way to achieve one’s desires. In those countries where it is illegal, abortion, with more or less risk, is practised. As long as we do not publicly discuss these issues, we will continue to perpetuate gender inequality in relation to the right to control over one’s body.
What role does religion, which is very present, play in these studies?
Because they promote behavioural values, religious standards also restrict women’s capacity to act. The religions promote the fact that the only goal of sexual relations is pregnancy and motherhood. Contraception raises the issue of sexuality for pleasure; this contradicts religious standards… In Gaza, for example, one is obliged to talk about "spacing of births", rather than "limitation of births", which is not acceptable at all. It becomes a word game…
Can you give an example of any differences between the countries studied ?
It’s complicated to answer that, because it is very difficult to obtain statistics in certain countries. Gaza, for example, does not know the rate of unwanted pregnancies, nor do they have figures on abortion. This is symptomatic of the very sensitive nature of these issues. It is problematic to speak of unwanted pregnancies because, theoretically, they do not exist.  




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