Malta Medical Students Association's
Policy Paper on Comprehensive Sexuality Education
March 2017
Comprehensive Sexual Education Malta Medical Students’ Association Policy Paper
Place:
University of Malta
Date of adoption: 28th March 2017 Date of expiry:
March 2020
Introduction In an era where sex is an icon of the media and used to promote things from franchises to products to services, it is inevitable that what we are exposed to, younger generations may be just as influenced by. Nowadays, children and adolescents are brought up in a culture where sex and sexuality is made apparent to them at a very young age, even if this is not yet a part of their life. Yet simultaneously, sex is indeed becoming a part of the life many youngsters which are progressively decreasing in age; that is, younger and younger individuals are beginning to experiment and engage in sexual activities. This of course, is accompanied by multiple risks having physical, social and psychological implications which the adolescent is more vulnerable to without the proper education, such as pregnancy, HIV and STIs, maternal morbidity and mortality, sexual abuse and relationship breakdown. Therefore, it becomes the responsibility of those educated on the matter, or influential to the youths to ensure that they are made aware of such risks, while fully understanding the importance of doing so. Standardized sex and sexuality education is incorporated into school curricula in most countries; this is significant as it is unwise to leave sexual education to chance. Within a controlled environment such as in a classroom from a qualified teacher, one can ensure that the information is correct and for the most part complete, as opposed to any information which could be encountered on the media, from friends and through experience. This could be done through the
establishment of Comprehensive Sexual Education. Comprehensive Sexuality Education (CSE) is an age-appropriate, culturally relevant approach to teaching about sex and relationships by providing scientifically accurate, realistic, non-judgemental information. Sexuality education provides opportunities to explore one’s own values and attitudes and to build decision-making, communication and risk reduction skills about many aspects of sexuality. The term comprehensive emphasizes an approach to sexuality education that encompasses the full range of information, skills and values to enable young people to exercise their sexual and reproductive rights and to make decisions about their health and sexuality. However the establishment of a standardized education may still vary, as sex and sexuality are viewed differently in various countries, cultures and religions, even though the risks remain constant for each individual. To combat this, it is recommended that students are nonetheless provided with all the necessary facts about safety and respect, albeit accompanied by any cultural and religious guidelines. In addition, encouraging such education attempts to liberate the youth from shame and judgment, as one is allowed to be more open about sexual problems and concerns without fearing punishment for addressing such topics. Youths should be supplied with the necessary skills needed to make smart decisions. An effective sexuality and relationships education programme should therefore aim to help children and young persons to:
develop a positive attitude of sexuality;
be able to communicate about sexuality, emotions and relationships;
develop the necessary skills to make informed and responsible decisions and choices about their sexual behaviour and health;
develop the necessary skills to enter into relationships which are based on mutual respect and understanding for one another’s needs and boundaries;
encourages critical thinking and reflection about gender identities and genderrole stereotyping;
develop acceptance and respect for people with different sexual choices and orientations;
acquire the necessary information that they need to take care of their sexual health;
acquire the necessary information about different types of sexually transmitted infections;
acquire the necessary information about different types of contraception;
acquire the knowledge and skills to be able to identify and access sexual health resources in the community.
(Stephen Camilleri, 2013, GUIDELINES ON SEXUALITY AND RELATIONSHIPS EDUCATION IN MALTESE SCHOOLS, pg6)
An effective sexuality and relationships education programme should tackle topics and themes before the child reaches the corresponding stage of development, to prepare him/her for the changes which are about to take place (WHO;2010, UNESCO;2009). Yet despite this, the situation still does not remain clear cut, as dilemmas arise questioning the age at which such education should begin, and to what degree of detail. Sexuality is understood to be a very personal experience, without requiring participation in sexual activities, making it difficult to generalize at what stage the adolescent is made conscious of this aspect of human nature, and how involved they will be with it in the future. Certain assumptions related to this, lead to a variety of misconceptions about sexual education, which could hinder the communication of proper sexual education. One such false misconception is that sexual education will lead to earlier sexual activity or riskier behaviour, when in fact such programmes have been proven to reduce irresponsible behaviour and evade things such as STIs and unplanned pregnancies. In response to this fear, certain educational systems provide abstinence-only programmes which studies show to be inconclusive or ineffective.
Background Information Comprehensive Sexual Education Worldwide Young people’s access to CSE is grounded in internationally recognized human rights, which require governments to guarantee the overall protection of health, wellbeing and dignity, as per the Universal Declaration on Human Rights, and specifically to guarantee the provision of unbiased, scientifically accurate sexuality education. These rights are protected by internationally ratified treaties, and lack of access to Sexual and reproductive health (SRH) education remains a barrier to complying with the obligations to ensure the rights to life, health, non-discrimination and information, a view that has been supported by the Statements of the Committee on the Rights of the Child, the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) Committee, and the Committee on Economic, Social and Cultural Rights. The commitment of individual states to realizing these rights has been reaffirmed by the international community, in particular the Commission on Population and Development (CPD), which – in its resolutions 2009/12 and 2012/13 – called on governments to provide young people with comprehensive education on human sexuality, SRH and gender equality. There is clear evidence that CSE has a positive impact on sexual and reproductive health (SRH), notably in contributing to reducing STIs, HIV and unintended pregnancy. Sexuality education does not hasten sexual activity but has a positive impact on safer sexual behaviours and can delay sexual debut (UNESCO, 2009). A 2014 review of school-based sexuality education programmes has demonstrated increased HIV knowledge, increased self-efficacy related to condom use and refusing sex, increased contraception and condom use, a reduced number of sexual partners and later initiation of first sexual intercourse (Fonner et al, 2014). A Cochrane review of 41 randomized controlled trials in Europe, the United States, Nigeria and Mexico also confirmed that CSE prevents unintended adolescent pregnancies (Oringanje et al, 2009). International Suggestions: International standards and guidance recommend that sexuality education starts early in childhood and progresses through adolescence and adulthood (WHO Regional Office for Europe and BZgA, 2010; UNESCO, 2009) building knowledge and skills through a carefully phased process over time, like any other
subject in the curriculum. Too often, topics are taught too late – for example, after young people have already experienced puberty or menstruation. Sexuality education must begin before the onset of sexual activity, should respond to young people’s evolving needs and develop their knowledge, attitudes and skills to prepare them appropriately for all stages of their development and capacities. The International Technical Guidance on Sexuality Education (UNESCO, 2009) proposes an age-appropriate set of topics and learning objectives that constitutes a CSE programme for ages 5 to 18+. The Standards for Sexuality Education in Europe recommend starting CSE education from birth. Starting sexuality education in primary school allows children to identify and report inappropriate behaviour (including child abuse) and develop healthy attitudes about their own body and relationships. Studies have repeatedly shown that favourable parental attitudes influence children’s attitudes, whether this is related to acceptance of sexuality education, uptake of HIV testing or contraceptives. Despite existing opposition to sexuality education by some political or religious groups who may have certain influence over public attitudes towards CSE, parents in many parts of the world support school-based sexuality education. Sexuality education may be delivered as a stand-alone subject or integrated across relevant subjects within the school curricula. These options have direct implications for implementation, including teacher training, the ease of evaluating and revising curricula, the likelihood of curricula being delivered, and the methods through which it is delivered.
The Local Scenario National Sexual Education Guidelines: The latest sexual education guidelines were published by the Ministry of Education in December 2014. It involves a set of guidelines outlining the objectives laid out by the Ministry for Sexual Education in schools. It also includes the legal obligations, considerations when it comes to special needs, and also mentions the importance of parents and care givers.1 However, one thing that is lacking is the existence of a comprehensive, concrete curriculum. At no point in these guidelines does the Ministry provide details on what should the PSD lessons include, leaving it up to their own institutions to map out their own curriculum, based on the guidelines provided. MMSA’s Manifesting SCORA: MMSA’s Standing Committee on Sexual and Reproductive Health including AIDS (SCORA), has several campaigns that aim to educate the public, particularly youths, on sexual education. One campaign, called ‘Manifesting SCORA’, involves MMSA members going to youth groups around Malta and carrying out an informative and interactive session of their choice. Over 75 youths participated in these sessions so far. Between October and February, the youth groups visited were the following:
1st Sliema Scout Group Date: 10th October 2016 Topic: STIs, Consent and Coercion
Tiberija Youths Rabat Date: 21st October 2016 Topic: STIs, Consent and Coercion and the Morning After Pill
Marsascala Girl Guides Date: 4th November 2016 Topic: Methods of Contraception, Consent and Coercion
ZAK Siggiewi Date: 30th November 2016 Topic: Consent and Coercion, the Male and Female Reproductive System
ZAK Mosta Date: 3rd February 2017 Topic: Consent and Coercion and the Morning After Pill
Before the session was given, the youths were asked questions regarding the topic they were going to be taught about. Sliema Scout Group: Questions asked: 1. 2. 3. 4. 5.
What is the commonest STI? Where can one get tested in Malta? What does HIV stand for? Which STIs are girls vaccinated against? State two forms of contraception
On average, the participants answered 1 of the 5 questions correctly before the session and 4 of the 5 questions correctly after the session.
Tiberja Youths Rabat: Question
Before Session (participants) Correct Incorrect Don’t know
After Session (participants) Correct Incorrect Don’t know
What’s the commonest STI Worldwide?
0
12
1
10
1
2
What does ‘HIV’ stand for?
1
6
6
5
8
0
Where can one get tested for an STI? Against which STI are girls being vaccinated? What is coercion?
1
9
3
12
1
0
0
3
10
11
1
1
0
13
0
13
0
0
Marsascala Girl Guides: Question
What is Coercion? Mention 2 indications of fertility when using the Natural Family Planning Contraceptive Method.
Which is the contraceptive method that prevents us most from getting an STI? What is an IUD?
Before Session (participants) Correct Incorrect Don’t know
After Session (participants) Correct Incorrect Don’t know
0
0
12
11
1
0
6
3
3
3
7
2
9
3
0
12
0
0
1
1
10
4
2
6
ZAK Siggiewi: Questions asked for ‘Consent and Coercion’: 1. What is Consent? 2. What is Coercion? Before the session, all the youths seemed to be aware of the meaning of consent. All answers were on the line of ‘giving permission’. However, only 2 people gave the correct answer to ‘What is Coercion?’
After the session, unfortunately, not everyone gave answers to the questions and there were other who still weren’t fully aware of what Coercion is. Questions asked for the Male and Female Reproductive System: 1. 2. 3. 4. 5.
What is the male’s Reproductive Hormone? Are younger or older men more at risk of getting Testicular Cancer? What is fertilization? Where is the Cervix located? How long is the Menstrual Cycle?
Before the session, the vast majority weren’t able to answer most of the questions correctly. In fact, the youths skipped most of the questions especially the 1 st and the 4th ones. The majority however were aware that Testicular Cancer is a disease of young men. Almost all those who gave an answer to the last question gave a correct answer. The same applies to the 3rd question. However, the session seemed to have been very effective because after the session. Almost everyone gave the correct answer to the first question and everyone gave the correct answer to the second, third and last questions. Nonetheless, the youths didn’t seem to have understood the exact position of the cervix in the woman’s body. ZAK Mosta: Question
What is consent? What is Coercion? Mention one way with which the Morning After Pill prevents pregnancy
Before Session (participants) Correct Incorrect Don’t know 10 1 0
After Session (participants) Correct Incorrect Don’t know 11 0 0
0
1
10
11
0
0
4
3
4
10
2
0
This campaign has highlighted the lack of sexual education that is present nationally. These youths are all at the end of their secondary education, and so face the possibility of facing the adult world without a sufficient background in sexual education. This would lead to consequences on a biological level (e.g. Sexually Transmitted Infections), on a social level (ez. inability to form healthy and respectful sexual relationships) and on a psychological level (psychological manifestations of the abovementioned consequences.
Local Data Analysis Due to insufficient local statistics with regards to the response to the level of Sexual Education in Malta, the MMSA has carried out research in the form of distribution of questionnaires to medical students of each year in Malta. This was focused on medical students as opposed to all students of different courses due to the fact that medical students too, originate from different backgrounds and previous educational institutions. Their current level of sexual education provided through the course itself and the MMSA will provide a good baseline for comparison to previous sexual education, allowing them to correctly judge the quality of such education prior to that provided at university level. From this, one can assume that students outside the medical course have received the same secondary school and sixth form level sexual education at those stages in their life. The questionnaires consisted of multiple “Yes or No� questions and the choice of a number from a scale of 1 to 5 involved with their previous sexual education in comparison to their current level of sexual education. Below is a chart portraying the different ratings of the level of sexual education given to them prior to university; 1 being the poorest and 5 being of adequate standard.
Rating of Sexual Education level prior to university (1- Least, 5-Most) 2% 3% 27%
16%
Rating 1 2 3 4 5
52%
At this level in university, 89% answered that they now consider themselves to be of an adequate sexual education level while 11% answered that they did not think so. This may be due to the fact that this survey was conducted on students from MD Year I to MD Year V, and certain individuals may have chosen not to go out of their way to seek and reaffirm that their level of sexual education was satisfactory. Such may be reflected in the following chart, where students rated how important they thought offering sexual education was on a scale of 1 to 5. 33% stated that it should be given just as much importance as any other academic subject while 7% thought that it would be enough if such education was optional.
Rating of percieved importance of Sexual Education (1-Least, 5-Most) 4%
6%
Rating 1
36%
20%
2 3 4 5
34%
The first part of the questionnaire concerned sexual education at primary school level. This would involve education adequate for the age group, including information about puberty and the risks of STDs, since students may start to experience physiological and physical changes at around that age. The results showed 42% of students received sexual education at primary school while 58% did not. 73% agreed that it was correct to provide some degree of sexual education at this level while 27% thought that it was unnecessary to teach students about this at that level. In addition 72% of the students taking the survey thought that the level of sexual education at primary schools should be increased. With regards to secondary school level sexual education, 91% thought that the level they were provided with should be increased, with 43% of the students coming from a Church school, 26% from a Government school and 31% from a Private School. In these institutions, a large proportion originating from a Church School reported that their sexual education was influenced by religious values, and while teaching religious values is not wrong, omitting certain information which does not coincide with the values may increase certain risks. For example if students are taught that abstinence and natural family planning are the only acceptable method of contraception within the church, these will exclude any barriers against STDs if the individual chooses to follow
different values in the future. 68% of the students therefore agreed that values should not result in the censorship of sexual education whereas 32% voted contrary. Concerning sixth form level sexual education, 87% felt that the level should be increased at this point, while at that time, 65% would have felt that this level of sexual education was sufficient. Thus at that stage not everyone would be aware that there is more to sexual education than what is taught at 6th form level. Another interesting fact, was that every 1 in 2 students filling in the questionnaire agreed that a formal refresher course involving sexual education should be introduced in university, as sometimes it is taken for granted that we remember what is taught to us in secondary and tertiary education. However it is important that this knowledge is reinforced and reaffirmed in university, as it is a period of time where such information and life skills are crucial in our day to day lives. So in all this, what did the students deem to be their primary source of sexual education? The results indicate which educational media are the most effective and leave the most long-lasting effects in educating our youths about safe sex and consent. The chart below indicates that school-provided sexual education is still widely effective in educating a large portion of the medical students taking the questionnaire, but not as influential as NGO-provided education. Thus campaigns like Mr. Breastestis, RuDI and IFMSA training provide the most effective sexual education; this might be due to a variety of reasons. Firstly, this education is provided during university and to sixth form and secondary students, thus potentially having a larger impact as such education becomes relevant in their lives, along with the fact that the more mature the students are, the more capable they are of understanding the significance of having such education. Secondly, knowledge is reinforced when taught; these forms of education are taught to students by students, making the learning experience bi-lateral so this may leave longer lasting learning experience.
Most effective methods of Sexual Education 24% 29%
School-provided Education
NGO-provided Education (eg MMSA, IFMSA) Peers and Parents 16% Personal Research
31%
Recommendations 1. Countries should provide a framework guaranteeing access to guidance, supervision or reporting requirements for teachers. This should involve skills and knowledge that would equip teachers with the ability to handle/tackle disclosure of sexual abuse during delivery of sex-ed programmes in a most professional and sensitive manner. a. Teachers should encourage students to make use of counselling services provided in the school to seek help for sexual concerns. b. Special care should be given to students who are perceived to be vulnerable or are putting other students at risk. 2. Young people (and at risk/marginalized groups) should be involved in the debate and drawing up of national curricula pertaining to CSE. Also, establish effective plan/course of action to capitalize on any venues for potential outreaching and education of hard-to-reach groups. 3. Measurable indicators to accurately [and reliably] gauge the effectiveness of current CSE programs in achieving greater gender equality, critical thinking skills, confidence, and sexual pleasure should be implemented. 4. Ensuring that Private, Government and Church schools are provided with all the basic information necessary for proper comprehensive sexual education, and personal values are added in addition, not replacing any important information.
a. Church schools provide students with more than abstinence and Natural Family Planning as contraceptive methods, even if the others may not coincide with religious values. Values should only be mentioned in addition to all the other information made available. 5. Students are heavily encouraged to make use of counselling services in the cases of sexual concerns, sexual abuse and illnesses and seek assistance for any issues. 6. Students and staff should be encourage from an early age to get tested for STDs, HIV and other illnesses regularly once they become sexually active. 7. Educational facilities must not assume that their students are not sexually active, no matter the age, and educate students as if they were all equally at risk of diseases and pregnancy. 8. Parents should be encouraged to provide their children with sexual education to develop a mature approach towards it when it is tackled at school. 9. Employers especially in healthcare should ensure that employees are regularly tested for STDs. 10. Individuals should be encouraged to ensure that any sexual partners including themselves are regularly tested when sexually active. a. Individuals should encourage peers to get tested. 11. University should introduce a refresher course involving sexual education as such topics are often not tackled again at this level, even though students are more likely to be sexually active at this stage. Education received at sixth form level may not be sufficient in providing a lifelong learning experience. 12. Introducing sessions about sexual education targeting non-students which may not have received sexual education at earlier stages of their life. Especially since individuals who do not continue their education are more vulnerable to misinformation and misconceptions. 13. Proper use of any contraceptives available in Malta should be explained at the location of purchase, to ensure that the individual is aware of the complications, risks and effectiveness of the method. This will reaffirm that people making use of contraceptives are able to use them properly and effectively.
References: 1. https://education.gov.mt/en/resources/Documents/Policy%20Documents%20201 4/Guidelines%20on%20Sexuality%20booklet.pdf 2. (Stephen Camilleri, 2013, GUIDELINES ON SEXUALITY AND RELATIONSHIPS EDUCATION IN MALTESE SCHOOLS, pg6) 3. http://www.unesco.org/new/en/hiv-and-aids/our-priorities-in-hiv/sexualityeducation 4. http://www.ippf.org/resource/ippf-framework-comprehensive-sexuality-education/ 5. http://www.unfpa.org/comprehensive-sexuality-education#sthash.d74QaIXO.dpuf 6. http://www.unfpa.org/sites/default/files/pub-pdf/CSE_Global_Review_2015.pdf 7. http://www.ippf.org/resource/ippf-framework-comprehensive-sexuality-education/ 8. http://www.ippf.org/sites/default/files/ippf_framework_for_comprehensive_sexuali ty_education.pdf