Newly released last week, to muted publicity, was the comprehensive, reliable and rigorous Cochrane review of studies reviewing school-based interventions on sex education. This was a large review, combining peer-reviewed data from more than 55,000 young people from around the world.
Some of its conclusions were startling and probably for many, unexpected.
The studies in the Cochrane review were all randomised controlled trials from Europe, Latin America and sub-Saharan Africa, mostly of high quality. The sex education programmes they investigated included peer and teacher-led education and ‘innovative uses’ of drama and group work.
One finding of the review was that providing a small cash payment, or giving away a free school uniform, can encourage students to remain at school, especially in places where there are financial barriers to attending. Such incentives to stay at school reduced pregnancy rates by around a quarter and also reduced sexually transmitted infections (STIs) in both girls and boys.
However, the more surprising, and no doubt controversial, finding (to many) will be the admission that the mainstay of the current approach to sex education is not working.
School-based sexual and reproductive health programmes are widely accepted and implemented as an approach to reducing high-risk sexual behaviour among adolescents, however the Cochrane review found that sex education programmes do not reduce pregnancy and STIs among the young. In fact, they have no effect on adolescent pregnancy and STI rates.
‘As they are currently designed, sex education programmes alone probably have no effect on the number of young people infected with HIV, other STIs or the number of pregnancies…’ said lead author of the review, Dr Mason-Jones.
Most current sex education programmes‘…aim to change attitudes, behaviours and social norms through improved knowledge and understanding of the risks of early sexual initiation and the importance of contraceptive and/or condom use.’ One of the UK programmes included in the Cochrane review ‘Aimed at improving skills in sexual communication and condom use and knowledge of pregnancy, STIs, contraception and local health services’.
This review clearly shows that promoters of current sex education policies do not know what works (or does not work) in practice.
Why the different findings to other studies?
Previous studies have been based on self-reported behaviours of young people, which are prone to bias. Sex and sexuality are sensitive topics, and relying on self-reporting is notoriously unreliable.
In contrast, this new Cochrane review only included studies featuring objective measurable biological outcomes from records or tests of pregnancy and STIs. This is the first review and meta-analysis to look only at measurable biological outcomes. And when the authors excluded studies from their review that were at high risk of bias, they found ‘no effect’ on long-term pregnancy prevalence in the remaining studies.
What effect should this research have?
If current sex education programmes are not working to reduce pregnancy and STIs among the young, this is highly significant.
We should be relying on much better quality evidence when developing public health policy on sex education, with measurable tracking of effectiveness to ensure that policies are working as expected. As the authors of the Cochrane review warn, regarding the UK Government Teenage Pregnancy Strategy (which incorporates school-based programmes), we ‘…need further evidence from controlled studies, preferably with randomised designs, as temporal trends can confuse and mislead.’
Furthermore, this shows us that the provision of continuing secondary education or training is a more effective measure for improving adolescent sexual and reproductive outcomes, especially for girls. While this study may highlight the failings of sex education at the moment, it clearly points to the effectiveness of school in general in the prevention of STIs and unwanted pregnancies. In other words, staying at school is a healthy contraceptive!
Campaigners for national action plans for statutory (compulsory) sex and relationships education in UK schools should consider this new evidence and reconsider their stance.Primary prevention strategies for STIs and unintended pregnancies need to be re-evaluated.
I said at the outset that these findings will be a surprise to many. But not to all, as this prescient 2007 BMJ editorial shows. I have also previously warned that current sexual health strategies for tackling teenage pregnancies are primarily based on three false presuppositions: that contraception is safe, that youngsters will actually use it and that abstinence is impossible. The liberal, value-free norms promoted in most sex education programmes (there is no right or wrong in teenage sexual activity, just choice) are not in the best interests of youngsters.
As well as showing that current sex education programmes have no effect on adolescent pregnancy and STI rates, the review does hint at the need to address wider structural issues that influence sexual health outcomes (in this case, educational achievement) and, I would add, parental influence. A much more comprehensive approach is key to improving outcomes, incorporating parental involvement and life opportunities for vulnerable young people.
Promoting correct use of condoms does not lead to a reduction in STI rates and pregnancies because, in reality, as the BMJ editorial says, much teenage sex has little to do with sex itself but is connected with a search for meaning, identity and belonging. These wider sociocultural aspects influencing sexual behavior need more attention now.