The journey towards comprehensive sexuality education - Global status report

Publication date: 2021

The journey towards comprehensive sexuality education Global status report The Global Education 2030 Agenda UNESCO, as the United Nations’ specialized agency for education, is entrusted to lead and coordinate the Education 2030 Agenda, which is part of a global movement to eradicate poverty through 17 Sustainable Development Goals by 2030. Education, essential to achieve all of these goals, has its own dedicated Goal 4, which aims to “ensure inclusive and equitable quality education and promote lifelong learning opportuni- ties for all.” The Education 2030 Framework for Action provides guidance for the implementation of this ambitious goal and commitments. UNESCO – a global leader in education Education is UNESCO’s top priority because it is a basic human right and the foundation for peace and sustainable development. UNESCO is the United Nations’ specialized agency for education, providing global and regional leadership to drive progress, strengthening the resilience and capacity of national systems to serve all learners and responding to contemporary global challenges through transformative learning, with special focus on gender equality and Africa across all actions. Published in 2021 by the United Nations Educational, Scientific and Cultural Organization (UNESCO), 7, place de Fontenoy, 75352 Paris 07 SP, France, UNAIDS Secretariat, Avenue Appia 20, CH-1211 Geneva 27, Switzerland, The United Nations Population Fund (UNFPA), 605 Third Avenue, New York, NY 10158, United States, The United Nations Children’s Fund (UNICEF), UNICEF House, 3 United Nations Plaza, New York, NY 10017, United States, UN Women, 220 East 42nd Street, New York, NY 10017, United States and The World Health Organization (WHO), Avenue Appia 20, CH-1211 Geneva 27, Switzerland © UNESCO 2021 ISBN 978-92-3-100481-0 This publication is available in Open Access under the Attribution-ShareAlike 3.0 IGO (CC-BY-SA 3.0 IGO) license (http://creativecommons.org/licenses/ by-sa/3.0/igo/). By using the content of this publication, the users accept to be bound by the terms of use of the UNESCO Open Access Repository (http://www.unesco.org/open-access/terms-use-ccbysa-en). 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This report draws on multiple data sources to provide analysis of countries’ progress towards delivering good quality school-based CSE to all learners. 85 per cent of 155 countries surveyed have policies or laws relating to sexuality education, with considerably more countries reporting policies to mandate delivery at secondary education level than at primary level. However, the existence of policy and legal frameworks do not always equate to comprehensive content or strong implementation. Most countries report that they have some curricula in place but more detailed analysis suggests that it often lacks the breadth of topics needed to make sexuality education effective and relevant. Moreover, while efforts to scale-up teacher training are evident in a range of settings, research with teachers shows that many feel they lack confidence to deliver sexuality education. Surveys show that students frequently feel that they received information too late and would have preferred sexuality education to have started earlier in their schooling. There is evidence of opposition to CSE across a range of settings, often reflecting misinformation about the content, purpose or impact of such education. However, in many countries involvement of communities, including parents, school officials, religious leaders, media and young people themselves, has created a favourable environment for CSE. Recommendations to countries in this report include: ● Clear mandates and budgets to ensure implementation of policies and programmes that support the availability of good quality comprehensive sexuality education for all learners. ● Invest in quality curriculum reform and teacher training. ● Strengthen monitoring of the implementation of CSE. How are countries advancing towards comprehensive sexuality education for all? In a recent survey of young people (aged 15-24) from Asia and the Pacific, fewer than 1 in 3 believed that their school taught them sexuality education well. The journey towards comprehensive sexuality education Global status report Contents Acknowledgements . 4 Lists of acrocnyms . 5 Executive summary . 6 1. Introduction . 11 1.1 Data sources and methodology . 15 2. Status of comprehensive sexuality education. 17 2.1 Laws & policies . 17 2.2 Coverage. 23 2.3 Curricula: Breadth and relevance of content . 24 2.4 Delivery . 33 2.5 Enabling environment . 41 2.6 Reaching vulnerable groups and out-of-school children and young people . 47 2.7 Sexuality education in the context of COVID-19 . 49 3. Conclusions and ways forward. 50 Annexes . 53 Annex 1: List of key informants . 53 Annex 2: Information about existing measurement tools and global indicators used in the report . 53 Annex 3: Table of data on adolescent health and provision of sexuality education in select countries. 54 References . 55 The journey towards comprehensive sexuality education 2 Tables Table 1. Major data sets used in this report . 16 Table 2. Key concepts and characteristics of CSE . 28 Figures Figure 1. Laws and/or policies relating to sexuality education . 19 Figure 2. National sexuality education programme coverage rates . 24 Figure 3. Curricula related to sexuality education in the education system . 25 Figure 4. Sexuality education delivery mode (primary schools) . 27 Figure 5. Sexuality education delivery mode (secondary schools) . 27 Figure 6. Comprehensiveness of sexuality education curriculum, as reported by survey respondents . 29 Figure 7. Reported extent of inclusion within curricula of a range of key CSE topics (Secondary education) . 29 Figure 8. Reported extent of inclusion within curricula of a range of key CSE topics (Primary education) . 29 Figure 9. SERAT weighted scores for overall curriculum content for different age groups . 31 Figure 10. SERAT weighted scores for key themes . 31 Figure 11. SERAT weighted scores for learning domain . 31 Figure 12. Sexuality education teaching method, as reported by survey respondents . 39 Figure 13. Access to sexual and reproductive services, as reported by survey respondents . 43 Case studies Case study 1: A journey towards comprehensive sexuality education in Lao People’s Democratic Republic . 15 Case study 2: England introduces statutory Relationships & Sex Education from 2021 . 21 Case study 3: A journey towards CSE in Tunisia . 21 Case study 4: Commitment to, and scale up of, CSE in Jharkhand State, India . 22 Case study 5: A journey towards CSE in Jamaica . 23 Case study 6: Body-emotion education for pre-primary school children in Finland . 26 Case study 7: Sexuality education within Scotland’s Health & Well-being curriculum . 30 Case study 8: A gender-transformative approach to sexuality education in Sweden . 32 Case study 9: Teacher training colleges as centres for excellence in CSE teacher training . 34 Case study 10: Dedicated life skills education teachers to achieve coverage in Namibia . 35 Case study 11: Scaling up teacher training in Kyrgyzstan . 35 Case study 12: Scripted lesson plans supporting teachers in South Africa . 36 Case study 13: Cameroon’s journey towards Holistic Sexuality Education . 37 Case study 14: Ensuring teachers have the right support to deliver sexuality education in Chile . 37 Case study 15: Armenia’s journey towards an integrated model of sexuality education . 38 Case study 16: A comprehensive tool for reviewing school-based sexuality education . 41 Case study 17: Strong ministerial commitment to scale up CSE in Eastern & Southern Africa . 43 Case study 18: Building community support for sexuality education in Pakistan . 44 Case study 19: CSOs providing strong support to sexuality education in Mexico . 45 Case study 20: Global Fund support to advance CSE within HIV response in sub-Saharan Africa . 46 Case study 21: Perspectives on CSE from young people in the Asia Pacific region . 46 Case study 22: Using digital platforms to strengthen school-based sexuality education . 47 Case study 23: Reaching young people with disabilities in Uruguay . 48 Case study 24: Sexuality education via Zoom during school closures in Estonia . 49 The journey towards comprehensive sexuality education 3 Acknowledgements UNESCO, along with co-publishing partners – WHO, UNFPA, UNAIDS, UNICEF and UN Women – gratefully acknowledges the contributions of many individuals from numerous organizations in preparing this report. The report was authored by Wendy Wisbaum, with considerable input from Sally Beadle, Parviz Abduvahobov and Joanna Herat. It draws extensively on a desk review authored by Susan Wood, with research assistance from Hannah Klein, as well as data collected and analyzed by UNESCO. Staff from WHO, UNFPA, UNAIDS UNICEF, and UN Women provided inputs to the conceptualization of the report and to its evolving drafts. Specifically, we thank the following individuals for their involvement in the development of this report:   Mary-Guinn Delaney, UNESCO Latin America & the Caribbean, Santiago Hongyan Li, UNESCO, Beijing Chris Castle, Christophe Cornu, Sylvain Seguy, Arushi Singh & Séverine Pillado, UNESCO Paris Sarita Jadev, UNESCO, New Delhi Aina Heita-Kantewa, UNESCO, Windhoek Ngozi Amanze Onyedikachi, UNESCO, Abuja Tigran Yepoyan, UNESCO Institute for Information Technologies in Education, Moscow Xavier Hospital, Delphine Santini & William Ngue, UNESCO Office in Dakar and Regional Bureau for Education Maria Bakaroudis, UNFPA East and Southern Africa, South Africa Venkatraman Chandra-Mouli & Marina Plesons, WHO, Switzerland Hege Wagan & Alicia Sanchez Argueta, UNAIDS, Switzerland Jo Sauvarin & Maki Akiyama, UNFPA Regional Office for Asia and the Pacific, Thailand Jenelle Babb & Thanh Loan Ngo, UNESCO Bangkok Office, Asia and Pacific Regional Bureau for Education, Thailand Sergio Meresman, Consultant, Uruguay Ilya Zhukov & Bente Faugli, UNFPA, USA Demilola Walker & Sarah Thomsen, UNICEF, USA Nazneen Damji, UN Women, USA Alice Saili, Mwilu Lenard Mumbi & Remmy Mukonka, UNESCO, Lusaka Patricia Machawira, Ygainnia Hamandawana, Naomi Mnthali & Remmy Shawa, UNESCO, Harare This report was made possible by the generous financial support of the Governments of Sweden and Norway. The journey towards comprehensive sexuality education 4 List of Acronyms AIDS Acquired Immunodeficiency Syndrome ASFE Annual Survey of Formal Education ASRH Adolescent sexual and reproductive health BZgA German Federal Centre for Health Education CRPD UN Convention on the Rights of Persons with Disabilities CSO civil society organization CARICOM Caribbean Community CSE Comprehensive sexuality education ECA Europe and Central Asia DBE Department of Basic Education (South Africa) DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe EMIS Education Management Information Systems ESA Eastern and Southern Africa ESHA Estonian Sexual Health Association GBV Gender-based violence FBO faith-based organization FLE Family Life Education FP Family Planning GFATM Global Fund to end AIDS, TB and Malaria HFLE Health and Family Life Education HIV Human Immunodeficiency Virus HWB Health and well-being IATT Inter-Agency Task Force ICPD International Conference on Population and Development ICT Information and communication technology iiDi Uruguayan Foundation for Disability and Inclusive Development IITE Institute for Information Technologies in Education IPPF International Planned Parenthood Federation ITGSE International Technical Guidance on Sexuality Education LAC Latin America and the Caribbean LGBTI Lesbian Gay Bisexual Transgender Intersex LMIC Low-to-middle-income country MENA Middle East and North Africa META Movimiento Estamos Tod@s en Acción (We’re All in Action), Young Latin American Activists for Inclusive Development) M&E Monitoring and evaluation NHS National Health Service (UK) NCPI National Commitments and Policy Instrument NGO Non-governmental organization OFSTED Office for Standards in Education, Children’s Services and Skills (UK) PEPFAR The President’s Emergency Plan For AIDS Relief RSHP Relationships, Sexual Health and Parenthood SADC Southern African Development Community SDG Sustainable Development Goal SEL Social and Emotional Learning SERAT Sexuality Education Review and Assessment Tool SRE Sex and Relationships Education SRH Sexual and reproductive health SRHR Sexual and reproductive health and rights SSA sub-Saharan Africa STI Sexually transmitted infection TCG Technical Cooperation Group UBRAF Unified Budget, Results and Accountability Framework (UNAIDS) UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WCA West and Central Africa WHO World Health Organization The journey towards comprehensive sexuality education 5 EXECUTIVE SUMMARY School-based comprehensive sexuality education (CSE) plays a vital role in promoting the health and well-being of children and young people. For many years, countries across the world have been interested in ensuring that learners have access to some form of sexuality education – referred to by different names across settings – often responding to pressing health and social problems such as high levels of HIV or early and unintended pregnancy. In more recent years this has often developed into a more holistic subject covering a wide range of topics across a number of years. As the evidence for the potential of truly comprehensive sexuality education has emerged, as well as research informing best practice, many countries have made efforts to make sexuality education increasingly comprehensive and expand coverage with the aim of reaching all learners at different stages of their education. Although there is variation, including set-backs in some contexts, progress has been made in many countries across the world. 1 UNAIDS National Commitments and Policies Instrument (2017, 2019); Survey on Sexuality Education in Europe and Central Asia (Ketting & Ivanova 2018); Survey on the Status of CSE (carried out in 60 countries in Asia and the Pacific, sub-Saharan Africa and Latin America and the Caribbean for this report, 2019-2020) 2 UNAIDS National Commitments and Policies Instrument (2017, 2019) This report seeks to provide a snapshot of the status of school-based CSE around the world. This will help inform continued advocacy and resourcing efforts, as governments and partners work towards the goal of ensuring all learners receive good quality CSE throughout their schooling. Quality and sustainable CSE is reliant on a range of factors, all of which need to be assessed to paint a picture of the global status of CSE: LAWS AND POLICIES The enabling framework for delivery COVERAGE The extent of delivery in school settings CURRICULA Breadth, quality and relevance of content DELIVERY How well teachers are prepared and are teaching quality CSE ENABLING ENVIRONMENT The wider school environment, community and political support or engagement. This report draws on a range of existing and new data sources in order to build a composite picture of the status of CSE. This includes global data sets collecting information relating to sexuality education, data collected across a number of regional surveys designed to monitor the status of CSE, an extensive desk review and a series of key informant interviews. While diverse data sources have been consulted, including internationally comparable sources such as the National Commitments and Policies Instrument (NCPI), there are some limitations. Notably, quantitative datasets often rely on self-reporting from national-level stakeholders who may not have access to the full, complex picture of CSE delivery in schools. This means that quantitative data, while providing a snapshot, need to be read with caution. As far as possible, quantitative data have been presented alongside other research findings, which serve to provide a more balanced picture and often highlight continued challenges that countries face in developing and scaling-up truly comprehensive and good quality sexuality education. Case studies throughout the report demonstrate how countries are advancing on their journeys towards CSE. Drawn from around the world, these examples highlight some commonalities, as well as the specific, locally tailored approaches that have enabled the delivery of sexuality education through policy commitments, curricula revisions, innovations in teacher training and engagement with stakeholders. Laws and policies Children and young people’s access to comprehensive sexuality education is grounded in international conventions on health, gender equality and/or education, as well as a range of regional agreements which include specific commitments around the implementation of sexuality education. At a national level, according to available data from 155 countries, 85 per cent report that they have policies (or, in some cases laws or legal frameworks) related to sexuality education1. A total of 78 countries reported that they have education policies on ‘life skills-based HIV and sexuality education’ in both primary and secondary schools and 30 said they have policies only in secondary education2. The remaining countries referred to an overall supporting legal framework, which includes laws, decrees, acts and policies. The journey towards comprehensive sexuality education 6 Considerably more countries report having policies on ‘life skills-based HIV and sexuality education’ at secondary education level than at primary level. Moreover, although a positive national-level policy environment is one of the key factors for successful implementation of sexuality education programmes, the reality behind these laws and policies is complex. Few countries have a national policy specifically on sexuality education. Where countries mention sexuality education in their policies, there is sometimes no guidance on the components of a sexuality education curriculum nor on how to implement it. In some settings, policies and strategies focus on a range of sexual and reproductive health issues, and others focus more specifically on life skills and prevention of HIV. Decentralisation of policy-making, financing and decision-making can enable local governments to ensure that programmes are more responsive to local needs, but it can also lead to inconsistencies in implementation of sexuality education across a country. Learning from country examples In England (United Kingdom), recent statutory guidance makes it compulsory for all schools to teach Relationships Education at primary level and Relationships and Sex Education at secondary level. Advocates hope that these changes in policy will raise the status of relationships and sex education, with the result that it will be taken more seriously as a school subject and lead to pathways for teachers to professionalise in this subject area (see full case study on page 21). In India, responsibility for sexuality education is decentralised to state level. In the State of Jharkhand, local government commitment, as well as a strong government- NGO partnership, has been key to scaling up sexuality education. A curriculum has been integrated into the school textbooks and into the in-service and pre-service education of teachers. A specific staff member is designated to coordinate and provide administrative support to the programme. This has been identified as the only at-scale, state-run initiative of its kind in the country (see full case study on page 22). 3 UNAIDS National Commitments and Policies Instrument (2017, 2019), Sustainable Development Goals (SDG) Thematic Indicator 4.7.2, Survey on the Status of CSE (carried out in 60 countries in Asia and the Pacific, sub-Saharan Africa and Latin America and the Caribbean for this report, 2019-2020) 4 Indicator as referred to in UNESCO (2013), Measuring the education sector response to HIV and AIDS: guidelines for the construction and use of core indicators Finally, while the existence of policy and/or law provides some indication of commitment to sexuality education in rhetoric, it must be followed up with resource allocation and implementation efforts. A number of countries report allocating domestic funding, while research also demonstrates that in some low- and middle-income countries external donor funding continues to make an important contribution. Coverage National-level coverage data gives some indication of progress with implementation, although the data is often not collected through school surveys, census or administrative databases and may reflect an estimate made at central level. According to the available data, about two-thirds of reporting countries stated that between 76 and 100 per cent of the schools in their country were providing some kind of sexuality education – defined as teaching about generic life skills, sexual and reproductive health and HIV prevention.3, 4 The remaining countries reported lower levels of coverage. However, these findings may depict an overly optimistic picture and should be read with caution. Divergent ideas about what constitutes sexuality education, unclear or different definitions of terms, and invalid assumptions contribute to reporting of numbers that may be inflated. Coverage data also fall short of detailing the important yet more complex question of quality of curriculum content and delivery. An indication of quality may be better reflected in specific research with learners and teachers. For example, research on student perspectives from a number of different countries shows that they often feel that they received information too late and would have preferred the sexuality education programme to have started earlier in their schooling. Learner perspectives Adolescents and young people provide valuable insights into the quality of sexuality education. In a 2019 online survey, over 1,400 young people (aged 15-24) from over 27 countries in Asia and the Pacific reflected on their experience of sexuality education. Less than one in three believed that their school taught them about sexuality very well or somewhat well (28 per cent). Young people with disabilities and young people who identified as Lesbian, Gay, Bisexual, Transgender, Intersex (LGBTI) were less satisfied with their sexuality education than their peers. Continuing to include the voices of adolescents and young people in efforts to monitor the status of CSE will be important. 28% of young people believed that their school taught them about sexuality very well or somewhat well . while the existence of policy and/or law provides some indication of commitment to sexuality education in rhetoric, it must be followed up with resource allocation and implementation efforts. The journey towards comprehensive sexuality education 7 https://hivhealthclearinghouse.unesco.org/library/documents/measuring-education-sector-response-hiv-and-aids-guidelines-construction-and-use Curricula: Breadth and relevance of content In recent years, many countries have been developing or revising their national curricula, bolstered by international guidance, including the updated UN International Technical Guidance on Sexuality Education (ITGSE). Some countries have a long history of curricula that includes a wide breadth of content; for others, this is relatively new. Of 123 countries that reported, 85 per cent indicated that relevant sexuality education content and topics are covered in their national curriculum5. When the data are analysed by the levels of education, more countries reported that ‘gender responsive life skills-based HIV and sexuality education is part of the curriculum’ at secondary level than in primary level. In many settings, there is evidence that the curricula have expanded from a narrow focus on HIV prevention and the biological aspects of sexual and reproductive health to a broader range of topics. In a 2019-2020 Survey on the Status of CSE, many countries self-reported that their curriculum is comprehensive according the international guidance and there is certainly evidence that curriculum revision/reform is under way or has recently taken place. 5 Sources: UNAIDS Unified Budget, Results and Accountability Framework (2016-21); Survey on Sexuality Education in Europe and Central Asia (Ketting & Ivanova 2018); Survey on the Status of CSE (carried out in 60 countries in Asia and the Pacific, sub-Saharan Africa and Latin America and the Caribbean for this report, 2019-2020) 6 Source: UNAIDS National Commitments and Policies Instrument (2017, 2019) On the other hand, when asked about specific topics, some (e.g. puberty, relationships, pregnancy and birth) are more likely to be well covered than others (e.g. accessing services, contraception, safe abortion). Emerging evidence also suggests that curriculum content is often stronger for older age groups than younger, although some countries are providing age-appropriate and comprehensive content from pre-primary level. Delivery Preparing and building the capacities of teachers to provide high quality CSE is critical. In fact, school-based programmes taught by poorly prepared teachers could be detrimental, delivering information that is inaccurate or reproducing values and attitudes that silence discussions on gender, sexuality and rights. Moreover, CSE, like other forms of transformative education, requires the use of participatory pedagogies which may be counter to the style of teaching that many teachers are familiar with. Of the 130 countries that responded in either 2019 or 2017, 75 per cent reported they had education policies in teacher training that guide the delivery of life skills based HIV and sexuality education according to international standards.6 Although there is evidence of many teacher-training initiatives in place, and in some countries this has been scaled up to almost full coverage, appropriate preparation on sexuality education for teachers is often considered to be lacking and there is evidence from many smaller studies that teachers are not sufficiently trained, including those that capture the voices of teachers themselves. This is reflected in information about the quality of delivery. CSE relies on delivery of a breadth of topics as well as the use of participatory methods. Many teachers report that they still lack the knowledge, skills and confidence to deliver diverse topics, or to use the participatory methods needed to ensure that students develop skills such as critical thinking and problem solving. Some studies highlight that teachers show a tendency to select and deliver only activities that focus on knowledge acquisition and use traditional didactic teaching methods. Emerging evidence also suggests that curriculum content is often stronger for older age groups than younger. Learning from country examples In Jamaica, the Family Life and Health Education curriculum has undergone a range of revisions, with diverse stakeholders involved, including faith-based organizations. Curriculum revisions have always been largely driven by data – responding to new and emerging health and social issues – and have involved subject specialists, curriculum officers and technical experts from a wide range of stakeholders (see full case study on page 23). In the Lao People’s Democratic Republic, the Life Skills curriculum was recently analysed against international guidance, finding that there was a lack of content in the areas of gender, rights, sexual behaviour and equitable social norms. In response, the Ministry of Education and Sport led a participatory process involving teachers, civil society and UN agencies to develop learning objectives for what is now called Comprehensive Sexuality Education (at secondary level) and lesson plans per grade (see full case study on page 15). In Sweden, current national guidelines mandate sexuality education to cover a range of topics, but exactly how the topics are included in lesson plans is at the discretion of individual schools. Some subjects require more content relating to gender equality, sexuality and relationships, but all teachers are encouraged to be involved. Importantly, sexuality education is expected to promote gender equality and the equal dignity of all, while promoting positive relationships and sexuality and preventing a range of health and social problems (see full case study on page 32). The journey towards comprehensive sexuality education 8 https://unesdoc.unesco.org/ark:/48223/pf0000260770 https://unesdoc.unesco.org/ark:/48223/pf0000260770 Learning from country examples In Namibia, under a policy implemented in 2011, schools are required to have a dedicated life skills teacher. These full-time life skills teachers receive ongoing training, with the percentage of those trained increasing from 42 per cent in 2017 to 70 per cent by 2019. Because life skills education has been integrated into the curriculum and there are specific teachers explicitly trained to deliver it, the topic has been given attention, recognition and legitimacy (see full case study on page 35). In Zambia, a new teacher training model was developed in 2019, utilising teacher training colleges as education hubs. These hubs, which are also responsible for delivering pre-service teacher training, are considered ‘centres of excellence.’ Under this new training model, the colleges provide information to teachers through a five-day sexuality education training, which aims to impart skills acquisition, confidence and refined participatory methods (see full case study on page 34). In Kyrgyzstan, training has been provided for pre-service teachers since 2018. This prepares them for the delivery of Healthy Lifestyle homeroom lessons which became mandatory in all schools in the same year (see full case study on page 35). Studies with teachers and students often highlight different perceptions of what is being taught. While teachers may believe that what they are teaching is comprehensive, student reports counter this. For example in a recent survey of young people (age 15-24) in Asia and the Pacific, less than one in three believed that their school taught them about sexuality ‘very well’ or ‘somewhat well’. Teachers report common barriers impeding the quality of delivery or leading to discrepancy between the way that a programme is designed to be delivered and the way that it is actually delivered. Barriers include insufficient time allocation within the school timetable, lack of planning of lessons, lack of available teacher time, lack of availability of materials, negative attitudes of staff and in some cases, fear of backlash from parents or other teaching staff. It is promising that a large number of teaching and learning materials have been developed to support the delivery of CSE, many with the support of non-government organizations (NGOs) and other development partners. However, such resources may not always be reaching teachers, with some reporting that they lack materials. Enabling environment An enabling environment is critical for effective delivery of CSE and the idea of embedding CSE within a ‘whole-school’ approach to health and well-being is gaining traction. This approach recognizes the multiple actions and interventions within and around the school that complement each other. For example, teaching of comprehensive curricula may go hand-in-hand with the use of gender transformative pedagogy, policies and rules that prevent violence and bullying, engaging with parents and linking with school or outside health services. It is well recognized that CSE is one component of a broader essential package of sexual and reproductive health and rights (SRHR) interventions. While CSE ensures adolescents and young people have information and skills to seek help for a range of issues related to their sexual and reproductive health and relationships, it must be partnered with efforts to ensure ready access to a full range of SRH services. Only with these efforts will CSE be effective in improving health outcomes such as the prevention of early and unintended pregnancy or the reduction of new HIV infections. Studies with teachers and students often highlight different perceptions of what is being taught. Learning from country examples Research in Chile highlights the importance of providing teachers with quality teaching and learning materials. Many teachers are more comfortable with lecture-style methods of teaching and for various reasons tend to avoid sensitive topics, such as gender, diversity and sexual violence. A subsequent study found that when provided with support, including quality lesson plans, not only did the teachers no longer avoid the more complex issues, but rather demonstrated a strong concern for incorporating gender perspectives in the majority of the classes. In response, a range of teaching and learning materials is being developed to support teachers across the country (see full case study page 37). In South Africa, teachers are supported with the provision of a range of scripted lesson plans. The lesson plans were developed by consulting closely with the revised UN ITGSE and aim to aid teachers to address a range of important topics in a systematic manner. While teachers also receive training, the lesson plans guide educators to plan and deliver lessons and empower them to discuss topics that might otherwise be found to be uncomfortable (see full case study on page 36). Increasingly, digital tools are being harnessed to strengthen sexuality education, including to train teachers. With the goal of enabling every learner in China to have access to CSE, Marie Stopes International developed the You&Me sexuality education platform. The platform provides free support to interested educators with basic teaching skills to conduct sexuality education. Teachers are also supported with lesson plans, presentations, demonstration videos, cartoons and interactive games (see full case study on page 47). The journey towards comprehensive sexuality education 9 Of 28 countries that responded to the 2019-2020 Survey the majority of respondents said that students in secondary schools could access individual counselling on issues related to SRH (86 per cent), referral by schools to health clinics (79 per cent) and information about where and how to obtain contraceptives (75 per cent). As with other nationally reported data, these responses may reflect national policy but mask a more complex situation at the school level for learners requesting counselling or referrals to services. CSE needs to be understood by different stakeholders, such as parents, community members, religious leaders and politicians, in order to promote comfort and understanding of what can be a sensitive topic. In several countries, there are documented processes of engaging with these multiple stakeholders in the design of CSE that is locally appropriate, while still striving to reach international guidelines for comprehensive content, with promising results. NGOs and other development partners have been central in supporting these efforts, and in some countries have worked closely with government to design curricula and implement teacher training. Nonetheless, CSE is subject to progress and setbacks in support, and in some contexts, has experienced significant opposition resulting in set-backs in its implementation. In countries experiencing setbacks, due to resistance from a small but sometimes influential opposition, extra efforts are needed to advocate for CSE, pointing to the evidence for its positive effects and countering misinformation that can fuel opposition. On the other hand, strong political will and support is evident across diverse settings, with countries recognizing the power of CSE and associated adolescent sexual and reproductive health (ASRH) interventions to address pressing health and social issues, as well as to contribute to the overall quality of education. Finally, regular and structured monitoring of sexuality education programmes is necessary to track the progress of implementation and to facilitate decision-making. While a range of assessment tools has been developed and indicators proposed, which together can start to paint a picture of the status of CSE globally, there is a need for more concerted efforts. This report, through its breadth of data, evidence and country case studies, demonstrates that countries across the world are at different stages on a journey towards the full delivery of good quality CSE. In some countries the journey is only just beginning and much work remains; others have been investing in this area for many years. In either case, this journey will need to continue to respond to emerging health and well-being challenges and the specific needs of children and young people, as well as emerging evidence of how to deliver CSE effectively. The report concludes with a number of recommendations on how countries can continue on their journey towards CSE. These include the need to continue to ensure that CSE is clearly mandated by law and/or policy, and backed up by dedicated budgets, alongside continued efforts to increase coverage. This will only be a worthwhile investment when attention is paid to the quality of delivery, which will be achieved through continued curriculum reform and significant investments in teacher training and support. As countries continue on their journey towards CSE, monitoring progress will be essential, including strengthening the use of globally recommended indicators, and drawing on a wide range of perspectives, including those of learners and teachers, to build a clear picture of progress. Learning from country examples In Cameroon, enthusiasm and open discussion about sexuality education at a policy level has not been reflected at local level, where there has been reluctance to embrace it. To address this challenge, substantive work has been initiated to involve and inform key actors in the communication sector. This includes a platform for journalists and influencers to exchange information related to sexuality education, and a network of community radio stations that helps reduce misinformation on the subject. In Tunisia an Expert Committee, established in 2017, was central in advocating for the need for sexuality education to the Ministry of Education (MoE). It subsequently worked closely with the MoE to establish a national sexuality education curriculum that reflects international guidance and is sensitive to local culture and context. Central to its success and acceptability was the engagement of multiple stakeholders, including representatives from different government sectors, religious leaders and NGOs (see full case study on page 21). NGOs in Pakistan have made concerted efforts to build community understanding and support, enabling them to deliver wide-ranging sexuality education programmes across four provinces. Efforts were made to ensure that programmes are responsive to the local context, with community-based research as the foundation of content development, and recognition of societal and cultural barriers to sexuality education from the planning stage. This success was also due to collaboration with an array of stakeholders—including parents, school officials, religious leaders, media personnel and adolescents themselves (see full case study on page 44). CSE needs to be understood by different stakeholders, such as parents, community members, religious leaders and politicians, in order to promote comfort and understanding of what can be a sensitive topic. The journey towards comprehensive sexuality education 10 1. Introduction Comprehensive sexuality education (CSE) has attracted growing interest and attention in the past decade. At the same time, young people themselves are increasingly demanding their right to it (Cense et al., 2020, UNFPA et al., 2020a). What began in many countries primarily as an HIV prevention, population control or reproduction education intervention, is evolving into CSE – a broad- reaching, holistic, age-appropriate, multidimensional learning process that takes place over a number of years. This learning process enables young people to make healthy, deliberate and respectful decisions about sexuality and relationships. There is a strong rationale for ensuring that all learners have access to good quality CSE. CSE is a form of transformative education – primarily enabling children and adolescents to develop the knowledge and skills to deal with critical aspects of their health and development while their bodies mature and they transition into adulthood. Delivered well, CSE can instill positive behaviours and values, as well as building personal and social competencies, such as critical thinking, risk assessment, problem solving and the ability to consider multiple perspectives. In this way, CSE equips learners to not only avoid negative health outcomes, but enjoy positive and healthy sexual and social relationships and thrive both now and in the future. At the same time, global health data highlights the critical role of CSE from the perspective of preventing poor sexual and reproductive health (SRH) outcomes including sexually transmitted infections (STIs) and early and unintended pregnancy. The gains to be made from CSE are important for all learners but are particularly promising for girls who carry a disproportionate burden of poor SRH and associated outcomes. Among adolescents, 15-19 year old girls make up six in seven new HIV infections in sub-Saharan Africa (UNAIDS, 2021). At least 10 million unintended pregnancies occur each year among adolescent girls aged 15–19 years (WHO, 2020) and while adolescent childbearing is declining in most regions, it remains high in many countries. Maternal conditions remain the top cause of mortality among girls aged 15-19 globally (UNICEF, 2019). Around the world, some 3 million young women aged 15 to 19 undergo unsafe abortions every year (WHO, 2020). The importance of CSE is more critical than ever in the context of the COVID-19 pandemic, with ongoing lockdowns and major disruptions to education and health services projected to result in increased early and unintended pregnancy, alongside evidence of elevated mental health problems and exposure to domestic and gender-based violence for adolescents and young people (UNICEF, 2020, QUILT.AI et al., 2021). In fact, the COVID-19 pandemic has been a strong reminder that schools are much more than just places of learning, and provide critical contributions towards learner health and well-being, including through the provision of CSE. A growing body of evidence demonstrates that CSE contributes to HIV and pregnancy prevention, as well as to broader positive sexual and reproductive health, social and learning outcomes, with greatest impact when it is combined with other interventions (notably service delivery). Broader outcomes include gender equality, self-efficacy and critical thinking skills (Haberland, 2015, UNESCO et al., 2018, Goldfarb and Lieberman, 2021). In the past 10 years, the evidence informing effective CSE has evolved, including increased attention to the importance of addressing gender norms and power in CSE (Haberland and Rogow, 2015). Revised guidance by the UN recommends that CSE promote gender equality, address gender-based violence, and help ensure the needs and rights of all young people (UNESCO et al., 2018). It has been found that effective CSE has to be both inclusive and non-stigmatising and respond to the lived realities of learners (UNESCO et al., 2015). © UNESCO/Tafara Gowera The journey towards comprehensive sexuality education 11 http://QUILT.AI COMPREHENSIVE SEXUALITY EDUCATION WITHIN THE SUSTAINABLE DEVELOPMENT GOALS (SDGS) Within the 2030 agenda, the importance of CSE and other forms of transformative education is reflected in: SDG Target 4.7 By 2030, ensure all learners acquire knowledge and skills needed to promote sustainable development, including, among others, through education for sustainable development and sustainable lifestyles, human rights, gender equality, promotion of a culture of peace and non-violence, global citizenship, and appreciation of cultural diversity and of culture’s contribution to sustainable development.” SDG target 3.7 By 2030, ensure universal access to sexual and reproductive health care services, including services for family planning, information and education, and the integration of reproductive health services into national strategies and programmes.” SDG target 5.6 Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences”. COMPREHENSIVE SEXUALITY EDUCATION Comprehensive sexuality education 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 realise 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 et al., 2018). CSE can be delivered in formal or non-formal settings. Good quality CSE is y Scientifically accurate y Incremental y Age- and developmentally- appropriate y Curriculum based y Based on a human rights approach y Based on gender equality y Culturally relevant and context appropriate y Transformative y Able to develop life skills needed to support healthy choices For more information and guidance on effective CSE, please refer to the revised UN International Technical Guidance on Sexuality Education (UNESCO et al., 2018). AGE- AND DEVELOPMENTALLY-APPROPRIATE SEXUALITY EDUCATION Sexuality education should start early, be age- and developmentally-appropriate and should follow an incremental approach. This helps learners internalise concepts, make informed decisions, understand sexuality and develop critical thinking skills that mature as they grow older (UNESCO et al., 2018). Starting CSE early is important because, in some countries, many students do not make the transition from primary to secondary school (Awusabo-Asare et al., 2017, UNESCO et al., 2016) and therefore need critical information before leaving formal education. Yet another reason is that adolescents need specific knowledge and skills at the appropriate time, for example, learning about puberty shortly before they go through it, not after. The journey towards comprehensive sexuality education 12 https://unesdoc.unesco.org/ark:/48223/pf0000260770 https://unesdoc.unesco.org/ark:/48223/pf0000260770 CSE, by definition, promotes healthy social and emotional development and therefore, as education systems recognize the importance of their role in promoting social and emo- tional learning (SEL), there is increasing interest in how CSE is already contributing to the development of social and emotional skills. This is particularly important given the rec- ognition that education that promotes social and emotional skills has a major role to play in generating shifts in mindsets and behaviours, which are critical for the achievement of all the SDGs. Across the world, there are many different names for and approaches to sexuality education. At the same time, countries are at varying stages of its implementation. In some countries, sexuality education in schools has existed for many years. In others it is relatively new. Although there is variation, including set-backs in some contexts, progress has been made in many countries across the world. Twelve years have passed since the publication of the first International Technical Guidance on Sexuality Education (UNESCO et al., 2009), designed to support governments in developing evidence-based sexuality education curricula and adapting it to local contexts. Revised in 2018, the UN International Technical Guidance on Sexuality Education (ITGSE), as well as supportive tools from a range of stakeholders,1 and a growing body of research, have facilitated an emerging consensus on what constitutes comprehensive age- and developmentally-appropriate and gender sensitive sexuality education. These tools, together with programme support and involvement of a vast array of stakeholders, are contributing to design, implementation, monitoring, and assessment of good quality sexuality education. In this context, many are seeking a clearer understanding of the status of school- based CSE. This will help to inform continued advocacy and resourcing efforts across the world, as governments and partners work towards the goal of ensuring all learners receive quality CSE. 1 These include such tools and guidance as the Standards for Sexuality Education in Europe (WHO Regional Office for Europe and BZgA, 2010) ; the UNFPA Operational Guidance for Sexuality Education (UNFPA, 2014); the IPPF Deliver and Enable toolkit (IPPF, 2016); WHO recommendations on adolescent sexual and reproductive health and rights (UNFPA et al., 2020c); UNFPA, WHO and BZgA’s Factsheet series (UNFPA et al., 2020c); and the joint UN International Technical and Programmatic Guidance on Out-of-School Comprehensive Sexuality Education (UNFPA et al., 2020b). Understanding the status of school-based CSE entails assessing multiple factors: LAWS AND POLICIES The enabling framework for delivery COVERAGE The extent of delivery in school settings CURRICULA Breadth, quality and relevance of content DELIVERY How well teachers are prepared and are teaching quality CSE ENABLING ENVIRONMENT The wider school environment, community and political support or engagement. All these components contribute to the long-term effectiveness and sustainability of CSE. However, these elements may not fully respond to the question of whether CSE is of a good quality. Quality would largely be judged by the outcomes of CSE (according to the objectives decided in each country or setting), which may be measured through a range of quantitative and qualitative evaluation approaches. Some indications of quality can be found in the analysis of existing data and research on curriculum and delivery, but a full analysis of the quality of CSE is beyond the scope of this report. The journey towards comprehensive sexuality education 13 https://www.bzga-whocc.de/fileadmin/user_upload/WHO_BZgA_Standards_English.pdf https://www.unfpa.org/pcm/node/10360 https://www.ippf.org/resource/deliverenable-toolkit-scaling-comprehensive-sexuality-education-cse https://www.who.int/reproductivehealth/publications/adolescent-srhr-who-recommendations/en/ https://eeca.unfpa.org/sites/default/files/pub-pdf/unfpa_turkey_factsheet_all_-_who_web_r4.pdf https://www.unfpa.org/sites/default/files/pub-pdf/Out_of_School_CSE_Guidance_with_References_for_Web.pdf Given the range of factors that contribute to effective and sustainable CSE, it is useful to see countries on a journey towards CSE. This journey takes time and involves establishing strong and supportive laws and policies, building community support and strengthening multiple components for its implementation. Inevitably, this journey looks different across different countries, and sometimes, progress is impeded by minor or significant setbacks, calling for continued advocacy and investment to ensure countries are moving in a positive direction. This report aims to present an overview of the journey towards CSE at this point in time – a global snapshot – presented through new and existing quantitative data, enhanced through qualitative data and further nuanced through case studies providing specific examples of implementation on the ground. The term comprehensive sexuality education (CSE) is used in UN guidance and describes an ideal in terms of content and delivery of sexuality education. While some countries have adopted this terminology, national policies and curricula use a range of terms to refer to sexuality education. These include: prevention education, relationships and sexuality education, family-life education, HIV education, life skills education and healthy life styles. At the same time, while all countries are on a journey towards sexuality education that is truly comprehensive, the reality is that in many countries sexuality education cannot be defined as comprehensive yet. Throughout this report we have used the term CSE where it is used by countries or where we are referring to truly comprehensive sexuality education. We also use the term sexuality education and a range of other terms as used across different settings. SEXUALITY EDUCATION IS KNOWN BY DIFFERENT NAMES IN DIFFERENT COUNTRIES SEXUALITY EDUCATION ACROSS DIFFERENT SETTINGS EDUCATION SEXUAL INTEGRAL COMPREHENSIVE SEXUALITY EDUCATION PS H E R SE B IO LO G Y PERSONNAL & SOCIAL DEVELOPMENT HEALTHY LIFESTYLE KULTUSMINISTERIUM LIFE SKILLS-BASED EDUCATION SEXUALITY EDUCATION H IS T O RY CIVICS EDUCATION LIFE SKILLS СЕРГЕК ЖАШОО ОБРАЗЫ ОСНОВЫ ЗДОРОВЬЯ CIVISMO BIOLOGY RSE KULTUSMINISTERIUM HISTORY HEALTH STUDIES 青春期教育 防性侵教育 EDUCACIÓN INTEGRAL PARA LA SALUD SEXUAL ENVIRONMENT, CULTURE & RELIGION HABILIDADES PARA LA VIDA PROTECTIVE BAHAVIOURS SEXUAL ABUSE PREVENTION EDUCATION HIV & LIFE SKILLS RELATIONELE EN SEXUELE VORMING PENDIDIKAN KESEHATAN RESPECTFUL FORMACIÓN CÍVICA Y ÉTICA RESPECTFUL RELATIONSHIPS HUMANITAARTEADUS RELATIONCHIPS C IV IS M O CIENCIAS NATURALES SEX & RELATIONSHIPS EDUCATION HEALTHY LIFESTYLES SEX & RELATIONSHIPS EDUCATION FAMILY LIFE EDUCATION OUT-OF-SCHOOL COMPREHENSIVE SEXUALITY EDUCATION While this reports focuses on school-based CSE, it fully acknowledges the importance of programmes that seek to reach children and young people who are not in school. As of 2018, 258 million children and youth were out of school (UNESCO Institute for Statistics, 2019). This number has increased with the pandemic, affecting girls in particular, and countries that are already reporting low learning outcomes and high drop-out rates (Insights for Education, 2021, UNESCO et al., 2020b). In this context, alongside work to scale-up CSE in schools, efforts to provide sexuality education in out-of-school settings is paramount to ensuring all children and adolescents are reached. The recently published International Technical and Programmatic Guidance on Out-of-School Comprehensive Sexuality Education (UNFPA et al., 2020b) has been developed to guide such efforts. The journey towards comprehensive sexuality education 14 https://www.unfpa.org/featured-publication/international-technical-and-programmatic-guidance-out-school-comprehensive https://www.unfpa.org/featured-publication/international-technical-and-programmatic-guidance-out-school-comprehensive 1.1 Data sources and methodology The report draws on a range of data sources in order to build a composite picture of the status of CSE: y Global data sets (2019, 2018 or 2017), including the National Commitments and Policy Instrument (NCPI), the UNAIDS Unified Budget, Results and Accountability Framework (UBRAF), and Sustainable Development Goal Thematic Indicator 4.7.2. (SDG 4.7.2); y Regional survey data: A 2018 Survey on Sexuality Education carried out by BZgA and IPPF EN across 25 countries in Europe and Central Asia ; a 2019-2020 Survey on the Status of CSE in 60 countries across Asia and the Pacific, sub-Saharan Africa and Latin America and the Caribbean (administered by a range of partners across regions, including UNESCO, UNFPA and IPPF); y Key informant interviews with 28 experts to inform a series of case studies presented throughout the report. A list of key informants is included in Annex 1. Where available, published research was also consulted to inform the case studies. y An extensive desk review (2019), which drew on the latest published and unpublished reports and academic research in the area of CSE. Case study 1 A JOURNEY TOWARDS COMPREHENSIVE SEXUALITY EDUCATION IN LAO PEOPLE’S DEMOCRATIC REPUBLIC Sexuality education has been delivered in Lao People’s Democratic Republic (PDR) in some form since 2001, when it primarily focused on HIV and AIDS prevention. By 2010, it was being implemented as a life skills course in around 75% of secondary schools nationwide (ARROW, 2011), although a 2016 assessment found that teachers faced challenges and called for stronger teaching aids and an upgraded curriculum (Ministry of Education and Sports and UNFPA, 2017). Lao PDR’s commitment to the integration of CSE into national educational curricula is evident in the country’s adoption of the International Conference on Population and Development (ICPD) Programme of Action. In recent years, steps have been taken to strengthen design and implementation of CSE, as reflected in the country’s development plans and policies, such as the Ninth Education and Sports Sector Development Plan (2021-2025) and the country’s recently-developed National Youth and Adolescent Policy. Responding to the 2016 assessment and thanks to the country’s strong policy backing, the Ministry of Education and Sports (MoES) has been working closely with UNFPA to strengthen the design and implementation of what is now called ‘Life Skills Education’ (in primary school settings) and ‘Comprehensive Sexuality Education’ (in secondary school settings). This involved analysing existing teaching guides against the revised UN ITGSE. Here, various findings from the teaching guides were revealed: first, there was a lack of focus on some content, such as gender, rights, sexual behaviour and equitable social norms. Second, the curriculum lacked a progressive link from the primary to the secondary level. Third, participatory methods, while included, were not clearly aligned with the curriculum. Finally, there was no connection with health services or parent and community engagement. Through a participatory process led by the MoES and involving teachers, civil society and UN agencies, key learning objectives for CSE were agreed on, which were used to develop lesson plans per grade. At the same time, MoES, along with a range of partners, has begun rolling out teacher training across the country, with trained teachers delivering sexuality education to over 25,000 secondary students in 2019. Training modules have also been introduced in eight teacher training colleges across the country, and in 2020, a partnership was established with the Faculty of Education at the National University of Laos. In scaling up school-based CSE across the country, MoES is ensuring that communities understand the rationale behind this important intervention. Principals and representatives from parent-teacher associations are included in the training to ensure that teachers have full support. While teachers still face some challenges, monitoring to date has found that many teachers are feeling confident about implementing sexuality education. Also, as part of the design of teacher training, local health service providers participate, building important links between teachers and health staff and facilitating easy referral to adolescent-friendly health services. In addition, MoES and the Laos Youth Union have developed a mobile application, Noi Yakhoo (Noi wants to know), which answers learners’ questions about sexual and reproductive health. When schools in Laos closed due to the COVID-19 pandemic, MoES promoted the Noi Yakhoo app to students. MoES and UNFPA also developed a series of 10 CSE videos, which have been broadcast on the MoES TV channel. With schools reopening, teachers are now also using the videos in the classroom.BTWImages/Shutterstock.com The journey towards comprehensive sexuality education 15 http://Shutterstock.com Table 1 Major data sets used in this report Datasets Overview Years collected Countries/territories represented National Commitments and Policy Instrument (NCPI) Collected by UNAIDS to measure progress in the development and implementation of national-level HIV and AIDS policies, strategies and laws 2017, 2019 From 130 to 133 countries/territories around the world, except North America, report on the availability of education policies in primary, secondary education and teacher training. From 45 to 67 countries/territories report on their school coverage rates in primary and secondary education. Unified Budget, Results and Accountability Framework (UBRAF) Follows the progress of the UNAIDS Joint Programme (including all 11 co-sponsors) towards the achievement of the 2016-2021 Strategy 2016, 2017, 2018, 2019 88 countries/territories around the world, except Central and Western Europe, North America and the Middle East. SDG thematic indicator 4.7.2 Assesses progress towards implementation of life skills-based HIV and sexuality education in all schools 2016, 2017, 2018, 2019 A few countries/territories (about 30) report on this indicator. Sexuality Education Review and Assessment Tool (SERAT) Provides a detailed review of curriculum content by age group, teacher training, and policy, and a snapshot of national health and social indicators 2011-2019 Data from 24 countries of sub-Saharan Africa were analysed and presented for this report. BZgA / IPPF questionnaire Reviews the development and current status of sexuality education focusing on implementation components 2018 25 countries in Europe and Central Asia. 2019-2020 Survey on the Status of CSE Reviews the development and current status of sexuality education focusing on implementation components 2020 60 countries across Asia and the Pacific, sub-Saharan Africa and Latin America and the Caribbean. More details about the data sets used in this report can be found in Annex 2. Limitations This report has made an effort to gather and use the most up-to-date data but recognizes that progress and setbacks will continue and the picture will change over time. Efforts have been made to draw on a wide range of data sources, and triangulate different data sources where possible to paint a picture of the status of CSE. Nevertheless, there are limitations in terms of data availability, comparability and quality. While there are many relevant indicators across different multi country data sets that provide a useful insight into certain elements of sexuality education (e.g., policy), they do not provide a full picture across all the factors ensuring sexuality education, such as implementation, coverage, quality and comprehensiveness. In addition, given that major data sets drawn on in this report were primarily collected between 2016 and 2020, the situation may have changed in the intervening period. Not all countries report on these indicators and much of these data are self-reported. This means that different stakeholders within government, or sometimes the UN, will be responsible for reporting and countries sometimes have different interpretations of the indicators or varied sources for their numbers. Many of the global data sets have been developed with the specific intention of monitoring in the area of HIV and AIDS. This means that not all survey tools are designed with the specific intention to monitor CSE, but rather refer to HIV and/or life skills education. The 2019-2020 survey on the status of CSE was designed to collect information on a range of factors central to the design and implementation of CSE. The survey was administered in 60 countries and some regions are not represented. There were also a number of limitations related to the subjectivity and different interpretation of the survey questions. For example, the comprehensiveness of curricula was self-assessed by each country and does not necessarily reflect global standards. The terms ‘extensively’ and ‘briefly’ in relation to coverage of sexuality education topics were also not defined in the survey tool. The journey towards comprehensive sexuality education 16 https://healtheducationresources.unesco.org/library/documents/sexuality-education-review-and-assessment-tool-serat https://healtheducationresources.unesco.org/library/documents/sexuality-education-review-and-assessment-tool-serat 2. Status of CSE 2 Ministries of Health: Antigua and Barbuda, Argentina, Barbados, Belize, Brazil, the Plurinational State of Bolivia, Chile, Colombia, Costa Rica, Cuba, Mexico, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Nicaragua, Panama, Paraguay, Peru, Dominican Republic, St. Vincent and the Grenadines, St. Kitts and Nevis, Suriname, Saint Lucia, Uruguay, the Bolivarian Republic of Venezuela. Ministries of Education: Argentina, Bahamas, Barbados, Belize, Brazil, the Plurinational State of Bolivia, Chile, Colombia, Costa Rica, Cuba, Mexico, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Nicaragua, Panama, Paraguay, Dominican Republic, Suriname, Saint Lucia, Uruguay, the Bolivarian Republic of Venezuela. 2.1 Laws & policies International and regional agreements have been influential in holding governments accountable for developing policies on sexuality education. International agreements Children and young people’s access to education on sexual and reproductive health are grounded in international human rights conventions that stress the right of every individual to education and to the highest attainable standard of health and well-being. These rights are endorsed in the Universal Declaration on Human Rights; the Convention on the Rights of the Child; the Convention on the Elimination of All Forms of Discrimination against Women; and the Convention on the Rights of Persons with Disabilities. The 1994 International Conference on Population and Development (ICPD) Programme of Action calls for sexuality education, counselling and support mechanisms for adolescents, and identifies essential topics (United Nations, 1994), with further commitments in the statement marking the 25th anniversary in 2019. Other political declarations and resolutions that include commitments and calls to scale up and/or give attention to scientifically accurate age- and culturally-appropriate CSE include the UN General Assembly 2016 Political Declaration on HIV and AIDS: On the Fast Track to Accelerating the Fight against HIV and to Ending the AIDS Epidemic by 2030; the Commission on the Status of Women 2016 Resolution on Women, the Girl Child and HIV and AIDS; and the Commission on Population and Development 2014 Resolution on Assessment of the status of implementation of the Programme of Action of the International Conference on Population and Development (United Nations, 2014, United Nations, 2016a, United Nations, 2016b). Within the Sustainable Development Goals (SDGs) agreed by governments in 2015 to guide development priorities globally until 2030, Goal 4 on achieving quality education for all, includes an optional, thematic indicator specifically focusing on sexuality education (see Table 1). Regional frameworks Regional agreements among countries may equally provide a supportive framework, and in some cases include specific commitments around the implementation of sexuality education. Such regional agreements include: y The Latin America and the Caribbean (LAC) Ministerial Declaration ‘Preventing Through Education’ (2008), agreed upon by 30 Ministers of Health and 26 Ministers of Education2 and, more recently, the Montevideo Consensus on Population and Development (2013), in which 38 LAC countries agree to ensure the effective implementation of ‘comprehensive sexuality education’ from an early age, with an emphasis on participation and intercultural approaches; CRS PHOTO/Shutterstock.com The journey towards comprehensive sexuality education 17 http://Shutterstock.com y The ‘ESA Commitment’ (2013), a ministerial commitment to CSE and sexual and reproductive health services for young people endorsed and approved by 20 countries3 within the Eastern and Southern Africa (ESA) region. Discussions are currently underway to renew the commitment until 2030; y The Asia and Pacific Ministerial Declaration on Population and Development (2013), which commits 47 countries to the design, funding and implementation of ‘comprehensive sexuality education and life skills’ programmes that ‘provide accurate information on human sexuality, gender equality, human rights, relationships, and sexual and reproductive health, while recognizing the role and responsibilities of parents’ (Cousins, 2018, DAWN et al., 2013). Progress towards commitment is evident in other regions. For example, in West and Central Africa (WCA), countries have expressed the wish to strengthen the political environment for culturally appropriate CSE programmes. Several of them have already produced recommendations through consultations with a wide range of stakeholders. Those recommendations will ultimately inform a commitment to be endorsed by ministers of education and health across the subregion. Enabling legal and policy environment at country level At country level, a national law or policy that stipulates the delivery of some form of sexuality education provides a critical guiding framework for the development of curricula, teacher training and student assessment. This could include laws or policies that use the terminology ‘sexuality education’, or those that focus on life skills-based education for the prevention of HIV, unwanted pregnancy, gender- based violence (GBV) and/or other health-related issues. Legislation can ensure the state’s role as the guarantor of the right to a quality education, with sexuality education being in some cases an explicit part of this definition. A lack of legislation and resources to install and implement CSE in education systems can make it vulnerable to political or cultural shifts in priorities. Evidence on the availability of supportive and enabling legal frameworks, as well as laws or policies for promoting and implementing sexuality education in the education sector, is drawn from the National Commitments and Policy Instrument (NCPI) 2017 and 2019, the 2019-2020 Survey on the Status of CSE, and the 2018 BZgA and IPPF EN Survey on Sexuality Education in Europe and Central Asia. Overall, according to the available data, 85 per cent or 132 of the 155 reporting countries said that they have policies (or, in some cases laws or legal frameworks) related to sexuality 3 Angola, Botswana, Burundi, Democratic Republic of Congo, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, South Sudan, Eswatini, Uganda, United Republic of Tanzania, Zambia, and Zimbabwe. 4 It should be noted that these datasets have slight differences in the way in which questions were formulated. The NCPI referred to the education policies on life skills-based HIV and sexuality education. On the other hand, the 2019-2020 Survey on the Status of CSE and regional studies asked questions about the awareness of national laws and policies relating to sexuality education or other related subjects in the formal education system. education. Half of the countries reported that they have education policies on ‘life skills-based HIV and sexuality education’ in both primary and secondary schools and 19 per cent said they have policies only in secondary education. The remaining countries referred to an overall supporting legal framework, which includes laws, decrees, acts and policies.4 When specifically analysing the NCPI data, considerably more countries report having education policies on ‘life skills-based HIV and sexuality education’ at secondary education level than at primary level. Of the 133 countries that responded either in 2017 or in 2019, 81 per cent said that they had policies according to international standards at the secondary level, in contrast to 60 per cent at the primary level. In all regions, it should be recognized that what is reported on as ‘sexuality education’ varies across countries, with some policies and strategies focusing on a range of sexual and reproductive health issues, and others focusing more specifically on life skills and prevention of HIV. Moreover, the picture of the policy environment becomes more nuanced when consulting other sources. For example, a study on sexuality education in sub-Saharan Africa (SSA) conducted in 2017, found that a policy or strategy to promote ‘life skills-based HIV education for young people’ existed in 27 out of 32 countries, with a higher percentage (94 per cent) of countries in ESA than in WCA (73 per cent) (UNESCO, 2018). Policy analysis for 15 countries (the bulk of which are in SSA) by the Population Reference Bureau found that discussion of CSE within policies is often unclear and complicated to assess. In general, even though countries mention sexuality education in their reproductive health policies, there is no guidance on the components of a sexuality education curriculum nor on how to implement it. Only 1 of 15 countries was considered to have a strong policy environment; all the others were categorised as having room to improve (Population Reference Bureau, 2020). In Asia, the majority of countries have a national law, policy or strategy that refers to the provision of sexuality education, and in the Pacific approximately half the countries have policies in place. Two countries have mandated the provision of sexuality education by law: the Philippines, and Thailand (UNFPA et al., 2020a). However, in a recent development in China, an amendment to the law on the protection of minors was passed in October 2020, by the National People’s Congress Standing Committee declaring that schools, including kindergartens, should conduct ‘age-appropriate sex education for minors’ (Xinhua News Agency, 2020). Although the government has issued policies on sexuality education for decades, implementation has been limited and uneven throughout the country. Sexuality education in schools will be mandatory by law starting in June 2021. The journey towards comprehensive sexuality education 18 (Data sources: NCPI 2017, 2019; 2019-20 Survey on the Status of CSE; BZgA & IPPF EN 2018 Survey on Sexuality Education) (Data sources: NCPI 2017, 2019) (Data sources: NCPI 2017, 2019) (Data sources: NCPI 2017, 2019) (Data sources: 2019-20 Survey on the Status of CSE; BZgA & IPPF EN 2018 Survey on Sexuality Education) Afghanistan, Bhutan, Brazil, Equatorial Guinea, Georgia, Haiti, Israel, Kuwait, Libya, Marshall Islands, Micronesia (Federated States of), Montenegro, Myanmar, Niue, North Macedonia, Panama, Paraguay, Republic of Korea, Russian Federation, Saudi Arabia, Suriname, Timor-Leste, Tuvalu Austria, Bangladesh, Belgium, Bosnia and Herzegovina, Bulgaria, Cyprus, Democratic Republic of the Congo, Eritrea, Estonia, Finland, Kiribati, Latvia, Maldives, Mexico, Netherlands, Pakistan, Samoa, Solomon, Islands, Sri Lanka, Sweden, Switzerland, Thailand, United Kingdom of Great Britain & Northern Ireland SerbiaAlgeria, Armenia, Azerbaijan, Belarus, Bolivia (Plurinational State of), Brunei Darussalam, Chile, Czechia, Ethiopia, Guinea, India, Iran (Islamic Republic of), Kazakhstan, Kyrgyzstan, Luxembourg, Malaysia, Mauritius, Monaco, Nepal, Nicaragua, Oman, Republic of Moldova, Saint Lucia, Singapore, Tajikistan, Tunisia, Ukraine, United Arab Emirates, Uruguay, Uzbekistan Albania, Angola, Antigua and Barbuda, Argentina, Bahamas, Barbados, Benin, Botswana, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, China, Colombia, Comoros, Congo, Costa Rica, Côte d'Ivoire, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Eswatini, Fiji, Gabon, Germany, Ghana, Guatemala, Guinea-Bissau, Guyana, Honduras, Iceland, Ireland, Jamaica, Kenya, Lao People's Democratic Republic, Lesotho, Liberia, Lithuania, Madagascar, Malawi, Mali, Malta, Mauritania, Mongolia, Morocco, Mozambique, Namibia, Nauru, New Zealand, Niger, Nigeria, Palau, Papua New Guinea, Peru, Philippines, Rwanda, Saint Vincent and the Grenadines, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, South Africa, South Sudan, Spain, Sudan, Syrian Arab Republic, Togo, Tonga, Uganda, United Republic of Tanzania, Vanuatu, Venezuela (Bolivarian Republic of), Viet Nam, Zambia, Zimbabwe No laws / policiesLegal frameworks, laws, decrees, acts and policies (level not speci�ed) Policies (primary only) Policies (secondary only) Policies (primary & secondary) WEST AND CENTRAL AFRICATHE PACIFICMIDDLE EAST AND NORTH AFRICA LATIN AMERICAEAST AND SOUTHERN AFRICAEASTERN, SOUTH AND SOUTH EASTERN ASIA EASTERN EUROPE AND CENTRAL ASIACENTRAL AND WESTERN EUROPETHE CARIBBEAN Figure 1 Laws and/or policies relating to sexuality education The journey towards comprehensive sexuality education 19 A 2017 UNFPA report on Latin America found that although all 18 countries in the review have some legal basis for sexuality education, only 7 of 18 had a ‘sexuality education policy’, and only two — Argentina and Colombia — had a specific law on sexuality education. A 2018 regional report on Europe and Central Asia (ECA)5 states that 21 out of 25 countries have a law, policy or strategy requiring or supporting sexuality education in schools, and 18 have a clear legal basis for it (Ketting and Ivanova, 2018). The majority of these countries updated their laws between 2010 and 2016. As in other regions, some countries have a policy or strategy, but no law. Even in countries with long-standing traditions of sexuality education, multiple policies that conflict with each other, or emphasize different obligations, can leave important considerations up to the discretion of schools (Ketting and Ivanova, 2018). Although a positive national-level policy environment is one of the key factors to successful implementation of sexuality education programmes (Panchaud et al., 2019, UNESCO, 2010, UNFPA, 2017a), the reality behind these laws and policies is complex. While the existence of a supportive policy and/or law is a useful indicator of commitment to CSE in rhetoric, it must be followed up with resource allocation and implementation efforts. Presently, many existing policies are not binding or support for sexuality education may be dispersed throughout different programmes and strategies. Few countries have a national policy specifically on sexuality education (Panchaud et al., 2019). While policy is central to providing the impetus for implementing sexuality education, and many countries are moving in a positive direction, in other countries, there have been explicit efforts to block or reverse policies, laws or implementation of sexuality education. This often reflects concerns that sexuality education may clash with cultural values or interfere with the family’s role in educating children, or a misguided fear that sexuality education could lead to early sexual activity. In some countries, opposition has been experienced as a cultural or political crisis, involving such significant public debate that governments have paused, or completely removed an existing curriculum. In Jamaica, Zambia, Uganda and Mali for example, vocal and public concerns expressed by some sections of society led to governments urgently debating, then reviewing, amending or withdrawing sexuality education programmes (Ninsiima et al., 2019, Lusaka Times, 2020, The Associated Press, 2012, Thurston, 2019). In Japan, socio-political disagreements about what should be taught in the classroom culminated in 2003 in a number of teachers being subject to disciplinary action by the Tokyo Metropolitan Board of Education. The case was challenged, and eventually overturned in 2009. However, the intervening years of public debate and legal dispute led to a ‘shifting landscape of sex education’ with serious 5 Albania, Austria, Belgium (Flanders region), Bosnia and Herzegovina (Canton Sarajevo), Bulgaria, Cyprus, Czech Republic, Estonia, Finland, Georgia, Germany, Ireland, Kazakhstan, Kyrgyzstan, Latvia, the former Yugoslav Republic of Macedonia, The Netherlands, The Russian Federation, Serbia, Spain, Sweden, Switzerland, Tajikistan, Ukraine, England (United Kingdom). concerns among educators about the risks of teaching (Fu, 2011) and longer term negative impacts on the legal framework and teaching of sexuality education. It should be noted that a change of government can dramatically shift the support for implementation of sexuality education. In LAC, governmental administrative changes have been identified as the most significant barrier to sexuality education implementation (UNFPA, 2017b). Changes in government point to the need to back policy or law by building a permanent team committed to sexuality education within the responsible ministry, although even this strategy cannot guarantee immunity from the effects of political shifts (UNESCO and Guttmacher Institute, 2019). In some settings, CSE is not only subject to progress and setbacks in support, but has experienced significant opposition resulting in set-backs in its implementation. In jurisdictions as varied as Poland, Brazil and the province of Ontario, Canada, for example, newly elected governments have promoted specific legislation or policies to withdraw sexuality education policies or curricula, as part of wider social measures (Alphonso, 2018, Pak, 2018, Human Rights Watch, 2020, Paiva and Silva Valeria, 2015). In Poland, proposed legislation extends beyond the retraction of sexuality education curriculum to include the criminalisation of teaching children about sex or sexuality. In Brazil, following many years of public acceptability of sexuality education in schools as an HIV prevention intervention, recent fundamentalist movements have led to recurrent waves of backlash on both health and educational policies relating to sexuality education. For example, in 2015, a national action of conservative politicians successfully eliminated any mention of ‘sexuality’ or ‘gender’ from numerous municipal educational plans (Paiva and Silva Valeria, 2015, Borges and Borges, 2018). In Ontario, Canada, guidance issued in 2018 mandated teachers to revert to an old sexuality education curriculum, putting aside a newer version which had been rolled out in 2015 and which included such topics as cyberbullying, consent, same-sex relationships and gender identity (Bialystok, 2018). A web portal was established for parents to report teachers who were failing to comply. Without a strong policy to guide implementation in schools, sexuality education is often left in the hands of civil society and youth-based organizations, sometimes without a clear framework or consensus on how to organize and mobilise these efforts, meaning that many learners will miss out. While CSOs and youth organizations certainly play a valuable role in delivering sexuality education outside the classroom, this is a missed opportunity for reaching a significant proportion of learners within the structured delivery of their wider education by trained teachers, and risks leaving many without essential information and skills for their future. The journey towards comprehensive sexuality education 20 Case study 2 ENGLAND INTRODUCES STATUTORY RELATIONSHIPS & SEX EDUCATION In England, statutory guidance released in 2020 makes it compulsory for all schools to teach Relationships Education at primary level and Relationships and Sex Education at secondary level. This change in the policy arose from concern about limited attention to this subject, with the curriculum last updated in 2000, and limited guidance provided to schools. Following over a decade of calls to make Sex and Relationships Education (SRE) compulsory, as well as concerted advocacy efforts from civil society, an Education Select Committee inquiry into SRE was held in 2014, resulting in the recommendation for SRE to be statutory with a strong emphasis on its critical role in the protection and safeguarding of children’s health and well-being (House of Commons, 2015, Sex Education Forum, 2020). It subsequently took a range of national advocacy campaigns, pressure from parents and learners, and concerted campaigning with members of parliament to see the legislation changed. Around this time, concerns about sexual abuse of children as well as the accessibility of digital pornography convinced many members of parliament that mandatory SRE was essential (Sex Education Forum, 2020, House of Commons, 2016). The new statutory guidance is based on the rationale that to lead a happy and successful adult life, ‘pupils need knowledge that will enable them to make informed decisions about their health, well-being and relationships and to build their self-efficacy’ (Department for Education, 2020b). In developing the guidance, the department took into account submissions from 23,000 parents, young people, schools and experts and consulted with over 40,000 members of the public. This included views on age-appropriate content on mental well-being, staying safe online and LGBT issues in the updated subjects. With some flexibility provided for timing given the challenges posed by COVID-19, schools are expected to implement the regulations between 2020 and 2021. Schools are free to determine how to deliver the content set out in this guidance, in the context of a broad and balanced curriculum. Implementation Guidance has been published by the Department to help schools with practical steps towards implementation (Department for Education, 2020a). The journey towards making SRE compulsory across schools has not been without resistance from a small constituent of concerned community members, although the majority of parents have been supportive. As part of implementation, schools are required to consult parents on their SRE policy, with the department providing guidance on best practice parental engagement (Department for Education, 2019a). It is hoped that this process will garner support from parents as well as encourage them to take a more active role in discussing the topics with learners at home. Advocates for SRE hope that these changes in policy will raise its status, with the result that it will be taken more seriously as a school subject and lead to pathways for teachers to become professionals in this subject area. Implementation of the regulations will be monitored by the Office for Standards in Education, Children’s Services and Skills (OFSTED), the independent quality regulator for schools. An evaluation is planned by the department. Case study 3 A JOURNEY TOWARDS CSE IN TUNISIA Sexuality education is currently undergoing a major reform in Tunisia, following concerted advocacy from a wide range of stakeholders. Sexuality education is backed by the first national law to combat violence against women, passed in 2017, which mandates l’éducation à la santé et à la sexualité (education for health and sexuality) (Republic of Tunisia, 2017, see Article 7). Strong advocacy efforts for sexuality education directed towards the Ministry of Education (MoE) have been led by the Arab Institute for Human Rights, the Tunisian Association for Reproductive Health (IPPF affiliate) and UNFPA (UNFPA, 2020b). Following a 2017 conference, an Expert Committee was established, which included members from the MoE. This group continued to advocate to the MoE, and started developing a range of teaching and learning resources for potential future use. In 2019, increasing reports of sexual harassment and violence in schools triggered the MoE to step up its efforts to strengthen sexuality education. The ministry released a circular mandating sexuality education for all learners aged 5-18 and appointed a ministry staff member to manage efforts. Further members joined the expert group, including representatives from the Ministry of Health, the Ministry of Women, Family and Children, education unions, teachers and youth, who worked together to integrate topics and learning objectives, guided by the revised UN ITGSE into the curriculum across several subjects, with recognition of local context. Teaching and learning resources that support the curriculum have also been developed, and braille and audio adaptations are being made for learners with disabilities. There has been some opposition from parents and religious leaders throughout the process and efforts have been made by MoE, UNFPA and CSOs to address misconceptions and ensure that the broader community understands the rationale for sexuality education. The Tunisian Association for Reproductive Health has worked with media organizations to clarify the intention of sexuality education, which has been central to challenging community misconceptions. As there was major pushback by teachers of Islamic Studies, representatives were invited to join the expert committee and have been part of efforts to revise some of the language seen as more sensitive. There are plans for all teaching and learning tools to be made available online. There will also be an interactive online forum where people can ask questions and make suggestions. A digital app is under development, which will provide another platform for learners to access information. With two recent changes of government in Tunisia and the onset of the COVID-19 pandemic, implementation has been delayed. However, with the curriculum and training tools ready to go, and a pool of trained master trainers, it is hoped that a two-year pilot in schools across 13 governorates – including schools for learners with disabilities – will begin soon. The journey towards comprehensive sexuality education 21 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908013/Relationships_Education__Relationships_and_Sex_Education__RSE__and_Health_Education.pdf Decentralisation In addition to policies, another factor that can influence sexuality education implementation nationwide is decentralisation of policy-making, financing and decision- making to provinces, districts or schools. On the positive side, decentralisation enables local governments to initiate programmes that are more responsive to local needs, but it can also lead to inequalities and inconsistencies across a country. In Nigeria a nationwide programme to scale up CSE was decentralised. While this meant that the process was better managed and supported in some states than in others, it is credited for reaching near-nationwide implementation with the decentralised model allowing for tailored implementation across all 36 states (Chandra-Mouli et al., 2018a, Udegbe et al., 2015). In Asia, countries with decentralised education systems such as India, Pakistan and Vietnam may have national strategies, but the decision to make the curriculum mandatory is made at the state or provincial level. As a result, in practice, sexuality education is not necessarily mandatory nationwide (UNFPA et al., 2020a). In Chile, delegating responsibility for certain content to the school level affected programme coherence and support to teachers (UNESCO, 2019c). In Bulgaria, local governments develop the school budget, producing significant variations in the amount of money available (Ketting and Ivanova, 2018). On the other hand, in Germany, states have autonomy to determine the curriculum, but a national framework sets required standards, which ensures a high degree of comprehensiveness nationally (Ketting and Ivanova, 2018). Government budget allocation While a policy and/or legal frameworks are important to provide the impetus for CSE, commitment to sexuality education needs to be reflected in resource allocation. Domestic financing through government allocation of funds is an indicator of commitment to ensuring that CSE is delivered and will be sustained. Out of 48 countries that responded to the 2019-2020 Survey on the Status of CSE, 79 per cent, or 38 countries, said that the government allocates some financial resources to sexuality education in schools. Sources of the funding vary from the ministry of education budget, congressional or parliamentary allocation, regional and local budgets, and other line ministries. While these findings are promising, indicating that sexuality education is integrated into national systems in the vast majority of these countries, it should be noted that the data comes from a limited number of reporting countries with existing commitment to delivering sexuality education, and therefore, may not be a reflection of regional or global trends. For countries that have decentralised education systems, the decision to fund CSE is made at the state or provincial level. For example, the scale up of the Udaan programme in India was possible in part because the state education department committed human resources and infrastructure for delivering the programme in schools, although it also relied on sustained donor funding for technical support provided by an NGO (Chandra-Mouli et al., 2018b). While it is promising that many countries are reporting allocation of budget to CSE, there is also evidence that in some low- and middle-income countries external donor funding continues to make an important contribution. While critical for donors to continue to support countries in their journey towards CSE as part of nationally-driven efforts towards HIV prevention, gender equality and general quality of education, this can lead to the perception that CSE is a foreign agenda. It can also have implications for its sustainability and ownership. Bosnia and Herzegovina, for example, was supported by the Global Fund and IPPF to create its curriculum, but efforts declined when those partnerships ended (Ketting and Ivanova, 2018). On the other hand, national scale-up efforts in Nigeria, which have been credited as being sustained, were funded jointly by the federal and state level government along with a range of donors (Huaynoca et al., 2014, UNESCO, 2010). Case study 4 COMMITMENT TO, AND SCALE UP OF, CSE IN JHARKHAND STATE, INDIA Udaan is a school-based adolescent education programme, implemented at scale in Jharkhand, India since 2006. By September 2019 it had reached over one million students and is recognized as a strong model of government-NGO partnership. Udaan began as an Adolescent Reproductive and Sexual Health programme led by the State AIDS Control Society but was subsequently mainstreamed into the Department of Education. In India, responsibility for sexuality education is decentralised to a state level. Although several factors can be attributed to its scale- up success, state-level government commitment in Jharkhand has been key. The state education department provides all the human resources and infrastructure for delivering the programme in schools through trained teachers and for supervising the effort through dedicated functionaries at state and district level. A State Level Core Committee under the chairpersonship of the Secretary of Education reviews progress and makes decisions on strategy and directions. A State Level Officer from Education Services has been designated to coordinate and extend necessary administrative support to the programme. The Udaan curriculum has been integrated into the regular school academic textbooks and into the in-service and pre- service education of teachers in Jharkhand. Udaan has also served as a blueprint for the national School Health and Wellness Ambassador Initiative, a school-based health and wellness programme, which has recently been rolled out as the third pillar of government’s Ayushman Bharat programme. Udaan is the only at-scale, state-run initiative of its kind in the country. Its reach is also thanks to a knowledgeable and committed NGO partner, Centre for Catalyzing Change (C3), sustained funding from the Packard Foundation, and a commitment to constant improvement through evaluation. Nonetheless, it has been the enabling policy environment created by the government that has provided a solid basis for its sustainability (Chandra-Mouli et al., 2018b). The journey towards comprehensive sexuality education 22 Case study 5 A JOURNEY TOWARDS CSE IN JAMAICA The Health and Family Life Education Programme (HFLE) has existed in Jamaica since 1997, but it was in 2004 when it was mandated as a government policy through a cabinet decision that still holds today. In 2006, the HFLE curriculum was revised to incorporate life skills, address gaps and align with new standards and core outcomes of the 20-country Caribbean community (CARICOM) Regional Framework for HFLE. During the period 2007-2012, through financial support from international development partners, UNICEF and the Global Fund, and technical support from the National HIV/STI Programme in the Ministry of Health, the Ministry of Education embarked on a series of sensitisation and training sessions to roll out the revised curriculum in all schools at the primary and secondary level. Led by a national coordinator, whose post was funded by the government, a team of health promotion specialists was also employed to monitor implementation of the programme across the country. In 2012, the government of Jamaica earmarked national funding to HFLE in order to institutionalise the programme. That year, the posts of HFLE officers were established and their salaries were completely funded by the government. Implementation of HFLE in Jamaica has not been without its challenges, not just as a non-academic subject, but particularly because of its inclusion of a sexuality and sexual health theme. In 2012, the Ministry of Education was forced to withdraw its secondary curriculum due to concern about content relating to sexual orientation. Instead of completely removing the subject, the government responded by embarking on a process of revision in collaboration with different stakeholders, including faith-based organizations (FBOs). This interactive, collaborative process required many consultations and meetings, and a thorough review of data, content and language to establish common ground. Following revision, the curriculum was relaunched in 2013, and included core values among the set of guiding principles. Since 2007, the HFLE curriculum has undergone a number of revisions to meet the needs of the students and reflect Jamaican context, with the most recent process commencing in 2016 to produce a new version of the HFLE curriculum. The curriculum revision process has been largely driven by data and involved consultants who developed the curriculum and engaged subject specialists, curriculum officers and technical expertise from key stakeholders. However, the revision of this new version of the curriculum has been led by the national coordinator and a team of HFLE officers with support from HFLE master trainers and technical experts in each field. This latest revision again entailed convening and bringing on board stakeholders to engage in the process, but involved an even wider cross-section than in previous years. Additionally, interest groups from both civil society and FBOs were also engaged in a more comprehensive review process of the sexuality and sexual health programme for all grade levels, and representatives were exposed to the documents at the same time, at the same table, to together review and address any gaps or areas of concern. In 2016 the profile of HFLE was raised, as it was transferred from the Guidance and Counselling Unit to the Core Curriculum Unit of the Ministry of Education, including it as part of the National Standard Curriculum and in national training activities. Lessons learned from Jamaica’s experience point to the importance of consulting a broad range of stakeholders, including FBOs, in the development of HFLE and establishing a monitoring framework to support implementation and delivery of the curriculum in schools. The implementation of the curriculum, once a major challenge, is accepted and supported by teachers, principals, parents and the broader community. 2.2 Coverage While from a policy perspective there is evidence that countries are committing to sexuality education, it is also important to look at implementation. How many schools are actually implementing sexuality education? National- level coverage data gives some indication of progress in implementation, although the data are often not collected through school surveys, census or administrative databases, such as Education Management Information Systems (EMIS), and may reflect an estimate made at the central level. The data on the coverage of sexuality education programmes have been triangulated and generated from three sources: the NCPI, the Sustainable Development Goals (SDG) Thematic Indicator 4.7.2, and the 2019-2020 Survey on the Status of CSE. According to the available data, about two-thirds of reporting countries stated that between 76 and 100 per cent of their schools in the country were providing sexuality education. The remaining countries reported lower levels of coverage (Figure 2). Both NCPI and SDG Thematic Indicator 4.7.2 use the globally recommended indicators on sexuality education as per international guidance (UNESCO et al., 2018, UNESCO, 2013), which provides a standardised benchmark as measured by inclusion of the following content: 1. generic life skills (such as decision-making, communication, and negotiating skills); 2. sexual and reproductive health and sexuality education (such as human growth and development, relationships, reproductive health, sexual abuse and transmission of sexually-transmitted infections); and 3. HIV transmission and prevention. The 2019-2020 Survey on the Status of CSE only asked the question about the percentage of schools providing sexuality education, with reference to the definition provided in the revised UN ITGSE (UNESCO et al., 2018). The journey towards comprehensive sexuality education 23 Figure 2 National sexuality education programme coverage rates 80 70 60 50 40 30 20 10 0 76-100% 61 71 0-25% 1311 % of schools delivering sexuality education Primary Secondary Nu m be r o f c ou nt rie s 20 12 51-75%26-50% 66 Data sources: NCPI 2019, SDG 4.7.2 and the 2019-2020 Survey on the Status of CSE. These findings may depict an overly optimistic picture and should be read with caution. Divergent ideas about what constitutes sexuality education, unclear or different definitions of terms, invalid assumptions (for example, some countries may assume that if the sexuality education curriculum is mandatory, then all schools following the national curriculum are delivering sexuality education), limitations of national data collection and reporting systems for these datasets contribute to reporting of numbers that may be inflated. Other data sources can provide a complementary, and sometimes divergent perspective. According to a regional study in SSA, almost all responding ESA countries ‘agreed’ or ‘strongly agreed’ that implementation of ‘school-based HIV education’ for young people had increased in the last year (UNESCO, 2018). In contrast, only 27 per cent (4/15) of responding WCA countries ‘agreed’, and none ‘strongly agreed’. Overall, the SSA study concludes that most countries have yet to implement sexuality education at scale. Coverage data also falls short of detailing the important yet more complex question of quality of curriculum content and delivery. In some cases, it is likely that high quality or comprehensive content may be being delivered as part of a small discrete project, but with very low coverage. An indication of quality may also be better reflected in specific research with learners and teachers. For example, research on student perspectives from a number of different countries shows that they often feel that they received information too late and would have preferred the sexuality education programme to have started earlier in their schooling (UNFPA et al., 2020a, Irvin and Trang, 2018, Awusabo-Asare et al., 2017). So while the coverage data available do not specifically highlight a difference in coverage between primary and secondary school levels nor the quality of the education delivered, qualitative research can shed light on the differences in delivery of sexuality education to younger and older learners, as well as provide an indication of quality. 2.3 Curricula: breadth and relevance of content Existence of curricula In recent years, many countries have been developing or revising their national curricula, bolstered by international guidance. Some countries have a long history of curricula that includes certain components of sexuality education, while for others, this is relatively new. The data on the availability of the sexuality education curriculum are drawn from the UNAIDS Unified Budget, Results and Accountability Framework (UBRAF), the 2019- 2020 Survey on the Status of CSE and regional reviews in Europe and Central Asia 2018 (Ketting and Ivanova, 2018). According to the available data, of 123 countries that reported, 85 per cent or 104 countries indicated that relevant sexuality education content and topics are covered in their national curriculum. A total of 49 countries reported having gender responsive life skills-based HIV and sexuality education curricula both in primary and secondary education and 16 reported only at the secondary level. The remaining 39 countries referred to the availability of the curriculum without specifying levels of education or topics covered (see Figure 3). When the data are analysed by the levels of education (UBRAF), more countries reported that ‘gender responsive life skills-based HIV and sexuality education is part of the curriculum’ at secondary level than at primary level. Of the 88 countries reporting to UBRAF in 2019, 72 per cent stated that sexuality education was part of their secondary school curriculum. In contrast, only 55 per cent reported the same for their primary schools. The journey towards comprehensive sexuality education 24 Data sources: UBRAF 2019; 2019-20 Survey on the Status of CSE; BZgA & IPPF EN 2018 Survey on Sexuality Education Data source: UBRAF 2019 Data source: UBRAF 2019 Data sources: 2019-20 Survey on the Status of CSE; BZgA & IPPF EN 2018 Survey on Sexuality Education Algeria, Belarus, Bolivia (Plurinational State of), Brazil, Chad, Djibouti, Ecuador, Egypt, Ethiopia, Georgia, Haiti, Iran (Islamic Republic of), Liberia, Mauritania, Panama Paraguay, Somalia, Sudan, Tunisia Afghanistan, Albania, Austria, Bangladesh, Belgium, Bhutan, Bosnia and Herzegovina, Bulgaria, China, Costa Rica, Cyprus, Czechia, Estonia, Fiji, Finland, Germany, Ireland, Kazakhstan, Kiribati, Latvia, Malaysia, Maldives, Mexico, Mongolia, Netherlands, Pakistan, Russian Federation, Samoa, Solomon Islands, Spain, Sri Lanka, Sweden, Switzerland, Timor-Leste, Tonga, Tuvalu, United Kingdom of Great Britain & Northern Ireland, Vanuatu, Viet Nam Benin, Chile, Colombia, Ghana, India, Indonesia, Mali, Nepal, Nigeria, Papua New Guinea, Republic of Moldova, Senegal, Tajikistan, Togo, Ukraine, Uzbekistan Angola, Argentina, Botswana, Burkina Faso, Burundi, Cabo Verde, Cambodia, Cameroon, Central African Republic, Congo, Côte d'Ivoire, Cuba, Democratic Republic of the Congo, Dominican Republic, El Salvador, Eritrea, Eswatini, Gabon, Gambia, Guatemala, Guinea, Guyana, Jamaica, Kenya, Kyrgyzstan, Lao People's Democratic Republic, Lesotho, Madagascar, Malawi, Morocco, Mozambique, Myanmar, Namibia, Nicaragua, Niger, Peru, Philippines, Rwanda, Sierra Leone, South Africa, South Sudan, Suriname, Thailand, Uganda, United Republic of Tanzania, Uruguay Venezuela (Bolivarian Republic of), Zambia, Zimbabwe No curriculum related to sexuality education Related curriculum – education levels and/or topics covered are not speci�ed Gender responsive life skills-based HIV and sexuality education is part of the curriculum only in secondary education Gender responsive life skills-based HIV and sexuality education is part of the curriculum both in primary and secondary education WEST AND CENTRAL AFRICATHE PACIFICMIDDLE EAST AND NORTH AFRICA LATIN AMERICAEAST AND SOUTHERN AFRICAEASTERN, SOUTH AND SOUTH EASTERN ASIA EASTERN EUROPE AND CENTRAL ASIACENTRAL AND WESTERN EUROPETHE CARIBBEAN Figure 3 Curricula related to sexuality education in the education system The journey towards comprehensive sexuality education 25 Case study 6 BODY-EMOTION EDUCATION FOR PRE-PRIMARY SCHOOL CHILDREN IN FINLAND In Finland, sexuality education has been integrated into school programmes since 1970, and it has been a part of the larger area of Health Education since 2004. Recently, there have been strong calls to integrate sexuality education into national curricula for early childhood education settings. In 2013-14, the Family Federation of Finland (a Finnish NGO) carried out a survey of 1,100 early childhood education professionals and parents of one-to-six-year-olds, exploring the experiences of and attitudes towards sexuality education for young children. It found that while many did not like to use the term ‘sexuality’ in relation to young children, there was consensus that pre-school children do need knowledge and skills about safety, sexuality, bodies and emotions, and that such knowledge and skills are critical to ensure that children learn healthy values, attitudes and norms, and respect for their own and others’ bodies. They also believed that such education provides children with the knowledge and skills to identify and report potential abuse. The study also found that early childhood education professionals were not currently delivering sexuality education and lacked confidence in how to do this (Cacciatore et al., 2020). The commitment to move towards formalised teaching of sexuality education for pre-school children has been reflected in policy discourse, with the National Institute for Health and Welfare prioritising sexuality education in early childhood settings in their Action programme for the promotion of sexual and reproductive health in 2014–2020, a flagship document which presents the national goals for sexual and reproductive health (Klemetti and Raussi-Lehto, 2018). In 2016, the Finnish National Agency for Education delivered new instructions for early childhood education. Although this does not refer explicitly to ‘sexuality education’, preferring the more accepted terminology of ‘body and emotion education’, it captures the core features of sexuality education, presented in an age-appropriate way for young learners. Municipalities are required to develop local curricula and qualification requirements based on national instructions. In 2020, with encouragement and support from the Family Federation of Finland, at least 22 municipalities out of the country’s 311 included sexuality education as a part of their mandatory local curricula. These municipalities cover 45 per cent of Finnish 0-6-year olds. In practice, this means that sexuality education is already being provided in many pre-schools, but not in all. The Family Federation of Finland has been instrumental in developing age-appropriate teaching and learning resources and delivering teacher training. In SSA, most countries in the ESA region now include sexuality education in the curriculum. Often this has occurred in the context of wider curriculum reform. A 2018 regional report found that six countries in ESA and two in WCA reported having approved and adopted revised curricula for both primary and secondary education levels. Other countries reported that curriculum development or revision was underway (UNESCO, 2018). 6 ‘Complete’ in 33%: Argentina, the Plurinational State of Bolivia, Cuba, El Salvador, the Dominican Republic, Uruguay;‘advanced’ in 17%: (Guatemala, Peru, the Bolivarian Republic of Venezuela); ‘medium’ in 28%: (Colombia, Costa Rica, Honduras, Mexico, Nicaragua); ‘initial’ in 11%: (Ecuador, Paraguay ); ‘none’ in 11% (Chile and Panama). In Asia, 16 of 20 countries reported that there is a national sexuality education curriculum at the primary level, while this was the case for 6 of 8 countries in the Pacific. At the secondary level, the proportion is slightly higher: 16 of 20 have a national curriculum in Asia, compared with 7 of 8 in the Pacific (UNFPA et al., 2020a). A 2017 regional report on LAC found that sexuality education appears to have advanced in the region, with curricula organized by ‘competencies’ and sexuality education given a specific position in the curriculum. According to this report, half of the 18 countries included had a ‘complete’ or ‘advanced’ conceptual or theoretical framework for sexuality education, another 40 per cent had a ‘medium’ or ‘initial’ framework, and a final 11 per cent had none.6 The same report confirms that sexuality education has advanced in the English-speaking Caribbean. Cuba and Uruguay were highlighted as standouts in terms of making substantial progress in incorporating sexuality education into the official curriculum (UNFPA, 2017b). A UNFPA regional study of 20 Arab States reported that nine countries in the region teach some topics relating to sexuality education, usually basic human body and development, while only two officially include CSE in the curriculum (Tunisia and Qatar) (UNFPA, 2020b). In ECA, most countries (14/21) have incorporated sexuality education into the formal curricula, with the remainder in the process of doing so (Ketting and Ivanova, 2018). Stand-alone or integrated Different countries are using different approaches to bring sexuality education into the curriculum. Some integrate it across many subjects, others integrate it into just two or three, and still others have a stand-alone curriculum. There are advantages and disadvantages of each approach, and countries have varied experience. While some countries introduce sexuality education as a separate subject, or place CSE content within one existing subject, it can be more practical to build upon and improve what teachers are already teaching, and to integrate sexuality education across existing subjects (UNESCO et al., 2009). On the other hand, integrating sexuality education can make accountability, and assessment, difficult. A telling quote from a study in China captured the feeling that integration creates an atmosphere where ‘everybody’s responsibility becomes nobody’s responsibility’ (UNESCO and UNFPA, 2018). Of 47 countries from Asia and the Pacific, SSA and LAC that responded to the question on ‘delivery mode’ in the 2019- 2020 Survey on the Status of CSE, 68 per cent responded that sexuality education is integrated and taught as part of other subjects in primary education; 23 per cent reported that it is taught mainly as a stand-alone subject. In secondary education, of 55 countries reporting, three The journey towards comprehensive sexuality education 26 https://www.oph.fi/sites/default/files/documents/varhaiskasvatussuunnitelman_perusteet_2018.pdf https://www.oph.fi/sites/default/files/documents/varhaiskasvatussuunnitelman_perusteet_2018.pdf quarters said that sexuality education is taught as part of other subjects and 24 per cent reported it is taught as a separate subject. Figure 4 Sexuality education delivery mode (primary schools) Integrated (taught as part of another subject) Stand-alone (separate subject) Not speci�ed 68% 9% 23% Data source: 2019-2020 Survey on the Status of CSE. Figure 5 Sexuality education delivery mode (secondary schools) Integrated (taught as part of another subject) Stand-alone (separate teaching subject) Not speci�ed 75% 2% 24% Data source: 2019-2020 Survey on the Status of CSE. A single-subject approach to sexuality education is applied in countries as far ranging as Nigeria, and Mongolia (Wood et al., 2015, Restless Development, 2016). In SSA, the Caribbean, Asia, and MENA, sexuality education is often delivered as part of a broader life skills or health course, which includes other topics, such as alcohol, tobacco and drugs, nutrition and traffic safety. It can be hard to discern how much of the life skills course actually covers the key concepts of sexuality education (UNICEF MENA, 2017). Sexuality education is mostly taught as an integrated subject in Asia and the Pacific region. Nonetheless, there is variation among countries. For example, in Thailand, the decision on how to integrate sexuality education is made at the school level (UNFPA et al., 2020a). Countries in the LAC region, which have traditionally favoured an integrated approach, appear to be moving toward integration into fewer subjects. Sexuality education topics are most often inserted into natural sciences or health (80 per cent), social sciences (67 per cent), and civics/ ethics (47 per cent) (UNFPA, 2017b). In ECA, sexuality education is almost always inserted into one obligatory subject or integrated into a few core subjects. In Ukraine, Armenia, Moldova, Estonia and several other countries, sexuality education is part of a stand-alone obligatory subject; in Kyrgyzstan, it is part of obligatory homeroom classes (Ketting and Ivanova, 2018). Mandatory or optional Another central question is whether or not sexuality education is mandatory. It is often considered mandatory if and when it is integrated into mandatory core subjects. Optional content receives less attention and fewer resources, and parents, principals, teachers and students are likely to consider it less important. An optional status also creates uncertain expectations for teaching and for teacher and student assessments. Of 58 countries from Asia and the Pacific, SSA and LAC that responded to the 2019-2020 Survey on the Status of CSE, 60 per cent said that their curricula for both primary and secondary levels were mandatory. In ECA, in only 11 out of 25 countries (less than half ), is sexuality education mandatory in all schools. However, it should be noted that even when mandatory, sexuality education is only going to be effective if a breadth of topics over time and the quality of delivery are also assured. For example, Nepal’s sexuality education is part of the compulsory curriculum, but it only covers reproductive health (TimilSina, 2017). Singapore has made sexuality education mandatory since 2000, yet the content focuses on abstinence only (Cheng, 2018). These examples underscore that making sexuality education mandatory will only lead to quality programmes when comprehensive content is in place. On the other hand, it should be noted that some countries have well developed, comprehensive curricula, but do not have mandatory implementation. For example, Wales (United Kingdom) requires sexuality education in primary and secondary schools and the country’s 2010 guidance is considered comprehensive according to international guidance. Nonetheless, what is delivered varies because sexuality education is at the discretion of the school (Welsh Government, 2017). It should be noted that even when mandatory, sexuality education is only going to be effective if a breadth of topics over time and the quality of delivery are also assured. The journey towards comprehensive sexuality education 27 Comprehensiveness of content In many settings, there is evidence that the curricula have expanded from a narrow focus on HIV prevention and the biological aspects of sexual and reproductive health to a broader range of topics. This reflects a growing recognition of the health and social issues that CSE can help to prevent (e.g. early and unintended pregnancy, gender-based violence), the recognition of how CSE can instill positive social and emotional skills in learners, as well as the availability of international guidance. CSE’s eight key concepts, along with its characteristics and domains of learning, have been outlined in the revised UN ITGSE and are summarised in Table 2 (UNESCO et al., 2018). The guidance provides recommended age-appropriate topics and learning objectives for each of the topics across four age categories. Of the 53 countries from Asia and the Pacific, SSA and LAC that responded to the 2019-2020 Survey on the Status of CSE, about 75 per cent responded that in their perception their curriculum is comprehensive, 17 per cent reported that their curriculum is focused on abstinewnce and use of condoms and other forms of modern contraception and the remaining 8 per cent said that their curriculum is focused on abstinence only (i.e. refraining from sexual activity) (Figure 6). Given the self-reported nature of this assessment, it is important to look at a range of sources shedding light on the comprehensiveness of content. Three-quarters of countries responding to the 2019-2020 Survey self-report that ‘HIV&AIDS/STIs’ is ‘extensively’ included in their secondary education curriculum. Additionally, the topic of ‘Puberty’ was reported to have been ‘extensively’ included by 67 per cent of countries. Slightly more than 55 per cent of countries also referred to the following topics as ‘extensively’ included in their secondary curriculum: gender and gender norms, pregnancy and birth, love and relationships and sexual abuse/violence. The topics that are included to a lesser extent were ‘access to safe abortion’, ‘sexual orientation and gender identity’, and ‘online media and technology’ (Figure 7). A much lower proportion of countries report inclusion of these major topics ‘extensively’ in their primary level curricula (Figure 8). One source that provides information on the comprehensiveness of curricula is the Sexuality Education Review and Assessment Tool (SERAT). The tool facilitates the review of curriculum content by age group (5-8, 9-12, 12-15, 15-18+) and measures against international recommendations for curriculum content as outlined in the revised UN ITGSE. The results enable national stakeholders and authorities to reflect not only on the key topics grouped with key concepts, but also on the types of learning, including knowledge, skills and attitudes. Responses are given on a scale from ‘fully present’ to ‘somewhat present’ and ‘not at all’. Eight key concepts 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 behaviour 8. Sexual and reproductive health Characteristics • Scientifically accurate • Incremental • Age- and developmentally- appropriate • Curriculum based • Comprehensive • Based on a human rights approach • Based on gender equality • Culturally relevant and context appropriate • Transformative • Able to develop life skills needed to support health choices Three domains of learning 1. Knowledge 2. Skills 3. Attitudes Table 2 Key concepts and characteristics of CSE davide bonaldo/Shutterstock.com The journey towards comprehensive sexuality education 28 http://Shutterstock.com Figure 6 Comprehensiveness of sexuality education curriculum, as reported by survey respondents 302520151050 35 40 Number of countries Primary Secondary Comprehensive Focused on abstinence + use of condom & other forms of modern contraception Focused on abstinence (refraining from sexual activity) Data source: 2019-2020 Survey on the Status of CSE. Figure 7 Reported extent of inclusion within curricula of a range of key CSE topics (Secondary education) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HIV&AIDS/STIs Puberty Gender and gender norms Pregnancy and birth Love and relationships Sexual abuse/violence Contraception Services for SRH Marriage Online media and technology Sexual orientation and gender identity Access to safe abortion Extensively Briefly Not included Data source: 2019-2020 Survey on the Status of CSE. Figure 8 Reported extent of inclusion within curricula of a range of key CSE topics (Primary education) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HIV&AIDS/STIs Puberty Gender and gender norms Pregnancy and birth Love and relationships Sexual abuse/violence Contraception Marriage Online media and technology Extensively Briefly Not included Data source: 2019-2020 Survey on the Status of CSE. The journey towards comprehensive sexuality education 29 This report analysed SERAT data files from 24 countries of SSA. Weighted scores/averages for the curriculum content component for each country were calculated7 and then labelled as either latent (<25 per cent), emerging (25-50 per cent), established (50-75 per cent) or advanced (>75 per cent). The merged results from the 24 countries showed that curriculum content is stronger for older age groups, particularly for 12-15 year-olds. Almost half of the countries are assessed as having either advanced or established curriculum content for this age group. However, many countries still have some way to go before their curricula can be considered truly comprehensive in both primary and secondary education. (Figure 9). When key concepts and themes are analysed, the findings show that on average for all age groups, about 37 per cent of countries have been assessed to have either advanced or established curriculum content for the following themes: interpersonal relationships, generic skills (communication, negotiation, decision making), human development, sexual and reproductive health, and youth empowerment. At the same time, little more than a quarter of countries have been assessed to have either advanced or established curriculum content for the topic of sexuality and sexual behaviour (Figure 10). When types of learning and focus areas of learning are analysed, on average about one-third of countries have either advanced or established focus areas of learning in knowledge, attitudes, life skills, human rights, gender and social norms and the remaining two-thirds have been assessed as either latent or emerging in these areas (Figure 11). On the whole, it can be concluded that when the comprehensiveness of the curriculum is analysed as per international guidance across these 24 countries, almost two-thirds do not include a full range of topics, or learning domains, within their sexuality education curriculum. There are many reasons for this and other studies explored below offer an insight into the variation among regions. The content of sexuality education is embedded in historical contexts and has evolved over time. In SSA, high HIV prevalence rates produced a focus on negative outcomes and risk reduction (Panchaud et al., 2019). In many countries, this resulted in a limited range of topics included in sexuality education (Sidze et al., 2017). Now, many countries are building on earlier ‘life skills education’ programmes, which were primarily established with an HIV prevention or population reduction focus, to create more comprehensive approaches. In Asia and the Pacific region, six countries reported that their primary level sexuality education curriculum was focused on 7 Weighted score = strong features/present x 1 (100%) + intermediate features (somewhat present) x 0.5 (50%). Case Study 7 SEXUALITY EDUCATION WITHIN SCOTLAND’S HEALTH & WELL-BEING CURRICULUM Scotland has shown commitment to promoting health and well- being (HWB) in schools, including the provision of Relationships, Sexual Health and Parenthood (RSHP) education. This commitment is grounded in a strong national policy and guidance for schools. Its curriculum reform in 2010, Curriculum for Excellence, placed HWB, along with literacy and numeracy, as one of the three core areas of children’s learning. Health and well-being isn’t a single subject or class, but is organized into seven areas: • mental, emotional, social and physical well-being • planning for choices and changes • physical education • physical activity and sport • food and health • substance misuse • relationships, sexual health and parenthood Each of these areas is integrated into the curriculum, as well as reflected in broader school culture and practice. For example, relationships education is not just about teaching students about positive relationships skills, but also about developing a positive whole school ethos and culture. All teaching staff are responsible for age-appropriate HWB learning for students 3-18, which is integrated across different subjects. Content is age-appropriate starting with information about health and relationships, then about sexual health, and then parenthood. The National Health Service (NHS) is a critical partner in the development of policy as well as delivery of RSHP. Due to an identified need to modernise RSHP in co-production with learners and to increase teachers’ confidence and consistency in delivery, a new national resource – the RSHP website – was launched in September 2019. This platform supports teachers and practitioners with relevant information and age-appropriate learning activities. It also involves and informs parents and presents sexuality education in a positive way. The process of developing the platform is noteworthy: it consisted of an iterative, collaborative, and participatory process by a network of over 1,500 professionals and partners that took place over a two- year period, drawing on the best practice currently available across Scotland. Numerous evaluations and interactive consultations were held with young people, and research was conducted, which fed into the new resource. Thirty-eight schools pilot-tested the resource, teachers provided feedback on what worked and what did not, and the website was changed accordingly. In 2020, because of COVID-19, the online resource is considered invaluable in the ‘recovery curriculum’. This focuses on three areas (1) supporting learning and re-engagement with school in terms of mental health and peer relationships, (2) sexual health, keeping in mind what might have been ‘missed’ with school closures, and (3) online lives/social media. A blog for pupil inclusion was developed with links to these three areas, as well as a link enabling teachers to readily find the age and stage-appropriate resource they need for the 2020 recovery year. For more information: see Scottish Government, 2021; Horrell et al., 2012 The journey towards comprehensive sexuality education 30 https://rshp.scot/ Figure 9 SERAT weighted scores for overall curriculum content for different age groups 80% 70% 60% 50% 40% 30% 20% 10% 0% 5-8 years 15-18+ years Latent or emerging Advanced or established 9-12 years 12-15 years Data source: SERAT data for 24 selected countries in SSA. Figure 10 SERAT weighted scores for key themes 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Youth empowerment SRH Human development Generic skills (communication, negotiations, decision-making) Sexuality and sexual behaviour Interpersonal relationships EstablishedAdvanced Emerging Latent Data source: SERAT data for 24 selected countries in SSA. Figure 11 SERAT weighted scores for learning domain 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EstablishedAdvanced Emerging Latent Knowledge Feelings Life skills Human rights Gender Social norms Data source: SERAT data for 24 selected countries in SSA. The journey towards comprehensive sexuality education 31 ‘abstinence and the prevention of pregnancies, STIs, HIV and AIDS’, and five countries reported the same for secondary level curricula. While other countries self-reported that their primary and secondary curricula was ‘very comprehensive‘, responses from experts commonly noted that sexuality education is better described as ‘abstinence plus prevention (of pregnancies, HIV and sexually transmitted infections) education’ or ‘life skills-based education’ in many countries, rather than ‘comprehensive sexuality education’. When looking at how countries reported on specific topics, secondary level included broader-reaching content than primary level, but many important topics are still missing (UNFPA et al., 2020a). For example, a 2018 study found that only three of 11 countries in Asia included the topic of ‘gender’ in sexuality education (ARROW, 2018). On the other hand, of 28 countries from the region that responded to the 2019- 2020 Survey on the Status of CSE, 8 reported that gender norms were covered ‘briefly’, and 18 ‘extensively’. Regarding human rights and non-discrimination, in a 2018 study in Asia, only Sri Lanka reported that they include diversity and non-discrimination toward lesbian, gay, bisexual and transgender (LGBT) youth (ARROW, 2018), although in the 2019-2020 Survey on the Status of CSE, 14 out of 28 countries reported that sexual orientation and gender identity were covered in the curriculum ‘extensively’ and eight ‘briefly’. India and Laos mention awareness of stigma toward people living with HIV (PLHIV) (ARROW, 2018). Vietnam’s sexuality education policies include an explicit reference to young women from ethnic minority communities (ARROW, 2018). In LAC, strong women’s movements in the 1990s advocated for a rights-based and gender-focused approach to sexuality education, which continue to influence the focus of the region’s programmes (UNFPA, 2017a). However, although information about STIs, HIV and pregnancy is available, it is found to be rarely in relation to gender, power or social norms. Information about contraception within the curriculum can be superficial, and rarely are practical issues addressed, such as deciding about which method to use or accessing services (UNESCO, 2017a). In this region, gender appears as an essential element in almost all the conceptual frameworks and discourse on sexuality education, but it does not show up strongly in the curricula (UNFPA, 2017b). In some countries, opposition groups have successfully demanded the removal of references to gender in school curricula and materials (UNESCO, 2017a). Human rights were well covered in about 40 per cent of the lower level materials (ages 9-11 yrs.), but not necessarily reproductive rights. Discrimination is discussed, but with no mention of diverse family forms (UNESCO, 2017a). Case Study 8 A GENDER-TRANSFORMATIVE APPROACH TO SEXUALITY EDUCATION IN SWEDEN Sweden was the first country in the world to make sexuality education compulsory in 1955. Since then, the curriculum has evolved, with significant changes made in 2011 when sexuality education was strengthened within the curriculum and integrated into more subjects. A gender perspective has long been an important part of the Swedish policy. The teaching of sexuality education is expected to promote gender equality and the equal dignity of all, while promoting positive relationships and sexuality and preventing a range of health and social problems. Since 2011, terms such as sexuality, relationships, gender, gender equality and norms have existed in subjects, and learning starts in pre-school. This means that the responsibility for sexuality education falls on several teachers and that topics are raised and reinforced within the scope of multiple subjects and over time (Swedish National Agency for Education, 2014). In Sweden, sexuality education is integrated across multiple subjects: • Biology • Science studies • Physical education & health • History • English • Geography • Civics • Home & consumer studies • Swedish/Swedish as a Second language • Music • Crafts • Religion • Technology National guidelines mandate sexuality education to cover a range of topics, but exactly how the topics are included in lesson plans is at the discretion of individual schools. Some subjects require more content relating to gender equality, sexuality and relationships, but all teachers are encouraged to be involved, regardless of subject (Swedish National Agency for Education, 2014). While strong from a policy and curriculum perspective, it is recognized that there is variation in quality of delivery of sexuality education between and within schools. In 2017, a review carried out by the Swedish Schools Inspectorate found that that while schools were integrating sexuality education across subjects, as per national policy, there were challenges around teacher confidence discussing and analysing gender norms – a critical element of the curriculum content (Swedish Schools Inspectorate, 2018). In a second study, students reported that while they were content with much of their sexuality education, they felt that norms, gender equality and consent were weaker elements (Public Health Agency of Sweden, 2017). In response to these findings, there are ongoing efforts to improve the quality of delivery of sexuality education. In 2020, following long-term advocacy from a range of stakeholders, the Swedish Ministry of Education announced that all pre-service teachers will now be assessed on their competency to teach about sex, identity and relationships (Government of Sweden, 2020). All teacher training institutions were expected to introduce specific objectives to this end from 1 January 2021. The journey towards comprehensive sexuality education 32 In ECA, 10 of 25 countries in a review were assessed as having comprehensive curricula, and another four as ‘approaching the standard of comprehensiveness’. While other countries were found to have curricula that focused almost entirely on biological aspects of sexuality, it was noted that many were in the process of updating their curriculum to align with regional and international guidance (Ketting and Ivanova, 2018). Scotland (United Kingdom) updated its curriculum in 2010 to make it more current and comprehensive, and in 2019, it launched a national sexuality education resource (Scottish Government, 2019). Estonia has been identified as a role-model for human rights and non-discrimination in sexuality education. The Estonian LGBT Association was involved in revising the 2011 curriculum, ensuring inclusion of information on LGBT identity and discrimination (Ketting and Ivanova, 2018). Other studies have shown that a negative view of sexuality often prevails in the curriculum, with a focus on the risks and dangers of sexuality (Ford et al., 2019). In many contexts, abstinence is emphasized and information on physiology and reproduction tends to focus more on females, reinforcing the messaging that girls bear more responsibility for averting unintended pregnancy and for avoiding sex altogether (Francis and DePalma, 2015, Shefer et al., 2015). 8 Eswatini, Lesotho, Madagascar, Malawi, Mozambique, United Republic of Tanzania and Zambia in ESA and Ghana and Nigeria in WCA 2.4 Delivery Teacher preparedness & capacity building Preparing and building the capacity of teachers in order to provide high quality CSE is critical. In fact, school-based programmes taught by poorly prepared teachers could be detrimental, delivering information that is inaccurate or reproducing values and attitudes that silence discussions of gender, sex, sexuality and rights. Teachers are embedded in the larger culture of their school and community. Strongly influenced by social norms and their own experiences, teachers bring their personal views into the classroom, and often feel uncomfortable, ill-prepared, judgmental or defensive about sexuality education. For example, studies from South Africa and Chile caution that the very subjects intended to challenge gender norms and practices, may actually reinforce them by emphasizing abstinence and conveying moralistic and negative messages about sexuality (Ngabaza et al., 2016, Shefer et al., 2015, UNESCO, 2019b). Taking into account the importance of the social norms that exist around sexuality education and working through teachers’ own views and possible biases are important parts of training and capacity building. According to NCPI data, of the 130 countries that responded in either 2019 or 2017, 75 per cent reported they had education policies in teacher training that guides the delivery of life skills based HIV and sexuality education according to international standards (Figure 13). In the 2019-2020 Survey on the Status of CSE, about two- thirds of countries (40/59 countries) reported that teachers are required to have training in sexuality education before teaching the subject in school, and about the same number of countries reported the existence of teacher training programmes/curricula for sexuality education. There are two kinds of training for teachers: pre-service (educational courses taken before entering the classroom full-time); and in-service training, or continuous professional development. Worldwide, in-service training on CSE appears to be more common than pre-service, but many countries have plans to increase the latter. Although many teacher-training initiatives are in place, appropriate preparation on sexuality education for teachers is often considered lacking (UNESCO and Guttmacher Institute, 2019, O’Brien et al., 2020). From a regional study in SSA, 9 of 32 countries8 report having curricula for teacher education, although adequate teacher preparation was found to be lacking (UNESCO, 2018). In a recent study conducted by UNESCO in Zambia and Uganda, many teachers reported that despite some training, they still felt embarrassed and uncomfortable in discussing certain topics due to their personal values, norms and cultures around sexuality (UNESCO, 2021). Kwame Amo/Shutterstock.com The journey towards comprehensive sexuality education 33 http://Shutterstock.com In Nigeria, time was deemed important for a residential training that enabled teachers to reflect critically, and to practice new participatory teaching methods. Given the challenge of removing teachers from the classroom for long periods of time, this suggests the need to explore different ways to build teacher capacity, such as classroom support, mentoring and additional learning resources (Wood et al., 2015). Case study 9 TEACHER TRAINING COLLEGES AS CENTRES FOR EXCELLENCE IN CSE TEACHER TRAINING Taking advantage of a national curriculum revision, CSE was incorporated into the curriculum in Zambia in 2013, and rolled out nationally in 2014. Currently, sexuality education reaches two million primary and secondary students throughout the country (Ministry of General Education, 2020). Students in grades 5-12 receive scientific and age-appropriate, culturally acceptable sexuality education that is examinable and is integrated into several different classes, such as integrated science, biology, religious studies, social studies, civic education and home economics. To ensure quality of delivery, a strong focus has been placed on teacher training. A cascade model for providing in-service training to teachers was initially put into place, consisting of training trainers at the national and provincial levels, who, in turn, trained teachers at the district and school levels. Although this model yielded positive results in some provinces, an evaluation discovered that it led to uneven training, with teachers from some provinces receiving shortened, insufficient and incomplete training. Thus, a new training model was developed in 2019, utilising teacher training colleges as education hubs. These colleges, which are also responsible for delivering pre-service teacher training, are considered ‘centres of excellence.’ Under this new training model, the colleges provide first-hand information to teachers through a five-day sexuality education training, which aims to impart skills acquisition, confidence and refined participatory methods. Well-trained teachers under the cascade approach serve as role models and resources for these training hubs. Four components are deemed central to this model: 1. Master trainers at these hubs are charged with training teams of teachers from a school, enabling groups of teachers from the same school to support one another. 2. Each of the five colleges has a civil society organization providing technical support. 3. A separate independent monitoring institution has been engaged to assess the quality of training delivered to teachers at the college hubs, as well the quality of CSE delivered to learners at schools. 4. There is buy-in and support from other ministries and groups, such as the health ministry and civil society, which was established from the beginning and enables national roll out of the programme. Although COVID-19 delayed the planned launch of the training in April 2020, the first training started in August 2020, and is concentrating on five of the country’s ten provinces. The plan is to use this new innovative approach to train relevant teachers in the five target provinces from the country’s 10,000+ schools by 2023. In Asia and the Pacific, two-thirds of countries (22/28 countries) reported the existence of training for teachers in sexuality education, and 23 countries reported that resources and teaching guidelines are available. Also, in-service training is more common in the region than pre-service training (UNFPA et al., 2020a). However, countries noted the challenges teachers face in providing sexuality education due to concerns regarding parent and community member views, as well as personal discomfort. Thus, although most countries reported providing some sexuality education training to teachers, findings indicate that this may be inadequate and a number of barriers may prevent effective delivery (UNFPA et al., 2020a). Innovative approaches to teacher training have been developed, such as the online You&Me education platform in China, which provides free-of-charge support to interested educators with basic teaching skills to conduct sexuality education, as well as access to a range of resources. According to a LAC review, based on a survey of key informants, five countries in the region offer pre-service training. Regarding in-service training, three countries consider it to be ‘advanced’, six ‘medium’ and seven ‘initial’. The lack of teacher training was third in a list of obstacles identified by country respondents (UNFPA, 2017b). In ECA, the report found that teachers in most countries have not been ‘sufficiently’ trained. Finland and Estonia stand out for institutionalising sexuality education into pre- service teacher education, or for incorporating it into the curriculum of teaching- training colleges. In Finland, many health educators specialise in sexuality education. Estonia plans to train all teachers through their university courses, and currently half of the sexuality education teachers have participated in post graduate courses (Ketting and Ivanova, 2018). Bulgaria currently trains some portion of teachers through NGO-run pilot programmes, but is trying to move towards a mandatory pre-service training system (Ketting and Ivanova, 2018). Armenia, Belarus, Kyrgyzstan and Ukraine are on the way to incorporating sexuality education © UNESCO/Remmy Mukonka The journey towards comprehensive sexuality education 34 (within wider health education or in a healthy lifestyle context) into postgraduate teacher training programmes (Yepoyan, 2020). Case study 10 DEDICATED LIFE SKILLS EDUCATION TEACHERS TO ACHIEVE COVERAGE IN NAMIBIA What began as an HIV-focused school curriculum in Namibia has evolved into a holistic programme on health and well- being, encompassing such topics as puberty, gender and gender-based violence. Education Management Information System (EMIS) data from Namibia shows that in 2019, about 97 per cent of Namibia’s schools taught life skills education to grade 4-12 learners, which includes the themes of career guidance, holistic wellness (including sexuality education), and civic education. That year, sexual and reproductive health was covered in 87 per cent of the schools, while HIV transmission and prevention were included in 90 per cent (Ministry of Education Arts and Culture, 2020). The country has shown its commitment to life skills education through a policy implemented in 2011 that requires schools of more than 250 learners to have a dedicated life skills teacher. This initiative was started by the Ministry of Education, to ensure that life skills is given the attention it deserves. Currently, there are approximately 2,000 full-time life skills teachers who have received ongoing training. The percentage of trained life skills teachers in the classroom increased from 42 per cent in 2017 to 70 per cent by 2019 (Ministry of Education Arts and Culture, 2020). Because life skills education has been integrated into the curriculum and there are specific teachers explicitly trained to deliver it, the topic has been given attention, recognition and legitimacy in communities. These efforts have also contributed to more active involvement of parents in life skills education. Between 2017 and 2019, the percentage of schools that held orientation sessions for parents and tutors rose from about 25 per cent to almost 32 per cent in 2019 (Ministry of Education Arts and Culture, 2020). Case study 11 SCALING UP TEACHER TRAINING IN KYRGYZSTAN Teacher training in CSE has become a priority in Kyrgyzstan in recent years. While sexuality education was first introduced in 2014 for grades 6-11 as part of Healthy Lifestyle obligatory homeroom classes (10 hours per year), teacher preparation was limited and covered only a fraction of schools. In 2017, large-scale training of teachers began after the Ministry of Education and Science of Kyrgyzstan issued a directive to organize seminars on healthy lifestyle and HIV prevention for teachers across all regions. A training manual and educational videos were produced. National trainers were trained, who then delivered training directly to teachers in six major cities around the country. Implementation and coordination of the training activities were carried out by Arabayev’s State Teacher Training University and supported by the Ministry of Education and Science, UNESCO and UNAIDS. Training expanded between 2017 and 2019, and a total of 600 teachers from 207 schools in the capital and in all regional/provincial cities have been trained by national trainers. A four-day training includes interactive teaching-learning approaches such as group discussion, brainstorming, role play, and situation modelling. During the seminars, the teachers plan and practice their own lessons and improve their teaching skills benefitting from feedback from the trainers. Positive results are evident in terms of student learning outcomes. For example, after the first year of implementation, a survey conducted in several schools found that HIV awareness had increased among students by 18 per cent, up to 95 per cent, and healthy lifestyle awareness had improved by 20 per cent, reaching 76 per cent. In a 2019 survey of 757 young people in grades 9-11, students who had regular classes on health education provided 30 per cent more correct answers to questions on content than those who did not (UNESCO IITE, 2019).  In 2018, it was decided that teaching of Healthy Lifestyle would be included in the compulsory curriculum for pre-service teachers, which provides a systematic way for training health educators. Positive outcomes also triggered the Ministry of Education to renew its decision and issue another decree in 2018 making it mandatory for all schools in the country to deliver Healthy Lifestyle homeroom lessons and report on this annually to local educational authorities by sending brief reports to the Ministry of Education focal point.  In 2020, the situation has been complicated by school closures due to COVID-19, but the Ministry of Education has decided to produce video lessons for all subjects, including Healthy Lifestyle homeroom classes, which are currently under development with support from the UNESCO Institute for Information Technologies in Education (IITE). Vladimir Tretyakov/Shutterstock.com The journey towards comprehensive sexuality education 35 http://Shutterstock.com Availability of teaching & learning resources Teacher preparation and support can be enhanced with the provision of quality teaching and learning support tools, but the availability of such materials varies widely. Teaching and learning materials can range from activity guides or short videos, to fully scripted lesson plans, as are currently being trialed in South Africa. Such resources should always be developed and distributed alongside training efforts to ensure that teachers build the skills and confidence to apply them in the classroom. The majority of countries (51/57) from Asia and the Pacific, SSA and LAC responding to the 2019-2020 Survey on the Status of CSE said that teachers have access to education materials and teaching guidelines (sometimes including online resources) to assist them with delivering sexuality education, although they were not asked to provide an analysis of quality. Case study 12 SCRIPTED LESSON PLANS SUPPORTING TEACHERS IN SOUTH AFRICA In South Africa, sexuality education has been part of the curriculum since 2000 and is integrated into the subject Life Orientation for learners in grades 4 to 12. In 2015, the Department of Basic Education (DBE) developed scripted lesson plans to support teachers in the delivery of sexuality education. The lesson plans were developed consulting closely with the revised UN ITGSE and aim to aid teachers to address a range of important topics in a systematic manner. The scripted lesson plans guide educators to plan and deliver lessons and empower them to discuss topics that might otherwise be found to be uncomfortable. The scripts describe each activity, the materials needed, instructions on how to complete the activity, the duration of the activity, the information to be presented, and the points that should be emphasized. The core aim of the scripted lesson plans is to ensure that teachers can help learners build an understanding of concepts, content, values and attitudes related to sexuality and sexual behaviour change as well as leading safe and healthy lives. They have been introduced alongside teacher training to build teacher skills and confidence to deliver sexuality education. The tools were implemented in a phased approach, initially in five provinces conducted between 2016 and 2018, and then scaled up into further provinces and districts in 2019. Teachers are trained on the use of the scripted lesson plans, which are aligned to the Life Skills and Life Orientation Annual Teaching Plans. A key strategy in introducing these new materials was the arrangement of district-level meetings to sensitize parents to the rationale and content of the curriculum materials. In 2019, the DBE published the materials online.9 This has helped to reassure parents and others who had misconceptions about the content of the curriculum (South African Government, 2019). 9 https://www.education.gov.za/Home/ComprehensiveSexualityEducation.aspx The LAC regional review reported that more than two-thirds of countries had developed specific teaching tools (UNFPA, 2017b). However, in a different study, in Guatemala and Peru which surveyed teachers directly, roughly 75 per cent reported that they lacked materials, suggesting that even where tools exist, they may not be distributed across the country (UNESCO and Guttmacher Institute, 2019). There are many examples of high quality teaching and learning resources. For example, Bosnia and Herzogovina has created a teachers’ manual to help teachers respond to questions that might arise in the classroom (Rogow, 2015). In 2018, Ukraine developed new guidelines for teachers to support them to better address sexuality education topics (UNESCO IITE, 2020). Finally, digital technology can supplement face-to-face teacher-training. Online training and support for teachers is increasingly used by both government and NGOs. For example, in 2015, a new online teacher training programme was rolled out in ESA. This programme, with support from USAID in collaboration with UNESCO and UNFPA, and run by South Africa’s Foundation for Professional Development with the support of the Medical Practice Consulting, has trained over 7,500 teachers in 21 countries (UNESCO, 2017b). This platform has also been adapted and put into use for teacher training in Nigeria. In Argentina, Facultad Latinoamericana de Ciencias Sociales (FLACSO) have partnered with UNFPA and UNESCO in the Latin America region to develop an online Higher Diploma in Comprehensive Sexuality Education targeting teachers and other educational professionals. Anecdotal reports, as well as the emerging evidence base on the efficacy of online teacher training, shows mixed results (Becker et al., 2014, Wuryaningsih et al., 2019, Mohammadyari and Singh, 2015). The use of digital platforms can be useful to complement face-to-face interactions but are not always effective as a standalone solution (UNESCO, 2017b). franco lucato/Shutterstock.com The journey towards comprehensive sexuality education 36 https://www.education.gov.za/Home/ComprehensiveSexualityEducation.aspx https://www.education.gov.za/Home/ComprehensiveSexualityEducation.aspx https://www.education.gov.za/Home/ComprehensiveSexualityEducation.aspx http://Shutterstock.com Case study 13 CAMEROON’S JOURNEY TOWARDS HOLISTIC SEXUALITY EDUCATION In the WCA region, Cameroon is a pioneer in sexuality education (currently called ‘Education Sexuelle Intégrée’ (ESI), or ‘Holistic Sexuality Education’) and has been at the forefront promoting a national curriculum and teacher training programme which has subsequently been adapted by several other central African states. During 2006-2007, teaching content and curricula were developed, along with teacher manuals. National-level workshops and campaigns for teacher training were also held, supported by UNAIDS and other UN agencies. Cameroon made an inter-ministerial decision to institute a national sexuality education curriculum in 2007. Teacher training was initially carried out using a traditional cascade, or ‘training of trainers’, approach. Although this method reaped benefits, it was costly, and training all teachers would have taken several years. As a result, Cameroon digitalised its teacher training tools onto DVD. As some schools did not have reliable electricity, delivery via DVDs was complemented by radio broadcasts. An important feature of this programme is that it included training of school directors, inspectors, managers and decision-makers, and involved them as supervisors and resource people. These digitalised training tools made it possible to achieve significant reach in a relatively short period of time. While progress has been made, there have also been challenges. In many cases, Integrated Sexuality Education is still considered a standalone ‘project’ that is not fully integrated into the reality of classroom teaching. In addition, while digitalised teacher-training tools have enabled wide reach, there has not been an evaluation of outcomes. Finally, while at a policy level there is much enthusiasm and open discussion about sexuality education, this has not been the case at a local level, where there has been more reluctance to embrace it. To address this challenge, substantive work has been initiated by UNESCO to involve and inform key actors in the communication sector. This includes a platform for journalists and influencers to exchange information related to sexuality education, and a network of community radio stations that helps reduce misinformation on the subject. Case study 14 ENSURING TEACHERS HAVE THE RIGHT SUPPORT TO DELIVER SEXUALITY EDUCATION IN CHILE Two studies were carried out in Chile, supported by UNESCO, that highlight the importance and value of targeted teaching support for CSE. In the first study, in 2017, teachers from various schools and grade levels were asked to design and plan a class based on learning objectives from the revised UN ITGSE. The study found that teachers struggled to produce a quality teaching plan, they relied on the more comfortable lecture style of teaching, and the majority avoided sensitive topics, such as gender, diversity and sexual violence. The study identified the clear need for teacher support (UNESCO, 2019b). Based on these findings, in a second study in 2019, teachers were again asked to design and plan a class, but materials and support from the research team were provided. Teachers worked to design and evaluate the material and continuous improvements were made. Here, it was noted that content and classroom materials were aligned more with the technical guidance rather than teachers’ preferences. Not only did the teachers no longer avoid the more complex issues, but a strong concern for incorporating gender perspectives was observed in the majority of the classes, although this could also be related to the impact of the feminist movement occurring in Chile in 2018 and its repercussions in the school system (Reyes, 2019). The findings suggest that despite a conservative context, if teachers have the necessary preparation and access to resources and materials, they have little difficulty in facilitating participatory learning and addressing controversial issues related to relationships and sexuality. Recently, a total of 32 teaching guides have been developed, one for each key concept from the revised UN ITGSE in each of the four age groups. For the dissemination of these guides countrywide, a web platform and videos are being prepared, which include testimonies from the participating teachers and clips of the observed classes. The teaching guides are especially relevant for the Latin American context, although they can easily be adapted across different settings. davide bonaldo//Shutterstock.com studiolaska/Shutterstock.com The journey towards comprehensive sexuality education 37 http://Shutterstock.com Quality of teaching While a quality comprehensive curriculum is central to ensuring that a range of topics is covered within sexuality education, it is also vital that teachers are delivering a breadth of content in the way that it is designed to be taught. Like other forms of transformative education, to be effective, CSE relies on the use of transformative pedagogical approaches. Even where quality curricula exist, if teachers are unable to deliver content well and with fidelity, quality will suffer. While teacher training is being strengthened in some settings which is promising, there is evidence that many continue to lack the knowledge, skills and confidence to deliver across diverse topics within sexuality education (e.g. UNESCO and Guttmacher Institute, 2019). A variety of research highlights a gap that exists between the curriculum content and what is delivered in the classroom. For example, in 2013 Ireland developed a programme on Growing up LGBT as a resource in the sexuality education programme, but a 2017 survey found a perceived absence of inclusive and relevant sexuality education in schools (Nolan, 2018).  Studies incorporating the perspectives of students give a useful insight on what is being taught. In Ghana, while the teachers surveyed rated the comprehensiveness of the topics being taught as ‘high’ in 83 per cent of schools, only 8 per cent of students judged the comprehensiveness to be ‘high’ (Awusabo-Asare et al., 2017). A study in Peru found that only 9 per cent of students said that they had been given instruction in all 18 topics that would be considered comprehensive (Motta et al., 2017). In Zambia, the newly revised sexuality education curriculum rolled out in 2014 was designed to be gender-responsive, although a study found that learners reported that they were missing any content on gender equity, suggesting a gap between what is in the curriculum and what is being delivered (ICF, 2018). Many studies have looked at factors impeding the quality of sexuality education from the perspective of teachers, with common barriers identified. These include school-level elements affecting programme fidelity, such as inefficient time allocation within the school timetable, lack of planning of lessons, lack of available teacher time, lack of availability of materials and computers, negative attitudes of staff and in some cases, fear of backlash from parents or other teaching staff (Vanwesenbeeck et al., 2016, UNESCO and Guttmacher Institute, 2019). Case Study 15 ARMENIA’S JOURNEY TOWARDS AN INTEGRATED MODEL OF SEXUALITY EDUCATION Over the last 20 years, sexuality education in Armenia has evolved from being an experimental and optional subject to becoming integrated across a range of mandatory subjects. Armenia’s journey highlights the importance of finding the right ‘home’ for sexuality education within the curriculum, and reveals challenges around ensuring adequate teacher preparation. In 1999 Armenia introduced an experimental life skills curriculum for grades 1-7 as a stand-alone, optional subject. Topics included healthy living, personal hygiene, gender, respecting diversity, safety, avoiding substance use and conflict resolution. In 2008-2010, the life skills curriculum was replaced by Healthy Lifestyle, and integrated into mandatory subjects for grades 1-4 (“Me and the surrounding world”) and grades 8-11 (Physical Education). These developments led to the delivery of sexuality education across most year groups and in all schools across the country. However, a 2016 review pointed to a range of concerns, mainly relating to a lack of monitoring and evaluation and limited teacher training or follow-up support (Mkhitaryan, 2016). In 2017-2019, with support from UNESCO and in cooperation with the Ministry of Education, Science, Culture and Sports and the Ministry of Health the Healthy Lifestyle curriculum was revitalised by a team of national experts from the Institute of Child and Adolescent Health and the National Education Institute. As well as revising and distributing the teacher guide, this encompassed rolling out a large-scale teacher preparation programme. Ten educational videos on sexuality education-related topics were developed to support teachers, and a website was created targeting teenagers, both of which were endorsed by the government as supplementary resources. Evaluation demonstrated an average 20 per cent increase in teachers’ knowledge of the subject matter. However, it also found that some teachers still felt uncomfortable discussing certain topics, and said that they would prefer a school nurse to deliver these topics (Institute of Child and Adolescent Health, 2019). More recently in 2020, as part of broader curriculum reforms, Armenia started to move from a stand-alone approach to Healthy Lifestyle, taught mostly by physical education (PE) teachers, to an approach where sexuality education is interspersed into core subjects in natural and social sciences and PE. This change was partly to enable sexual health and other more complex topics to be imparted by natural and social science teachers, in addition to content taught by PE teachers. Having faced challenges in integrating health education content fully into core subjects with limited space and other competing priorities, particularly at secondary school level, a decision was made early in 2021 to introduce in grades 5-10 obligatory Healthy Lifestyle club activities which will accommodate the most critical sexual and reproductive health and relationships topics and provide more interaction between teachers and learners for interpersonal and social skills building. It should be noted that there is clear commitment to sexuality education by the government, which in May 2020 ratified the Lanzarote Convention making it mandatory for the state to provide children with information on the risks of sexual exploitation, on sexual abuse and where appropriate, on sexuality (Council of Europe, 2020). The journey towards comprehensive sexuality education 38 https://rm.coe.int/protection-of-children-against-sexual-exploitation-and-sexual-abuse/1680794e97 Participatory, learner-centred methods It is well recognized that participatory, learner-centred methodologies are critical to effective sexuality education. Of 56 countries from Asia and the Pacific, SSA and LAC that responded to the 2019-2020 Survey on the Status of CSE, 38 per cent said that they use participatory teaching methods (e.g., group work, role plays, discussions, creative learning) in teaching sexuality education, 21 per cent use lecture-based classroom teaching and the remaining 41 per cent said they use a mixed-approach utilising lecture-based formal classroom teaching, participatory teaching, peer education (i.e. learning from peers) and self-learning activities. Figure 12 Sexuality education teaching method, as reported by survey respondents Mix Lecture-based, formal classroom teaching Participatory teaching 41% 38% 21% Data source: 2019-2020 Survey on the Status of CSE. These results, often collected at national level without specific surveys among schools or teachers, provide evidence that countries may be progressing in the use of, or the intention to use, varied teaching methodologies. However, other studies show a more mixed picture, finding that the lecture format dominates teaching across regions, especially where it is integrated across a range of subjects (UNFPA, 2017a, Irvin and Trang, 2018, Keogh et al., 2019). Country- level studies in SSA found that participatory methods are rarely used, in part due to the lack of time in the teaching period as well as the number of learners per class. Also, teachers often turn to lecturing because they don’t feel equipped to handle questions or comments that might arise from more participatory models (Jimmyns and Meyer-Weitz, 2020, Keogh et al., 2018). Studies in Ghana, Kenya, Mongolia, Viet Nam, Guatemala, and Peru show a tendency to focus on knowledge rather than skills and attitudes (UNFPA, 2017a, Irvin and Trang, 2018, Keogh et al., 2019). Teachers in Viet Nam, for example, reported that they felt uncertain about how to teach sexuality education and how to handle classroom situations. Furthermore, they tend to prescribe values for students, rather than using participatory methods to help them think critically and independently about their own values (Irvin and Trang, 2018, UNESCO, 2019b). A regional report in LAC from 2017 found that more than half of the countries predominantly use a lecture methodology. Only Uruguay reported using mostly participatory methodologies (UNFPA, 2017b). It has been suggested that the approach in the region is often prescriptive, without providing students with opportunities for critical reflection or for applying the new knowledge to daily life experience (UNESCO, 2017a). In ECA, there are some good examples of participatory approaches. For example, Finland’s national curriculum includes student research projects, which require information-gathering, critical thinking and problem solving, as well as input into course content (Ketting and Ivanova, 2018). Armenia also provides an example of participatory models of teaching, using self-learning activities, interactive discussions, case studies, personal reflection and student presentations (Mkhitaryan, 2016). Frequency and time International guidance stresses the importance of the regularity of delivering sexuality education, as well as the fact that learners require sufficient time to process new information and develop skills. Little information has been reported by countries about the frequency and total hours of sexuality education teaching. The integration of sexuality education components into numerous subjects makes it difficult to calculate and each institution needs to make practical decisions based on their overall curriculum planning. Some examples of time allocation in SSA show, for example, that in Botswana, the average is 40 minutes per week (UNESCO, 2017b), and in Zimbabwe, it is 35 minutes per week (Gudyanga et al., 2019). In Namibia, one 45-minute period per five-day cycle is dedicated to sexuality education for grades 4-7, which increases to two 45-minute periods per seven-day cycle for grades 8-12 (UNESCO, 2017b). Ghana dedicates a total 90–105 minutes per week (Awusabo-Asare et al., 2017). Regardless, many teachers and students have stated that the time and duration is insufficient. In LAC, countries identify time limitations as one of the greatest barriers to delivering sexuality education (UNESCO, 2017a). A report on eight countries in the Dutch and English-speaking Caribbean asserts that most offered one-to-two sessions per week (UNFPA, 2018). In ECA, Armenia is currently integrating health education content into core subjects and is trying to determine how to do this within limited learning hours, particularly at secondary school level. Assessment of learning Ensuring that sexuality education is assessed in a structured way is important to monitoring learning outcomes. In addition, including some level of assessment is likely to enhance the status of CSE in line with other subjects (UNESCO and Guttmacher Institute, 2019). Whether or not learners are formally assessed on sexuality education varies tremendously and can be difficult to discern. The journey towards comprehensive sexuality education 39 As in other regions, reports from SSA stress that when students are assessed, it tends to be on knowledge rather than on skills and attitudes, which are typically much harder to assess (Awusabo-Asare et al., 2017). A four- country study in Africa and Latin America again shows a mixed picture. In Ghana and Kenya, the majority of both teachers and students claimed that year-end examinations and ongoing student assessments include sexuality education, although this was much lower in Guatemala and Peru (UNESCO and Guttmacher Institute, 2019). In Asia and the Pacific, a majority of countries reported that the sexuality education curricula or its integrated subjects include some level of assessment and/or examination for students. However, it is unclear as to whether these were continuous (UNFPA et al., 2020a). Thailand stands out as having an examinable curriculum, although this is through mid- and end-year exams that do not evaluate critical thinking skills (UNICEF, 2017a). In the LAC region, information is limited, but at least four countries (the Plurinational State of Bolivia, Cuba, Mexico, Uruguay) have indicators for student achievement in some aspect of sexuality education, covered within other core subjects, within national monitoring systems (UNFPA, 2017b). The ECA review found that CSE is often not assessed or examinable (Ketting and Ivanova, 2018). The Department of Education in England (United Kingdom), for example, suggests that schools should assess sexuality education, but does not require any formal examination (Department for Education, 2019b). In Belgium, new goals were set in September 2019 that are not based on teachers, but on students, who will be measured by the school inspectorate (Magits, 2019). Health education in Finland is included in the national matriculation examination at the end of secondary school, which aims to measure whether students have assimilated the knowledge and skills required by the curriculum. Since 2016, the online examination includes essay and multiple-choice questions, drawing assignments and data analyses (Sormunen, 2019). As the important role of schools in delivering health and well-being interventions, including CSE, is increasingly recognized, there are strong calls for the inclusion of health and well-being indices in international metrics of school performance (Bonell et al., 2012, Bonell et al., 2014). It is hoped that this will lead to recognition within school systems of the importance of assessment of learning within subjects such as sexuality education. Given the necessary focus on skills-based learning, countries need to move beyond traditional examinations to include both formative and summative assessments (UNESCO, 2019a). Monitoring sexuality education Regular and structured monitoring of sexuality education programmes is necessary to track the progress of implementation and to facilitate decision-making. In recent years, a range of assessment tools have been developed and indicators proposed, which together can start to paint a picture of the status of CSE globally. For example, Sustainable Development Goal (SDG) Thematic Indicator 4.7.2 provides quantitative information about how many schools are implementing life skills-based HIV and sexuality education. The Sexuality Education Review and Assessment Tool (SERAT), developed by UNESCO, uses a participatory process to collect information across a number of domains, generating a range of scores across the areas of policy, curriculum and delivery considerations. The NCPI measures progress in the development and implementation of national-level HIV and AIDS policies, strategies and laws. At a national level, since many countries already use an Educational Management Information System (EMIS) or similar administrative databases to compile national data, it is important for sexuality education to be included as an indicator in a country’s EMIS or routine data collection mechanisms. In some countries, education level monitoring may form part of a wider health intervention such a multi-sectoral HIV response. According to UBRAF 2019 data, 20 out of the 33 UNAIDS ‘fast-track’ countries (those with high HIV burden, and intensified response) report having integrated the core indicators for measuring the education sector response to HIV and AIDS in national education monitoring systems, in line with the recommendations of the Inter-Agency Task Team (IATT) on Education (UNESCO, 2013). In SSA, all ESA countries except one have integrated at least one HIV and sexuality education indicator in their EMIS (UNESCO, 2018). Zambia was the first country to include in the EMIS all the globally recommended indicators for HIV, including sexuality education, and trained standards officers to monitor implementation. Nonetheless, the lack of timely feedback mechanisms has meant that opportunities to use data to improve the delivery of sexuality education have been missed (ICF, 2018). Despite progress made in the SSA region, monitoring systems are weak overall (UNESCO, 2018). According to the 2019-2020 Survey on the Status of CSE, more than half of the countries (25/45) reported that the national EMIS tracks the delivery of sexuality education. Monitoring at the school level also has its challenges. The four-country study in Africa and Latin America reveals confusion about who is responsible for monitoring sexuality education teaching, with some principals saying they see it as the role of the central government and others saying that schools are responsible (UNESCO and Guttmacher Institute, 2019). The journey towards comprehensive sexuality education 40 In Asia and the Pacific, although some countries reported including sexuality education indicators in their EMIS, most ministry of education survey respondents were unsure or did not know whether this was the case or not (UNFPA et al., 2020a). This a telling sign of EMIS’ limited existence in the region. In LAC, monitoring and evaluation (M&E) of programme implementation is a continuing area of weakness. Nearly half of the countries in the region lacked M&E systems, although a 2017 report noted that there had been some improvement in monitoring systems since 2013 (UNESCO, 2017b). In the English and Dutch speaking Caribbean, systematic M&E was identified as a major gap (UNFPA, 2018). The ECA review reported that less than one-third of the countries had established an M&E system for sexuality education. Four have a partial system in place and another eight have nothing (the remaining four do not have an official sexuality education curriculum). In England (United Kingdom), Relationships and Sex Education is one of the topics included for review by the national inspecting body (Sex Education Forum, 2020). 2.5 Enabling environment An enabling environment is critical for effective delivery of CSE. This includes a supportive school setting through its policies and ethos, and also an informed and engaged wider community. CSE needs to be understood by different stakeholders, such as parents, community members and religious leaders and politicians, in order to promote comfort and understanding of what can be a sensitive topic. In addition, an enabling environment for good health that goes hand in hand with CSE, is reflected in youth- responsive access to health and social services, including sexual and reproductive, and child protection services. School environment It is well recognized that curriculum interventions are more effective when they are delivered in a safe and supportive school environment and accompanied by other interventions that make up a ‘whole school’ or ‘whole education’ approach. Such an approach recognizes the multiple actions and interventions within the school that complement each other. Alongside teaching of comprehensive curricula, this may include the use of gender transformative pedagogy, school policies and rules that prevent violence, including bullying. It can also promote a sense of ownership among varied stakeholders by linking with parents, health providers and the broader community (Vanwesenbeeck et al., 2016). More recently the term ‘whole education approach’ emphasizes the importance of strong leadership and guidance at a policy level, providing the mandate and expectation that schools will implement curricula and accompanying interventions. Policies for a safe school environment are an important starting point. In SSA, six countries report having a policy on school safety, non-discrimination, or related issues (UNESCO, 2018). An example of a government tackling school violence is the Ministry of Education, Culture and Research of the Republic of Moldova, which in 2017 developed a ‘Code of Conduct’ for teachers and, with UNESCO support, provided all schools in the country with guidelines on violence prevention and child protection. This includes a practical toolkit for teachers, a methodology for identifying and responding to cases of violence, including bullying, and tips for eliminating discrimination due to HIV (Schools for Health in Europe, 2019). Case Study 16 A COMPREHENSIVE TOOL FOR REVIEWING SCHOOL-BASED SEXUALITY EDUCATION The Sexuality Education Review and Assessment Tool (SERAT) is designed to support the review of all aspects of national- level school-based sexuality education programmes. SERAT’s principal benefit is that it enables countries to identify and discuss the strengths and weaknesses of their sexuality education programmes, making it a useful tool for country self-reflection. To ensure the most effective results, SERAT should be completed through a multi-stakeholder participatory process, which normally entails designating an external person with expertise in CSE to facilitate the process. The tool is considered valuable for understanding the status of country-level sexuality education programmes and for informing joint decision-making when several partners need to agree on priorities. It can also be used to make comparisons among programmes within and between countries when the same team of experts carries out the studies. Originally developed in 2012, and recently updated to reflect the revised UN ITGSE the tool includes questions that assess the status of CSE in such areas as the legal and policy context, curriculum content by age group, integration into the national curriculum, teaching and learning, teaching training, and monitoring and evaluation. Results are presented in colour-coded, visual bar charts, which are automatically created to provide an immediate picture of areas of strength and areas needing improvement. SERAT has been instrumental in reviewing and guiding investment in CSE across over 50 countries and continues to be one of the most comprehensive tools for assessing the strength of national level programmes. For example, SERAT was used in Cameroon to assess progress towards CSE. The process uncovered the strength of teaching training, but pointed to the need for more interactive teaching and learning skills and techniques. In order to overcome this, a pedagogical guide including interactive skills was piloted in Cameroon, and curriculum reform has led to the inclusion of skills-based approaches and interactive activities in primary and secondary schools. SERAT is available online in English, French and Russian1. 1 https://healtheducationresources.unesco.org/library/documents/sexuality-education-review- and-assessment-tool-serat The journey towards comprehensive sexuality education 41 https://healtheducationresources.unesco.org/library/documents/sexuality-education-review-and-assessment-tool-serat https://healtheducationresources.unesco.org/library/documents/sexuality-education-review-and-assessment-tool-serat https://healtheducationresources.unesco.org/library/documents/sexuality-education-review-and-assessment-tool-serat Engaging parents and caregivers Parents and other caregivers play a central role in the lives of children and young people, and can be a powerful force supporting or opposing sexuality education in schools. Teachers cite fear of parental opposition as a reason they hesitate to teach sexuality education, but some evidence reveals that parents are often supportive. For example, the four-country study in Africa and Latin America found that more than 90 per cent of students say their parents support sexuality education in schools, yet teachers perceive much less parental support (UNESCO and Guttmacher Institute, 2019). In a survey on barriers to implementation of sexuality education in Latin America, family opposition was named as a low barrier, coming in at tenth place out of 11 identified obstacles (UNFPA, 2017b).  The literature provides many accounts of efforts to reach out to parents and caregivers to build support for sexuality education. Twelve ESA countries report that they had provided parent communication programmes, many of these countries adapting and rolling out the Our Talks programme, with support from UNESCO or the Let’s Chat programme with support from UNFPA. In Zambia, head teachers were trained to work with parent teacher associations (PTAs) to provide educational sessions with parents (ICF, 2018). In WCA, Ghana and Côte d’Ivoire reported conducting sensitisation forums or parent communication programmes (UNESCO, 2018). In India, in selected schools, some 78 per cent of the teachers and 80 per cent of the principals report that parents get involved in the sexuality education programme (UNESCO et al., 2017). The governments of Uruguay and Argentina have produced materials for children to take home to their families, clarifying doubts about content and serving as educational resources (Vanwesenbeeck et al., 2016). Austria has a system of ‘parent-teacher conferences’ to keep parents involved. In the Ukraine, sexuality education topics are part of a plan for working with parents, and the IPPF member association supports teachers in this area (Ketting and Ivanova, 2018). Access to sexual and reproductive health services CSE is one component of a broader essential package of sexual and reproductive health and rights (SRHR) interventions to achieve Universal Health Coverage (UNFPA, 2019, Engel et al., 2019). CSE ensures adolescents and young people have information and skills to seek help for a range of issues related to their sexual and reproductive health and relationships. As such, efforts to scale-up CSE need to be partnered with efforts to ensure ready access to a full range of sexual and reproductive health services (including services that are either delivered within schools or linked to schools via referral systems). Only with these efforts will CSE be effective in improving health outcomes such as the prevention of early and unintended pregnancy or the reduction of new HIV infections. Ensuring that services are youth-friendly, as well as fostering close collaboration between schools and health services can improve the effectiveness (and cost-effectiveness) of sexuality education (Apter, 2011, Kivela et al., 2011, Haldre et al., 2012, UNFPA et al., 2016, Kirungi et al., 2020, WHO and UNESCO, 2021 (forthcoming)). Of 28 countries from SSA and LAC that responded to the 2019-2020 Survey on the Status of CSE, the majority of countries reported that students in secondary schools could access individual counselling on issues related to sexual and reproductive health (86 per cent or 24 countries), referral by schools to health clinics (79 per cent or 22 countries) and information about where and how to obtain contraceptives (75 per cent or 21). As with other nationally reported data, these responses may reflect national policy but mask a more complex situation at the school level for learners requesting counselling or referrals to services. A total of 17 ESA countries have set targets for increasing the number of health service points that offer ‘standard, youth-friendly’ services. The number of countries in WCA is lower, with only five countries having established a target for youth-friendly services (UNESCO, 2018). The link between school-based sexuality education and health services has been signaled as a weak area in the region.  Since 2012, 10 Asian countries have built on their national commitments in the context of Family Planning 2020 (FP2020) by investing in rights-based family planning services (UNFPA et al., 2020a). While most countries reported on the availability of SRH services for adolescents, in reality these may not be accessible to all young people. In some countries, services are only accessible to married couples, as seen through survey results from countries such as Indonesia, the Maldives, Pakistan and India (Chandra- Mouli et al., 2018c, Hurley et al., 2017). In the ECA review, 10 of 25 countries offer comprehensive SRH services to young people, another 10 make some services available, but only 3 countries provide free contraception. Five countries fail to provide SRH services to young people at all (Ketting and Ivanova, 2018). Estonia stands out for its efforts to scale-up a small grassroots adolescent SRH initiative to a national programme, alongside scaling up of school-based sexuality education. These simultaneous efforts have been linked to improved adolescent SRH outcomes (Haldre et al., 2012, Kempers et al., 2015). In Estonia and Sweden, secondary school classes regularly visit youth-friendly clinics and get their lessons there, which helps pupils become familiar with a clinic that they may need to access in the future (Ketting and Ivanova, 2018). Efforts to scale-up CSE need to be partnered with efforts to ensure ready access to a full range of sexual and reproductive health services. The journey towards comprehensive sexuality education 42 Case study 17 STRONG MINISTERIAL COMMITMENT TO SCALE UP CSE IN EASTERN & SOUTHERN AFRICA A commitment to the health and well-being of all young people in Eastern and Southern Africa was endorsed and affirmed in 2013 by Ministers of Education and Health from 20 ESA countries. Together they agreed to work collaboratively towards a vision of young Africans who are global citizens of the future, are educated, healthy, resilient, socially responsible, informed decision-makers, and have the capacity to contribute to their community, country and region. The ESA Commitment process was co-led by the East African Community (EAC) and the Southern African Development Community (SADC), with support from UNESCO, UNAIDS, UNFPA and other UN partners. The commitment also drew on the support of Civil Society Organizations (CSOs), and religious and youth leaders. The ESA Commitment has been strategic in bringing together the education and health sectors to secure their commitment towards a common rights-based agenda on the needs and rights of adolescents and young people, in response to the high levels of new HIV infections, early and unintended pregnancy, gender-based violence and child marriage. The commitment called upon sectors to work together on a common agenda for adolescents and young people to deliver CSE alongside adolescent-friendly SRH services, ultimately strengthening national responses and reducing new HIV/ STI infections and unintended pregnancy. A recent report reflecting on the progress between 2013 and 2020 found that while challenges remain - particularly in relation to monitoring and accountability – the ESA Commitment has instigated notable progress, made possible in part by the emphasis on multi-sectoral collaboration between health and education sectors nationally and regionally. It is recognized as a key driver of progress in CSE implementation in the region, with the political momentum it provided leading many governments to scale-up delivery of CSE within the formal school curriculum (Watson et al., 2021). Given the recognized value and success of this commitment in providing a supportive environment for CSE and broader efforts to ensure adolescent SRHR, discussions are currently underway to renew the commitment until 2030, and countries in WCA have expressed the wish to undertake a similar process towards a commitment in their region. Political support and opposition Ensuring that the concept and benefits of CSE are well understood by those in positions of decision-making power, and those with influence over cultural and religious norms in a country, is critical to its effective implementation and sustainability. Across many countries, CSE is already well-recognized as a critical enabler of young people’s education, health and well-being and important to prevent health and social issues, as well as ensure children and young people have the knowledge and skills to engage in positive and healthy relationships. This is reflected in the commitments that governments have made by signing of international and regional agreements, as well as by establishing national policies and laws that mandate delivery of sexuality education. However, CSE includes a range of topics that may be considered sensitive or difficult to discuss in some cultural contexts. In some settings, this, along with misinformation about the purpose and impacts of CSE, has led to opposition from within community, religious or sometimes political settings. This debate (or opposition) has sometimes been substantial, negatively impacting progress. Of 48 countries from Asia and the Pacific, SSA and LAC responding to the 2019-2020 Survey on the Status of CSE, and Europe and Central Asia regional reviews, 40 per cent reported that there are organizations or institutionalized campaigns against sexuality education. In ECA, in nearly half the countries, opposition to CSE is viewed as ‘serious.’ The primary argument driving such opposition is that it will encourage young people to become sexually active at an earlier age, even though evidence shows that this is not the case (Lindberg and Maddow-Zimet, 2012, Kirby, 2009, Kirby et al., 2007). Another criticism leveled at CSE is that parents, not schools, should be responsible for educating their children about these topics (Ketting and Ivanova, 2018). Discussions on culturally inappropriate content can be enough to create political turmoil and stop all initiatives to develop CSE programmes in a country, even those that have been designed to fit the cultural context. In Figure 13 Access to sexual and reproductive services, as reported by survey respondents 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Other SRH services Contraceptives Information about obtaining contraceptives Referr

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