Ethical considerations and challenges of sex education for adolescents in Iran: a qualitative study
Adolescence is a period in one’s lifetime during which sexual maturation occurs. Major changes and increased sexual instinct raise many questions in the minds of adolescents. Receiving wrong education or inappropriate information can affect adolescents’ life and future deeply. Obviously, ethical considerations cannot be ignored in nationwide macro policies and educational programs on such a sensitive issue. In this qualitative study, we attempted to explore the ethical considerations and challenges of sex education for adolescents.The study was conducted between May 2015 and March 2017. Data were collected through semi-structured in-depth interviews with 25 participants, and MAXQDA 11 was used for coding.Six hundred sixty-two codes (662) were extracted and classified into four categories: 1) the potential risks of sex education for adolescents; 2) the advantages of sex education for adolescents, and the approaches; 3) the challenges in the interval between sexual maturation and marriage, and the role of religion; and 4) the measures implemented in Iran.Shame, embarrassment, and some cultural beliefs surrounding the subject of sex education are obstacles to providing adolescents with the necessary information. According to the principles of medical ethics, the main principle in sex education is beneficence, and sometimes infringement of confidentiality has its advantages.
Anonymous. WHO: Adolescent health and development. [cited 2020 January]; Available from: http://www.searo.who.int/entity/child_adolescent/topics/adolescent_health/en/
McNeely C, Blanchard J. The teen years explained: A guide to healthy adolescent development. [cited 2020 January]; Available from: https://www.jhsph.edu/research/centers-and-institutes/center-for-adolescent-health/_docs/TTYE-Guide.pdf
Noori Sistani M, Merghati Khoi E, Taghdisi M H. Comparison among viewpoints of mothers, girls and teachers on pubertal health priorities in guidance schools in District 6, Tehran. Journal of school of Public Health and Institute of Public Health Research. 2008; 6(2): 13-22. [in Persian]
Azizzadeh Forouzi M, Mohammad Alizadeh S, Pouraboli B, Nazari T. Study of the attitude of school teachers in Kerman towards sexual education and their opinion regarding contents of adolescent sexual education. Journal of Shahid Sadoughi University of Medical Sciences and Health Services. 2002; 9(4): 87-90. [in Persian].
Latif Nejad R, Javad Nouri M, Hasanpour M, Hazaveyi SMM, Taghipour A. The necessity of sexual-health education for Iranian female adolescents: a qualitative study. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2012; 15(12): 7-17.
Kalantary S, Ghana S, Sanagoo A, Jouybari LM. Puberty and sex education to girls: experiences of Gorganians' mothers. Journal of Health Promotion Management. 2013; 2(3): 74-90.
British Medical Association. Medical Ethics today: The BMA’s Handbook of Ethics and law. UK: BMJ Books; 2012, p. 224-40.
Bourton V. Sex education in school: young people’s views. Paediatr Nurs. 2006; 18(8): 20-2.
Jalali Aria K, Nahidi F, Akbari AA, Alavi Majd H. Parents and teachers' view on appropriate time and method for female reproductive health education. Journal of Gorgan University of Medical Sciences. 2010; 12(3): 84-90. [in Persian]
DeJong J, Jawad R, Mortagy I, Shepard B. The sexual and reproductive health of young people in the Arab countries and Iran. Reprod Health Matters. 2005; 13(25): 49–59.
Leigh Gk, Loewen IR, Lester ME. Caveat emptor: values and ethics in family life education and enrichment. Family Relations. 1986; 35(4): 573-80.
Majdpour M, Shams M, Parhizkar S, Mousavizadeh A, Rahimi Z. Informal sexuality education to adolescent girls through empowering their mothers: a field trial. Scientific Journal of School of Public Health and Institute of Public Health Research. 2017; 15(3): 267-79. [in Persian]
Latifnejad Roudsari R, Javadnouri M, Hasanpour M, Hazavehei SMM. Taghipour A. Socio-cultural challenges to sexual health education for female adolescents in Iran. Iran J Reprod Med. 2013; 11(2): 101-10.
Refaie Shirpak K, Eftekhar Ardebili H, Mohammad K, et al, Developing and testing a sex education program for the female clients of health centers in Iran. Sex Education. 2007; 7(4): 333-49.
Alimordi Z, Simbar M. Puberty health education for Iranian adolescent girls: challenges and priorities to design school-based interventions for mothers and daughters. Payesh 2014; 13(5): 621-36. [in Persian]
Kirby D, Laris BA. Effective curriculum-based sex and STD/HIV education programs for adolescents. Child Development Perspectives. 2009; 3(1): 21-29.
Curvino M, Fischer MG. Claiming comprehensive sex education is a right does not make it so: a close reading of international law. New Bioeth. 2014; 20(1): 72-98.
Shrestha RM1, Otsuka K, Poudel KC, Yasuoka J, Lamichhane M, Jimba M. Better learning in schools to improve attitudes toward abstinence and intentions for safer sex among adolescents in urban Nepal. BMC Public Health. 2013; 13: 244.
Santelli J, Ott MA, Lyon M, Rogers J, Summers D, Schleifer R. Abstinence and abstinence-only education: a review of U.S. policies and programs. J Adolesc Health. 2006; 38(1): 72-81
Polit DF, Beck CT. Essentials of Nursing Research: Appraising Evidence for Nursing Practice, 6th ed. USA: LWW Publication; 2013, p. 332-6.
Devers KJ, Frankel RM. Study design in qualitative research--2: Sampling and data collection strategies. Educ Health (Abingdon). 2000; 13(2): 263-71.
Shenton AK. Strategies for ensuring trustworthiness in qualitative research projects. Education for Information. 2004; 22: 63-75.
Bengtsson M. How to plan and perform a qualitative study using content analysis. NursingPlus Open. 2016; 2: 8-14.
Heller, J. The Relationship Between Parental Opinion of School-Based Sex Education, Parent-Child Communication about Sexuality, and Parenting Styles in a Diverse Urban Community College Population [dissertation]. New York (USA). City New York University; 2009.
Marsiglio W, Mott FL. The impact of sex education on sexual activity, contraceptive use and pre-material pregnancy, among American teenagers. Fam Plann Perspect. 1986; 18(4): 151-62.
Pereda N, Guilera G, Forns M, Gómez-Benito J. The prevalence of child sexual abuse in community and student samples: a meta-analysis. Clinical psychology review. 2009; 29(4): 328-38.
Ghahremani L, Heydarnia A, Babaie G, Nazary M. Effects of puberty health education on health behavior of secondary school girl students in Chabahar City. Iranian South Medical Journal. 2008; 11(1): 61-68. [in Persian]
Javadnoori M, Latifnejad Roudsari R, Hasanpour M, Hazavehei MM, and Taghipour A. Female adolescents’ experiences and perceptions regarding sexual health education in Iranian schools: a qualitative content analysis. Iran J Nurs Midwifery Res. 2012; 17(7): 539–46.
Darling CA, Mabe AR. Analyzing ethical issues sexual relationships. Journal of Sex Education and Therapy. 1989; 15(4): 234-46.
Bruess CE, Greenberg JS. Resolving ethical issues when conducting sexuality education. American Journal of Sexuality Education. 2008; 3(4): 313-22.
Abolghasemi N, Merghati Khoei E, Taghdissi H. Teachers' perceptions of sex education of primary school children. Journal of School of Public Health and Institute of Public Health Research. 2010; 8(2): 27-39. [in Persian]
Malek A, Abbasi SH, Faghihi AN, Bina M, Shafiee-Kandjani AR. A study on the sources of sexual knowledge acquisition among high school students in northwest Iran. Arch Iran Med. 2010; 13(6): 537-42.
Koohestani HR, Roozbahani N, Baghcheghi N. Adolescent boys' lived experience of puberty: a qualitative study. Iran Journal of Nursing. 2009; 22(57): 53-65. [in Persian]
Mirzaii Nagmabadi K, Babazadeh R, Shariati M, Mousavi SA. Iranian adolescent girls and sexual andreproductive health information and services: a qualitative study. Iran Journal of Obstetrics Gynecology and Infertility. 2014; 17(92): 9-18.
Merghati-khoei E, Shams Alizadeh N, Bayat A, Zarei F, Rimaz S. Priorities of health risk behaviors among high school students in the public schools in 5th restrict of Tehran: A qualitative study. Journal of School of Public Health and Institute of Public Health Research. 2014; 12(2): 69–80. [in Persian]
Baldwin SE, Baranoski MV. Family interactions and sex education in the home. Adolescence. 1990; 25(99): 573-82.
Bleakley A, Hennessy M, Fishbein M, Jordan A. How sources of sexual information relate to adolescents’ beliefs about sex. Am J Health Behav. 2009; 33(1): 37–48.
Noroozi M, Taleghani F, Merghati-khoei EF, Tavakoli M, Gholami, A. Premarital sexual relationships: explanation of the actions and functions of family. Iran J Nurs Midwifery Res. 2014: 19(4): 424-31.
Maasoumi R, Lamyian M, Khalaj abadi Farahan F, Montazeri A. Women’s perception of sexual socialization in Iran: a qualitative study. Journal of Qualitative Research in Health Sciences. 2013; 2(3): 221-33.
Sajjadi M, Moshki M, Abasnezhad A, Bahri N. Educational needs of fathers about boy’s puberty period and its related factors. Zahedan Journal of Research in Medical Sciences (Tabib- e- Shargh). 2012; 14(2): 66-70. [in Persian]
Boromand far K, Abedi M, Hasanzadeh A. Investigation of high school boys' educational needs concerning adolescence period, in Isfahan City, 2002. Iranian Journal of Medical Education. 2002; 2(2): 15-20. [in Persian]
Marcell AV, Wibbelsman C, Seigel WM; Committee on Adolescence. Male adolescent sexual and reproductive health care. Pediatrics. 2011; 128(6): e1658-76.
Faghihi AN, Shokouhi Yekta M, Parand A. Sex education to children and teenagers of an Islamic viewpoint and psychological studies. Biquarterly Journal of Islamic Education. 2008; 7(3): 51-80. [in Persian]
Mohammadi MR, Alikhani S, Abadi Farahani FK, Bahonar A. Parents' attitudes towards adolescent boy's reproductive health needs and practice in Tehran. Iranian Journal of Psychiatry. 2007; 2(1): 13-24.
Simbar M, Alizadeh S, Hajifoghaha M, Golezar S. Review of Iranian adolescents' educational needs for sexual and reproductive health. Journal of Isfahan Medical School. 2017; 34(412): 1563-72.
Hedayati-Moghaddam MR, Eftekharzadeh-Mashhadi I, Fathimoghadam F, Pourafzali SJ. Sexual and reproductive behaviors among undergraduate university students in Mashhad, a city in northeast of Iran. J Reprod Infertil. 2015; 16(1): 43–8.
National AIDS Committee Secretariat, Ministry of Health and Medical Education. Islamic Republic of Iran AIDS progress report: on monitoring of the United Nations general assembly special session on HIV and AIDS. [cited 2020 January]; Available from: https://www.unaids.org/sites/default/files/country/documents/IRN_narrative_report_2015.pdf
Haglund KA, Fehring RJ. The association of religiosity, sexual education, and parental factors with risky sexual behaviors among adolescents and young adults. J Relig Health. 2010; 49(4): 460-72.
Bahrami N, Simbar M, Soleimani M. Sexual health challenges of adolescents in Iran: a review article. Journal of School of Public Health and Institute of Public Health Research. 2013; 10(4): 1-16. [in Persian]
Victor EC, Miles A, Vaisey S. The role of moral worldviews in predicting sexual behavior from adolescence to emerging adulthood. Journal of Adolescent Research. 2015; 30(6): 779–99.
Cheng W. Effects of Alternative Sex Education Policies on Adolescents' Sexual Risk Behavior: Towards Better High School Sex Education [dissertation]. Georgetown (USA). Georgetown University; 2012.
Anonymous. UNFPA operational guideline for comprehensive sexuality education: a focus on human rights and gender. [cited 2020 January]; Available from: https://www.unfpa.org/sites/default/files/pub-pdf/UNFPA%20Operational%20Guidance%20for%20CSE%20-Final%20WEB%20Version.pdf
Eskandari H, Rafieifar S. [Barname darsi jame amoozesh behdasht dar madares az doreh pish dabestani ta payane daneshkade]. [Cited 2020 January]; Available from: http://behdasht.gov.ir/uploads/1_94_33.pdf. [in Persian]
Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 7th Ed. USA: Oxford University Press; 2012, p.153-3.