The International Technical and Programmatic Guidance on Out-of-School Comprehensive Sexuality Education – an evidence-informed approach for non-formal, out-of-school programmes reaching young people from left-behind populations

Background

As defined in the UN Technical Guidance on Sexuality Education (ITGSE), comprehensive sexuality education (CSE) is a curriculum-based process of teaching and learning about the cognitive, emotional, physical, and social aspects of sexuality, which 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.¹ A solid body of evidence has demonstrated that CSE, when delivered with fidelity and quality, can increase children’s and young people’s knowledge and improve their attitudes and behaviours related to sexual and reproductive health (SRH).¹ Inversely, it has confirmed that CSE does not increase sexual activity, sexual risk-taking behaviour, or STI/HIV infection rates, and that abstinence-only programmes are ineffective in delaying sexual initiation, reducing the frequency of sex, or reducing the number of sexual partners.¹

CSE has thus been recognised as a central component of the recommended package of actions to support the health and development of children and young people and fulfil their rights.² Guidance is available on age and developmentally appropriate concepts, topics, and learning objectives, and stakeholders at global, regional, and local levels have called for provision of CSE^3,4 to all children and young people.

To date, most efforts have focused on in-school CSE. However, with the adoption of the 2030 Agenda for Sustainable Development in 2015, UN agencies and other development partners committed to leaving no one behind and to reaching the furthest behind first.⁵ Among children and young people, those left furthest behind include the 263 million children and young people who are out of school and millions more who face discrimination and human rights violations for various reasons such as disability, sexual orientation and identity, or humanitarian crises.⁶ There is therefore a need to also provide CSE beyond the school classroom. However, dedicated guidance on how to design and implement CSE in out-of-school settings has been lacking. To respond to this gap, UNFPA along with UNESCO, WHO, UNICEF, and UNAIDS, published International Technical and Programmatic Guidance on Out-of-School CSE in 2020.

Why is there a need for CSE to go beyond the school classroom for specific groups of young people?

The International Technical and Programmatic Guidance on Out-of-School CSE provides an overview of the current needs of adolescents from populations of young people left further behind. Such children and young people often face greater challenges to accessing sexual and reproductive health services that meet their needs and preferences.⁷

For example, Indigenous children and young people in many contexts lack access to culturally appropriate care that takes into account traditional preventive care, healing practices, and medicines.⁸ The report of the Global Indigenous Youth Councils' meeting on culturally safe and peer-led approaches to HIV, sexual health, and harm reduction in Indigenous communities (2015) advocates strongly for “the vital, lifesaving importance of peer-based models of education and support”, including for HIV positive and substance-using Indigenous youth, because other models tend to favour and impose Western worldviews and attitudes about sex and sexuality and create power imbalances in favour of non-Indigenous people.

Children and young people with disabilities often have very limited opportunities for sexual exploration for a range of reasons, such as a lack of privacy or limited social circles.⁹ Stereotypes and negative attitudes about the sexuality of people with disabilities add to the stigma and discrimination they experience and to their difficulties in having a satisfying and pleasurable sex life.¹⁰ The adults in their lives sometimes do not provide them with chances to interact socially and romantically with others, and those around them may react negatively, express disapproval, or even perpetuate guilt or shame when they encounter sexual expression or normal sexual behaviours in them.¹¹ Young people with disabilities are also less likely to report violence, seek care, or access justice, in part because they are often overlooked in programmes addressing violence.^12,13

Young lesbian, bisexual, and queer females in some countries are more likely to experience pregnancy than heterosexual females in the same age range, ¹⁴ that can be caused by “coming out” problems, non-accepting their own sexuality and taking action “to be heterosexual” by having multiple sex with males.¹⁵ LGBTQ+ youth perceive that current sexuality education mostly excludes them. This exclusion is done through the complete absence of discussion about LGBTQ+ people in sexuality education programmes, by ignoring or avoiding questions about LGBTQ+ issues when they are raised or saying that discussing LGBTQ+ issues is not allowed, by presenting heterosexuality as the norm (for example, by focusing only on vaginal intercourse prevention or sexual abstinence until marriage), and by only discussing gay people when discussing HIV, thereby linking LGBTQ+ people with diseases and their behaviour with harmful consequences.¹⁶ LGBTQ+ young people want sexuality education that directly discusses sexual orientation and gender identities using an evidence-based positive approach, that includes all types of sex and not just pregnancy prevention, and they want facilitators and teachers to provide information about LGBTQ+ resources in the community or online.

As a result of these access barriers and other challenges related to their circumstances and identities, such children and young people often face greater risks of poor sexual and reproductive health outcomes.¹⁷

What is out-of-school CSE?

Out-of-school CSE is that which is not delivered at school to students as a part of the school curriculum, whether as part of the core or non-core hours. It may be delivered in face-to-face sessions in a range of settings, including in communities, at a non-governmental or community-based organisation, in religious institutions, in youth centres or at youth clubs, in health clinics, summer camps, at schools or training institutions after hours (if not by a teacher from the school to students from the school), in families, and in institutional settings such as jails or detention centres. It may be delivered by facilitators, peer educators, parents, or possibly through technology, including computers, the Internet, and mobile phones or smartphones, although the latter is still an evolving area. Those reached by out-of-school CSE may be children and adolescents who do not go to school as well as those who do.

Out-of-school CSE programmes can meaningfully engage young people and be tailored to their realities and specific needs. Compared with in-school programmes, out-of-school programmes have greater potential to complement sexuality education for young people with programme components that seek to change outdated and harmful norms and practices at the community or societal level. Such components can fundamentally change the social-cultural and political environments in which the young people they reach must live, supporting their individual transformation and enabling them to thrive. While gender transformative and empowerment approaches to sexuality education are recommended, they need to be integrated with social justice approaches that seek to address the multiple inequities that affect young people. A social justice approach, combined with empowerment, is especially critical when working with marginalised and stigmatised young people.¹⁸

On the other hand, out-of-school CSE also presents a number of challenges.¹⁹ For example, technology-based sexuality education interventions offer some potential advantages over face-to-face interventions; however, the Internet is also subject to the digital divide, can be inaccurate, and may result in unwanted exposure to sexually explicit material. While some types of technology-based sexuality education may also be relatively cheap, some are complex to develop. In addition, there are still a lot of questions about the extent to which technology-based interventions can provide satisfactory sexuality education as opposed to “just sexuality information”, how comprehensive they can be, especially if the user selects which parts they want to access, and whether any can meet the definition of being “curriculum-based”.

Surprisingly, hardly any reviews or studies on out-of-school CSE discuss the fidelity of programme delivery, which could have a considerable impact on outcomes. Most reviews and studies before 2020 also did not have much to say about the effect of different types of facilitators or programme deliverers, outside of those which discussed peer-delivered programmes.

What is the International Technical and Programmatic Guidance on Out-of-School CSE?

The UN International Technical Guidance on Sexuality Education (ITGSE) was published by UNESCO, UNAIDS, UNICEF, UNFPA, and WHO in 2009. In the eight years since then, the field of sexuality education has experienced exponential development globally, with positive shifts in the political and cultural climate for its implementation at national, regional, and international levels. Many challenges also continue to exist, including political, social, and religious opposition and conservative views of adolescents’ capacity and their sexuality. A 2015 global review of the status of comprehensive sexuality education implementation and coverage, published in partnership with UNFPA and UNAIDS, identified key milestones in political support and global advocacy on CSE, and documents the progress, challenges, lessons learned, and the gaps and opportunities that remain for achieving wide-scale implementation of quality CSE programmes. In 2016, UNESCO led a process to update the ITGSE to reflect new evidence and good practice. That process also included a literature review of comprehensive sexuality education, focused more, but not exclusively, on in-school CSE.²⁰ With the adoption of the 2030 Agenda for Sustainable Development in 2015, UN agencies and other development partners have committed to leaving no one behind and to reaching the furthest behind first. Among young people, those left furthest behind include those who are out of school and those who face discrimination and human rights abuses – young people who are also those at greatest risk of poor sexual and reproductive health outcomes. Therefore, stakeholders at the technical consultation on the revised Technical Guidance, conducted in October 2016, in Paris, expressed their strong interest in and support for the development of a complementary guidance to ITGSE focused on out-of-school CSE. As a first step in the development of that guidance, UNFPA supported the literature review with a focus on out-of-school CSE,²¹ and then led the development of the International Technical and Programmatic Guidance on Out-of-School CSE.

This guidance provides evidence- and practice-informed recommendations specifically for programmes that deliver CSE out of school, and programmes that seek to address the needs of specific groups that are unlikely to be addressed in CSE programmes for children and young people generally: girls and boys separately; young people with disabilities; young people in humanitarian settings; Indigenous young people; young lesbian, gay, bisexual, and other young men who have sex with men; young transgender people; young intersex people; young people living with HIV; young people who use drugs; young people who sell sex; young people who are in detention. It is intended to assist anyone developing or implementing CSE in out-of-school settings, including governments, international and national civil-society organisations, community-based organisations, UN agencies, and young people.

The Guidance begins by providing an overview of out-of-school CSE including a clear definition. It then provides guidance on how to develop and implement out-of-school CSE in general, including areas of particular interest such as engaging peer educators, involving parents/guardians, and using technology. The rest of the document provides guidance on how to deliver out-of-school CSE to specific groups of children and young people, taking into account their particular needs, circumstances, and preferences.

How is the guidance being tested and disseminated?

The Guidance was finalised, translated into several languages (Russian, Spanish, French, Persian), and launched at a global virtual event in 2020. The launch activities – which took place in five regions – took advantage of opportunities to strengthen partnerships for implementing and integrating out-of-school CSE, including with governments, UN partners, community and youth organisations, youth advocates, regional representatives, and the private sector.

Under a multi-country global initiative, it was adapted at the regional level and in five pilot countries in Phase 1 in 2020–2022 (Colombia, Ethiopia, Malawi, Ghana, and Iran) and in an additional seven countries in Phase 2 in 2022–2024 (Philippines, Indonesia, Moldova, Tunisia, Palestine, Nicaragua, Nigeria) into age-appropriate and culturally relevant curricula, training manuals for instructors and online courses or radio programmes, along with supporting materials to advocate for CSE. For example, in the East and Southern Africa region, the Guidance was produced for young people living with HIV and for young people with disabilities and in the Latin America and the Caribbean region, a Centre of Excellence was established with digital training courses based on the Guidance.²² The knowledge and evidence base for out-of-school CSE was developed through formative research, data collection, and the publication of case studies for each of the five countries, showcasing the needs and progress so far.¹⁹ Implementation research is also being carried out in each of the countries to further strengthen the evidence base on how to overcome specific challenges presented by out-of-school CSE.

What is the particular relevance of the guidance in the context of the COVID-19 pandemic?

The COVID-19 pandemic caused massive disruptions in the lives of people around the world, including children and young people. Amid the myriad concerns that have emerged since the virus arose on the global stage in early 2020 is the potential devastating effect that the pandemic could have on the sexual and reproductive health of children and young people, especially girls and young women and those who already face stigma and discrimination. One year into the pandemic it was estimated that 12 million women may have been unable to access family planning services as a result of the COVID-19 pandemic, and as many as 1.4 million unintended pregnancies may have occurred before women were able to resume use of family planning services.²³

At the peak of the first wave of the pandemic in May 2020, nation-wide school closures were in place in 157 countries, affecting more than 800 million students and drastically curtailing opportunities to deliver CSE in schools and communities and restricting access to sexual and reproductive health services.²⁴ Governments and organisations around the world are modifying their programmes to meet children and young people’s needs in these new circumstances, including by finding new ways to deliver CSE in out-of-school settings.²⁵

Conclusion

Now, more than ever, with the experience of the COVID-19 pandemic fresh in our minds, there is an urgent need to expand human rights-based CSE beyond the classroom to make sure that all children and young people have the knowledge, attitudes, and skills required to fulfil their rights and make informed decisions about their bodies and lives. Thus, designing and delivering CSE to meet the needs of those most left behind is key to accelerate impact in the last decade of the Sustainable Development Goals era. The International Technical and Programmatic Guidance on Out-of-School CSE offers the opportunity to ensure that such efforts are grounded in the best technical and programmatic evidence currently available.

Funding Statement

This work was supported by United Nations Population Fund [grant number ZRHM-2022-C9293; ZRHM-2022-0136].

Disclosure statement

No potential conflict of interest was reported by the author(s).