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date: 02 July 2022

# Comprehensive Sexuality Education

• Ine VanwesenbeeckIne VanwesenbeeckInterdisciplinary Social Sciences, Utrecht University, the Netherlands; Rutgers, Centre of Expertise on Sexual and Reproductive Health and Rights, Utrecht, the Netherlands

### Summary

Comprehensive sexuality education (CSE) is increasingly accepted as the most preferred way of structurally enhancing young peoples’ sexual and reproductive well-being. A historical development can be seen from “conventional,” health-based programs to empowerment-directed, rights-based approaches. Notably the latter have an enormous potential to enable young people to develop accurate and age-appropriate sexual knowledge, attitudes, skills, intentions, and behaviors that contribute to safe, healthy, positive, and gender-equitable relationships. There is ample evidence of program effectiveness, provided basic principles are adhered to in terms of content (e.g., adoption of a broad curriculum, including gender and rights as core elements) and delivery (e.g., learner centeredness). Additional and crucial levers of success are appropriate teacher training, the availability of sexual health services and supplies, and an altogether enabling (school, cultural, and political) context. CSE’s potential extends far beyond individual sexual health outcomes toward, for instance, school social climates and countries’ socioeconomic development. CSE is gaining worldwide political commitment, but a huge gap remains between political frameworks and actual implementation. For CSE to reach scale and its full potential, multicomponent approaches are called for that also address social, ideological, and infrastructural barriers on international, national, and local levels. CSE is a work never done. Current unfinished business comprises, among others, fighting persevering opposition, advancing equitable international cooperation, and realizing ongoing innovation in specific content, delivery, and research-methodological areas.

### Subjects

• Sexual & Reproductive Health

### Introduction

Sexuality education is indispensable to adolescents and young people. Their whole “being in the world” is fundamentally interlaced with sexuality. Adolescents are eager to learn about sex and have a right to accurate information. Sexuality is a central aspect of being human, encompassing sexual behaviors, gender identities, sexual orientations, eroticism, and reproduction. It is crucial to the development of identity, morality, and the capacity of intimacy. And weighty public health issues are at stake, certainly but not exclusively in the area of sexuality and reproduction. Obviously, parents (or other educators), have a broad socializing role, as do peers, but it is widely acknowledged that their capacities in the area of sexual socialization aren’t always optimally suited to meet young peoples’ health needs and evolving social contexts. States and formal educational bodies are therefore important duty bearers in this respect.

In Europe, school-based sexuality education has been around since the second half of the 20th century. It has become increasingly widespread since the sexual revolution in the 1970s and the rise of the HIV epidemic in the 1980s. The 1994 International Conference on Population and Development (ICPD) provided a vital impetus for states and non-governmental organizations (NGOs) around the world to meet young people’s needs for sexuality education. Initiatives have intensified since. However, ideological battles on overall purpose, content, and methods of sexuality education also seem to have deepened. At one extreme of the spectrum, there are abstinence only until marriage (AOUM) models, primarily aiming at discouraging young people from sexual intercourse until they marry. AOUM has been powerfully promoted in the United States, where the Bush administration spend billions of dollars on the effort and also attempted to insert the framework into the international arena (see Corrêa, Petchesky, & Parker, 2008). At the other end, comprehensive (increasingly also qualified as holistic) sexuality education (CSE/HSE) has come to typify the “European standard” and principally aims at enhancing young people’s capacity for informed, satisfactory, healthy, and respectful choices with regard to sexuality (Ketting, Friele, & Michielsen, 2016; WHO & BZgA, 2010).

On international platforms, CSE is increasingly promoted as the preferred and most effective way to enhance young peoples’ sexual and reproductive health and rights, in formal as well as non-formal settings (e.g., UN, 1999; UNESCO, 2012, 2013, 2015, 2016, 2018; UNFPA, 2010, 2014, 2015; WHO & BZgA, 2010). CSE is gaining worldwide acceptance and political commitment (for an overview of international and regional resolutions, see UNESCO, 2018, Appendix 1). A survey of CSE in Europe and Central Asia (WHO & BZgA, 2017) demonstrates remarkable progress in developing and integrating CSE in formal school settings. A worldwide review of the status of CSE in 48 countries (UNESCO, 2015) also demonstrates that a majority of those countries are embracing the concept of CSE and are engaged in strengthening its implementation at a national level. However, a huge gap remains between legal frameworks and the actual implementation of CSE. Few policies are fully operationalized, but an indication of overall implementation level is difficult to provide. However, it’s fair to say that in most low- and middle-income countries, CSE is a long way from being institutionalized (see Haberland & Rogow, 2015). Many obstacles to effective implementation have been identified (e.g., Chandra-Mouli et al., 2015; UNESCO, 2012; UNFPA, 2015, Vanwesenbeeck, Westeneng, de Boer, Reinders, & van Zorge, 2016). In the employment of CSE around the world, substantial progress has been made, but progress is also seriously confined by persistent barriers and regretful setbacks on international, national, and local levels.

This article provides an overview of the theoretical underpinnings, core elements, and learning objectives of CSE. It reviews evidence on effectiveness and discusses factors in successful implementation and scale-up. Finally, some matters of unfinished business are highlighted to illustrate how the implementation of CSE is always a work in progress.

### Principles of CSE

A number of publications (e.g., IPPF, 2017; UNFPA, 2014; WHO & BZgA, 2017) elucidate the core principles and essential elements of CSE. Remarkably, they all present slightly different definitions. The latest revised United Nations Educational, Scientific and Cultural Organization (UNESCO) guidance on sexuality education presents the following, “commonly agreed” (Herat, Castle, Babb, & Chandra-Mouli, 2018) one:

Comprehensive sexuality education (CSE) is a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. It aims to equip children and young people with knowledge, skills, attitudes and values that will empower them to: realize their health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and, understand and ensure the protection of their rights throughout their lives (UNESCO, 2018, p. 16).

Clearly, the aims of CSE are ambitious. Moreover, they have broadened over time and continue to evolve. CSE always needs to respond to progressive insights and emerging evidence, as well as to relevant developments in technology and society (e.g., young peoples’ Internet and social media use). Comprehensiveness may rightfully be qualified an “elastic term” (Hague, Miedema, & Le Mat, 2017). A distinction may be made between “conventional,” health-based programs and empowerment-directed, rights-based approaches (see Bonjour & van der Vlugt, 2018; Haberland & Rogow, 2015). When applied appropriately, the latter approaches have proven particularly effective. Although both have been practiced since the early 21st century, the distinction in part reflects historical developments.

#### “Conventional,” Health-Based CSE

The main goal of conventional CSE is the prevention of sexual risks and negative outcomes such as sexually transmitted infections (STIs), HIV infections, and unplanned (teenage) pregnancies. As all CSE does, it provides curriculum-based, scientifically appropriate (be it sometimes markedly limited) information on reproductive and sexual physiology and a diversity of contraceptive and protective methods. Conventional CSE distinguishes itself from AOUM approaches in that it promotes all available strategies to sexual risk prevention. Next to abstinence, safe(r) sexual practices, particularly the use of condoms (and/or other forms of contraception) are encouraged. Conventional CSE may be more or less similar to so-called abstinence-plus programs that promote ABC (Abstinence, Be faithful, use a Condom) and/or DEF+ (Delay intercourse, Equal consent, Fewer partners, and testing).

Behavior change theory provides the most important theoretical underpinning of conventional CSE, calling for attention to social values and norms, attitudes, relationships, and social skills that are theoretically seen as determinants of (in this case sexual) health behavior. In their attention for norms, attitudes, and skills, programs should be needs-based and culturally appropriate on the basis of an assessment of important local specificities. Preferably, they apply a logic-model approach, specifying behavioral goals, their determinants, and ways to address them (Kirby, 2007) or intervention mapping, a protocol for developing effective behavior change interventions (see Schaalma, Abraham, Gillmore, & Kok, 2004). In focusing on skills, conventional CSE shows a resemblance to life skills education (LSE), but the latter may be broader, also taking, for instance, livelihood skills into consideration. In paying attention to the relational context and negotiating skills, some parallels may be seen with sexuality and relationships education (SRE). Conventional CSE recognizes that girls may have less control over their sexuality than boys do and may thus apply a certain gender-sensitiveness. But the focus on gender is much stronger in “empowerment” CSE.

#### A Rights-Based, Empowerment Approach

Gradually, it has become apparent that narrow risk- and health-focused educational approaches do not match well with young peoples’ complex sexual and relational realities and overall developmental tasks. A positive approach to sexuality that accepts young people as sexual beings with sexual feelings and desires is more realistic and can bear much more fruit. In general, sexual health has come to be understood as more than just the absence of disease and, moreover, as fundamentally reliant on the fulfillment of sexual rights (WHO, 2006). CSE is thus required to go beyond education on risks, danger, and disease and be sex-positive and rights-based (Hirst, 2012; Ingham & Hirst, 2010). The promotion of sex education as rights-based encompasses the affirmation of sexuality education itself as a human right for young people as laid down in the Convention on the Rights of the Child in 1990. The Netherlands, with its pragmatic, liberal, so-called “Dutch approach” to sexuality education, has long been considered a forerunner in sex-positive and rights-based sex education (e.g., Brown, 2012; Ferguson, Vanwesenbeeck, & Knijn, 2008). Since the early 21st century, these principles of a rights-based approach (RBA) have been widely shared internationally (Hague et al., 2017; OHCHR, 2006; UNESCO, 2016, 2018; UNFPA, 2010, 2015; Vanwesenbeeck, Flink, van Reeuwijk, & Westeneng, 2019).

An important extension of an empowerment approach stems from critiques of the early, health-focused CSE traditions as promoting gender conformity and silencing, in particular, girls’ desire (Allen, 2005; Fine, 1988; Fine & McClelland, 2006; Holland, Ramazanoglu, Sharpe, & Thomson, 1998; Rogow & Haberland, 2005; Tolman, 1994). Authors observe that girls’ sexuality is often pictured exclusively in terms of risks, danger, and vulnerability, with girls figuring as gatekeepers of boys’ “natural” sexual urges. Programs built on gendered assumptions, the sexual double standard, and the discursive silencing of girls’ sexual desire lead to distorted understandings of (particularly) girls’ sexual agency, subjectivity, and autonomy, so it is argued. Calls to include gender and pleasure in CSE are thus first and foremost advocated to serve the empowerment of girls. But when absent, all young people’s understandings of sexual choices, rights, consent, sexualised harassment, and violence are affected (Sundaram & Sauntson, 2016). Increasingly, the benefits of addressing gender for boys and young men are also being stressed, inside (e.g., Limmer, 2010) as well as outside the sphere of sexuality education (e.g., American Psychological Association (APA), 2018).

Rights-based, empowerment CSE aims to encourage non-sexist attitudes and behaviors in girls and boys and aims to empower them to achieve safe, consensual, egalitarian, mutually satisfying relationships and gender equality. This also highlights the relevance to include sexual coercion and violence, sexual consent, and ethical relations (Lamb, 2010) in (empowerment) CSE. Complex ethical and legal questions such as coerced sex and unethical sexual subjectivity have been avoided in many CSE programs (Allen & Carmody, 2012). The prevention of sexual violence is habitually addressed in separate interventions (Carmody & Ovenden, 2013; Schneider & Hirsch, 2019). However, empowerment CSE cannot be fully comprehensive without addressing (gendered) sexual violence and consent and is, increasingly, seen to do so.

Historically speaking, the paradigm shift toward the inclusion of gender and rights as core elements in CSE programming is most outstanding (see UNFPA, 2010). This is true for CSE as well as for HSE, a term predominantly applied for the sexuality education developed in Europe (see WHO & BZgA, 2010). Empowerment-focused CSE may have a slightly stronger focus on gender transformativity than HSE does, while HSE focusses relatively strongly on sex-positivity and also more explicitly offers support following (traumatic) incidents and sexual health problems and services (Hague et al., 2017). Gradually, the two may merge completely.

A rights-based approach implies the adoption of a broad curriculum. UNESCO’s latest guidelines describe content comprehensiveness as covering the full range of topics that are important for all learners to know, including those that may be challenging in some social and cultural contexts (UNESCO, 2018, p. 16). The authors list eight concepts they consider key to CSE curricula:

1.

Relationships

2.

Values, rights, culture, and sexuality

3.

Understanding gender

4.

Violence and staying safe

5.

Skills for health and well-being

6.

The human body and development

7.

Sexuality and sexual behavior

8.

Sexual and reproductive health

Advancing young people’s knowledge, attitudes, and skills supportive of making informed sexual choices and of building safe and respectful relationships is key to CSE. This includes awareness of cultural (ideological, religious, political) contexts and of the ways these contexts affect people’s sexual choices, behaviors, and relationships. Empowerment, rights-based CSE is notably non–value-free in this respect. It promotes positive values such as mutual respect, human (sexual and reproductive) rights, and gender equality. It aims to contribute to societal transformation and to strengthen young peoples’ roles in these processes. The capacity of critical reflection and successful navigation of normative contexts (see Cense, 2019b) is broadly acknowledged as one of CSE’s primary learning objectives (UNESCO, 2018). Related goals are the cultivation of “sex cultural intelligence” (Mukoro, 2017), of “media-literacy” (the skills to critically use, evaluate and create media content), of help-seeking and advocacy skills, and of young peoples’ capacities for sexual citizenship (Illes, 2012; Lamb, 2010).

#### Empowerment CSE Delivery Principles

Schools are no doubt the most important locations for CSE delivery, in which they show huge variation. CSE may be provided as a stand-alone subject or as integrated in other courses. It may be mandatory or optional. In addition, health centers and community-based settings provide many opportunities for CSE as well. These settings are particularly important to make CSE available to out-of-school young people and children—often the most vulnerable to misinformation, coercion, and exploitation (UNESCO, 2018). CSE should always be age- and developmentally appropriate, i.e., responsive to the changing needs and capabilities of young people and addressing developmentally relevant topics in a timely, diversity accommodating fashion. CSE is preferably “incremental,” i.e., engaging learners in a continuing educational process that starts at an early age and builds new information upon previous learning in a spiral-curriculum approach (UNESCO, 2018).

Crucial for adequate CSE delivery is a learner-centered approach. Empowering methods need to put young people at the center; be sensitive to (the heterogeneity of) their concerns, realities, suggestions, interests, and resistance; and aim at fine-tuning a program to fit all of these requirements (see Vanwesenbeeck et al., 2019). Instead of merely being recipients, the active participation of students is key in empowering them to become capable of representing themselves and making their own decisions. Teachers are supposed to facilitate the empowerment process rather than teach content, improve knowledge, or regulate behaviors. This model of learning is closely aligned with rights-based pedagogy and what has been called “critical pedagogy” (e.g., Kincheloe, 2008), aiming to improve young people’s lives not merely through behavioral change but also through cognitive and social transformation. The didactic vision is also aligned with Freirian theory, which emphasizes engaging learners to question prevailing norms through critical thinking, and current educational strategies such as outcomes-based learning and competency-based education (e.g., Power & Cohen, 2005).

Finally, CSE should be delivered by well-trained and supported teachers and educators and take place in a safe, healthy, and supportive learning environment. The educational context is preferably fully in line with what the program aims to achieve and the messages it brings across. It is also essential that sexuality education efforts are further complemented by a sexual and reproductive health system that provides young people with the adequate and high-quality services and supplies they need, both in and out of school (WHO, 2002). But with those requirements, we drift away from principles of CSE to the area of preconditions for successful delivery. Those will be elaborated upon later.

### CSE’s Potential

A significant body of evidence (Fonner, Armstrong, Kennedy, O’Reilly, & Sweat, 2014; Kirby, 2011; for overviews see UNESCO, 2018; UNFPA, 2010, 2014, 2015; WHO, 2011) shows that good-quality CSE indeed enables young people to develop accurate and age-appropriate sexual knowledge, attitudes, skills, intentions, and behaviors that contribute to safe, healthy, and positive relationships. CSE has the potential to provide young people with the necessary information about their bodies and sexuality; reduce misinformation, shame, and anxiety; clarify and solidify positive attitudes and perceptions; increase communication; help them reflect on social norms and cultural values; and improve their overall sexual agency and abilities to make safe and informed choices about their sexual and reproductive health. Most evidence stems from secondary schools, but some studies in Dutch primary education show that CSE can also improve 9- to 12-year-old pupils’ knowledge, awareness, attitudes, and skills (e.g., Bagchus, Maratens, & van der Sluis, 2010). Students in primary as well as secondary education (see Vanwesenbeeck et al., 2016) often experience high satisfaction with CSE programs, as do many teachers, parents, and school boards.

In terms of actual sexual behavior change, research has shown that CSE may help young people delay debut of sexual intercourse, reduce the frequency of unprotected sex, reduce the number of sexual partners, and increase the utilization of sexual and reproductive health services, contraceptives, and condoms. Two-thirds of rigorously evaluated CSE programs lead to reductions in one or more risk behaviors. In contrast, CSE has been persuasively shown not to foster early sexual debut or unsafe sexual activity (UNFPA, 2014). In comparison to less comprehensive programs, notably to abstinence-only programs, CSE has invariably been found to contribute more adequately to gains in young peoples’ sexual health (de Castro et al., 2018; Fine & McClelland, 2006; Haberland & Rogow, 2015; Kirby, 2008; McCave, 2007; Santelli et al., 2017; Shepherd, Sly & Girard, 2017; Trenholm et al., 2007; Underhill, Montgomery, & Operario, 2007; UNFPA, 2015). Abstinence-only programs typically focus exclusively on discouraging young people from sexual activity, which leaves them ill-prepared to enhance the safety, equity, and pleasure of the sexual interactions once they engage in them anyway.

General access to good-quality CSE may also contribute to more distant, “hard” outcomes such as reductions in early childbirth, (unsafe) abortion, sexual violence, and sexual ill health. However, studies on the (long-term) effects of CSE on biomarkers, such as the prevalence of STIs/HIV and teenage pregnancies, are notably scarce. Research that assesses “hard” biological outcomes is time-consuming, expensive, and complex. Besides, employing the “golden standard” of randomized controlled trials in resource-poor contexts and in an area as complex as adolescent sexuality is associated with many ethical and methodological difficulties (Kippax, 2003; Michielsen et al., 2010; Vanwesenbeeck, 2011b, 2014). Studies and meta-analyses that are available for “hard” outcomes show, at most, only moderately strong, often even weak effects (Doyle et al., 2010; Kirby, 2007; Haberland & Rogow, 2015; Kohler, Manhart, & Lafferty, 2008; Oringanje et al., 2016; UNFPA, 2010; Vanwesenbeeck et al., 2016; Yankah & Aggleton, 2008). In addition to methodological problems, this must be attributed to the many persistent shortcomings in CSE design, content, and delivery as well as by normative, cultural, and political environments that are notably unsupportive of empowering CSE messages. Nevertheless, young people’s sexual and reproductive health is often better in countries where CSE is widely implemented. For the Netherlands, the relatively low STI rates, high prevalence of contraceptive use, low teenage pregnancy and abortion rates, and overall good adolescent sexual and reproductive health have invariably been explained by its long-standing tradition of sex-positive sexuality education (e.g., Brown, 2012; Ferguson et al., 2008). A study in Finland (Apter, 2011) has shown that prevention behavior has improved and abortion rates have declined after a national curriculum and accompanying teacher training was introduced in 2003 and vastly improved the quality of sex education in Finnish schools. In contrast, high teenage pregnancy rates in a number of central Asian countries (such as Georgia, Russian Federation, Tajikistan) have been connected to the infancy stage of sexuality education in these areas (IPPF & BZgA, 2018).

CSE’s potential extends beyond individual sexual health outcomes. Qualitative research suggests, for instance, that CSE may have benefits for students’ self-esteem, assertiveness, and overall well-being, as well as for teacher–student relationships in the classroom, parent–child communication, community norms, school social climate, and school drop-out rates (e.g., Vanwesenbeeck et al., 2016). Again, rigorous studies are scarce. Outcomes such as greater gender equality, critical thinking skills, psychological well-being, and sexual pleasure have hardly been addressed because of the challenge they pose in terms of reliable and valid assessment and, in particular, because of the dominant focus on (HIV-related) health behaviors in most evaluation research (see Boonstra, 2011). The dominance of a HIV-related public health perspective has seriously limited views of CSE as relevant to the attainment of broader goals such as social health and development, livelihoods, emancipation, and community well-being (Germain, Dixon-Mueller, & Sen, 2009; Rotheram-Borus, Swendeman, & Flannery, 2009). CSE could support adolescents, not least girls, in a safe passage to adulthood and in reaching their full potential in educational achievement, earning capacity, and societal participation. Widespread availability of CSE could contribute to the socioeconomic development of countries and to the sustainable development goals (SDGs) of the global 2030 development agenda. Inclusive access to high-quality CSE is deemed vital to realizing human rights, gender equality, and health and well-being for all. Hague et al. (2017) also value CSE’s potential in peace-building processes.

In the early 21st century, verification of CSE’s potential has been limited by biomedical perspectives on sexual health behaviors and a rather narrow conceptualization, actually an underestimation, of CSE’s many promises on many levels, as well as of the processes underlying positive effects. Employment of a wider range of success indicators in CSE evaluation (as well as a more diverse palette of research methodologies) has been called for by many (e.g., Haberland, 2015; Keogh et al., 2018; Ketting, Friele, & Michielsen, 2016; Leung, Shek, Leung, & Shek, 2019; Shearn, Allmark, Piercy, & Hirst, 2017; UNFPA, 2015; Vanwesenbeeck, 2011b, 2014). Nevertheless, we do have some knowledge about its levers of success.

### Levers of Success

Levers of success (as measured in relation to short term positive changes in knowledge, attitudes, and preventive behaviors, unless indicated differently) have been identified in program content and methods of delivery and implementation. In addition, the political and cultural contexts in which CSE is provided and adjacent strategies to improve those contexts have also proven important in program success, most certainly when reach and scale-up are looked at as outcome measures.

#### Comprehensive Program Content

Regarding program content, first, it is important that recommended procedures are adhered to during the development phase, such as using a logic model, involving young people and other stakeholders, assessing local needs, and pilot testing the program (Keogh et al., 2018; UNFPA, 2014). Other content features proven beneficial include focusing on specific behaviors, providing clear messages, focusing on risks or factors that are amenable to change and on situations that might lead to unsafe sex, while addressing personal values, norms, and perceptions and enhancing skills and self-efficacy (Kirby, 2007; UNFPA, 2014). Context specificity of program content is another prerequisite in program effectiveness. This requires culturally appropriate inclusion of all issues relevant to the specific circumstances faced by children and young people in their context (IPPF, 2017). Often, however, this requirement produces tension when key CSE elements, programmatic values, or core principles are considered controversial or taboo in a certain context. Hague, Miedema, and LeMat (2017) identify the problem that CSE can “work against itself” in that sociocultural sensitivity may lead to undesirable reductions of a program’s comprehensiveness.

One chief characteristic of effective program content stands out: addressing gender and power explicitly, by purposefully raising the subject and/or fostering personal reflection and critical thinking about how gender norms manifest and operate. Based on her comprehensive review of evaluation studies, Haberland (2015) concludes that education programs that address gender or power are five times more likely to be effective in terms of reduced rates of pregnancy or STIs as those that do not. Limitations in study designs have not granted us decent evidence for outcome measures other than individual health behaviors.

An explicit rights-based approach in CSE programs is another crucial content-related impact factor. There is evidence that a well-designed rights-based approach in CSE programs can lead to short-term positive effects on knowledge and attitudes, increased communication with parents about sex and relationships, and greater self-efficacy to manage risky situations, such as the risk of abuse, sexual exploitation, and domestic violence. Long-term significant positive effects have also been found for psychosocial and some behavioral outcomes (Constantine et al., 2015; Rohrbach et al., 2015; UNESCO, 2016).

Program fidelity, i.e., high-quality programs being delivered as intended, is an obvious impact-enhancing factor. Program fidelity may be hampered by factors related to students, teachers, and school contexts (see Vanwesenbeeck et al., 2016). Students may not be able to attend lessons. Teachers may skip key messages deemed too controversial, eliminate or shorten certain (sensitive) elements, and reduce the number or length of sessions. Schools may be unable to provide materials or effective lesson plans. UNESCO’s (2015) review of curricula shows that key competencies, including critical thinking, and the examination of how norms, religion, and culture affect learners choices, are often attributed little or no attention in existing sexuality education programs. A study on the effects of program fidelity for a CSE program in Uganda revealed that almost all significant positive effects disappeared in those schools that implemented less than 50% of the lessons (Rijsdijk et al., 2013).

A related element in adequate program implementation that stands out are teacher skills and norms. A study in Finland on the impact of school-based sexuality education on pupils’ sexual knowledge and attitudes showed that positive effects were largely due to the motivation, attitudes, and skills of teachers and the ability to employ participatory teaching techniques (Kontula, 2010). However, many teachers may grapple to come to terms with conflicts they experience between teaching CSE and dominant socio-cultural and religious norms. Girls, in particular, may be seen as the vulnerable sex for whom teachers feel abstinence is the best option. Traditional gender norms may often be strengthened rather than transformed. All pupils may potentially feel embarrassment and discomfort with sexuality as a topic. Gendered processes may further impede proper student engagement, not least among girls (see Pound, Langford, & Campbell, 2016). Educators’ professional norms and identity, in addition, may require a form of teacher authority that is at odds with the participatory teaching methods proposed by the program (e.g., De Haas, 2013). Much is expected in terms of CSE educator skills, as an overview of desired competencies shows (WHO & BZgA, 2017). A study by the Dutch Inspectorate for Education (2016) showed that even in the Netherlands there is still much room for improvement in this area.

The active involvement of students and learner-centered teaching are a prerequisite for positive results. The methods employed by teachers who say they do use interactive, participatory, or critical thinking pedagogy seem to, however, vary widely, and relevant research is scarce. In the review by Haberland (2015), “good pedagogy” alone could not distinguish effective from ineffective programs. What is clear, though, is that it does require proper training and a supportive school environment. Priority number one for an effective delivery of CSE is to better support teachers in being able to do so (see Poobalan et al., 2009; Pound, Langford, & Campbell, 2016). The ideal form of teacher training is a continuous process, which includes coaching and provides guidelines on how to successfully adapt a program to local needs, groups, and contexts (see Rotheram-Borus et al., 2009), preferably without compromising its key elements of effectiveness. There is heightened awareness that sexuality educators need proper facilitation, training, and support, both within and outside schools, to deliver sexuality education in an effective, enabling, and inclusive way (e.g., Vanwesenbeeck et al., 2016; WHO & BZgA, 2017). And there is increasing evidence that there is a lack of such support in the Global South (see Vanwesenbeeck et al., 2016) and East (Leung et al., 2019) as well as in the North or West (e.g., Martínez, 2012, for Spain; Spencer, Maxwell, & Aggleton, 2008, for the United Kingdom).

#### An Enabling (School) Environment

The school environment is essentially conducive of program success in many additional ways. Program fidelity, teacher performance, and program effectiveness all profit enormously when sexuality education is structurally embedded in the official school curriculum and does not need to be provided in after-school hours with little organizational support. For CSE to be given sufficient weight when integrated in the curriculum, Keogh et al. (2018) suggest it might be useful to choose a dedicated topic that can be made formally examinable so as to increase the educational status of a program. All infrastructural barriers to program fidelity, as mentioned above, should, of course, be reduced as much as possible. Sufficient funding (for materials and technical support or even proper teacher wages) is an obvious priority that is, unfortunately, all too often not conceded to. Conservative U.S. funding strategies play an important role in (inadequate) funding of CSE in resource-poor settings (see Center for Health and Gender Equity (CHANGE), 2018; Corrêa et al., 2008; Vanwesenbeeck, 2011a) as well as in the United States itself (e.g., Cushman, Kantor, Schroeder, Eicher, & Gambone, 2014).

In addition, positive messages, even from high-quality programs, may be seriously undermined by gender and status power differentials between teachers and learners and risks of harassment, exploitation, and violence against and among students (see Jewkes, 2010). The prevention of school-based gender-based (sexual) violence is a priority in this respect. Development and broad advertisement of school policies and careful implementation of action plans to this purpose may be highly effective. A promising strategy to build a supportive, enabling school base for CSE is the employment of a so-called whole school approach for sexuality education (WSA for SE) (Rutgers, 2016; Vanwesenbeeck et al., 2019). Pilot evaluations of this approach show positive results in terms of school safety, the development of a teacher supportive infrastructure, student participation in school policies, parental involvement, links with nearby SRH service providers, and relations with the community and political stakeholders. WSA for SE schools were shown to have developed a number of techniques to increase teacher motivation, such as teacher teams to improve collaboration and mentorship. Moreover, teachers have reported changes in their own beliefs, attitudes, and knowledge regarding the teaching of sensitive topics such as contraception, abortion, and sexual diversity, which they had previously skipped. Teachers also reported the increased use of and confidence in participatory teaching methods (see Flink, Schaapveld, & Page, 2018).

Positive support from parents and communities and availability of a range of out-of-school educational possibilities and, not least, of accessible (youth-friendly) sexual health services and supplies are of crucial importance. Links with outside school settings and partnerships with community and religious leaders in marginalized areas, including rural areas, may be particularly important in order to reach the most vulnerable populations (UNESCO, 2018). Clearly, adolescent sexual and reproductive health and rights cannot be realized by CSE alone (see Vanwesenbeeck et al., 2019). Successful behavior change is best achieved if multilevel inputs are provided to support and reinforce this change synergistically (Palmer, 2010, p. 23).

#### Multicomponent Approaches

The desirability of so-called multicomponent approaches (bringing together actions to improve individual empowerment, strengthen the health system, and create a more CSE and SRHR supportive environment) has become particularly evident when HIV programming shifted from an emergency to a longer-term response. This has called for a shift from individualistic to social/structural approaches that address the key drivers of HIV vulnerability (e.g., Auerbach, Parkhurst, & Caceres, 2011; Fitzpatrick, 2018; UNESCO, 2018; Vanwesenbeeck, 2011a). Multicomponent approaches are also more sustainable than single-component interventions since they also achieve change in social and cultural factors. They are more synergetic because they address both demand and supply in relation to the uptake of health education and services. They target different groups and are therefore more diverse in reach (see Chandra-Mouli et al., 2015; Denno, Hoopes, & Chandra-Mouli, 2015; Fonner et al., 2014; Kesterton & Cabral de Mello, 2010; Svanemyr, Amin, Robles, & Greene, 2015a; Svanemyr, Baig, & Chandra-Mouli, 2015b; UNESCO, 2018; Vanwesenbeeck et al., 2019).

Svanemyr et al. (2015b) have argued for an “ecological framework” to enable the environment at different levels: at the individual level (empower girls, create safe spaces), at the relationship level (build parental support, peer support networks), at the community level (engage men and boys, transform gender and other social norms), and at the broad societal level (promote laws and policies that protect and promote human rights). A 20-year ICPD progress report by Chandra-Mouli et al. (2015) shows that sexuality education is most impactful when school-based programs are complemented by community elements, including condom distribution, building awareness and support, and increasing demand for SRH education and services among youth. Additionally, addressing gender inequalities, providing training for health providers, and involving parents, teachers, and other community gatekeepers such as religious leaders may be beneficial. The authors argue for “SRH intervention packages” to improve CSE’s effectiveness.

Multicomponent approaches are indispensable to bringing CSE to appropriate scale. If CSE is not accessible to substantial and diverse masses of adolescents, its effects may remain no more than the proverbial drop in the ocean. Scale-up also improves cost-effectiveness. Kivela, Ketting, and Balthussen (2011) calculated that costs of school-based sexuality education may be as low as $5 to$7 per student when integrated in regular curricula, taught by regular teachers, and reaching many students per class/school. These calculations do not yet take into account the huge costs (to the individual, societies, and countries at large) that are being saved when good CSE substantially reduces unintended pregnancies, STIs and other aspects of sexual and reproductive ill-health. And we can’t even begin to estimate the financial profits of broader benefits, such as increased self-esteem and gender equality, not least when CSE reaches proper scale. An effective strategy in scale-up processes may be the whole school approach for sexuality education (Rutgers, 2016). The approach aims to include more pupils per school, reach them earlier, and develop a cost-effective, scalable implementation model. Selected schools are facilitated in taking the lead in designing feasible interventions, making the best possible use of available school budgets, staff, relationships, and resources in order to overcome challenges. Combined with support from local governments, these schools will become advocates for other schools and further bring CSE to scale. Frameworks for scale-up, e.g., ExpandNetwork, propose starting to develop a plan for scale-up early, during intervention design and implementation, developing that into a detailed scale-up strategy and a careful, systematic management of scale-up processes (see Chau, Traore, Seck, Chandra-Mouli, & Svanemyr, 2016). Keogh et al. (2018) studied scale-up processes in four different (low-income) countries and conclude that the prime conditions for successful scale-up are positive cultural norms and values, presence of infrastructural needs (such as accessibility of services, links with communities, and supportive media), and overall policy and community level support. These authors suggest that installment of dedicated permanent teams at the central and regional levels could enable greater coordination of activities around CSE and could significantly enhance coverage and continuity of programs within countries.

Overall, a CSE-positive cultural climate and state politics are crucial for CSE to fulfill its potential to the fullest. However, CSE-negative cultural contexts are highly prevalent everywhere, in the Global South (e.g., Michielsen, Chersich, Temmerman, Dooms, & van Rossem, 2012; Wood & Rolleri, 2014) as well as in the Global North (e.g., Cushman, et al., 2014). In the United States, Cavazos-Rehg et al. (2012) found that the effects of sexuality education were constrained by state-level characteristics, notably religiosity and political conservatism/abortion politics, and that state characteristics also influenced adolescent birth rates above and beyond sexuality education. CSE-negative environments hamper programs’ effectiveness in producing barriers to program development, implementation, delivery, and scale-up and provide major challenges for the realization of the whole range of CSE’s potential benefits. Particularly in conservative contexts, careful community engagement to increase support for and reduce resistance toward CSE is widely considered a prime lever of success in CSE implementation and scale-up (Chau et al., 2016; Svanemyr et al., 2015b; Vanwesenbeeck et al., 2019).

As illustrated, there is still much room for improvement in most settings in terms of vitally important requirements for successful CSE programming. In this section, a couple of aspects in pressing need of (unremitting) attention are highlighted.

#### Fighting Opposition

Despite all the evidence of positive CSE effects on adolescent sexual health, its compelling logic, the intrinsic values of human rights and gender equity, and the many satisfied users, opposition to CSE remains astoundingly strong. In many countries, overall public opinion may be notably positive, but small yet extremely vocal conservative and religious groups strongly keep resisting CSE in many places (Chau et al., 2016; Keogh et al., 2018). Unfortunately, these groups often manage to negatively influence national educational politics as well as political agreements by international bodies such as the UN. Twenty-five years after the landmark ICPD 1994, UNFPA emphasizes that “the struggle for rights and choices is an ongoing one” (2019, p. 7). And increasingly so, one might add. During the session of the Commission on the Status of Women in 2019 (CSW63), attainments of the landmark ICPD in 1994 with regard to the sexual and reproductive rights of women and girls could only barely be retained. Particularly the U.S. delegation, in an “unholy alliance” with the Vatican, Russia, and orthodox Muslim countries, has been pushing vehemently toward a conservative, religious agenda. Nationally in the United States, “sex education wars” (Kendall, 2012) have long raged between believers in AOUM and activists for CSE. The Bush administration adopted AOUM as the singular approach to adolescent sexual and reproductive health, resulting in up to 49 of the 50 states accepting federal funds to promote AOUM in the classroom (Hall, McDermott Sales, Komro, & Santelli, 2016). In the early decades of the 21st century, CSE is gaining popularity in the United States, but in the more socially and politically conservative states, schools often still prefer AOUM (e.g., Leung et al., 2019).

Partly because of the Americanization of international sexual and reproductive health politics (see Altman, 2001; Corrêa et al., 2008; Vanwesenbeeck, 2019), opposition against CSE is also and sometimes increasingly strong in many conservative countries in the Global South. UNESCO Bangkok (2012) found only 6 of 28 countries in the Asia Pacific region to even discuss sexuality education in any detail in their national policies at the time. Opponents criticize CSE for being “sex positive,” sometimes for being “Western,” and persist to believe, against all evidence, that sexual knowledge is dangerous and might encourage experimentation. Religion-based morality politics are notably evidence resistant. Overall, the transformative goals of CSE may be unsettling because they are considered threatening to gender norms, family values, and the status quo. Nevertheless, UNESCO successfully mobilized substantial high-level political support in East and Southern Africa for the improved provision of sexuality education and sexual and reproductive health services for young people. In December 2013, in Cape Town, 20 ministers of health and education from the region affirmed their commitment. However, inclusion of sexual diversity (LGBTQ) issues have not been addressed in these commitments due to social and cultural constraints. Particularly sexual rights and sensitive topics such as same-sex sexual relationships and abortion remain extremely controversial, both in sex education and beyond (Bijlmakers, de Haas, & Peters, 2018; UNFPA, 2019). Public controversy around sexuality and gender issues seems to also be on the rise in Europe. A strengthened focus on reproduction and family values, a prominent backlash against reproductive rights, and an infringement on women’s rights and LGBT organizations can be observed, notably in the Eastern region and the Balkans (Kuhar & Paternotte, 2017; Outshoorn, 2015; Verloo, 2016). Štulhofer (2016) notes that this growing public controversy over gender equity and sexual rights in a number of countries also seriously threatens the comprehensive nature of sexuality education. Štulhofer calls for a European-wide collaboration on CSE.

Clearly, opposition to CSE needs to be persistently fought. In international fora, the presence of CSE advocates is indispensable to keep a balance with the CSE opposition movement. And, as said, there is a huge need for community building to strengthen positive attitudes toward sexuality education in general and to sexual rights specifically. This has been shown to be possible and fruitful, even in sex-conservative settings, provided it is implemented with tact and care (e.g., Chandra-Mouli, Plesons, Hadi, Baig, & Lang, 2018; Denno et al., 2015; Institute for Reproductive Health, 2016). In Pakistan, for instance, NGO Rutgers Pakistan has been successful in advancing support for sexuality education with careful implementation of a number of key strategies that included sensitizing and engaging key stakeholders, including religious groups, schools, health and education government officials, parents, and young people themselves; tactfully designing and framing the curricula with careful consideration of context and sensitive topics; institutionalizing programs within the school system; showcasing school programs to increase transparency; and engaging the media to enhance and build positive public perceptions (Chandra-Mouli et al., 2018; Svanemyr et al., 2015a, 2015b). Comparable positive results have been described for a community building project by BRAC University in Bangladesh (Rashid, Standing, Mohiuddin, & Ahmed, 2011). Community building to enhance attitudes toward sexuality education is also vital to (parts of) conservative Global North countries such as the United States (e.g., Secor-Turner, Randall, Christensen, Jacobson, & Meléndez, 2017), Australia (Ferfolja & Ullman, 2017), and Ireland (Wilentz, 2016). In the Netherlands, relentless advocacy has brought about continued success, but sometimes religious groups protest against one or another intervention there as well, particularly when CSE programs in primary schools are at stake. In addition to community building at a national level, the usefulness of regional cooperation at the level of continents has also been illustrated, for instance, for Latin America (Steinhart et al., 2013; see also UNFPA, 2015).

In addition to national and regional cooperation, international cooperation in relation to CSE programming is, obviously, commonplace and standard procedure in international development aid. However, North–South partnerships in international development aid are precarious. Colonial histories, strong versus weak positions in the global economy, and the (assumed) unidirectional nature of funding streams may hamper the establishment of an equitable power balance between international partners (see Vanwesenbeeck et al., 2019). Imperialist tendencies and (northern) countries wishing to impose their values on other (southern) ones are well-known phenomena in international cooperation.

Clearly, such relations have been met with criticism, for instance, in anti- or postcolonial scholarship. Ethical debate about development aid has grown and diversified (Gasper, 1999). Shaping CSE has been one area in which signs of notable inequity between stakeholders from the Global North versus the Global South have been noted. After thorough review of the international literature on CSE-related implementation processes, Hague et al. (2017) are wary of the fact that guidance still appears to remain strongly top-down. A problematic binary between “progressive secular” and “backward religious” cultures and the idea that secularity would guarantee sexual freedom have been criticized (Le Mat, Kosar-Altinyelken, Bos, & Volman, 2019; Rasmussen, 2012; Roodsaz, 2018). LeMat et al. (2019) disapproved of uncritical conceptions of tradition versus modernity and of “good” versus “bad” cultures in relation to teaching young people in Ethiopia about the determinants of sexual violence. Relying on such a distinction fails to address and discuss gender relations and patriarchy as the root causes of gender-based violence, enhances the vulnerability of young women, and reduces CSE effectiveness, the authors avow. Roodsaz (2018) found evidence of frustration, annoyance, and resistance to, in particular, a rights-based approach among some stakeholders in CSE implementation in Bangladesh. The interviewees claimed that sensitive topics such as sexual diversity, gender norms, and child marriage are difficult to discuss in the context of Bangladesh. By promoting a rights-based approach to CSE in countries in the South, European development organizations and NGO representatives risk being culturally insensitive by seeking to advantage “the dominant, the transnational” over “the particular,” Roodsaz argues. Her analysis strongly condemns the downplay of local modes of sexuality knowledge, and politics and provides a strong plea for equal collaboration between parties.

Remarkably, however, it is exactly the human rights framework that has, gradually over the years, become the standard for ethical relations in development cooperation and in dealing with the clash of values that may present itself between countries and stakeholders (OHCHR, 2006). There are two main rationales for the adoption of a human rights-based approach: (1) the intrinsic rationale, acknowledging that a human rights–based approach is the right thing to do, morally or legally; and (2) the instrumental rationale, recognizing that a human rights–based approach leads to better and more sustainable human development outcomes. In practice, the reason for pursuing a human rights–based approach is usually a blend of these two. In international cooperative work on CSE, a human rights–based approach needs to be employed with respect to both program content as well as the implementation process. For one thing, a proper balance needs to be found between Northern and Southern stakeholders in defining and tuning concepts such as “empowerment,” “rights” and “agency” (for girls as well as boys), or “comprehensiveness” in the first place. Collaborative tuning with local stakeholders is one of the most crucial aspects of the implementation of sexuality education in the context of development cooperation (see Vanwesenbeeck et al., 2016, 2019).

Differences in approaches to CSE show at macro, meso, and micro levels of international cooperation and shape the varied understandings and delivery of CSE as a result (Hague et al., 2017). These variations are bound to change over time. Hague et al. (2017) express hope that, rather than the still all-too-prevalent top-down approach to guidance of CSE, a circular learning process will gradually prevail that will increasingly create understanding and consensus among different sets of actors and across varying contexts as to what CSE should encompass. Sexual rights are bound to be a crucial area about which actors may have widely divergent opinions, as they are essential to CSE while at the same time extremely controversial in many cultural contexts. Respect for sexual rights may always remain patchy, with proponents and adversaries entangled in eternal battles and/or with support for some rights being relatively strong (e.g., the right to information) but not so for others (e.g., same-sex sexuality or abortion rights). Indeed, appropriate attention to non-normative sexualities may be one of the biggest challenges in many contexts. In general, CSE has been criticized for LGBT silencing, both in the North and the South (Bang Svendsen, 2012; Ferfolja & Ullman, 2017; Haggis & Mulholland, 2014; Sherlock, 2012). Hague et al. (2017) stress that comprehensiveness does not automatically equal inclusivity. The circular learning process for international cooperation in development aid contexts, as suggested by these authors, will often, maybe always, necessarily involve subtle maneuvering, balancing, and compromise, most likely in the area of sexual rights and inclusivity.

#### Ongoing Innovation

CSE requires constant innovation in other areas as well. CSE needs to be continually adaptive to progressive insights, societal developments, and shifting conditions and is, principally, always a work in progress. Every new generation of young people has at least slightly different needs, possibilities, and perspectives. Contexts change. Globalization and the intense mediatization of our modern world have, for instance, brought about a totally different landscape for sex education. The extent to which new technologies, such as social media and Internet access, and their implications for young peoples’ sexual development should be covered in CSE, and how, is a matter of unresolved consideration. Likewise, new technologies may add to (the diversification of) educational methods and strategies. Ways in which new options may be benefited best need to be investigated on an ongoing basis. Innovation in terms of methods and implementation processes is a constant challenge. The jury is still out on issues such as the role of parents, the right of withdrawal, how to deal with complaints, how to adequately incorporate young people’s views, etc. The same is true for the treatment of topics that are notably complex and therefore far from easily dealt with in educational settings. Sexual empowerment, choice, agency, and pleasure are central aims in a gender transformative approach to young peoples’ sexuality, but their conceptualization and approach remain to be subject to heated (scientific) debate. Inclusion of these themes in CSE in truly transformative and evolutionary ways turns out to be far from a self-evident endeavor and certainly needs further and careful consideration (see, e.g., Allen, 2012, 2013; Allen & Carmody, 2012; Bay-Cheng, 2019; Cense, 2019a; Naezer, Rommes, & Jansen, 2017; Rasmussen, 2012; Vanwesenbeeck et al., 2019).

### Conclusion

Comprehensive sexuality education (CSE) may be considered the flagship of the worldwide social movement for sexual and reproductive health and rights (SRHR). CSE is the prime premise, the ultimate requirement to even come close to realizing SRHR for all. CSE clearly sets the bar high. Its aims are ambitious. The potential of CSE is enormous and at least partly shown to be realized indeed, but research investigating success and its levers is limited at the same time. Long-term investigations are rare. Outcome measures mostly used have been dictated by a biomedical perspective on health interventions. The wider, psychological, social, and cultural potential of CSE has hardly been the subject of scientific research, no doubt in part due to the complexity and versatility of young peoples’ sexual well-being. Also in the area of planning, monitoring, and evaluation (PME), a world is still to be gained. There is progress in guidance for high-quality methods and procedures in CSE research (e.g., UNESCO, 2018; UNFPA, 2015). Tools for standardized PME procedures have become available (e.g., UNESCO’s Serat, IPPF’s Inside & Out, Rutgers’s planning and support tool). Multiple research designs and multiple methods are required to assess multi-layered processes. The many promises of CSE will remain unknown and underestimated until the body of knowledge on its processes, outcomes, and impact is substantially increased and, not least, diversified.

At the same time, cautiousness about CSE’s potential is warranted. In the past, the field has been criticized for breathing “pan-optimism” (Lesko, 2010) in assuming that individual decision-making is the key site of risk minimization and progress toward sexual health (Bromnick & Swinburn, 2003; Dworkin & Ehrhardt, 2007). It has now, gradually, been brought home to CSE advocates that “SRHR for all” will not be realized by CSE alone. We should neither underestimate nor overestimate CSE’s potential. CSE needs to be bolstered by an enabling (cultural, political, economic) environment with an overall sound (sexual and reproductive) health system. The structural and social drivers of SRHR must be unrelentingly addressed at multiple levels. Multi-track policies are vital. Adequate training and support systems for educators and schools rank high on the list. And, not least because of persistent opposition to CSE, careful community building and advocacy around CSE are key, on the level of local and regional as well as international cooperation. Great care will have to be taken to make CSE available to all, including the more vulnerable populations and in the more isolated regions. This means CSE will also have to spread to out-of-school settings. True inclusivity is still a challenge in many, probably all, contexts.

Clearly, developing and implementing CSE is a treacherous, complex process with many risks, threats, and pitfalls, truly a job never done. There is no alternative to simply moving on with unrelenting purpose and energy. Fortunately, CSE advocates and practitioners are strengthened by the notion that CSE, in all its ambition and potential, is a sine qua non for young peoples’ productive sexual citizenship and for sexual and reproductive health and rights for all.

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