Comprehensive Sexuality Education in The Indian Context: Challenges and Opportunities

Sexuality is a central aspect of being human throughout life that encompasses vast areas, including sex, gender identity, gender roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. People experience and express sexuality in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. Sexuality is influenced by biological, psychological, socio-economic, political, and cultural factors. Legal, historical, religious, and spiritual factors can also influence it. ¹ Human sexuality has a lifespan perspective, from our birth to death. It is not something that appears in adolescence and goes away once a person reaches old age. According to the current working definition, sexual health is a “state of physical, emotional, mental, and social well-being about sexuality;” it is not merely the absence of disease, dysfunction, or infirmity. ¹ Sexual and reproductive health (SRH) requires a positive and respectful approach to sexuality and sexual relationships, with the possibility of having pleasurable and safe sexual experiences free of coercion, discrimination, and violence. For SRH to be attained and maintained, the sexual rights of all people must be respected, protected, and fulfilled. ¹ World Health Organization (WHO) understands the importance of SRH for young people and introduced different global programs for addressing SRH needs. ²

The Need for Sexuality Education: Global and Indian Scenario

Children between 0 and 14 years constitute 25%, adolescents and young adults between 10 and 24 years constitute 24%, and those between 10 and 19 years constitute 16% of the world population, as of 2022. ³ Our children and young adults have specific SRH needs. Many have misconceptions about sexuality and sexual health. ⁴ Teenage pregnancies, lack of contraceptive awareness and use, high-risk sexual behavior, sexually transmitted infections (STIs), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), sexual abuse, gender-based violence, unsafe abortions, and childhood marriages are all issues our children face. ⁴ If we look at these issues, we can see that most children and youth around us do not have adequate knowledge or skills to address their SRH needs. Organizations like the United Nations (UN), programs like UN Program on HIV and AIDS, and the WHO have understood these issues related to SRH. They prioritized Comprehensive Sexuality Education (CSE), as it can help the youth and children understand their sexuality and related areas and will help build positive sexual knowledge, beliefs, attitude, and skills. CSE will help them to make better decisions regarding sexual health and to prevent the specific problems they face. ⁵ Even with more significant efforts from international organizations to implement CSE in different countries, they face many obstacles. The coverage of CSE among schools remains low, with only 1/3rd of school students receiving some form of CSE at their schools. ⁶

India is one of the fastest-growing populations, with almost 40% of the population belonging to <24 years. A quarter of the total population is <14 years of age, and adolescents and young adults aged 10–24 years constitute 27% of the population. ³ However, our youths face many health and social issues that are easily preventable, and their attitude and knowledge regarding sexuality and sexual health are limited. A few studies have examined the sexual knowledge and attitude of the Indian youth and found that sexual knowledge is limited and that most hold a conservative attitude toward sexuality.^{7, 8} This poor knowledge and attitude reflect among youth as high-risk sexual behaviors and practices.

A recent review from India found that there is a high prevalence of high-risk sexual behaviors among youth, including low condom use, multiple sexual partners, and poor awareness about STIs and HIV. ⁹ Child marriage and teenage pregnancies are still a significant concern in India, with almost 45% married before 24 years and 11.9% getting married between 15 and 19 years. In addition to this risk, around 1/3rd of these girls give birth to at least a child before 19 years. ¹⁰ Lifetime physical and sexual intimate partner violence in India is 28.8%, one-year prevalence is 22%, and our gender inequality rank is at 125, meaning that we have to go a long way to achieve gender rights for women. ¹¹ STIs and HIV/AIDS also cause significant concern for our youth, as 31% of active cases of HIV-AIDS are among those between 15 and 29 years. ¹² Unplanned pregnancies and unsafe abortion practices are prevalent in India, and there is a significant need for contraceptive services. ¹³ The most important intervention to address these significant concerns is ensuring adequate SRH and knowledge among youth. An essential way to achieve that is via CSE for our children and youth. ⁵ Even though we have come a long way in public health by reducing maternal and child mortality and other health statistics, we do not have a uniform program or a nationwide CSE curriculum for addressing the essential SRH needs of our children and youth today. ¹⁴

Because of the problems discussed above, it is essential to understand the basic facts about sexuality education and its effective delivery. Mental health professionals are often called upon to take sexuality education classes and provide training to teachers or school students. So, our mental health professionals must get adequate training and exposure in the area. ¹⁵ This viewpoint will try to provide a brief account of the basics of CSE and examine the historical and current scenario of CSE in India with a specific focus on the challenges we face and the opportunities we have for implementing an effective sexuality education program.

Understanding CSE and Its Components

Today, the best guideline on CSE available to us was published in 2018 by United Nations Educational, Scientific and Cultural Organization (UNESCO) and United Nations Population Fund (UNFPA). It is known as the International Technical Guidance on Sexuality Education (ITGSE). It provides a basic evidence-based framework for designing school curriculum-based CSE programs for countries and institutions, based on their specific needs. ¹⁶ ITGSE defines CSE as a “curriculum-based process of teaching and learning about the cognitive, emotional, physical, and social aspects of sexuality.” It aims to equip our children and young people with knowledge, skills, attitudes, and values that will empower them to improve their health, well-being, and dignity. The guideline also helps them develop respectful social and sexual relationships, consider how their decisions and choices affect their well- being and that of others, and understand and protect their rights throughout their lives. ¹⁶ The essential features of CSE are described below.

1. CSE is a curriculum-based process; it should be integrated into the school curriculum.

2. CSE is a comprehensive education program that discusses the different domains of sexuality, including gender; it is not something that covers just sexual or reproductive health.

3. CSE is an educational model which aims at behavioral change by providing knowledge and aim to equip young people to make informed decisions about their life.

Goals of CSE

The goals of the different components of CSE are to equip children and young adults with the knowledge, attitudes, and skills that will empower them to improve their health, well-being, and dignity; consider the well-being of others affected by their choices; understand and act upon their rights; and respect the rights of others. It is achieved by

• Providing scientifically accurate, incremental, age and developmentally appropriate, gender-sensitive, culturally relevant, and transformative information about the cognitive, emotional, physical, and social aspects of sexuality

• Providing the opportunity to explore values, attitudes, and social and cultural norms and rights impacting sexual and social relationships

• Promoting the acquisition of life skills. ¹⁶

CSE is not just about providing all the information related to sexuality to all age groups of children. CSE also provides information according to the children’s age and cognitive development. For this, children are separated into four age group categories, 5–8 years, 9–12 years, 12–15 years, and 15–18+ years, covering primary and secondary school levels. The learning objectives are logically staged, with concepts for younger students typically including more basic information, less advanced cognitive tasks, and less complex activities. ¹⁶

Structure and Key Concepts of CSE

Eight key concept areas are being discussed and taught in CSE. Each concept is equally important, mutually reinforcing, and intended to be taught alongside one another. The same topic may get repeated multiple times, and the complexity will increase as age increases, building on the previous learning, using a spiral- curriculum approach. ¹⁶ The eight key concepts are briefly described below:

• Relationships: Under this, the children will learn about different types of families and the roles of each person in families, friendships, love, romantic relationships, long-term commitment, and parenting. The skills focused on are inclusion, respect, and tolerance.

• Values, Rights, Culture, and Sexuality: Topics covered are values and rights about sexuality and how culture and society influence sexuality.

• Understanding Gender: Here, the social construction of gender, gender norms, gender equality, stereotypes and bias, and gender-based violence are discussed.

• Violence and Staying Safe: This focuses on equipping children to identify and understand violence, bullying, and sexual and physical abuse and training them in skills like consent, privacy, bodily integrity, and safe use of information and technologies.

• Skills for Health and Wellbeing: Here, the focus is on learning the essential skills about sexuality and relationships, like decision-making, communication, consent, refusal, negotiation skills, media literacy, and finding help and support.

• The Human Body and Development: The children will learn about the anatomy and physiology of the human sexual and reproductive system and changes that occur during puberty, menstruation, and reproduction.

• Sexuality and Sexual Behavior: What is sex, the role of sex in human life, the changes during the sexual response cycle, masturbation, and the different human sexual behaviors are discussed here.

• SRH: Here, more focus is on pregnancy and pregnancy prevention, safe sexual practices, and also how to prevent STIs and HIV.

These eight key concepts are divided into two to five topics and learning objectives. Figure S1 provides a more detailed account of the topics discussed under each concept. The information is delivered as part of the school curriculum by trained teachers. The key concepts and topics may overlap often. Each topic has three learning domains (Figure S2). ¹⁵ A combination of all three domains of learning is critical to empowering young people and for effective CSE. The three domains are as follows:

• Knowledge: Provides a critical foundation for learners.

• Attitudes: Help young people shape their understanding of themselves, sexuality, and the world.

• Skills: Enable learners to take action.

Delivery of an Effective CSE program

ITGSE provides a detailed account of delivering the CSE program. Evidence shows that the delivery of CSE is as crucial as the content. Effective sexuality education must take place in a safe environment, where young people are comfortable, their privacy is respected, they are protected from harassment, and the school atmosphere reflects the principles of the content. ¹⁷ The guideline describes the characteristics of an effective curriculum, guidelines for designing and implementing CSE, and guidelines for monitoring and evaluating sexuality education programmes. ¹⁶

Why Should We Go Forward with CSE Programs? The Evidence Base.

Even today, there is ongoing opposition against CSE programs worldwide and in India. One critical concern raised by those who oppose CSE is that school children are too young to be taught such information and that they will start to experiment at a younger age if they are taught about sex at school.^{18, 19} However, the current evidence proves that such concerns are not valid and that our children acquire more knowledge and skills regarding sexuality. UNESCO conducted the evidence review in 2016 based on 22 rigorous systematic reviews and 77 randomized controlled studies. ²⁰ They found that CSE leads to delay in initiation of sexual intercourse, decreases the frequency of sexual intercourse, decreases the number of sexual partners, and reduces risk-taking behavior, increasing condom use, which are its primary objectives. The review also found positive changes in areas related to sexuality, gender, and gender-based violence. ²⁰ Thus, there is a solid evidence base for implementing CSE. ²⁰

CSE in India: Historical Perspectives and Current Status

Probably, the first nationwide program to discuss SRH in India was the School AIDS Education Program (SAEP), which was first introduced in 2002 with collaborative efforts from the Department of Education and the National AIDS Control Organization (NACO). ²¹ The aim was to ensure the recommendations of India’s national AIDS policy, which focused on sexual health, contraception, and prevention of STIs and HIV. The primary goal of the SAEP was to reduce the spread of HIV/STIs among students in schools and colleges by providing relevant knowledge, life skills, guidance, and counseling services. ²¹

In 2006–2007, NACO and the Ministry of Human Resource and Development (MHRD) introduced a more CSE program named Adolescent Education Program (AEP). ²² Its objective was to equip every adolescent (aged 10–19 years) with scientific information, knowledge, and life skills to protect themselves from HIV infection and manage their concerns about reproductive and sexual health. AEP covered all the secondary and senior secondary schools in the country. Nodal teachers delivered the AEP for students in grades 9th and 11th for a minimum of 16 hours in an academic year. Topics covered under the AEP were growing up and adolescence, reproductive and sexual health, mental health and substance abuse, HIV/AIDS and STIs, and life skills for HIV prevention. However, the government had to back off and stop the AEP due to strong protests from some religious groups and parents.^{18, 22}

Later, in 2009, MHRD and NACO reintroduced the AEP under the name Life Skills Education Program (LSE), which is our current school-based sexuality education program. Trained teachers deliver the curriculum through a 16–23-hour model to students in classes 8, 9, and 11, that is, between the ages of 13 and 18. As of 2010, the program consolidated its focus to five UNFPA priority states (Punjab, Orissa, Karnataka, Maharashtra, and Madhya Pradesh) in 5002 schools. The LSE curriculum covered changes during adole- scence, body image, positive relationships, gender- and sexuality-based stereotypes and discrimination, violence and abuse, STI/HIV/AIDS, and substance abuse. Content-wise, the curriculum had gone beyond the typical sexuality education topics, but the implementation was poor. ¹⁴

The last independent evaluation of the LSE program in India was done in 2010–2011 by UNFPA. The report gives us an idea about the impact of the LSE program and its limitations as well. ²³ Even though the LSE program gave the children information regarding STIs and sexual health, they had inadequate knowledge and poor attitude change regarding relationships and gender-based violence. Knowledge retention was also poor, as follow-up sessions were minimal. ²³ After 2011, there has been no evaluation of the LSE program in our country; the current status of the program and its impact on children and youth remain unknown.

The Challenges for CSE in India

India is very heterogeneous in terms of culture, beliefs, education, and many other parameters. We are not comfortable talking about sex or sexuality, as sexuality is considered a taboo subject, and we think that only adults must talk about it. So we do not discuss sexuality at home or school.^{24, 25} Sex and sexuality go hand in hand with religious and moral beliefs, and many such communities impart a sinful model about sexuality to children, and often the communities have a negative attitude toward CSE. Our parents and teachers had never received any sexuality education, which made the discussion about sexuality very uncomfortable for them. Many objections against CSE are based on myths and false information that people have regarding CSE which does not have much evidence base according to recent reviews.^{15, 20} Parents and teachers also have concerns regarding the right age for starting CSE. ¹⁵ Above all, research on sexuality and sexual health is limited in our country, and we do not have an evidence-based CSE curriculum till today. The changing governments had shown little interest in addressing society’s concerns and moving on with CSE.

Opportunities

Even when we say that we face so many difficulties in implementing CSE in India, it is not impossible because we have evidence from India that if there is a strong political will and a solid team to support it, a CSE program can be implemented. UDAAN is a flagship program that received international appreciation. It was implemented in the state of Jharkhand, which is economically backward and has a good proportion of the tribal population as well. ²⁶ In 2006–2016, they covered all primary and secondary schools in 24 districts and included most of the topics of CSE in their curriculum. Jharkhand’s Department of Education implemented it with technical assistance from the Centre for Catalyzing Change. ²⁷

We already have a school-based LSE program that is partially implemented and has not been evaluated recently. ¹⁴ We can update the LSE curriculum with discussions and support from the experts and NGOs (talking about reproductive and sexual health issues [TARSHI] and Sex Education Kerala [SEK] Foundation) working in the field, considering our students’ and youth’s diverse cultural needs.

We have an RMNCH+A program (Reproductive, Maternal, Newborn, Child, and Adolescent Health) managed by the National Health Mission, which provides out-of-school sexuality education via Adolescent-Friendly Health Clinics (AFHC). Through these AFHC, adolescents get information regarding contraception and STI/HIV prevention and counseling on sex, gender, delaying marriage, and pregnancy. ²⁸

We have the National Adolescent Health Mission 2014 (Rashtriya Kishor Swasthya Karyakram, RKSK), which aims to address five priority areas: improving nutrition, SRH, and mental health; preventing injuries and violence; and preventing substance misuse, with the help of peer educators attached to AFHCs. ²⁹

How Can We Go Forward with CSE in India?

We already have the LSE program, RMNCH+A, and RKSK program that cover an overlapping aspect of CSE. By careful integration of these different programs, we will be able to provide all the critical areas of CSE to our children via school-based programs and out-of-school CSE programs. The policy decision should come from the government, which can be made possible by advocacy work. We need to develop a robust curriculum for CSE in India that should be scientifically sound and, at the same time, consider our country’s social and cultural aspects Focused discussions among different professionals and organizations involved will help in making a culturally appropriate curriculum. Based on this, we need to train our health professionals and teachers, as they will be the ones talking to children about CSE at the ground level. We must have a plan regarding how the contents of CSE should be delivered to children at the school level and how to tackle specific problems we may face during implementation. Finally, there should be a monitoring and evaluation system for carefully tracking the program’s implementation and effectiveness. Thus, detailed discussions and careful planning could make this a reality.

Conclusions

This article tried to provide a general account of the subject of CSE and its essential components and structure. It also looked into the status of CSE programs in India, focusing on our specific challenges and opportunities. We must cooperate with stakeholders to provide our children and youth with evidence-based CSE to lead a life with positive feelings regarding their sexuality, not with guilt and shame. Psychiatrists and other mental health professionals have a vital role in this process.