Comprehensive Sexuality Education (CSE) for out-of-school refugee youth: What is known and what is needed?

This article is one of three linked discussions of Comprehensive Sexuality Education (CSE) produced as part of the scoping work of the ACCESS consortium by the Open University team. The other articles focus on Effective CSE in general and Online CSE.

Little is known about the SRHR needs of very young adolescents, sexual minorities and persons with HIV and disability because most studies on the SRHR experiences of refugees and internally displaced persons do not gather and present disaggregated data. This makes it difficult to understand the unique experiences of these populations, as well as challenging to design targeted interventions (Tirado et al., 2020; Jennings et al., 2019).

Comprehensive sexuality education, of varying levels of quality, is mostly delivered in schools due to the opportunity that schools offer in reaching large numbers of young people with accurate and developmentally appropriate knowledge. This leads to the exclusion of about 48 percent of refugee youths who are out-of-school (United Nations High Commissioner for Refugees, 2021), the majority of whom are girls (United Nations High Commissioner for Refugees, 2019). In view of this data, it is unsurprising that available evidence on the SRHR knowledge of refugee youth show that most lack knowledge on SRHR topics such as STIs and their prevention, and contraception (Ivanova, 2019, Tirado et al., 2020).

There are few interventions and studies of CSE for out-of-school youth in humanitarian and challenging environments, and particularly few that are discussed in peer-reviewed journal articles (Jennings et al. 2019, United Nations Population Fund, 2020, Tirado et al., 2020). This is indicative of the low attention given to CSE for out-of-school youth in SRHR programming. However, there are interventions by local government organisations and non-governmental organisations which are either not evaluated, documented, and published. 

Sources of sexual and reproductive health knowledge for out-of-school refugee youth

Young people acquire knowledge on SRHR from a range of sources. Among these are family, peers, teachers, health workers, print and digital media. For out-of-school refugee youth, the main sources of SRHR knowledge are family and peers (Ivanova, 2019). While these sources are useful, there are significant gaps in the type and quality of information that are received. In a study on the reproductive health of young Burmese refugees in Thailand, for example, Benner et al. (2010) report that while adolescent girls receive information about body changes from their parents, they do not receive information on menstruation and sexual relationships. Similarly, several studies report that SRHR topics such as relationships and pleasure, gender and sexuality, diversity and violence are not taught to refugee youth (Benner et al., 2010).

Peer education is the most commonly-adopted means of providing SRHR information to young people in out-of-school contexts. However, available evidence shows that its impact on improving the knowledge and sexual health behaviours of young people is limited (Chandra-Mouli et al., 2015). Also, as peer education targets only peers, there are calls for interventions to include the education of parents and communities on SRHR issues, since it is clear that parental and community attitudes have an important role to play in whether CSE is effective (Wekesh et al., 2019), often reflecting broader social structures that negatively impact the lives of young people (Tanner and O’Connor, 2017). 

In the age of widespread internet usage, young people are increasingly turning to the internet for information on SRHR (United Nations Children’s Fund, 2019; UNESCO, 2020). These sources allow for greater privacy without the fear of being judged. Also, they enable young people to seek information on topics that are often side-stepped in face-to-face CSE. There are, however, concerns about young people’s usage of the internet to acquire SRHR knowledge. Among these are the credibility of the sources accessed digitally, safeguarding, and unequal access to information due to the digital divide between refugee communities and host communities. Other related concerns include the extent to which out-of-school refugee youth have digital and critical thinking skills to evaluate the information they receive and make the most of online resources (United Nations Children’s Fund, 2019). Despite these concerns, digital sexuality education offers an opportunity for developing innovative, personalised, and engaging interventions with the potential to reinforce learning, address gaps in traditional sources of information, and positively influence sexual behaviours. Their potential can be maximised with further research on best practices and the development of international guidance for developing digital CSE, to complement the International Technical Guidance on Sexuality Education (ITGSE).

Key points in the development of out-of-school CSE interventions in humanitarian and complex settings

There is consensus, at the international level, that CSE ought to be underpinned by a rights-based approach. A rights-based approach to CSE is characterised by four elements namely (a) underlying principle of sexual rights (b) expanded goals centred around empowerment and the development of critical thinking skills (c) youth centred pedagogy and (d) broadened content which includes gender, sexuality, relationships, and pleasure (Berglas et al., 2014). This approach to CSE has the potential to improve outcomes such as unintended pregnancies and STIs whilst empowering young people to make informed decisions about their wellbeing (Hamberland and Rowgow, 2015). In the design and delivery of many CSE interventions, however, a preventive approach (rather than an empowerment approach) is usually adopted (Tirado, 2020). Two reasons may account for this. The first is the predominant focus on the prevention of diseases or infection, pregnancy, and sexual violence as highlighted earlier in this article. The second is the perception that CSE, particularly if based upon the underpinning values of sexual rights, encourages young people to think about sex and may conflict with the values of communities in which those programmes are implemented (Tanebe et al., 2011). In view of this, it is vital for programme implementers to engage in extensive discussion with community stakeholders about the purpose and goals of CSE and obtain the required support, without compromising on important issues of concern to young people. 

In out-of-school humanitarian and crisis contexts, CSE is usually integrated within other SRHR services (Tanebe et al., 2011) and there is good evidence that this is more effective in preventing unwanted pregnancies than providing CSE alone (Oringanje et al., 2009). However, it is also important to consider and strengthen the integration of CSE with vocational skills training or livelihood opportunities. This is because several studies report that boredom and financial difficulties predispose young people to engage in unsafe sexual practices (Tirado et al., 2020; Ruzibiza et al. 2021). Vocational skills training and work opportunities shape the aspirations of young people and enable them to have more control and agency in making informed decisions about their sexual and reproductive health.

Out-of-school contexts provide the flexibility for adopting creative arts approaches such as theatre and music to deliver CSE. The use of theatre, for example, encourages critical reflection and dialogue on sensitive issues as well as harmful social practices and norms. In a sexual health programme for multicultural youth in Perth, the theatre of the oppressed methodology was drawn upon to educate and engage youth on a range of topics such as relationships, sexual violence and STIs (Roberts, Lobo and Sorenson, 2017). Workshops that were organised with youth were not pre-structured and therefore allowed them to recommend topics based on the issues that are relevant to their lives and context. An evaluation of the programme showed that it was effective in improving the knowledge of young people on STIs, creating a positive attitude towards sexual health, and confidence in referring issues to the relevant duty bearers (Roberts, Lobo and Sorenson, 2017). This approach could be tried in other contexts to gain more understanding of its benefits to young people.

Recommendations for the future development of CSE interventions for out-of-school refugee youth

Vocational training already plays a key role in helping refugees integrate into host communities so including CSE interventions within vocational training has potential to enhance their agency to make informed decisions and choices relating to the sexual and reproductive health and wellbeing.

Being delivered outside of school makes it possible for CSE to take less didactic, more participatory and creative forms. Future work should take advantage of this affordance, since there is evidence that these approaches can be more effective, especially in disrupting harmful norms around gender and sexuality (see Effective comprehensive sexuality education: What is known and what is needed?)

So little is known about CSE for out-of-school refugees that more research is needed. This should include fundamental questions such as what sources of information about SRHR young refugees trust, and what information and skills they wish to gain. It is also important to undertake research that focuses on the experiences of specific groups of refugees, such as young adolescents, disabled people, LGBT people and those with HIV/AIDS, rather than considering refugees and internally-displaced people as one category.

The findings about what makes for effective CSE in general, reported in our companion paper Effective comprehensive sexuality education: What is known and what is needed? are also applicable to CSE for out-of-school refugees. In addition, our findings about online CSE, reported in the companion paper Online comprehensive sexuality education: What is known and what is needed? are applicable to online forms of CSE for this group, although any online intervention would need to take account of likely difficulty in accessing online resources among this group. 

References

1. Benner, M. T., Townsend, J., Kaloi, W., Htwe, K., Naranichakul, N., Hunnangkul, S., ... & Sondorp, E. (2010). Reproductive health and quality of life of young Burmese refugees in Thailand. Conflict and health, 4(1), 1-9.
2. Berglas, N. F., Constantine, N. A., & Ozer, E. J. (2014). A rights‐based approach to sexuality education: Conceptualization, clarification and challenges. Perspectives on sexual and reproductive health, 46(2), 63-72.
3. Chandra-Mouli, V., Lane, C., & Wong, S. (2015). What does not work in adolescent sexual and reproductive health: a review of evidence on interventions commonly accepted as best practices. Global Health: Science and Practice, 3(3), 333-340.
4. Haberland, N., & Rogow, D. (2015). Sexuality education: emerging trends in evidence and practice. Journal of adolescent health, 56(1), S15-S21.
5. Ivanova, O., Rai, M., Mlahagwa, W., Tumuhairwe, J., Bakuli, A., Nyakato, V. N., & Kemigisha, E. (2019). A cross-sectional mixed-methods study of sexual and reproductive health knowledge, experiences and access to services among refugee adolescent girls in the Nakivale refugee settlement, Uganda. Reproductive health, 16(1), 1-11.
6. Jennings, L., George, A. S., Jacobs, T., Blanchet, K., & Singh, N. S. (2019). A forgotten group during humanitarian crises: a systematic review of sexual and reproductive health interventions for young people including adolescents in humanitarian settings. Conflict and health, 13(1), 1-16.
7. Oringanje, C., Meremikwu, M.M., Eko, H., Esu, E., Meremikwu, A., & Ehiri, J. E. Interventions for preventing unintended pregnancies among adolescents. The Cochrane database of systematic reviews. 2009(4): Cd005215.
8. Roberts, M., Lobo, R., & Sorenson, A. (2017). Evaluating the Sharing Stories youth theatre program: an interactive theatre and drama‐based strategy for sexual health promotion among multicultural youth. Health Promotion Journal of Australia, 28(1), 30-36.
9. Ruzibiza, Y., Berckmoes, L., Neema, S., & Reis, R. (2021). Lost in freedom: ambivalence on sexual freedom among Burundian adolescents living in the Nakivale refugee settlement, Uganda. Sexual and Reproductive Health Matters, 29(1), 1889750.
10. Tanabe, M., Schlecht, J., & Manohar, S. (2011). Adolescent sexual and reproductive health programs in humanitarian settings: an in-depth look at family planning services. New York: Women's Refugee Commission.
11. Tanner, S., & O’Connor, M. (2017). A safe place to shine: creating opportunities and raising voices of adolescent girls in humanitarian settings. New York: International Rescue Committee. Retrieved August 15 2021
12. Tirado, V., Chu, J., Hanson, C., Ekström, A. M., & Kågesten, A. (2020). Barriers and facilitators for the sexual and reproductive health and rights of young people in refugee contexts globally: A scoping review. PloS one, 15(7), e0236316.
13. United Nations Children’s Fund (2019). The Opportunity for Digital Sexuality Education in East Asia and the Pacific. UNICEF East Asia and Pacific, Bangkok. Retrieved August 18 2021
14. United Nations High Commissioner for Refugees (2021) Staying the course: The challenges facing refugee education. Education report 2021 Retrieved Nov 18, 2021
15. United Nations High Commissioner for Refugees (2019). Coming together for refugee education. Education report 2020. Retrieved September 1, 2020
16. United Nations Population Fund (2020). International Technical and Programmatic Guidelines on out-of-school Comprehensive Sexuality Education: an evidence informed approach for non-formal, out-of-school programmes. Retrieved August 10 2021
    Wekesah, F. M,, Nyakangi, V., Onguss, M., Njagi, J., & Bangha, M. (2019) Comprehensive Sexuality Education in Sub-Saharan Africa. Nairobi, Kenya