The purpose of sexuality education curriculum in Europe is to facilitate adolescents
to gain knowledge, attitudes, skills and values to make appropriate and
healthy choices in their sexual behavior, thus preventing them from sexually transmitted infections, including HIV and HPV, teenage or unwanted pregnancies, and from domestic and sexual violence, contributing to a greater society. While European educators and policy makers recognize the benefits of sexuality education as being essential in the realm of sexual health,
the content and approach of the curriculum have undergone significant
changes over time and differ among each European country. Influenced by politics,
as well as social and religious movements, European educators and
policy makers recognize the struggle to find common criteria of
sexuality education curriculum.
Common Sex Education Curricula
Researchers identify the most common delivery of sexuality education curriculum as being through a biology, relationship, and ideological focus.
In this form of curriculum, practiced through a moral and informative
approach by a teacher’s instruction, attention is directed towards the
reproductive and physical aspects of sexuality education rather than the emotional and social aspects. While this approach is identified as the most common form of sexuality education in Europe, Europe is not limited to this practice. With a total of twenty seven countries within the European Union, a wide variety of practices are implemented in an attempt to address and/or ignore sexuality education.
European policy makers and educators recognize the need for an
implementation of an ideal curriculum for European countries to adopt,
while distinguishing the political, social, and religious movements that
hinder this action.
The Safe Project
The Safe Project was introduced by a coalition of European health organizations including the IPPF European Network, WHO Regional Office for Europe, and Lund University,
in 2004 in response to European policy makers and educators speaking
out about the political, social, and religious struggles encountered
when implementing sexuality education curriculum in Europe.
The SAFE project conducted extensive research, implemented advocacy,
engaged the youth, and created a greater recognition among public health
organizations of the sexual rights of European youth as well as the
creation of a model curriculum, providing an outline of the ideal sexuality education curriculum to be practiced within the European Union. This model of sexuality education curriculum was charted in a ninety eight page product entitled The Reference Guide to Sexuality Education in Europe, selling thousands of copies to public health organizations and journals, as well as various books within academia.
The Model Sex Education Curricula
The ideal sexuality education curriculum within the European Union,
as proposed by the SAFE Project, is one that would be provided for
varying ages of students, from the primary to the secondary level. A multi-dimensional staff including public health professionals, school instructors with knowledge in the sciences, and non-governmental organizations, would be responsible for providing instruction in an interactive approach.
Educators recognize the benefits of health organizations and agencies
not only as offering a more emotional and social approach to sexuality education, but also expertise in recognizing issues among youth such as indications of sexual abuse, sexually transmitted diseases, and pregnancy. Similarly, non-government organizations(NGOs)
provide students as well as the public with private counseling,
sexuality seminars, public health campaigns, as well as peer-led
informational groups, in which they are able to step outside of a
strictly lecture and informational curriculum in sexuality education and accommodate the personal needs of European youth.[2][page needed]
While the ideal curriculum would be altered to accommodate the needs of
its audience, its goal is to inform students on the topic of sexuality,
raising awareness and therefore allowing students to make healthier
decisions in regards to sexuality and relationship activity as well as
European youth distinguishing their sexual rights. Younger audiences within the primary setting would be instructed by their classroom teacher in areas of puberty, sexual development, and bullying while secondary audiences would be instructed by a multi-dimensional staff in the topical areas of racism, homophobia, sexual violence, abstinence, safe sex, sexually transmitted diseases, pregnancy and contraceptives, as well as the biological, emotional, and social effects of sexuality.
Complications
Several complications are associated with the implementation of an ideal sexuality education
curriculum including the area and diversity of each European country,
variances in political and religious views, and a lack of
sustainability.
The area in which a country is located can affect religious and
political beliefs, as well as resources and access to health education, similarly the idea of diversity and the exposure to information and resources as well.
Politics and religion are two controversial topics that both have strong oppositions to sexuality education.
With strong oppositions and public protests, political and religious
affiliated organizations voice their negative opinions of a sexuality education curriculum that informs youth of sexual resources and options concerning contraception and abortion. With sexuality education not being mandatory in all twenty seven countries of the European Union and the controversial opposition of political and religious organizations, policy makers are unable to make an ideal sexuality education curriculum concrete.
A lack of sustainability within sexuality education
curriculum is also an issue addressed by European policy makers and
educators. Upon a country acknowledging the benefits, as well as a need
for sexuality education, they implement the ideal sexuality education curriculum in which they see positive results in the decline of sexually transmitted diseases as well as teenage and unplanned pregnancies.
Upon government officials recognizing the positive results of the
curriculum, the program is eliminated due to the significant
improvements and the mindset that the problem is fixed and therefore the
curriculum is no longer needed. With governmental cuts in sexuality education
programs as well as the funding provided for those programs, policy
makers and educators face great difficulty in the implementation of a
continent-wide curriculum.
Corrupted Children
A child's mindset is shaped in numerous ways whether it is from their:
parents
environment
experiences
As they grow, sex education will become a topic in their life that
they will be curious about. Depending on how they are raised, they will
have many questions or no questions at all. This article explains sexual
innocence and how children flourish as adults.
"Sexuality education debates and policy may sometimes posit young people as categorically less
able, less intelligent, and less responsible than their adult counterparts. In the United
States, young people’s relationships are at times denigrated as no more than puppy love,
their sexual desires simply signs of raging hormones, and their sexual behaviors transgressions
to control. Within this adult-leaning framework, young people are at their best when
sexually innocent. At their most vulnerable, they are on the verge of succumbing to sexual
danger; and, at their most corrupting, they are the source of significant risks to others."
From a more liberal standpoint, the sexuality of a teenager is
complex. Truly age of consent cannot be put on the liberal or the
conservative side of a liberal to conservative spectrum. However,
liberals will debate that teenage sexuality should be expressed more
often than the conservative side.
The
IPPF European Network strives for support and access to sexual and
reproductive health services, while serving as a voice for the sexual
rights of European individuals globally.
The WHO Regional Office for Europe advocates for public health,
implements programs for disease prevention and control, addresses
health threats, responds to health emergencies, and sustains and
supports the implementation of public health policies.
Lund University is one of Europe’s most renowned universities, as well as one of the top one-hundred universities globally.
Sexuality education in Belgium
is a mandatory practice that offers schools a great amount of autonomy
on the curriculum that they offer. Majority of the curriculum offered to
students is mandated by school instructors calling upon outside
resources such as health organizations or facilities for guidance.
Topics discussed within the curriculum are gender, physical development, sexual orientation, intimacy, morality, and risk prevention.
The curriculum of sexuality education within Cyprus is referred to as Sexuality Education and Interpersonal Relationship Education. The curriculum is taught through the instruction of biology, home economics, and religion educators in which a great emphasis is placed on the importance of family relationships and development, rather than sexuality.
Sexuality Education has been mandatory since 1970 in Denmark
in which school staff and educations have great autonomy within the
curriculum. The curriculum is delivered through a biological and Danish
focus, in which topics discussed include contraceptives, pregnancy, and puberty.
Estonia
Sexuality education within Estonia is offered through the lens of human studies in formal classroom settings, in which an instructor focuses on a personal relationships curriculum.
Sexuality education in Ireland
is a mandatory practice as of 2003, however parents are able to remove
their children from the curriculum, focusing on a variety of topics in
the areas of relational, social, and personal health.
Italy
Italy, with great influence from the Catholic Church, has created a sexuality education curriculum taught through formal classroom instruction, focusing on the biological aspects of sex and behavior.
Sexuality education in Lithuania is taught through the perspective of Biology, Ethics,
and Physical Culture in which instructors base a curriculum off of
their responsibility to inform students how to make healthy life style
choices.
Sexuality education in Spain
is not a mandatory practice however upon a school deciding to instruct
its students on the topic, educators rely heavily on outside health organizations and professionals to provide private workshops.
Other Countries
Australia
The Victorian Government (Australia) developed a policy for the promotion of Health and Human Relations Education in schools in 1980 that was introduced into the State's primary and secondary schools during 1981. The initiative was developed and implemented by the Honorable Norman Lacy MP, Minister for Educational Services from 1979-1982.
A Consultative Council for Health and Human Relations Education was established in December 1980 under the chairmanship of Dame Margaret Blackwood; its members possessed considerable expertise in the area.
The Council had three major functions:
1. to advise and to be consulted on all aspects of Health and Human Relations'Education in schools;
2. to develop, for consideration of the Government, appropriate curriculum for schools;
3. to advise and recommend the standards for in-service courses for teachers and relevant members of the school community.
Support services for the Consultative Council were provided by a new Health and Human Relations Unit within the Special Services Division of the Education Department of Victoria
and was responsible for the implementation of the Government's policy
and guidelines in this area. The Unit advised principals, school
councils, teachers, parents, tertiary institutions and others in all
aspects of Health and Human Relations Education.
In 1981 the Consultative Council recommended the adoption of a set of guidelines for the provision of Health and Human Relations Education
in schools as well as a Curriculum Statement to assist schools in the
development of their programs. These were presented to the Victorian
Cabinet in December 1981 and adopted as Government policy.
Comprehensive sex education (CSE) is a sex education
instruction method based on-curriculum that aims to give students the
knowledge, attitudes, skills and values to make appropriate and healthy
choices in their sexual lives. The intention is that this understanding will prevent students from contracting sexually transmitted infections in the future, including HIV and HPV.
CSE is also designed with the intention of reducing unplanned and
unwanted pregnancies, as well as lowering rates of domestic and sexual violence, thus contributing to a healthier society, both physically and mentally.
Comprehensive sex education ultimately promotes sexual abstinence
as the safest sexual choice for young people. However, CSE curriculums
and teachers are still committed to teaching students about topics
connected to future sexual activity, such as age of consent, safe sex, contraception such as: birth control, abortion, and use of condoms.
This also includes discussions which promote safe behaviors, such as
communicating with partners and seeking testing for sexually transmitted
infections. Additionally, comprehensive sex education curricula may
include discussions surrounding pregnancy outcomes such as parenting,
adoption, and abortion. The most widely agreed benefit of using comprehensive sex education over abstinence-only sex education
is that CSE acknowledges the student population will be sexually active
in their future. By acknowledging this, CSE can encourage students to
plan ahead to make the healthiest possible sexual decisions.
This ideology of arming students to most successfully survive their
future sexual experiences underlies the majority of topics within CSE,
including condoms, contraception, and refusal skills.
History
As
of the year 2019, sex education in the United States is mandated on a
state level. It is up to the different states, districts, and school
boards to determine the implementation of federal policy and funds for
sex education. 24 out of the 50 U.S. states and the District of Columbia mandate sex education and 34 states mandate HIV education. Where sex education is mandated, there is no federal policy requiring the instruction of comprehensive sex education.
In prior years under the Bush administration, there was strong
support in congress by conservative republicans for the sanction of
abstinence-only-until-marriage sex education.
Under President Obama's administration, abstinence-only-until-marriage
sex education was opposed and suggested to be eliminated. Now under President Trump's administration, federal agenda has reverted back to supporting an abstinence approach.
The Centers for Disease Control and Prevention’s 2014 School Health
Policies and Practices Study found that on average high school courses
require 6.2 hours of taught class time on human sexuality, but only 4
hours or less on HIV, other sexually transmitted infections and
pregnancy prevention.
Benefits
Studies
have found that comprehensive sex education is more effective than
receiving no instruction and/or those who receive abstinence-only
instruction.
Acknowledging that people may engage in premarital sex rather than
ignoring it (which abstinence-only is often criticized for) allows
educators to give the students the necessary information to safely
navigate their future sexual lives.
CSE advocates argue that promoting abstinence without accompanied
information regarding safe sex practices is a disregard of reality, and
is ultimately putting the student at risk.
For example, programs funded under AEGP are reviewed for compliance
with the 8 standards (listed below in "Abstinence Education Grant
Program (AGEP) Requirements), but are not screened for medical accuracy.
Therefore, critics believe that students under these educational
programs are put at a disadvantage because it prevents them from making
informed choices about their sexual health. Additionally, under these
AEGP programs, health educators have referred to those that engage in
sex, especially females, as "dirty" and "used." They have also used
phrases such as "stay like a new toothbrush, wrapped up and unused" and
"chewed-up gum" to teach abstinence. Under a CSE model, language would
be more sensitive.
There is clear evidence that CSE has a positive impact on sexual
and reproductive health (SRH), notably in contributing to reducing STIs, HIV and unintended pregnancy.
Sexuality education does not hasten sexual activity but has a positive
impact on safer sexual behaviours and can delay sexual debut.
A 2014 review of school-based sexuality education programmes has
demonstrated increased HIV knowledge, increased self-efficacy related to
condom use and refusing sex, increased contraception and condom use, a
reduced number of sexual partners and later initiation of first sexual
intercourse.
A Cochrane review of 41 randomized controlled trials in Europe, the
United States, Nigeria and Mexico also confirmed that CSE prevents
unintended adolescent pregnancies.
CSE is very beneficial in regards to teen pregnancy because studies
show that, teen pregnancy and childbearing have a significant negative
impact on high school success and completion, as well as future job
prospects.
A study in Kenya, involving more than 6,000 students who had received
sexuality education led to delayed sexual initiation, and increased
condom use among those who were sexually active once these students
reached secondary school compared to more than 6,000 students who did
not receive sexuality education.
CSE also reduces the frequency of sex and the number of partners which
in turn also reduces the rates of sexually transmitted infections.
UNAIDS and the African Union
have recognized CSE’s impact on increasing condom use, voluntary HIV
testing and reducing pregnancy among adolescent girls and have included
comprehensive, age-appropriate sexuality education as one of the key
recommendations to fast track the HIV response and end the AIDS epidemic
among young women and girls in Africa.
As the field of sexuality education develops, there is increasing
focus on addressing gender, power relations and human rights in order
to improve the impact on SRH outcomes. Integrating content on gender and
rights makes sexuality education even more effective.
A review of 22 curriculum- based sexuality education programmes found
that 80 per cent of programmes that addressed gender or power relations
were associated with a significant decrease in pregnancy, childbearing
or STIs. These programmes were five times as effective as those
programmes that did not address gender or power.
CSE empowers young people to reflect critically on their environment
and behaviours, and promotes gender equality and equitable social norms,
which are important contributing factors for improving health outcomes,
including HIV infection rates. The impact of CSE also increases when
delivered together with efforts to expand access to a full range of
high- quality, youth-friendly services and commodities, particularly in
relation to contraceptive choice.
A global review of evidence in the education sector also found that teaching sexuality education builds confidence,
a necessary skill for delaying the age that young people first engage
in sexual intercourse, and for using contraception, including condoms.
CSE has a demonstrated impact on improving knowledge, self-esteem,
changing attitudes, gender and social norms, and building self-efficacy.
Criticism
Comprehensiveness
While
CSE implementation is on the rise in the United States, it remains
difficult for state officials to regulate what is and is not taught in
the classroom. This is due in large part to the undefinability of CSE;
CSE has the potential to comprise such a wide range of sexual
information, and over-all focus varies widely between curriculums.
Educators have also accused CSE as fundamentally operating as a form of
"abstinence-plus," due to the reality that CSE often involves minimal
body related information and excessive promotions of abstinence.
"So-called Comprehensive Sex Ed" says Sharon Lamb, a professor at the
University of Massachusetts Boston, "has been made less comprehensive as
curricula are revised to meet current federal, state, and local
requirements."
Inclusion of LGBT community
The
LGBT population experiences health disparities associated with stigma,
discrimination, negative connotations as well as stereotypes.
This population is subject to systemic barriers to adequate healthcare
services ultimately impacting their wellbeing and welfare negatively.
The care that they are provided with often is from clinicians who are
not trained well in addressing the concerns of this population.
This lack of training from the provider hinders the experience and
ultimately influences the quality of care and adequate delivery of
healthcare.
Due to discrimination and lack of cultural sensitivity that perpetuate
prejudice, this population experiences limited health-seeking behaviors.
Thus, making preventative services unattainable, furthermore,
increasing and prolonging illnesses and ailments. Research shows higher
risk of contracting HIV and other STDs; the number is increased when
assessing the intersecting population of gay men of color. Lesbian and bisexual females are less likely to obtain routine care like: breast and cervical cancer screenings.
Gay men are at an increased risk of prostate, testicular, anal, and
colon cancers, while lesbian and bisexual women have an increased risk
of ovarian, breast, and endometrial cancers.
As a result stigma, discrimination, victimization, and sexual abuse
LGBT youth is more likely to be involved in high-risk sexual behaviors
at an earlier age.
While comprehensive sex education exists in schooling, many
programs do not address the needs of the LGBT community. This population
faces different health disparities ultimately driven by discrimination,
shortfalls of peers, the lack of parental support, community services,
and school based sex education.
The implementation of LGBT comprehensive sex education utilized as an
intervention seeks to combat these health disparities, by informing the
population of the importance of developing sexual health.
Sexual health involves not only preventing disease, but also a
respectful approach to sexual relationships, sexuality, and accepting an
individual's gender iedntity and sexual orientation.
The term "comprehensive" is also often misleading because some
comprehensive programs do not show the holistic picture of human
sexuality. LGBT
advocates have long been critical of the ways in which comprehensive
sex education generally promotes marriage as the end goal for students.
LGBT advocates want to express other forms of relationships other than
marriage. Students should have sex education that encompasses the
different forms and should be allowed to exercise those forms in which
they are most comfortable with. Even when curriculums claim to be
inclusive of LGBT experiences, they often promote heteronormative
lifestyles as "normal." Inclusion of LGBT identities and health topics is necessary for LGBT students to feel safe and seen in their sex ed classrooms.
When sex education fails to include LGBT identities and experiences,
LGBT youth can be vulnerable to risky sexual behaviors and encourage
negative sexual health outcomes. Due to the lack of LGBT sex education
provided in schools, LGBT youth will look to peers and the internet
which can lead to misinformation. When these students do not have access to or an interest in marriage they are practically erased from the CSE narrative.
In a Canada, a federal report showed that LGBT community has less
access to health services and faces more comprehensive health
challenges compared to the general population. As a result of lack of
support for the LGBT population, the Comprehensive Health Education
Workers (CHEW) Project emerged in October 2014. Their goal is to educate
the LGBT community about topics such sexual and gender identity,
sexually transmitted infections (STIs), healthy social relationships,
and depression. They do this though workshops, arts‐based projects, and
one‐on‐one meetings. The CHEW project is set exclusively to the LGBT
community in order to establish a safe environment in which LGBT youth
can gain resources for sex education.
A cross sectional study done in New York City analyzed the sexual
behaviors of high school girls. Studies found that, "high school girls
who identified as LGBT were more likely to report substance use such as:
alcohol, marijuana, cocaine, heroin, meth, ecstasy and prescription
drugs. They also had higher rates of contemplating and/or attempting
suicide." Another study found that "the LGBT youth accesses health information online five times more than the heterosexual
population, and these rates are even higher for LGBT youth that
identify as a person of color which stems from the fact that they lack
health resources.
Rights, Respect, Responsibility includes an inclusive LGBT curriculum
for grades K-12. By having a curriculum, such as the Right, Respect,
Responsibility suggests, students will be have accurate information to
all identities as well as establish a safe classroom for LGBT students.
As of May 2018, only 12 states require discussion of sexual
orientation and of these, only 9 states require that discussion of
sexual orientation be inclusive (California, Colorado, Delaware, Iowa,
New Jersey, New Mexico, Oregon, Rhode Island, and Washington).
Additionally, several states have passed legislation that bans teachers
from discussing gay and transgender issues, such as sexual health and
HIV/AIDS awareness, in a positive light.
Furthermore, three states require that teachers only portray LGBT
people in a negative light (Alabama, South Carolina, and Texas).
School context
"Before
the late 1800s, delivering sex education in the United States and
Canada was primarily seen as a parent’s responsibility.
Today, programs under the Sexuality Information and Education Council
of the United States (SIECUS) begin comprehensive sex education in
pre-kindergarten, drawing criticism related to the age at which it is
appropriate to address sexual matters with children.
Federal funding for sexual education
Although
there is no federal mandate that requires states to teach sexual
education, there is federal funding available to assist with sexual
education programs.
Abstinence Education Grant Program (AGEP)
Historically,
funding for abstinence education has always been favored over CSE. In
1996, during Bill Clinton's presidency, legislation was passed to
promote abstinence in education programs. Under Title V Section 510 of
the Social Security Act, the Abstinence Education Grant Program (AGEP),
was passed. AEGP has always been renewed before its expiration date, and
each time funds gradually increase from fifty million dollars per year
to seventy-five and as high as $6.75 million per state grant in 2015.
The way the funds are disbursed are based on the proportion of
low-income children in each state. So far, thirty-six states have been
given AEGP funds.
Abstinence Education Grant Program (AGEP) Requirements
Part
of Section 510(b) of Title V of the Social Security Act, contains the
"A-H guidelines," which are the eight criteria that programs must abide
by order to be eligible to receive federal funding. They are as follows:
A. Has as its exclusive purpose teaching the social,
psychological, and health gains to be realized by abstaining from sexual
activity;
B. Teaches abstinence from sexual activity outside marriage as the expected standard for all school-age children;
C. Teaches that abstinence from sexual activity is the only certain
way to avoid out-of-wedlock pregnancy, sexually transmitted diseases,
and other associated health problems;
D. Teaches that a mutually faithful, monogamous relationship in the
context of marriage is the expected standard of sexual activity;
E. Teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects;
F. Teaches that bearing children out of wedlock is likely to have
harmful consequences for the child, the child's parents, and society;
G. Teaches young people how to reject sexual advances and how
alcohol and drug use increase vulnerability to sexual advances; and
H. Teaches the importance of attaining self-sufficiency before engaging in sexual activity;
In addition to abiding by these 8 conditions, AGEP compliant programs
cannot discuss contraception, STIs, or methods for protecting against
STIs, except when describing failure rates.
Teen Pregnancy Prevention Program (TPP)
More recently legislation has pushed for funding that goes beyond abstinence only education.
In 2010, President Obama introduced the Teen Pregnancy Prevention
Program (TPP), which provides a total of $114.5 million annually to sex
education programs that are "medically accurate and age-appropriate."
TPP falls under a subsection of United States Department of Health and
Human Services ("HHS") which is overseen by the Office of Adolescent
Health. Funding for TPP is dispersed if "they emulate specific
evidence-based programs promulgated under TPP."
California Comprehensive Sexual Health and HIV/AIDS Prevention Education Act
In
January 2016, the California Healthy Youth Act, amended the California
Comprehensive Sexual Health and HIV/AIDS Prevention Education Act to
include minority groups and expand health education. Before it
authorized schools to provide comprehensive sex education and required
that all materials are made accessible to students with a variety of
needs. It also focused solely on marital relationships. It now mandates
that schools provide comprehensive sex education and states that
"materials cannot be biased and must be appropriate for students of all
races, genders, sexual orientations, and ethnic and cultural
backgrounds, as well as those with disabilities and English language
learners." Additionally, education must now include "instruction about
forming healthy and respectful committed relationships," regardless if
marital status. Furthermore, it is now required to have discussions
about all FDA-approved contraceptive methods in preventing pregnancy,
including the morning after pill.
In conclusion now requires that all sex education programs promulgated in the state should
normalize sexuality as part of human development;
ensure people receive integrated, comprehensive, accurate, and unbiased sexual health and HIV prevention and instruction; and
provide pupils with the knowledge and skills to have healthy, positive, and safe relationships.
As a human right
Some critics state that young people’s access to CSE is grounded in internationally recognized human rights, which require governments to guarantee the overall protection of health, well-being and dignity, as per the Universal Declaration on Human Rights, and specifically to guarantee the provision of unbiased, scientifically accurate sexuality education.
The commitment of individual states to realizing these rights has
been reaffirmed by the international community, in particular the Commission on Population and Development
(CPD), which – in its resolutions 2009/12 and 2012/13 – called on
governments to provide young people with comprehensive education on
human sexuality, SRH and gender equality.
Other analysis show that comprehensive sex education is not an
international right nor a human right because it not clearly stated in
either a treaty nor custom. By international law, states are required to
provide access to information and education about reproductive health,
but this does not require a sex education curriculum. It may take
different forms such as mandating that local school districts create a
system for providing information to students, or mandating that health
clinics and practitioners dispense information to patients.
In curricula
Teaching methods
As
CSE gains momentum and interest at international, regional and national
levels, governments are increasingly putting in place measures to
scale-up their delivery of some form of life skills-based sexuality
education, as well as seeking guidance on best practice, particularly
regarding placement within the school curriculum.
Sexuality education may be delivered as a stand-alone subject or
integrated across relevant subjects within the school curricula. These
options have direct implications for implementation, including teacher
training, the ease of evaluating and revising curricula, the likelihood
of curricula being delivered, and the methods through which it is
delivered.
Within countries, choices about implementing integrated or
stand-alone sexuality education are typically linked to national
policies and overall organization of the curricula. The evidence base on
the effectiveness of stand-alone vs. integrated sexuality education
programming is still limited. However, there are discernible differences
for policy-makers to consider when deciding the position of CSE within
the curriculum.
As a stand-alone subject, sexuality education is set apart from
the rest of the curriculum, whether on its own or within a broader
stand-alone health and life skills curriculum. This makes it more
vulnerable to potentially being sacrificed due to time and budget
constraints, since school curricula are typically overcrowded.
However, a stand-alone curriculum also presents opportunities for
specialized teacher training pathways, and the use of non-formal
teaching methodologies that aim to build learners’ critical thinking
skills. The pedagogical approaches promoted through sexuality education –
such as learner-centred methodologies, development of skills and
values, group learning and peer engagement – are increasingly being
recognized as transformative approaches that impact on learning and
education more widely. As a standalone subject, it is also significantly
easier to monitor, which is crucial in terms of evaluating the
effectiveness of programming, and revising curricula where it is not
delivering the desired learning outcomes.
When sexuality education is integrated or infused, it is
mainstreamed across a number of subject areas, such as biology, social
studies, home economics or religious studies. While this model may
reduce pressure on an overcrowded curriculum, it is difficult to monitor
or evaluate, and may limit teaching methodologies to traditional
approaches.
Terminology
Apart
from the different teaching methods, termiology also differs. Abortion,
homosexuality, abstinence have connotations and definitions that vary
state. For example, the word "abstinence" may refer to disengaging from
all forms of sexual activities until marriage or may refer to only
disengaging from sexual intercourse. Furthermore, the degree of sexual
activity that "abstinence" connotates is often unclear, because sexual
behavior that is not sexual intercourse may or may not be included in
its definition. As a result, students are left confused about what
activities are risky and teachers do not know what they can and cannot
teach.
The term "comprehensive," is also falls on spectrum, therefore
can be considered an umbrella term. CSE means something radical for some
institutions while it can mean something moderate and even conservative
for others.
According to the Sexuality Information and Education Council of
the United States (SIECUS), the guidelines for comprehensive sexuality
education are as follows:
appropriate to the age, developmental level, and cultural background of students;
respects the diversity of values and beliefs represented in the community;
complements and augments the sexuality education children receive
from their families, religious and community groups, and healthcare
professionals;
teaches not only about abstinence, but also contraception, including emergency contraception and reproductive choice;
teaches about lesbian, gay, bisexual, transgender (LGBT) issues and questions issues;
teaches anatomy, development, puberty, and relationships;
teaches all of the other issues one would expect to be covered in a traditional sexuality education class; and
should be science-based and medically accurate
Sexual education exemption
Just
as teaching methods and curricula vary by state, excusal from sex
education also varies by state. States may have with an opt out or opt
in produce. In some states, students can opt out of receiving sexual
education without specifying a particular reason. In other states,
students can only opt out for religious or moral reasons. In an opt-in
provision, parents must actively agree to allow their children to
receive sex education prior to the start of the sexual education.
Sexual content in the media
Since 1997, the amount of sexual content on TV has nearly doubled in the United States.
Additionally, a study done in 2008 showed that nearly 40% of popular
music lyrics contained sexual references which were often sexually
degrading. These lyrics were also often accompanied with mentions of
other risk behaviors, such as substance use and violence.
Teens (ages 13–15) in the United States, use entertainment media
as their top source for education in regards to sexuality and sexual
health. Additionally, a study found that 15-19 year olds in the U.S use
media far more than parents or schools to obtain information about birth
control.
Some studies have found that, "very few teen television shows mention
any of the responsibilities or risks (e.g., using contraception,
pregnancy, STIs) associated with sex and almost none of the shows with
sexual content include precaution, prevention, or negative outcomes as
the primary theme."
Television shows 16 and Pregnant and its spin-off, Teen Mom, which
first aired on MTV in 2009 received major disapproval from some parents
as they thought the shows glamorized teen pregnancy and motherhood.
However, 16 and Pregnant actually led to a 4.3 percent reduction in teen
pregnancy, mostly as a result of increased contraceptive use.
In contrast, other data shows that exposure to high levels of sexual
content on the television causes adolescents to have twice the risk of
becoming pregnant in the following 3 years, compared to those who were
exposed to low levels.
The film Mean Girls, directed by Mark Waters shed light on the
state sex education in some parts of the United States. In the film the
health instructor states, "At your age, you're going to have a lot of
urges. You're going to want to take off your clothes and touch each
other. But if you do touch each other, you will get chlamydia and die."
This line is meant to be satirical, but it illustrates common flaws
within sex education in the U.S. It depicts simplistic descriptions of
sexual activity and implementation of fear without any legitimate basis.
Comprehensive sex education is the main topic in the documentary The Education of Shelby Knox released in 2005 about Lubbock, Texas, which has one of the highest teen pregnancy and STD rates in the nation. The "solution" to which is a strict abstinence-only sex education curriculum in the public schools and a conservative preacher who urges kids to pledge abstinence until marriage.
Not only have films portrayed sex education, but so has social media. Platforms such as YouTube, Facebook, Vine, and others are used as a tool to uplift the narratives of marginalized communities such as persons of color and LGBT persons in hopes to "strengthen sexual health equity for all."
As a result of the mass amount of sex content in media, media
literacy education (MLE) has emerged. It was created to address the
influence of unhealthy media messages on risky health decisions, such as
intention to use substances, body image issues, and eating disorders.
A study analyzed the effectiveness of a teacher-led MLE program, called
Media Aware Sexual Health (MASH), which provides students with accurate
health information and teaches them how to apply that information to
critical analysis of media messages. This comprehensive sex education
resulted in increased intentions to talk to a parent, partner and
medical professional prior to sexual activity, and intentions for condom
use.
Due to knowledge gaps in most sex education curricula for teens, free online resources like Sex, Etc., Scarleteen.com, and teensource.org have been created to promote comprehensive, inclusive, and shame-free sex education for teenagers.
Within the framework of the World Health Organization's (WHO) definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene, addresses the reproductive processes, functions and system at all stages of life. UN agencies claim sexual and reproductive health includes physical, as well as psychological well-being vis-a-vis sexuality.
Reproductive health implies that people are able to have a responsible, satisfying and safer sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. One interpretation of this implies that men and women ought to be informed of and to have access to safe, effective, affordable and acceptable methods of birth control; also access to appropriate health care services of sexual, reproductive medicine and implementation of health education programs to stress the importance of women to go safely through pregnancy and childbirth could provide couples with the best chance of having a healthy infant.
Individuals do face inequalities in reproductive health services.
Inequalities vary based on socioeconomic status, education level, age,
ethnicity, religion, and resources available in their environment. It is
possible for example, that low income individuals lack the resources
for appropriate health services and the knowledge to know what is
appropriate for maintaining reproductive health.
Reproductive health
The
WHO assessed in 2008 that "Reproductive and sexual ill-health accounts
for 20% of the global burden of ill-health for women, and 14% for men." Reproductive health is a part of sexual and reproductive health and rights. According to the United Nations Population Fund
(UNFPA), unmet needs for sexual and reproductive health deprive women
of the right to make "crucial choices about their own bodies and
futures", affecting family welfare. Women bear and usually nurture
children, so their reproductive health is inseparable from gender
equality. Denial of such rights also worsens poverty.
Adolescent health
Teenage birth rate per 1,000 females aged 15–19, 2000–2009
Adolescent health
creates a major global burden and has a great deal of additional and
diverse complications compared to adult reproductive health such as
early pregnancy and parenting issues, difficulties accessing
contraception and safe abortions, lack of healthcare access, and high
rates of HIV and sexually transmitted infections, and mental health
issues. Each of those can be affected by outside political, economic and
socio-cultural influences.
For most adolescent females, they have yet to complete their body
growth trajectories, therefore adding a pregnancy exposes them to a
predisposition to complications. These complications range from anemia,
malaria, HIV and other STI's, postpartum bleeding and other postpartum
complications, mental health disorders such as depression and suicidal
thoughts or attempts. In 2016, adolescent birth rates between the ages of 15-19 was 45 per 1000. In 2014, 1 in 3 experienced sexual violence,
and there more than 1.2 million deaths. The top three leading causes of
death in females between the ages of 15-19 are maternal conditions
10.1%, self-harm 9.6%, and road conditions 6.1%.
The causes for teenage pregnancy are vast and diverse. In
developing countries, young women are pressured to marry for different
reasons. One reason is to bear children to help with work, another on a dowry system
to increase the families income, another is due to prearranged
marriages. These reasons tie back to financial needs of girls' family,
cultural norms, religious beliefs and external conflicts.
Adolescent pregnancy, especially in developing countries, carries increased health risks, and contributes to maintaining the cycle of poverty. The availability and type of sex education
for teenagers varies in different parts of the world. LGBT teens may
suffer additional problems if they live in places where homosexual
activity is socially disapproved and/or illegal; in extreme cases there
can be depression, social isolation and even suicide among LGBT youth.
Maternal health
Maternal Mortality Rate
worldwide, as defined by the number of maternal deaths per 100,000 live
births from any cause related to or aggravated by pregnancy or its
management, excluding accidental or incidental causes.
Ninety nine percent of maternal deaths occur in developing countries
and in 25 years, maternal mortality globally dropped to 44%.
Statistically, a woman's chance of survival during childbirth is
closely tied to her social economic status, access to healthcare, where
she lives geographically, and cultural norms.
To compare, a woman dies of complications from childbirth every minute
in developing countries versus a total of 1% of total maternal mortality
deaths in developed countries. Women in developing countries have
little access to family planning services, different cultural practices,
have lack of information, birthing attendants, prenatal care, birth
control, postnatal care, lack of access to health care and are typically
in poverty. In 2015, those in low-income countries had access to
antenatal care visits averaged to 40% and were preventable. All these reasons lead to an increase in the Maternal Mortality Ratio (MMR).
One of the international Sustainable Development Goals developed by United Nations is to improve maternal health by a targeted 70 deaths per 100,000 live births by 2030.
Most models of maternal health encompass family planning,
preconception, prenatal, and postnatal care. All care after childbirth
recovery is typically excluded, which includes pre-menopause and aging into old age.[16]
During childbirth, women typically die from severe bleeding,
infections, high blood pressure during pregnancy, delivery
complications, or an unsafe abortion. Other reasons can be regional such
as complications related to diseases such as malaria and AIDS during
pregnancy. The younger the women is when she gives birth, the more at
risk her and her baby is for complications and possibly mortality.
Map of countries and territories by fertility rate as of 2018
There is a significant relationship between the quality of maternal services made
available and the greater financial standings of a country. Sub-Saharan Africa and South Asia
exemplify this as these regions are significantly deprived of medical staff and affordable health
opportunities. Most countries provide for their health services through a combination of
funding from government tax revenue and local households. Poorer nations or regions with
extremely concentrated wealth can leave citizens on the margins uncared for or overlooked.
However, the lack of proper leadership can result in a nation's public sectors being
mishandled or poorly performing despite said nation's resources and standing. In addition,
poorer nations funding their medical services through taxes places a greater financial burden on
the public and effectively the mothers themselves.
Responsibility and accountability on the part of mental health sectors are strongly
emphasized as to what will remedy the poor quality of maternal health globally. The impact
of different maternal health interventions across the globe stagger variously and are vastly
uneven. This is the result of a lack of political and financial commitment to the issue as most
safe motherhood programs internationally have to compete for significant funding. Some
resolve that if global survival initiatives were promoted and properly funded it would prove to be
mutually beneficial for the international community. Investing in maternal health would
ultimately advance several issues such as: gender inequality, poverty and general global health
standards. As it currently stands, pregnant women are subjugated to high financial costs
throughout the duration of their term internationally that are highly taxing and strenuous.
A page from De Morbo Gallico (On the French Disease), Gabriele Falloppio's treatise on syphilis. Published in 1564, it describes an early use of condoms.
Margaret Sanger, birth control advocate, and her sister Ethyl Byrne, on the courthouse steps in Brooklyn, New York City,
January 8, 1917, during their trial for opening a birth control clinic.
Contraception has been and still remains in some cultures a
controversial issue.
Access to reproductive health services is very poor in many countries. Women are often unable to access maternal health services due to lack of knowledge about the existence of such services or lack of freedom of movement. Some women are subjected to forced pregnancy
and banned from leaving the home. In many countries, women are not
allowed to leave home without a male relative or husband, and therefore
their ability to access medical services is limited. Therefore,
increasing women's autonomy is needed in order to improve reproductive
health, however doing may require a cultural shift. According to the
WHO, "All women need access to antenatal care in pregnancy, skilled care
during childbirth, and care and support in the weeks after childbirth".
The fact that the law allows certain reproductive health services, it does not necessary ensure that such services are de facto
available to people. The availability of contraception, sterilization
and abortion is dependent on laws, as well as social, cultural and
religious norms. Some countries have liberal laws regarding these
issues, but in practice it is very difficult to access such services due
to doctors, pharmacists and other social and medical workers being conscientious objectors.
In developing regions of the world, there are about 214 million
women who want to avoid pregnancy but are unable to use safe and
effective family planning methods. When taken correctly, the combined oral contraceptive pill is over 99% effective at preventing pregnancy. However, it does not protect from sexually transmitted infections (STIs). Some methods, such as using condoms, achieve both protection from STIs and unwanted pregnancies. There are also natural family planning methods, which may be preferred by religious people, but some very conservative religious groups, such as the Quiverfull movement, oppose these methods too, because they advocate the maximization of procreation. One of the oldest ways to reduce unwanted pregnancy is coitus interruptus - still widely used in the developing world.
There are many types of contraceptives. One type of contraceptive includes barrier methods. One barrier method includes condoms for males and females. Both types stop sperm from entering the woman's uterus, thereby preventing pregnancy from occurring.
Another type of contraception is the birth control pill, which stops
ovulation from occurring by combining the chemicals progestin and
estrogen. Many women use this method of contraception, however they discontinue using it equally as much as they use it.
One reason for this is because of the side effects that may occur from
using the pill, and because some health care providers do not take
women's concerns about negative side effects seriously. The use of the birth control pill is common in western countries, and
two forms of combined oral contraceptives are on the World Health Organization's List of Essential Medicines, the most important medications needed in a basic health system.
There are many objections to the use of birth control, both
historically and in the present day. One argument against birth control
usage states that there is no need for birth control to begin with.
This argument was levied in 1968 when Richard Nixon was elected
president, and the argument stated that since birth rates were at their
lowest point since World War II ended, birth control was not necessary. Demographic planning arguments were also the basis of the population policy of Nicolae Ceaușescu in communist Romania, who adopted a very aggressive natalist policy which included outlawing abortion and contraception, routine pregnancy tests for women, taxes on childlessness,
and legal discrimination against childless people. Such policies
consider that coercion is an acceptable means of reaching demographic
targets. Religious objections are based on the view that premarital sex
should not happen, while married couples should have as many children
as possible. As such, the Catholic Church encourages premarital
abstinence from sex. This argument was written out in Humanae Vitae, a papal encyclical released in 1968.
The Catholic Church bases its argument against birth control pills on
the basis that birth control pills undermine the natural law of God.
The Catholic Church also argues against birth control on the basis of
family size, with Cardinal Mercier of Belgium arguing, "...the duties
of conscience are above worldly considerations, and besides, it is the
large families who are the best" (Reiterman, 216).
Another argument states that women should use natural methods of
contraception in place of artificial ones, such as having sexual
intercourse when one is infertile.
Support for contraception is based on views such as reproductive rights, women's rights, and the necessity to prevent child abandonment and child poverty.
The World Health Organization states that "By preventing unintended
pregnancy, family planning /contraception prevents deaths of mothers and
children".
Sexually transmitted infection
Estimated prevalence in % of HIV among young adults (15–49) per country as of 2011.
There are more than 600 million cases of STI's worldwide and more than 20 million new cases within the United States. Numbers of such high magnitude weigh a heavy burden on the local and global economy. A study conducted at Oxford University in 2015 concluded that despite giving participants early antiviral medications (ART),
they still cost an estimated $256 billion over 2 decades. HIV testing
done at modest rates could reduce HIV infections by 21%, HIV retention
by 54% and HIV mortality rates by 64%, with a cost-effectiveness ration
of $45,300 per Quality-adjusted life year.
However, the study concluded that the United States has led to an
excess in infections, treatment costs, and deaths, even when
interventions do not improve over all survival rates.
There is a profound reduction on STI rates once those who are
sexually active are educated about transmissions, condom promotion,
interventions targeted at key and vulnerable populations through a
comprehensive Sex education courses or programs.
South Africa's policy addresses the needs of women at risk for HIV and
who are HIV positive as well as their partners and children. The policy
also promotes screening activities related to sexual health such as HIV
counseling and testing as well as testing for other STIs, tuberculosis,
cervical cancer, and breast cancer.
Young African American women are at a higher risk for STI's, including HIV.
A recent study published outside of Atlanta, Georgia collected data
(demographic, psychological, and behavioral measures) with a vaginal
swab to confirm the presence of STIs. They found a profound difference
that those women who had graduated from college were far less likely to
have STIs, potentially be benefiting from a reduction in vulnerability
to acquiring STIs/HIV as they gain in education status and potentially
move up in demographic areas and/or status.
Abortion
Globally, an estimated 25 million unsafe abortions occur each year. The vast majority of such unsafe abortions occur in developing countries in Africa, Asia and Latin America.
The abortion debate is the ongoing controversy surrounding the moral, legal, and religious status of induced abortion. The sides involved in the debate are the self-described “pro-choice” and “pro-life”
movements. “Pro-choice” emphasizes the right of women to decide whether
to terminate a pregnancy. “Pro-life” emphasizes the right of the embryo
or fetus to gestate to term and be born. Both terms are considered loaded in mainstream media, where terms such as “abortion rights” or “anti-abortion” are generally preferred.
Each movement has, with varying results, sought to influence public
opinion and to attain legal support for its position, with small numbers
of anti-abortion advocates using violence, such as murder and arson.
Articles from the World Health Organization call legal abortion a fundamental right of women regardless of where they live, and argue that unsafe abortion is a silent pandemic.
In 2005, it was estimated that 19-20 million abortions had
complications, some complications are permanent, while another estimated
68,000 women died from unsafe abortions.
Having access to safe abortion can have positive impacts on women's
health and life, and vice versa. "Legislation of abortion on request is
necessary but an insufficient step towards improving women's health.
In some countries where it abortion is legal, and has been for decades,
there has been no improvement in access to adequate services making
abortion unsafe due to lack of healthcare services. It is hard to get an
abortion due to legal and policy barriers, social and cultural barriers
(gender discrimination, poverty, religious restrictions, lack of
support etc., health system barriers (lack of facilities or trained
personnel), however safe abortions with trained personnel, good social
support, and access to facilities, can improve maternal health and
increase reproductive health later in life.
The Maputo Protocol, which was adopted by the African Union in the form of a protocol to the African Charter on Human and Peoples' Rights,
states at Article 14 (Health and Reproductive Rights) that: "(2).
States Parties shall take all appropriate measures to: [...] c) protect
the reproductive rights of women by authorising medical abortion in
cases of sexual assault, rape, incest, and where the continued pregnancy
endangers the mental and physical health of the mother or the life of
the mother or the foetus."
The Maputo Protocol is the first international treaty to recognize
abortion, under certain conditions, as a woman's human right.
The General comment No. 36 (2018) on article 6 of the International Covenant on Civil and Political Rights, on the right to life, adopted by the Human Rights Committee
in 2018, defines, for the first time ever, a human right to abortion -
in certain circumstances (however these UN general comments are
considered soft law, and, as such, not legally binding).
"Although States parties may adopt measures
designed to regulate voluntary terminations of pregnancy, such measures
must not result in violation of the right to life of a pregnant woman or
girl, or her other rights under the Covenant. Thus, restrictions on the
ability of women or girls to seek abortion must not, inter alia,
jeopardize their lives, subject them to physical or mental pain or
suffering which violates article 7, discriminate against them or
arbitrarily interfere with their privacy. States parties
must provide safe, legal and effective access to abortion where
the life and health of the pregnant woman or girl is at risk,
and where carrying a pregnancy to term would cause the pregnant
woman or girl substantial pain or suffering, most notably where
the pregnancy is the result of rape or incest or is not viable.
[8] In addition, States parties may not regulate pregnancy or abortion
in all other cases in a manner that runs contrary to their duty to
ensure that women and girls do not have to undertake unsafe
abortions, and they should revise their abortion laws accordingly.
[9] For example, they should not take measures such as
criminalizing pregnancies by unmarried women or apply criminal
sanctions against women and girls undergoing abortion [10] or
against medical service providers assisting them in doing so,
since taking such measures compel women and girls to resort to
unsafe abortion. States parties should not introduce new barriers
and should remove existing barriers that deny effective access by
women and girls to safe and legal abortion, including
barriers caused as a result of the exercise of conscientious
objection by individual medical providers."
When negotiating the Cairo Programme of Action at the 1994 International Conference on Population and Development
(ICPD), the issue was so contentious that delegates eventually decided
to omit any recommendation to legalize abortion, instead advising
governments to provide proper post-abortion care and to invest in
programs that will decrease the number of unwanted pregnancies.
The Committee on the Elimination of Discrimination against Women
considers the criminalization of abortion a "violations of women’s
sexual and reproductive health and rights" and a form of "gender based
violence"; paragraph 18 of its General recommendation No. 35 on gender based violence against women, updating general recommendation No. 19
states that: "Violations of women’s sexual and reproductive health and
rights, such as forced sterilizations, forced abortion, forced
pregnancy, criminalisation of abortion, denial or delay of safe
abortion and post abortion care, forced continuation of pregnancy,
abuse and mistreatment of women and girls seeking sexual and
reproductive health information, goods and services, are forms of gender based violence that, depending on the circumstances, may amount to torture or cruel, inhuman or degrading treatment." The same General Recommendation
also urges countries at paragraph 31 to [...] In particular, repeal:
a) Provisions that allow, tolerate or condone forms of gender
based violence against women, including [...] legislation that
criminalises abortion".
In 2008, the Parliamentary Assembly of the Council of Europe,
a group comprising members from 47 European countries, has adopted a
resolution calling for the decriminalization of abortion within
reasonable gestational limits and guaranteed access to safe abortion
procedures. The nonbinding resolution was passed on April 16 by a vote
of 102 to 69.
Accesses to abortion is not only a question of legality, but also an issue of overcoming de facto barriers, such as conscientious objections from medical stuff, high prices, lack of knowledge about the law, lack of access to medical care (especially in rural areas). The de facto
inability of women to access abortion even in countries where it is
legal is highly controversial because it results in a situation where
women have rights only on paper not in practice; the UN in its 2017
resolution on Intensification of efforts to prevent and eliminate all forms of violence against women and girls: domestic violence urged states to guarantee access to "safe abortion where such services are permitted by national law".
There are two primary arguments for maintaining legalized
abortion today in the U.S. The first is recognizing the full citizenship
of women. The Roe v. Wade court case on abortion compared the citizenship of women and fetuses Because the Constitution defines born people as citizens, Justice Harry Blackmun ruled that fetuses were not citizens. The citizenship of women is emphasized because fetuses are not individual entities that can exist without the woman.
Another reason why the full citizenship of women is defined by
advocates for abortion is that it recognizes the right of women to
manage their own bodies. Fertility affects women's bodies. The argument for abortion prevents others from making decisions that alter a woman's body.
Pro-choice advocates also attempt to confirm that state-mandated
education or other outside biases don't attempt to influence these
decisions. Feminists argue that women throughout history have had to justify their citizenship politically and socially. The right to manage one's own body is a matter of health, safety, and respect.
The citizenship of women and the right to manage their own bodies is a
societal confirmation that feminists highlight as a pro-choice
justification.
The second primary argument to uphold legalized abortion and
creating better access to it is the necessity of abortion and the health
and safety of pregnant women. There are two events that largely changed the course of public opinion about abortion in the U.S.
The first is Sherry Finkbine, who was denied access to an abortion by
the board of obstetrician-gynecologists at her local hospital.
Although she was privileged enough to afford the trip, Finkbine was
forced to travel to Sweden for an abortion to avoid caring for a damaged
fetus in addition to four children. The other event that changed public opinion was the outbreak of rubella in the 1950s and 60s.
Because rubella disrupted the growth of fetuses and caused deformities
during pregnancy, the California Therapeutic Abortion Act was signed in
1967. This Act allowed doctors to perform abortions when the pregnancy risked the physical or mental health of the pregnant person.
These two events are commonly used to show how the health and safety of
pregnant women are contingent upon abortions as well as the ability to
give birth to and adequately take care of a child. Another argument in
favor of legalized abortion to service necessity are the reasons why an
abortion might be necessary. Nearly half of all pregnancies in the
United States are unintended, and over half of all unintended
pregnancies in the United States are met with abortion.
Unintended pregnancy can lead to serious harm to women and children for
reasons such as not being able to afford to raise a baby,
inaccessibility to time off of work, difficulties facing single
motherhood, difficult socio-economic conditions for women.
Unintended pregnancies also have a greater potential for putting women
of color at risk due to systematically produced environmental hazards
from proximity to pollution, access to livable income, and affordable
healthy food. These factors as threats to the health and safety of pregnant women run parallel to data that shows the number of abortions in the United States did not decline while laws restricting legal access to abortion were implemented.
Prevalence of FGM by country, according to a 2013 UNICEF report
Anti-FGM road sign, Bakau, Gambia, 2005
Female genital mutilation (FGM), also known as female genital
circumcision or cutting, is the traditional, non-medical practice of
altering or injuring the female reproductive organs, often by removing
all or parts of the external genitalia.
It is mostly practiced in 30 countries in Africa, the Middle East, and
Asia, and affects over 200 million women and girls worldwide. More
severe forms of FGM are highly concentrated in Djibouti, Eritrea,
Ethiopia, Somalia, and Sudan.
The WHO categorizes FGM into four types:
Type I (Cliteridectomy) is the removal of all or part of the clitoris. This may or may not include removing the prepuce along with the clitoral glans.
Type II (Excision) is the removal of the clitoris along with all or part of the labia minora. This may or may not include removing all or part of the labia majora.
Type III (Infibulation) is the act of removing the inner or outer labia and sealing the wound, leaving only a narrow opening.
Type IV refers to "all other harmful procedures to the female
genitalia for non-medical purposes (piercing, scraping, cauterizing of
the genital area)."
FGM often takes the form of a traditional celebration conducted by an
elder or community leader. The age that women undergo the procedure
varies depending on the culture, although it is most commonly performed
on prepubescent girls. Certain cultures value FGM as coming of age
ritual for girls, and use it to preserve a woman's virginity and
faithfulness to the husband after marriage. It is also closely connected
with some traditional ideals of female beauty and hygiene. FGM may or may not have religious connotations depending on the circumstances.
There are no health benefits of FGM, as it interferes with the
natural functions of a woman's and girls' bodies, such as causing severe
pain, shock, hemorrhage, tetanus or sepsis (bacterial infection), urine
retention, open sores in the genital region and injury to nearby
genital tissue, recurrent bladder and urinary tract infections, cysts,
increased risk of infertility, childbirth complications and newborn
deaths. Sexual problems are 1.5 more likely to occur in women who have
undergone FGM, they may experience painful intercourse, have less sexual
satisfaction, and be two times more likely to report lack of sexual
desire. In addition, the maternal and fetal death rate is significantly
higher due to childbirth complications.
FGM can have severe negative psychological effects on women, both
during and after the procedure. These can include long-term symptoms of
depression, anxiety, post-traumatic stress disorder, and low
self-esteem.
Some women report that the procedure was carried out without their
consent and knowledge, and describe feelings of fear and helplessness
while it was taking place. A 2018 study found that larger quantities of
the hormone cortisol
were secreted in women who had undergone FGM, especially those who had
experienced more severe forms of the procedure and at an early age. This
marks the body's chemical response to trauma and stress, and can
indicate a greater risk for developing symptoms of PTSD and other trauma
disorders, although there are limited studies showing a direct
correlation.
Legislation has been introduced in certain countries to prevent
FGM. A 2016 survey of 30 countries showed 24 had policies to manage and
prevent FGM, although the process to provide funding, education, and
resources were often inconsistent and lacking. Some countries have seen a
slight decline in FGM rates, while others show little to no change.
The practice of forcing young girls into early marriage, common in
many parts of the world, is threatening their reproductive health.
According to the World Health Organization:
"The sexual and reproductive health of the female in a
child marriage is likely to be jeopardized, as these young girls are
often forced into sexual intercourse with an older male spouse with more
sexual experience. The female spouse often lacks the status and the
knowledge to negotiate for safe sex and contraceptive practices,
increasing the risk of acquiring HIV or other sexually transmitted
infections, as well as the probability of pregnancy at an early age."
Niger has the highest prevalence of child marriage under 18 in the world, while Bangladesh has the highest rate of marriage of girls under age 15. Practices such as bride price and dowry can contribute to child and forced marriages.
International Conference on Population and Development, 1994
The International Conference on Population and Development (ICPD) was held in Cairo,
Egypt, from 5 to 13 September 1994. Delegations from 179 States took
part in negotiations to finalize a Programme of Action on population and
development for the next 20 years. Some 20,000 delegates from various
governments, UN agencies, NGOs, and the media gathered for a discussion of a variety of population issues, including immigration, infant mortality, birth control, family planning, and the education of women.
In the ICPD Program of Action, 'reproductive health' is defined as:
a state of complete physical, mental and social
well-being and...not merely the absence of disease or infirmity, in all
matters relating to the reproductive system and its functions and
processes. Reproductive health therefore implies that people are able to
have a satisfying and safe sex life and that they have the capability
to reproduce and the freedom to decide if, when and how often to do so.
Implicit in this last condition are the right of men and women to be
informed [about] and to have access to safe, effective, affordable and
acceptable methods of family planning of their choice, as well as other
methods of birth control which are not against the law, and the right of
access to appropriate health-care services that will enable women to go
safely through pregnancy and childbirth and provide couples with the
best chance of having a healthy infant.
This definition of the term is also echoed in the United Nations Fourth World Conference on Women, or the so-called Beijing Declaration of 1995.
However, the ICPD Program of Action, even though it received the
support of a large majority of UN Member States, does not enjoy the
status of an international legal instrument; it is therefore not legally
binding.
The Program of Action endorses a new strategy which emphasizes
the numerous linkages between population and development and focuses on
meeting the needs of individual women and men rather than on achieving demographic targets. The ICPD
achieved consensus on four qualitative and quantitative goals for the
international community, the final two of which have particular
relevance for reproductive health:
Reduction of maternal mortality: A reduction of maternal mortality
rates and a narrowing of disparities in maternal mortality within
countries and between geographical regions, socio-economic and ethnic
groups.
Access to reproductive and sexual health services including family planning: Family planning counseling, pre-natal care, safe delivery and post-natal care, prevention and appropriate treatment of infertility, prevention of abortion and the management of the consequences of abortion, treatment of reproductive tract infections, sexually transmitted diseases
and other reproductive health conditions; and education, counseling, as
appropriate, on human sexuality, reproductive health and responsible
parenthood. Services regarding HIV/AIDS, breast cancer, infertility, delivery, hormone therapy, sex reassignment therapy, and abortion should be made available. Active discouragement of female genital mutilation (FGM).
The keys to this new approach are empowering women, providing them
with more choices through expanded access to education and health
services, and promoting skill development and employment. The programme
advocates making family planning universally available by 2015 or
sooner, as part of a broadened approach to reproductive health and
rights, provides estimates of the levels of national resources and
international assistance that will be required, and calls on governments
to make these resources available.
Sustainable Development Goals
Half of the development goals put on by the United Nations started in 2000 to 2015 with the Millennium Development Goals (MDGs). Reproductive health was Goal 5 out of 8. To monitor the progress, the UN agreed to four indicators:
Contraceptive prevalence rates
Adolescent birth rate
Antenatal care coverage
Unmet need for family planning
Progress was slow, and according to the WHO in 2005, about 55% of women did not have sufficient antenatal care and 24% had no access to family planning services.
The MDGs expired in 2015 and were replaced with a more comprehensive
set of goals to cover a span of 2016-2030 with a total of 17 goals,
called the Sustainable Development Goals.
All 17 goals are comprehensive in nature and build off one another, but
goal 3 is "To ensure health lives and promote wellbeing for all at all
ages". Specific goals are to reduce global maternal mortality ratio to
less than 70 per 100,000 live births, end preventable deaths of newborns
and children, reduce the number by 50% of accidental deaths globally,
strengthen the treatment and prevention programs of substance abuse and
alcohol.
HIV/AIDS in Africa is a major public health problem. Sub-Saharan
Africa is the worst affected world region for prevalence of HIV,
especially among young women. 90% of the children in the world living
with HIV are in sub-Saharan Africa.
In most African countries, the total fertility rate is very high,
often due to lack of access to contraception and family planning, and
practices such as forced and child marriage. Niger, Angola, Mali,
Burundi and Somalia have very high fertility rates.
The updated contraceptive guidelines in South Africa
attempt to improve access by providing special service delivery and
access considerations for sex workers, lesbian, gay, bisexual,
transgender and intersex individuals, migrants, men, adolescents, women
who are perimenopausal, have a disability, or chronic condition. They
also aim to increase access to long acting contraceptive methods,
particularly the copper IUD, and the introductions of single rod
progestogen implant and combined oestrogen and progestogen injectables.
The copper IUD has been provided significantly less frequently than
other contraceptive methods but signs of an increase in most provinces
were reported. The most frequently provided method was injectable
progesterone, which the article acknowledged was not ideal and
emphasised condom use with this method because it can increase the risk
of HIV: The product made up 49% of South Africa's contraceptive use and
up to 90% in some provinces.
Tanzanian
provider perspectives address the obstacles to consistent contraceptive
use in their communities. It was found that the capability of
dispensaries to service patients was determined by inconsistent
reproductive goals, low educational attainment, misconceptions about the
side effects of contraceptives, and social factors such as gender
dynamics, spousal dynamics, economic conditions, religious norms,
cultural norms, and constraints in supply chains. A provider referenced
and example of propaganda spread about the side effects of
contraception: "There are influential people, for example elders and
religious leaders. They normally convince people that condoms contain
some microorganisms and contraceptive pills cause cancer". Another said
that women often had pressure from their spouse or family that caused
them to use birth control secretly or to discontinue use, and that women
frequently preferred undetectable methods for this reason. Access was
also hindered as a result of a lack in properly trained medical
personnel: "Shortage of the medical attendant...is a challenge, we are
not able to attend to a big number of clients, also we do not have
enough education which makes us unable to provide women with the methods
they want". The majority of medical centers were staffed by people
without medical training and few doctors and nurses, despite federal
regulations, due to lack of resources. One center had only one person
who was able to insert and remove implants, and without her they were
unable to service people who wanted an implant inserted or removed.
Another dispensary that carried two methods of birth control shared that
they sometimes run out of both materials at the same time. Constraints
in supply chains sometimes cause dispensaries to run out of
contraceptive materials. Providers also claimed that more male
involvement and education would be helpful.
Public health officials, researchers, and programs can gain a more
comprehensive picture of the barriers they face, and the efficacy of
current approaches to family planning, by tracking specific,
standardized family planning and reproductive health indicators.
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