Sexual knowledge of Canadian adolescents after completion of high school sexual education requirements

Abstract

BACKGROUND:

Formal sexual education is a mandatory component of the high school curriculum in most Canadian provinces. The present study was a preliminary assessment of sexual knowledge among a sample of Ontario adolescents who had completed their high school sexual education requirements.

METHODS:

A questionnaire, testing understanding of the learning objectives of Ontario’s minimally required high school sexual education course, was distributed in a paediatric emergency department to 200 adolescent patients who had completed the course.

RESULTS:

Respondents demonstrated good understanding of pregnancy physiology and sexually transmitted infections, but poor understanding of concepts related to reproductive physiology, contraception, HIV/AIDS and sexual assault. Most respondents could not identify Canada’s age of sexual consent.

CONCLUSIONS:

Respondents demonstrated concerning gaps in sexual knowledge despite completion of their sexual education requirements. Further studies must determine whether a representative, population-based student sample would exhibit similar findings. Sexual education currently offered in Ontario may require investigation.

Adolescence is a crucial period for learning about healthy sexuality (1,2). As teenagers struggle to complete the developmental tasks of adolescence, such as accepting their changing bodies and defining their sexual identities, they are at risk for negative sexual consequences (3). Sexually active Canadian teenagers commonly engage in risky sexual behaviours, including unprotected sex, multiple sexual partners and intercourse, before 15 years of age (4). Canadians 15 to 24 years of age also have the country’s highest incidences of chlamydia and gonorrhea infections (5). Such statistics raise concerns about whether young Canadians have sufficient knowledge to make responsible sexual decisions. Comprehensive sexual education for adolescents effectively reduces the incidence of negative sexual outcomes (6,7). The Canadian Paediatric Society and the American Academy of Pediatrics (8,9) recommend that paediatricians participate in the development and implementation of comprehensive sexual education programs in schools.

In Canada, education is under provincial jurisdiction and almost every province’s high school curriculum contains formal sexual education. Within the province of Ontario, sexual education is a subcomponent of health and physical education courses; each course is comprised of approximately 110 h of instruction. However, only a fraction of course time, determined by each school, is dedicated to sexual education; consequently, there is potential for significant variability among schools. Ontario’s Ministry of Education has outlined six course expectations (Table 1) for its Grade 9/10 Healthy Growth and Sexuality unit (10). Completion of this unit is the minimum sexual education required for a high school diploma or certificate in Ontario.

TABLE 1.

Course expectations for Ontario’s Grade 9/10 Healthy Growth and Sexuality course (10)

Identify the developmental stages of sexuality throughout life Describe the factors that lead to responsible sexual relationships Describe the relative effectiveness of methods of preventing pregnancies and sexually transmitted diseases (eg, abstinence, condoms, oral contraceptives) Demonstrate understanding of how to use decision-making and assertiveness skills effectively to promote healthy sexuality (eg, healthy human relationships, avoiding unwanted pregnancies and sexually transmitted infections such as HIV/AIDS) Demonstrate understanding of the pressures on teens to be sexually active Identify community support services related to sexual health concerns

There are currently no standardized examinations or evaluation processes to assess the knowledge of students who have completed their sexual education requirements and no other standardized assessments of sexual education quality.

Several studies have attempted to assess the sexual knowledge of Canadian adolescents. The majority of these studies, however, limited the scope of their assessment to knowledge of HIV/sexually transmitted infections (STI) alone (11–16) or HIV/STI, contraception and limited reproductive physiology (17).

The present study will expand on previous Canadian work in two ways. First, it will assess student knowledge in multiple domains using an assessment questionnaire addressing all major topics included in Ontario’s high school human sexuality curriculum, including reproductive physiology throughout life (not just adolescence), HIV/STI, contraception and responsible sexuality including sexual consent. Second, unlike most previous Canadian studies, participants will be recruited from many different schools.

The objective of the present study was to conduct a preliminary assessment of sexual knowledge related to the learning objectives of Ontario’s minimally required high school sexual education course, among a sample of adolescents presenting to an emergency department who had completed their provincial high school sexual education requirements.

METHODS

The present descriptive study used a convenience sample of adolescent patients (see patient eligibility below), from the paediatric emergency department of the London Health Sciences Centre, a tertiary care facility located in London, Ontario, whose catchment is two million people and which treats 37,500 patients annually. Ethics approval was obtained from the Health Sciences Research Ethics Board at the University of Western Ontario (London, Ontario) and the Clinical Research Impact Committee at the Lawson Health Research Institute (London, Ontario).

Questionnaire development

A questionnaire (Appendix A) designed to test expectations 1 through 4 outlined in the Ontario Ministry of Education’s Grade 9/10 Healthy Growth and Sexuality course (Table 1) was developed (achievement of expectations 5 and 6 was not considered objectively testable by the authors.) Specific questions pertaining to each objective were developed using the Guidelines for Comprehensive Sexuality Education, 3rd Edition published by the Sexuality Information and Education Council of the United States (SIECUS) (18). This guideline, created by a national task force of health care professionals, educators and experts in adolescent development, contains recommendations for subject matter to be included in a comprehensive sexual education curriculum. Questions were also created using Canadian laws relevant to responsible sexuality (19–21) and Canadian health guidelines (22–25).

Questions were arranged into six categories: pregnancy; reproductive physiology and puberty; STI; contraception; HIV/AIDS; and sexuality and the law. Questions were true/false/unsure or multiple-choice. Participants were not asked about their personal experiences or values related to sexuality.

Additionally, participants used a seven-point Likert scale to rate the usefulness of various sources of sexual information (Table 2), in which 1 = not at all helpful, 4 = somewhat helpful and 7 = extremely helpful.

TABLE 2.

Frequencies of respondents’ ratings of usefulness for six common sources of sexual information on a seven-point Likert scale

Source	Not at all helpful		Somewhat helpful			Extremely helpful
	1	2	3	4	5	6	7
Sexual education classes received in high school	4 (2.0)	7 (3.5)	16 (8.0)	58 (29.0)	48 (24.0)	48 (24.0)	16 (8.0)
Sexual education classes received before high school	22 (11.0)	32 (16.0)	48 (24.0)	53 (26.5)	25 (12.5)	13 (6.5)	3 (1.5)
Parents	34 (17.0)	35 (17.5)	22 (11.0)	39 (19.5)	19 (9.5)	19 (9.5)	29 (14.5)
Friends	20 (10.0)	26 (13.0)	31 (15.5)	33 (16.5)	37 (18.5)	28 (14.0)	22 (11.0)
Popular media (television, movies, magazines)	41 (20.5)	35 (17.5)	29 (14.5)	40 (20.0)	29 (14.5)	13 (6.5)	10 (5.0)
Internet	38 (19.0)	29 (14.5)	34 (17.0)	35 (17.5)	28 (14.0)	14 (7.0)	20 (10.0)

Data presented as n (%)

Baseline characteristics were assessed, including age and sex; whether currently in school, and current/highest grade successfully completed; the number of high school health courses completed; whether the school in which these courses were taken was private or public, religious or secular; municipality in which the school was located; household structure (eg, two-parent, single-parent or alternative arrangement); and reason for presenting to the emergency department.

The questionnaire was piloted among a convenience sample of adolescents before distribution. Feedback was obtained about readability, time required to complete the survey, printed layout of the questionnaire, subject matter covered by the questions and whether any questions were perceived as invasive; further revisions were consequently made. The questionnaire took 10 min to 15 min to complete. Its Flesch Reading Ease score was 68% and its Flesch-Kincaid Grade level was 6.8.

Patient eligibility

Adolescent patients attending London Health Sciences Centre’s paediatric emergency department were considered eligible if they had completed at least one credit of health education in an Ontario high school (minimum provincial requirement), and triage scores upon presenting to the emergency department were neither resuscitative nor emergent (ie, Canadian Pediatric Triage and Acuity Scale score of 3 [urgent], 4 [less urgent] or 5 [non-urgent]). No age minimum was set as long as the educational requirement was met, but all participants were younger than 18 years of age (maximum patient age accepted by the paediatric emergency department). Exclusion criteria included incapacity to provide one’s own consent (assessed by the attending physician); insufficient fluency in written English (as self-reported by patient after inquiry); and acute pain, psychiatric or psychosocial crisis of such severity that recruitment was deemed inappropriate (assessed by the attending physician).

Questionnaire distribution

Once deemed eligible, the patient received the questionnaire with an accompanying letter of information. Completion of the questionnaire implied informed consent. Participants could complete the questionnaire in the presence of parents/guardians but were asked to refrain from discussion while completing it. However, respondents and parents/guardians were informed that upon return of the questionnaire, they would receive an answer key with explanations for each question that they could review together and take home. This allowed parents/guardians to let their child complete the questionnaire privately, knowing that the answer key would be available shortly for review and discussion.

If an eligible patient did not wish to participate, their reason for declining was documented.

Statistical analysis

Because this was a descriptive study without primary or secondary end points, a sample size calculation was not performed. It was decided that a sample size of 200 would obtain a sufficient cross-section of adolescents from different socioeconomic backgrounds and types of schools, while acknowledging that the convenience sample of emergency department patients may not be representative of the general adolescent population. Mean (± SD) scores were calculated for each question category and each question. Categorical variables were reported as percentages. A χ² test was used to assess associations between categorical variables; P<0.05 was considered to be statistically significant.

RESULTS

Of the 206 patients approached who met eligibility criteria, 200 agreed to participate. The six patients who declined cited disinterest in the subject matter as their reason. Respondents experienced a variety of presenting complaints, but the most common were musculoskeletal complaints (31%), minor trauma (13.5%) and abdominal pain (13.5%). Other baseline characteristics are summarized in Table 3. Ages ranged from 14 to almost 18 years; the mean (± SD) age was 16±0.9 years. The mean current grade was 10.6±1.8. Fifty-six per cent were girls. Almost all were currently in school, with most attending a publicly funded school. Of the five available health/physical education courses offered in Ontario schools, almost one-half of respondents had completed one course (the minimum requirement) and approximately one-fifth had completed two courses.

TABLE 3.

Baseline characteristics of participants (n=200)

Characteristic	Value
Age, years, mean ± SD	16.0±0.9
Male participants	88 (44)
Currently enrolled in school	193 (96.5)
Current grade or highest grade completed, mean ± SD	10.6±1.8
Completed health and physical education courses (maximum available courses = 5)
1	94 (47)
2	44 (22)
3	26 (13)
4	7 (3.5)
5	2 (1)
Type of school attended
Public	170 (85)
Private	7 (3.5)
Religiously based	58 (29)
Secular	129 (64.5)
Urban	149 (74.5)
Rural	39 (19.5)
Living situation
With both parents	129 (64.5)
With one parent	43 (21.5)
Divides time between both parents	9 (4.5)
Other	19 (9.5)

Data presented as n (%) unless otherwise indicated

Mean scores within each question category are summarized in Table 4. Respondents correctly answered most questions relating to pregnancy physiology (79.6%), but performed less well on questions related to general reproductive physiology (61.6%). For example, 27% of respondents reported that pregnancy could result from oral sex, anal sex or mutual masturbation; 40% agreed with the statement that when a couple cannot conceive, the woman usually has a medical problem; and 55% could not identify when a woman is most likely to get pregnant during her menstrual cycle.

TABLE 4.

Mean scores within each question category

Category	Total questions per category, n	Correctly answered questions, mean (%)
Reproductive physiology and puberty	6	3.7 (61.6)
Pregnancy	9	7.2 (79.6)
Sexually transmitted infections	7	5.5 (79.1)
HIV/AIDS	2	1.0 (51.4)
Contraception	3	1.3 (43.1)
Sexuality and the law	6	4.0 (66.3)

Respondents demonstrated good understanding of STI prevention (79.6% of questions correct). Each of the following were correctly identified by 75% to 90% of respondents: the need for regular sexual health examinations in both sexes; the potential for untreated STI to cause infertility or fetal harm during pregnancy; that STI are transmittable through oral sex; that condoms do not protect against all STI; and that STI may be asymptomatic. However, the majority (almost 60%) did not know that human papillomavirus may cause genital cancer in males in addition to females. Respondents also performed relatively poorly on questions related to HIV/AIDS (51.4% correct). Only 54% knew that HIV is not transmitted through all types of skin-to-skin contact, and when presented with a list of activities that included tattooing, piercing, sexual intercourse, intravenous drug use and blood transfusion, only 43% correctly selected blood transfusion as an uncommon method of contracting HIV in Canada.

Respondents held several misconceptions regarding common contraceptive methods (43.1% of questions correct): 78.5% erroneously agreed that the ‘morning-after pill’ terminates an existing pregnancy; 38% overestimated the contraceptive efficacy of male condoms with typical use; and 37.5% did not agree with the statement that oral contraceptives can be dangerous for women who smoke.

When presented with four scenarios, each depicting an instance of sexual assault, only 29.6% of respondents identified all four incidents as assault and 29.1% only recognized two or fewer as assault. Only 42.5% correctly identified Canada’s age of sexual consent as 16 years.

Girls scored better than boys in the pregnancy category (81.7% versus 76.9% correct; P=0.03) and the reproductive physiology/puberty category (64.5% versus 57.9% correct; P=0.04); other baseline characteristics did not correlate with any significant differences in scores. With respect to different types of schools attended (eg, private versus public, urban versus rural, religious versus secular) or the number of sexual education courses taken, no statistically significant differences were detected between the subgroups.

Respondents’ ratings of the usefulness of six common sources of sexual information are shown in Table 2.

DISCUSSION

The present study built on previous Canadian assessments of student sexual knowledge in several important ways. Only one previous study attempted to assess sexual knowledge in multiple domains (17), and still failed to assess knowledge of reproductive physiology throughout life (including pregnancy), any STI other than chlamydia or HIV, abortion, sexual assault or sexual consent. Another weakness of earlier Canadian studies was that most recruited students from only one or two schools, making them vulnerable to selection bias. Three studies were performed on a national level with large samples (11,12,16) but all limited their assessment to knowledge of HIV/STI. The current study’s questionnaire was more comprehensive and included most of the topics recommended by an internationally recognized body of experts (ie, SIECUS).

Similar questionnaire-based studies have been performed in other nations to assess general sexual knowledge among youth (26–30), but the current study was the first to use a questionnaire systematically designed to correspond to our provincially mandated sexual education curriculum.

Sexual knowledge

Although respondents performed well on questions related to pregnancy physiology, they carried several concerning misconceptions related to general reproductive physiology, which could lead to negative outcomes throughout their lifespan.

Respondents were knowledgeable about STI prevention but performed less well on questions related to HIV/AIDS transmission. A previous study showed that most surveyed Canadian teenagers could identify major risk factors for HIV transmission (eg, sharing needles, unprotected sex, multiple sexual partners) (31). However, our results suggest that teenagers may have a poorer understanding of minor risk factors for HIV transmission (eg, that HIV is not transmitted through all skin-to-skin contact, and is rarely contracted via blood transfusions in Canada).

Many respondents held misconceptions about contraception that could lead to unsafe choices. Belief that the ‘morning-after’ pill causes abortion may lead to underuse of emergency contraception. Overestimation of the contraceptive efficacy of male condoms may explain why many sexually active Canadian girls use condoms without back-up contraception (32). Failure to understand the risk of smoking while taking oral contraceptives may increase the risk of thromboembolism in later adulthood.

No previous Canadian studies have assessed understanding of sexual consent laws among high school students. Canadians 15 to 24 years of age have an incidence of sexual victimization almost three times higher than the general population (33). Although learning to engage in ‘responsible sexual relationships’ is an expectation of Ontario’s sexual health curriculum (10), our findings suggest that Ontario students may have a poor understanding of sexual consent laws despite completing their course requirements. The relationship between this knowledge gap and the risk of sexual victimization could represent a potential area for future study.

Sources of sexual knowledge

High school sexual education classes received the highest average rating of usefulness among all listed sources. Ontario students appear to place great importance on their high school sexual health courses, which should motivate educators and policymakers to ensure that educational quality is maintained.

Interestingly, 17% of respondents rated the usefulness of the Internet as 6 of 7 or 7 of 7, putting it ahead of sexual health classes received before high school and popular media. A decade ago, many young Canadians were already using the Internet as their main source of sexual information (31). Given the recent explosion of social networking, further studies could explore how the ‘Facebook generation’ uses the Internet for sexual information, to determine whether it would be advantageous to incorporate modern online venues (eg, social networking sites) into sexual education.

Study limitations

The present study used a convenience sample of 200 adolescents from a southwestern Ontario paediatric emergency department. The emergency department setting permitted recruitment of students attending many different schools, an important advantage given the potential for variability in sexual education among schools. However, it is uncertain whether the sample was sufficiently representative to generalize the data to other adolescents in our region. Even more caution is needed before generalizing the data to adolescents from other parts of Canada where cultural, socioeconomic and municipal factors may affect local delivery of sexual education.

Teenagers did not have a separate space in which to complete the questionnaire without the presence of parents. Although parents were asked to refrain from discussing any questions with their children until provided with the answer key, their physical presence may have caused respondents to answer some questions differently. We observed that the study design frequently fostered healthy discussions about sexuality between participants and their parents; however, we must acknowledge that it may have also created bias.

Our questionnaire had an uneven distribution of questions from each category, which may have affected validity through its heterogeneity. For example, there were only two HIV-specific questions; therefore, answering one correctly produced a subscore of 50%; subscores may have been different had there been more HIV-specific questions.

Emergency department patients may also have other risk factors, such as lower socioeconomic status and/or more risk-taking behaviour (34), which may have affected their scores. While the results may not generalize well to youth outside of the emergency department, they at least suggest that this subset of students has gaps in sexual knowledge.

An important limitation was the use of a previously unvalidated assessment questionnaire, necessitated by the absence of standardized examinations or evaluation methods for sexual education courses in Ontario. Unlike the United States, where the SIECUS guidelines have long existed, Canada lacks national guidelines for content and delivery of school sexual education, which could have provided a benchmark for investigators to use when assessing the sexual knowledge of Canadian students. The Canadian Guidelines for Sexual Health Education, while providing general principles for administering sexual education, provide no specific suggestions for curriculum content or teaching strategies (35). In the absence of national standards and existing assessment tools, we had to create an original tool. A strength of the present study, however, was the systematic development of its questionnaire based on objective resources (ie, Ontario’s sexual education curriculum, SIECUS guidelines, and Canadian health laws and guidelines). Piloting the questionnaire among a sample of adolescents before its distribution was also a strength of the study; an additional pilot among health care providers experienced in working with adolescents may have further ensured accuracy and inclusion of an appropriate range of topics.

Although respondents disclosed the number of sexual education classes they had taken and the types of schools they attended (urban versus rural, private versus public, religious versus secular), the sample size was inadequately powered to detect significant differences between subgroups. Larger population-based studies are required to determine whether meaningful differences exist.

Finally, the present study could not assess the respondents’ knowledge of topics missing from Ontario’s sexual education curriculum, including sexual orientation, masturbation, sexual fantasy and sexual dysfunction. These topics are excluded despite SIECUS’s recommendations that they be included in any comprehensive sexual education program (18). Additional studies should assess understanding of these topics among Canadian adolescents, and intervention is required to incorporate these topics into Ontario’s curriculum.

CONCLUSION

The present study demonstrated significant gaps in sexual knowledge among a sample of Ontario adolescents who had completed their high school sexual education requirements. Subsequent studies are necessary to determine whether these findings can be replicated, and whether clinically meaningful differences exist between subgroups, by using a representative, population-based sample. Educators and policy-makers should consider conducting formal evaluations of high school sexual education courses that are currently being offered.

APPENDIX A. Children’s Hospital Sexual Education Assessment Survey