Keeping girls at school may reduce teenage pregnancy and STIs – but sex education doesn’t

It’s not always that simple. Shutterstock

Worldwide, more than 65m adolescent girls have no access to school. And it’s not just poorer countries that suffer from bad education. In the UK, one in five young people don’t complete post-16 education, making it one of the worst performing countries in league tables measuring how well young people are educated. This affects not only life chances but also health outcomes and well-being.

Studies conducted as far afield as the US, Norway and rural South Africa, for example, have suggested that encouraging school attendance can help young people avoid early sexual activity – and girls to avoid unplanned pregnancy. But this has never been confirmed by experimental evidence – until now.

A comprehensive Cochrane review of studies from around the world combined the data from more than 55,000 young people aged on average between 14 and 16. And it has shown that providing a small payment or giving away a free school uniform can incentivise the young to stay in school for longer, especially in places where there are financial barriers to attending.

Most significantly, it also reveals that the approach could prevent three in every ten pregnancies among that age group globally, and may also delay sexual activity and reduce sexually transmitted infections (STIs) in both girls and boys – although further high quality studies are needed to confirm this. Additionally, it suggests that the mainstay of the current approach – “sex education” – isn’t working to achieve these ends.

Sex education is failing

The studies in the Cochrane review were all randomised controlled trials from Europe, Latin America and sub-Saharan Africa. Most were of high quality and had follow-ups at between 18 months and seven years.

The sex education programmes they investigated included peer and teacher-led education and the innovative uses of drama and group work. But most of the programmes did not provide access to the necessary health services, such as condoms or other contraception, especially for the youngest age groups.

What is clear is that we really don’t know what works and for whom when it comes to curriculum-based sex education in schools. We are often told that we do know, but the studies quoted previously have been based on self-reported behaviours of young people which are prone to bias.

Sex and sexuality are sensitive topics, especially when there are legal or moral ramifications for someone admitting to having sex. This new review, by contrast, has for the first time only included studies featuring measurable biological outcomes from records or tests of pregnancy and STIs. The fact that it points to sex education not working to reduce pregnancy and STIs among the young, therefore, is all the more significant. It seems we need a radical rethink.

Staying at school: a healthy contraceptive? Shutterstock

But what should be done? Most people agree that sex education should start early and focus on relationships, not just on the mechanics of sex. Most also agree that it should be inclusive and sensitive to a range of sexualities, including not assuming that all young people have started to have sex. Equally, few would disagree that we need to reform current approaches to take into account new risks from digital communications and social media, and that schools are a good place to encourage the development of healthy relationships.

However, MP Sarah Champion, whose Dare to Care national action plan calls for “compulsory resilience and relationships education” in UK schools, needs to consider this new evidence. She talks about young people needing “the tools to rebuff harmful requests and behaviour from abusers”. This focus solely on an individualised notion of resilience is flawed unless it incorporates more ecological and culturally sensitive definitions, and a clear understanding that it is not at all easy to “rebuff” violent approaches, especially in young people’s intimate relationships.

We need to build schools that are safe, welcoming and supportive – with adults, including parents, that are open and have the skills to talk to children about sexuality. We also need to think carefully about how the sexuality education offered by schools can effectively achieve its aims.

New ways of thinking about sex

Certainly, current strategies are failing. Talking about sex in schools doesn’t encourage young people to have sex, but equally – as the Cochrane review shows – it is not likely to delay them having it either, as some previous authors have suggested.

Some, for example, have claimed that programmes such as TeenStar, which encourage abstinence from sexual activity, are effective. But this conclusion is based on studies that are considered to have serious flaws.

The Cabezon study, for example, examined pregnancy outcomes from a programme in Chile that promoted abstinence from sexual activity. They suggested that the programme was successful by comparing the number of girls who were pregnant at the end of the study (19), with the number of pregnancies from a group who didn’t receive the programme (52). This made the programme look amazingly successful, but it excluded miscarriages and also illegal abortions that go unrecorded in Chile, so they were unlikely to have included all unwanted pregnancies that had occurred. The study also suffered from a number of biases including during randomisation and recruitment to the study, and selective reporting of the results.

In future, we need to rely on good quality evidence when developing public health policy. If sex education were to become compulsory, for example, it would be sensible to track its effectiveness experimentally to ensure that policies are working as expected.

While this study may highlight the failings of sex education at the moment, it also points to the effectiveness of school in general in the prevention of STIs and unwanted pregnancies. That, at least, is a good start.

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