Too Little Too Late: Perceptions of Sexual Health Education in Spain

Abstract

Introduction

Despite the importance of school-based sexual health education (SHE) for enhancing sexual health outcomes, little is known about the SHE youth receive in Spain.

Objective

The goal of this research was to shed light on the experience of SHE of Spanish adults.

Method

Participants were 524 Spaniards (73% women, 27% men) between 18 to 70 years of age (M = 35.29, SD = 11.68) who completed an on-line survey. This survey collected information on whether and during which courses they had received SHE in high school. In addition, participants indicated the extent to which each of 10 important sexual health topics had been covered in their school-based SHE.

Results

On average, participants indicated that these 10 important SHE topics were covered between not at all and poorly. Biological topics were most likely to be covered at least to a small extent. Participants who received SHE on average received it in two different grades, most often around 14–16 years old. These participants, on average, rated the quality of the SHE as poor. There were no differences in perceptions of the extent or quality of SHE based on age-group or sexual orientation. However, women reported receiving significantly less SHE than did men; there were no gender differences in perceptions of the quality of SHE. Participants who had received SHE in more grades reported more extensive and higher quality SHE.

Conclusions

Results reflect that SHE in high schools in Spain is still very limited, which could be related to poorer sexual health. To improve sexual health, it would be necessary to enhance the SHE provided in Spanish schools.

Sexual health is defined as “a state of physical, emotional, mental, and social well-being in relation to sexuality; it is not simply the absence of disease, dysfunction, or infirmity” (World Health Organization [WHO], 2018). An important factor that can contribute to sexual health is sexual health education (SHE). SHE is an important tool to ensure sexual rights in addition to meeting the United Nations Sustainable Development Goals in the 2030 agenda on gender equity and sexual and reproductive health (United Nations, 2015). This is particularly true for adolescents because adolescence is a period of transition, growth, and exploration generally and with respect to sexuality specifically (Lindberg et al., 2021; Martinez et al., 2011; Maticka-Tyndale, 2008; WHO, 2018). During adolescence, school environments are key sites for implementing SHE and promoting sexual health (Denford et al., 2017). Indeed, quality school-based SHE has been linked to a number of positive outcomes including greater acceptance of sexual diversity, lower rates of teenage pregnancy and sexually transmitted infections (STI), increased understanding of gender and gender norms, dating and intimate partner violence prevention, and development of healthy relationships (Goldfarb & Lieberman, 2021; Kantor et al., 2021; Kivela et al., 2014; Vivancos et al., 2013). It is especially important to provide SHE in Spain because Spanish adolescents have high rates of risky sexual behaviors compared to other developed countries (Alonso-Martínez et al., 2023; Fernández-Rouco et al., 2019; Moliner Miravet et al., 2018; Ramiro-Sánchez et al., 2018). This includes a lower age of sexual debut (Ball et al., 2023; Crochard et al., 2009; Espada et al., 2014; HBSC, 2018; Kaestle et al., 2005), frequent use of pornography and sexting from a very early age (Ballester-Arnal et al., 2023; Ballester & Orte, 2019; Gámez Guadix et al., 2017; Save the Children, 2020), low rates of condom use (Alvarez-Bruned et al., 2015; Ramiro-Sánchez et al., 2018; Sánchez-SanSegundo et al., 2022), high rates of intimate partner and sexual violence (Fernández-Fuertes et al., 2020; Muñoz‐Rivas et al., 2023), and high prevalence of harmful myths about sexual violence and sexual aggression (Ballester-Arnal et al., 2022; Fernández-Fuertes et al., 2020; Rubio-Garay et al., 2017; Soriano et al., 2023; Vives et al., 2020). As a result, many researchers and health professionals have advocated for improving SHE in Spain as a means to improve the sexual health of young people (Alonso-Martínez et al., 2023; Fernández-Rouco et al., 2019; Moliner Miravet et al., 2018; Ramiro-Sánchez et al., 2018). However, little is known about the SHE youth receive in Spain. Therefore, the goal of this study was to shed light on Spanish young and older adults’ perceptions of the SHE they received.

Sexual health education

Quality SHE that is effective at preventing negative and promoting positive sexual health outcomes must be based on scientific knowledge, be adapted to the level of the students, and cover a wide range of topics including the cognitive, emotional, physical and social aspects of sexuality (UNESCO, 2018). However, there is great variability in whether and how SHE is taught in different countries. In some countries (e.g., Canada, Germany, Switzerland, Estonia, Sweden), SHE is taught in all public schools. However, even in these countries, whether and how specific topics are covered may vary from one area of the country to another. In general, SHE tends to focus on biological topics and reducing risky behavior, with a general neglect of more controversial and positive sexual health topics (e.g., sexual pleasure, sexual behavior, gender and sexual diversity) (Garcia, 2015; Ketting et al., 2021; Kivela et al., 2014; MacDougall et al., 2020). This trend is even more marked in countries that do not mandate SHE (e.g., the U.S., Ireland, England, Ukraine, Spain) (Bordogna et al., 2023; Ketting et al., 2021; Lameiras-Fernández et al. 2021; Lindberg et al., 2016; Szucs et al., 2023).

There are a number of historical reasons why Spanish adults may not have received SHE. Until 1975, Spain was still living under a dictatorship that dictated that sexual topics should not be addressed in the schools (Cunha-Oliveira et al., 2021). During this time period, sexual freedom was severely repressed, and open expression of sexuality was considered dirty and sinful (Cancelo et al., 2014; Pérez, 1994). Even after 1975, implementation of SHE was slow and inconsistent. Therefore, it is likely that many older adults received little, if any, sex education in school. However, as a result of increases in the prevalence of HIV/AIDS in the 1980s and 1990s, educational reforms were implemented that focused on SHE as a means of STI prevention. However, these changes did not involve providing comprehensive SHE; rather this SHE tended to focus on a negative or restrictive approach to sexuality (Cunha-Oliveira et al., 2021; Fernández-Costa et al., 1999). Furthermore, both in this and in subsequent reforms, authority for SHE was transferred to the regional governments. As a result, there was considerable variability in SHE, including whether, where, and when it was taught depending on the willingness and training of administrators and teachers (Espada et al., 2015; Parker et al., 2009; Rodrigues et al., 2024; Vázquez Ramil & Porto Ucha, 2020).

However, a review of the literature revealed no studies that have documented students’ actual experiences with school-based SHE in Spain. Given variability in SHE over time and across Spanish regions, it is important to determine whether and in what grades students received SHE, the extent of coverage of various sexual health topics, and students’ perceptions of the quality of the SHE they received (Byers et al., 2017). Research in Canada which does have SHE found that the topics that were rated as best covered are puberty/physical development, menstruation, reproduction and birth, birth control methods and safer sex, abstinence, and sexually transmitted infections. In contrast, personal and interpersonal aspects of sexuality were less well covered (Byers et al., 2017; SIECCAN., 2023). Yet these latter topics (e.g., social, emotional, and relational aspects of sexuality and identity, including sexual pleasure) are precisely the topics that students are interested learning more about (Allen, 2008; Astle et al., 2021; Helmer et al., 2015).

Group differences in perceptions of sexual health education

It is also important to determine whether individual characteristics are associated with perceptions of the SHE adults received as adolescents, including gender, sexual orientation, and age. Byers et al. (2017) found that male students’ appraisal of the SHE they had received in middle school was more positive than the appraisals of female students. One of the reasons may be that girls biologically mature earlier than boys, so certain topics such as biological aspects of sexuality may be covered when girls have already gone through these changes (Langille et al., 2001). Another reason may be related to the fact that in some countries, gender roles and scripts are very marked and often modulate attitudes, beliefs, and behaviors related to sexuality (Fugère et al., 2008; Giménez-García et al., 2020). As such, SHE may be based on the traditional sexual script that prescribes male initiation and female passivity and privileges male needs and pleasure (Byers, 1996; Curtis & Burnett, 2017; Willis & Smith, 2022). However, other studies have not found gender differences in evaluations of SHE (Byers et al., 2003; Meaney et al., 2009). Nonetheless, gender differences are likely to be more pronounced in more socially and politically conservative countries, such as Spain where traditional gender roles and traditional scripts are still prevalent and women’s sexuality and enjoyment of sexuality are less accepted (Cunha-Oliveira et al., 2021; Rembeck & Gunnarsson, 2011). As such it is likely that in Spain SHE is taught from an androcentric perspective—for example, prioritizing male pleasure and assigning women responsibility for the prevention of STIs and unwanted pregnancies

Given heteronormativity in Spain and other countries, it is likely that SHE is based on the assumption that students are heterosexual and thus SHE may not meet the needs of 2SLGBQ + individuals (Gegenfurtner & Gebhardt, 2017; Santelli et al., 2017). Research in countries other than Spain has found that 2SLGBQ + individuals perceive having had less information in schools about how to protect themselves when participating in sexual activities and report that sexuality and same-sex sexual behavior were not included in the SHE they received in school (Kubicek et al., 2010; Pingel et al., 2013; Rabbitte, 2020). Similarly, Andújar and Gómez (2019) and Lameiras-Fernández et al. (2021) found in their studies of recent school-based SHE-specific programs in Spain that coverage of content related to 2SLGBQ + orientations, if present at all, was isolated from the rest of the SHE content, superficial, and did not include same-sex relationships and desires.

Finally, perceptions of the SHE received likely differ between younger and older adults given the changes to SHE in Spain (and other countries) in recent years. However, a review of the literature revealed no studies that have compared younger and older adults’ perceptions of the SHE they received. It would be important to explore the generational gaps as there have been shifts from a more conservative/repressive approach to a seemingly more open one.

The current study

This study aimed to shed light on Spanish adults’ experiences with school-based SHE. Specifically, we asked the following research questions (RQ):

• RQ1: To what extent were SHE topics covered in school-based SHE?

• RQ2. In what and how many grades did participants receive SHE?

• RQ3. How do participants perceive the quality of SHE received in high school?

We also proposed the following hypotheses (H):

H1:

Adults who are younger, male, have a heterosexual sexual orientation, and have received SHE in more grades would report more extensive school-based SHE.

H2:

Adults who are younger, male, have a heterosexual sexual orientation, and have received SHE in more grades would perceive the quality of school-based SHE they received more positively.

Method

Participants

A total of 624 participants were recruited. However, 100 participants were dropped from the sample: 24 because they provided inconsistent or false information (e.g., 0 years old, 274 years old; gender: “coach”); 54 because of missing data on the SHE variables; and 22 because they did not identify as male or female, and this group was not large enough to include in the analyses of gender. Thus, a total of 524 Spanish individuals met the inclusion criteria (Spanish, 18 years old or older) and completed the online survey.

In terms of gender, 72.7% (n = 381) identified as a woman and 27.3% (n = 143) as a man. They ranged in age from 18 to 70 years (M = 35.29, SD = 11.68). Most participants (75.4%) identify as heterosexual, followed by 12.6% as bisexual/pansexual, 5.5% as gay/lesbian, 4% as questioning, 0.6% as asexual, 0.4% as queer and the remaining 1.5% as another identity. Regarding their relationship status, 139 participants were single (26.5%), 38 (7.2%) were in an open relationship, 116 (22.1%) were in a committed relationship, and 231 (44.1%) were married (22.5%) or living with their partner (21.6%). Most participants (75.2%) had university studies whereas 22.7% had a secondary education (16 years), and 2.1% had an elementary education (12 years).

Measures

Background questionnaire

Participants completed a background questionnaire that assessed sociodemographic characteristics including gender identity, age, nationality, sexual orientation, relationship status, and educational level. For the purpose of analysis, participants were grouped into two age groups: young adults (age below 30) and older adults (age 30 and above).

School-based sexual health education

Participants indicated in which of the school years of Educación Secundaria Obligatoria or ESO (1^st, 2^nd, 3^rd, and 4^th corresponding to 12, 13, 14, and 15 years old, respectively) they received SHE. They also had the option of indicating that they did not receive any SHE. These items were used individually. In addition, the total number of different high school grades in which individuals received SHE was calculated, ranging from 0 to 4. Based on a similar question used by Byers et al. (2013) but with somewhat different topics, participants indicated the extent to which each of 10 important sexual health topics had been covered in their school-based SHE (see Table 1 for the list of topics). Responses were on a five-point scale ranging from not at all covered (0) to covered very well (4). Participants also had the option to indicate a topic was not covered or that they received no SHE and were given a score of 0, corresponding to the lowest point on the scale, for that topic. Responses were used individually. In addition, responses were summed to determine the extent of SHE received by each participant, with scores ranging from 0 to 40. Finally, in keeping with Byers et al. (2003), participants rated the quality of the SHE they had received in high school using a five-point scale: poor (1); fair (2); good (3); very good (4); excellent (5). They also had the option of indicating that they had not received SHE. These participants did not get a score and were thus excluded from the analyses on the quality of SHE (H2).

Table 1.

Frequencies and descriptive statistics of the topics covered in sexual health education.

Sexual Health Topic	Not Covered % (n)	Covered Poorly % (n)	Covered % (n)	Covered well % (n)	Covered very well % (n)	M (SD); Mdn
Puberty and physical development Pubertad/desarrollo físico	26% (136)	39.9% (209)	21.9% (115)	8.8% (46)	3.4% (18)	1.24 (1.04); 1
Reproduction and childbirth Reproducción y parto	27.7% (145)	30.3% (159)	25.8% (135)	12.2% (64)	4% (21)	1.35 (1.13); 1
Contraceptive methods Métodos Anticonceptivos	25.8% (135)	36.3% (190)	23.3% (122)	8.4% (44)	5.7% (30)	1.32 (1.12); 1
Safer sex practices and prevention of STIs Prácticas sexuales más seguras y prevención de ITSs	27.1% (142)	34.7% (182)	24.2% (127)	8.6% (45)	5.2% (27)	1.30 (1.11); 1
Sexual coercion/sexual assault Coerción sexual/agresión sexual	64.7% (339)	22.5% (118)	6.1% (32)	3.1% (16)	3.2% (17)	.57 (.97); 0
Sexual relationships and behavior Relaciones y comportamientos sexuales	62.0% (325)	25.4% (133)	8.4% (44)	2.5% (13)	1.7% (9)	.56 (.88); 0
Communication about sexual consent Comunicación sobre el consentimiento sexual	69.3% (363)	18.3% (96)	6.7% (35)	2.5% (13)	2.7% (14)	.50 (.93); 0
Managing pressure to be sexually active Manejar la presión para ser sexualmente activo	71.0% (372)	18.9% (99)	6.3% (33)	2.7% (14)	1.0% (5)	.43 (.81); 0
Sexuality in the media or internet Sexualidad en los medios de comunicación e Internet	54.0% (283)	29.6% (155)	11.3% (59)	2.7% (14)	2.1% (11)	.69 (.93); 0
Making sexual decisions Toma de decisiones sexuales	60.5% (317)	21.4% (112)	10.5% (55)	3.2% (17)	2.3% (12)	.63 (.96); 0

Procedure

Data were collected between July and November 2021 through an online survey administered on the Qualtrics platform. Participants were recruited for a study exploring sexuality and sexual consent through advertisements on various social networks such as Facebook, Telegram, Instagram, etc., posting to online groups of Spanish individuals (e.g., residents of a Spanish city, people looking for leisure, people looking for friends). Potential participants first read an informed consent page that described the inclusion criteria and emphasized confidentiality and freedom to withdraw. Participants who gave consent to participate were linked to the survey, which took approximately 20–25 minutes to complete. This study adhered to the ethical principles outlined in the Declaration of Helsinki and received approval from the Ethics Committee of the Jaume I University. There was no compensation for taking part in the study.

Data analysis strategy

Descriptive statistics (means, standard deviations, percentages) were calculated for all the study variables. Separate one-way ANOVAS were used to examine group differences based on age group, gender, and sexual orientation in both the extent of SHE (H1) and quality of SHE (H2). Zero-order correlations were used to examine the association between the number of years in which SHE was received and these two criteria (H2). All analyses were carried out using RStudio software, and .05 was used as p value for all analyses. Eta-squared (η²) was used as effect size where η² = .01 indicates a small effect, η² = .06 indicates a medium effect, and η² = .14 indicates a large effect (Cohen, 1988).

Results

Coverage of sexual health education topics

The extent to which each of the 10 SHE topics were covered in participants’ school-based SHE (RQ1) are presented in Table 1. On average, participants indicated that the 10 SHE topics were covered between not at all and poorly (M = 8.59, SD = 7.19). The average response for six of the topics was also between not at all and covered poorly with a median response of not covered; whereas for the other four topics it was between covered poorly and covered with a median response of covered poorly. Of note, for the specific topics between 25.8% and 71% of participants indicated that they had not received any coverage of the topic, and 36% indicated that they had not received SHE on any of the topics. The topics least likely to be covered (reported as not covered by more than half the sample) were the non-biological topics including managing pressure to be sexually active, communication about sexual consent, sexual coercion/sexual assault, sexual relationships and behavior, making sexual decisions, and sexuality in the media or on the internet. The biological topics (puberty and physical development; reproduction and childbirth; and contraceptive methods) and the prevention of STIs were more likely to have been covered to some extent, although more than one-quarter of participants had not received SHE on these topics.

For the 384 participants who indicated they had received SHE (RQ2), this was most likely to have occurred in ESO 3^rd (36.3%) followed by ESO 4^th (30%), ESO 2^nd (23.5%) and ESO 1^st (13.4%), suggesting that they mostly received SHE around the age of 14 to 16 years old (RQ2). On average participants who had received SHE reported receiving it in 2 different grades (M = 2.03, SD = 1.02). In terms of their perceptions of the quality of the SHE they received, (RQ3) both the mean (M = 1.42, SD = 0.75) and median (Median = 1 corresponding to 70% of respondents) ratings of poor. In contrast, only 4% of participants rated the quality of their SHE as very good or excellent.

Factors associated with perceptions of the extent and quality of SHE

The results of the ANOVAs testing group differences in the perceptions of the extent of SHE (H1) are presented in Table 2. Contrary to predictions, there were no differences based on age group (F (1) = 0.001, p = .981) or sexual orientation (F (4) = 0.81, p = .370) in reports of the extent of SHE. However, as predicted, the women reported significantly less SHE coverage than did the men. In addition, a Pearson bivariate correlation showed that participants who had received SHE in more grades reported more extensive coverage (r = .29, p < .001).

Table 2.

Group differences in perceptions of the extent of sexual health education based on age group, gender and sexual orientation.

Predictors	Mean (SD)	F	p	ηp2
Age		.001	.981	<.001
Below 30	8.63 (6.8)
30 and above	8.56 (7.5)
Gender		8.69	.003	.021
Men	9.91 (7.9)
Women	8.08 (6.8)
Sexual Orientation		.81	.370	<.001
Heterosexual	8.62 (7.2)
LGBTIQ	8.50 (8.6)

Given the large number of participants who reported receiving no SHE, we conducted an additional t-test analysis to examine whether older adults were less likely than younger adults to have received any form of SHE. This difference was not significant, t (471.36) = .108, p = .914. Then, given that on average participants reported limited coverage of any of the topics, we dichotomized coverage of each of the 10 sexual health topics (no coverage, any coverage) and conducted additional chi-square analyses to examine whether older adults who had received at least some SHE were more likely to report no coverage of each of the 10 SHE topics. Four significant differences were found. Older adults who had received at least some SHE were significantly more likely than younger adults to report no coverage of contraceptive methods (30% vs. 20%, χ² (1) = 5.92, p = .015) and prevention of STIs (32% vs. 21%, χ² (1) = 7.66, p = .006). However, older adults were significantly less likely than younger adults to report no coverage of sexual pressure (66% vs. 79%, χ² (1) = 11.28, p < .001) and sexual decision-making (58% vs. 70%, χ² (1) = 5.61, p = .018).

The ANOVAs examining group differences in the perceptions of the quality of SHE for the participants who reported that they had received SHE (H2) found no significant differences based on age group (F (1) = .001, p = .998), gender (F (1) = 2.11, p = .147), or sexual orientation (F (4) = .02, p = .880). However, Pearson correlation revealed that participants who reported receiving SHE in more grades rated the quality of their SHE more positively (r = .62, p < .001).

Discussion

There is limited knowledge regarding school-based sexual health education (SHE) in Spain, but this study, based on a fairly large sample of Spanish adults, provides novel insights into the topic. Our original findings indicate that a significant proportion of Spanish adults reported not receiving any formal sexual health education during high school. Among those who did report receiving SHE, the coverage of 10 important sexual health topics was minimal and delivered late. Furthermore, it tended to focus on biological topics, neglecting topics related to sexual behavior and experiences. Thus, the results point to a pressing need to enhance the SHE provided in Spanish schools. Although the extent and the quality of SHE did not differ according to age group and sexual orientation, women reported a less extensive coverage of SHE coverage than men.

Extent of sexual health education in Spain

Our findings revealed that over a third of participants did not receive any SHE during high school. Among those who did, SHE was most commonly provided in the third and/or fourth year of high school, corresponding to ages 14 to 16. This timing appears misaligned with the average age of sexual debut in Spain (around the age of 13 for non-penetrative sexual intercourse) (Ramiro-Sánchez et al., 2018) suggesting that SHE may be introduced after adolescents have already begun their sexual experiences. If SHE is intended to increase awareness and prepare adolescents for healthy sexual relationships (Gruskin et al., 2019), it should be introduced earlier. Furthermore, to be fully effective, SHE should be reinforced over time with increasing complexity in the topics (Goldfarb & Lieberman, 2021). However, on average our participants who received SHE only received it in two academic years.

Furthermore, our results revealed that the extent and quality of the SHE received was poor. Specifically, none of the 10 important sexual health topics assessed were rated well covered in SHE in Spain. The topics most likely to be covered focus on biological and reproductive aspects (puberty and physical development; reproduction and childbirth; and contraceptive methods) and the prevention of STIs. This is in keeping with research that has found in a range of countries that SHE tends to focus on biological topics and reducing risky sexual behavior, with limited focus on more controversial and positive sexual health topics (e.g., sexual pleasure, sexual behavior, gender and sexual diversity) (Byers et al., 2017; Garcia, 2015; Ketting et al., 2021; Kivela et al., 2014; MacDougall et al., 2020). Yet, few participants in our study rated even those somewhat more frequently taught topics as covered well or very well in the SHE they received. Furthermore, most participants indicated that several important SHE topics focusing on the personal and interpersonal aspects of sexuality had not been covered at all. These included managing pressure to be sexually active, communication about sexual consent, sexual coercion/sexual assault, sexual relationships and behavior, making sexual decisions or sexuality in the media or internet. Indeed, few participants (and fewer participants than in Byers et al.’s Canadian sample) who had received SHE on these topics rated the coverage as extensive. Yet these topics are important to sexual health including preventing sexual victimization and ensuring that sexual experiences are wanted and pleasurable (Lameiras-Fernández et al., 2021; Mark et al., 2021; Schneider & Hirsch, 2020). Furthermore, these are also the topics that students most want to learn about (Allen, 2008; Astle et al., 2021; Helmer et al., 2015). Of note, Spanish participants perceive the quality of coverage of sexual topics as poor compared to other countries such as Canada (Byers et al., 2017).

As expected, we found that the more academic years participants received SHE, the higher they rated the extent of its coverage and its quality. This likely indicates that repeated exposure to the material over time allowed for more in-depth coverage and better integration of key topics. We also found that female participants reported receiving less extensive SHE, although the men and women did not differ in their perceptions of the (poor) quality of the SHE they received. This is partially consistent with a Canadian study (Byers et al., 2017), which found that adolescent boys rated the quality and the extent of SHE coverage in middle school, although not in high school, more favorably than did adolescent girls. As Byers et al. (2017) suggested, this disparity may reflect a misalignment between the timing of SHE and the developmental needs of girls, who enter puberty earlier than boys do. Given that we were assessing SHE received when participants were 12 to 16 years old and girls typically start puberty between 8 and 13 years old, SHE on even biological topics occurs later than ideal for girls, whereas the timing may be more appropriate for boys between the ages of 10 and 14 years old (Güemes-Hidalgo et al., 2017). Alternately, if SHE is based on the traditional sexual script that prescribes male initiation and female passivity and privileges male needs and pleasure (Byers 1996), it may meet the needs of male students more than of female students. Of note, the gender difference in perceptions of the extent of SHE was small, accounting for only 2% of the variance, with both men and women providing ratings corresponding to very limited covered (between not covered and covered poorly). This suggests that SHE in Spanish high schools is insufficient for all students, although it is worse for female students.

Contrary to our predictions we found no group differences in perceived extent or quality of SHE based on sexual orientation. This likely reflects the low overall ratings by both groups. We also found no group differences in perceived extent or quality of SHE based on age. We also did not find that older adults were more likely to report having had no SHE. Furthermore, older adults who had received some SHE were more likely to report that contraception and prevention of STIs were not included. Surprisingly, older adults were less likely than were younger adults to report that there was no coverage of sexual pressure and sexual-decision-making in the SHE they received. Of note, the majority of both younger and older adults reported that these topics were not covered. Taken together these findings suggests that despite some reforms in Spain (Cunha-Oliveira et al., 2021; Fernández-Costa et al., 1999), there has not been substantial improvement in the SHE provided to students in school over the generations.

Limitations and conclusion

Although this study was conducted among a fairly large sample of adults from Spain and used measure that have been used in other countries, there are important limitations to mention. The cross-sectional retrospective design limits all inference to causality and longitudinal designs and cohort studies would be necessary to clearly establish a temporal sequence with actual SHE offered during adolescence and later perception of coverage and quality in adulthood. Responses may have been influenced by biases inherent in self-report measures including recall bias and social desirability. Recall bias may have particularly affected participants in our older age group given the large time span since they would have been in school. The generalization of the findings is limited by the use of a convenience sample that may not be representative or all Spaniards. In particular, the fact that this was an online survey distributed through social networks likely limited the population we could access. Furthermore, the vast majority of participants had attended university, so the results may not reflect the perceptions of individuals with less education. Future research, should examine coverage of a more comprehensive list of topics (including sexual orientation and gender identity) as well as coverage of sexual health in elementary school.

Nonetheless, the results of the current study are important because they are the first to document the limited coverage of sexual health topics in Spanish schools currently and historically. They also document that there has not been a significant improvement in SHE over the years. Our findings highlight the fact many youths are not receiving any school-based SHE and that that when SHE is of poor quality and delivered too infrequently and too late. The lack of quality SHE in schools in Spain may in part account for the poor sexual health outcomes experience by Spanish youth given that quality school-based SHE has been linked to a number of positive sexual health (Goldfarb & Lieberman, 2021; Kantor et al., 2021; Kivela et al., 2014; Vivancos et al., 2013). These findings have several important implications. In keeping with calls for improved SHE in Spain (Alonso-Martínez et al., 2023; Fernández-Rouco et al., 2019; Moliner Miravet et al., 2018; Ramiro-Sánchez et al., 2018), these results suggest that it is important that SHE be made a mandatory part of the health curriculum and that it be comprehensive rather than focusing largely or exclusively on biological topics. This likely would involve establishing national standards that includes coverage of a wide range of topics. Many sex education experts advocate for beginning SHE in elementary school, with age-appropriate topics (e.g., naming the genitalia, exploring gender identity) (Depauli & Plaute, 2018; Fakinos, 2010; Schmidt et al., 2015). In keeping with this, such a curriculum should be age-appropriate by introducing basic foundational topics in early grades, with more complex relational and ethical issues addressed in later years, as adolescents mature. Developing such a curriculum would also require training teachers in providing SHE. Research in a number of countries, including Spain, has shown that typically teachers who are required to provide SHE have little to no training (Byers et al., 2025; Cohen et al., 2011; Cummings et al., 2021; Ketting et al., 2021; O’Brien et al., 2021; Plaza-del-Pino et al., 2021). Yet, the quality of the SHE provided depends not only on the curriculum, but also on the way that the curriculum is delivered, and effective delivery requires training (Byers et al., 2025). Implementing quality SHE at different levels would not only meet the UN’s sustainable development goals, but could also help improve the sexual health of Spanish youth.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Author contributions

All authors contributed to the study conception and design. Material preparation was performed by E.S.B. and M.G.B. Data collection and analysis were performed by E.S.B., M.E.M., A.B and M.G.B. The first draft of the manuscript was written by E.S.B., M.E.M., A.B and M.G.B. and subsequent revisions were done by E.S.B., M.E.M., M.G.B. and A.B. All authors read and approved the final manuscript.

Disclosure statement

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