SEX EDUCATION WORK WITH YOUNG PEOPLE . THEORY AND PRACTICE

In June 1999, I was invited to offer my experience in sex education work with young people in Britain with Russian colleagues at the Sverdlovsk Oblast Family Planning Centre in Ekaterinburg. This post was organised through Voluntary Service Overseas and was to last one year. The progressive view of the centre manager and regional service director enabled me to work with colleagues of other youth services and organisations as their representative. Such training experience and working with young people in Sverdlovsk broadened my scope and understanding of the sex education needs of Russian youth and adults involved in their lives. The experience of developing together with my colleagues a training course for Medics and sharing our ideas resulted in my extending my placement for a further 6 months. This package is the culmination of that work.

Introduction
This pack results from the training experience of medics and psychology staff at the Sverdlovsk Oblast Family Planning Centre. It is based on concepts of the course “Principles and Practice of Sex Education” delivered by the centre to medics and professionals working with young people across the Sverdlovsk region.
The pack is written from a medical bias concentrating on topics pertinent to the role of a medic. However it is essential that the medical model be placed in the context of the lifestyle requirements of the young person. Hence a holistic element is emphasised throughout the material.
Medics are one group of people who may be involved in the lives of young people, if sex education is to be effective, other adults need to contribute to the work, consequently, the pack includes sections on working with teachers and parents.
Sex education work may take place in various settings: formal education classes in schools, informal sessions in youth clubs, and within the medical environment of the clinic. The pack presents various activities and ideas for working in these situations and methods appropriate for both group work and individual consultation.
This pack is intended for the use of medics who currently work in, or propose to embark on teaching sex education to children and young people. It has been devised to provide information and guidance in the theory of sex education work and its delivery in practice with young people. Some concepts and issues are complicated, in these sections the various advantages and disadvantages of particular points and information are highlighted thus allowing the medic to draw their own conclusion and consequences for the work.
Like other areas of Russia the Sverdlovsk region has been affected by a decline in the social and economic conditions associated with a country in transition. The area consists of large industrial towns and small villages that provide various degrees of access (some very limited) to health and social services for the population, and in particular, for young people. The changes in Russian society have impacted upon the relationships and behaviour of young people. The consequences of certain behaviours are evident in the rise of unplanned pregnancies and sexual transmitted infections such as syphilis and chlamydia, which affect both the reproductive and sexual health of this group. The steep increase in HIV and Hepatitis B infections associated with drug use amongst a predominantly young population, may become a significant sexual health issue for their partners. The family planning services are concerned to provide information and education to teenagers and professionals who work with young people in an attempt to address these issues.

International approaches to sex education
Internationally, there is a wide range of sex education available to young people. Sex education ranges from no education to very explicit. Cultural, political and religious considerations affect the type of sex education taught in young people organisations. Many of these beliefs compete and conflict in society.The six basic types of sex education are:
a. - No education = no sex. The most conservative approach; adolescents are treated as asexual beings
b. - Abstinence only. Conservative approach treats STI prevention and pregnancy as an issue of morality.
c. - Abstinence-based. Practical approach based on medical fact that abstinence prevents pregnancy and STIs.
d. - Combination approach. Promotes abstinence as fact but also acknowledges teen sexuality and discusses most sexual facts about pregnancy and STIs.
e. - Reality-based without condom distribution. More liberal approach talks about sexual activity and promotes postponement, monogamous relationships, and all aspects of ‘safer sex’, including use of condoms and contraception.
f.  - Reality-based with condom distribution. Alternative to unprotected sexual intercourse and distributes condoms on request.

In consultation with Russian medics and teachers, they consider Russia currently promotes approach (c). The majority of these medical professionals would like to achieve an approach in Russia similar to (e).

Why is sex education important?
Without sexual knowledge, unplanned pregnancy and sexual infection transmission is not clearly understood. Sexual secrecy can lead to ignorance and unnecessary risk-taking. Independent research studies show that sex education can prevent risk behaviour and young people have less risky (unprotected) sex after sessions. Sex education does not promote promiscuity; rather, it promotes postponement and ‘safer sex’ practices. Without sex education programs, adolescents learn glorified sex from the media which promotes entertainment rather than health care.
What is sex education?
Sex education is a term which encompasses the teaching of physical, psychological, emotional, sexual, moral, spiritual, intellectual and social aspects of young people’s personal development. It takes into account personal relationships, cultures, beliefs, value systems, attitudes and behaviour. It involves the exploration of issues, attitudes and skills, and includes: • Sharing and acquiring knowledge • Understanding personal sexuality • Exploring relationships • Raising awareness of personal attitudes and values • Practicing skills which promote sexual health and safety • Building confidence in decision making • Encouraging respect and empathy for others
What should be taught when?
Sex education is often described by professionals and young people as ‘too little too late’. Development of skills and work on attitudes towards family, relationships and lifestyles can be started at a very young age. Work with very young children does not contain details of sexual activity but provides a foundation for more sophisticated and sensitive areas during teenage years. In many countries this begins as soon as children enter their school life. The following considerations are vital for any sex education program with children and young people • The language used is relevant and age appropriate • Information is prioritised and given in small clear stages; too much information leads
to confusion and ‘overload’ • The children must be developmentally ready for topics of a personal and sensitive nature; a gradual introduction to intimate subjects is essential
What young people say
Experience of working with Russian young people and carrying out needs assessments with groups from the age of 14 years, highlights their knowledge of the following; • basic facts regarding sexual activity • some methods of contraception such as the pill and condom • how to prevent acquiring a sexual transmitted infection including HIV • basic knowledge about anatomy and physical changes at puberty • basic information about pregnancy • particular values regarding parenthood and family
When asked what they would like to know, young people emphasise the application of the above to their lifestyle and health. They were more concerned about practicalities  
 - Effectiveness and suitability of contraceptive methods for young women “How long
can a woman take the pill?”
- Gender issues “How can a woman make her partner use a condom?” € Infections “How does a man or woman know they have an infection and where can  you go to get treatment?”
-  Relationships and image “I was first attracted to my girlfriend because she looked
sexy. Now I want her to tone down the way she dresses.”
The above examples indicate a need for young people to discuss the wider issues related to sex education; often those associated with skills and attitudes although they also identified gaps in their knowledge.
Knowledge, Skills and Attitudes
The aim of sex education is to promote behaviour that prevents transmission of STIs and unwanted pregnancy. Learning the behavioural skills that are needed for prevention forms a major part of the program. If young people are to adopt healthy behaviour what is needed is the motivation to act skills to translate knowledge into practice and positive attitudes. Consequently, an effective sex education program will consider three main areas: knowledge, skills and attitudes.
Knowledge
Information that will help young people decide what behaviours are healthy and responsible includes: ways HIV/STI are transmitted and not transmitted, planned and unwanted pregnancy, anatomy and changes at puberty, contraceptive methods, and local sources of help and advice.
Skill development
The skills relevant to preventive behaviours are: self-awareness, decision making, assertiveness to resist pressure to have sex, negotiation skills to ensure protected sex, and practical skills for effective condom use. These skills are best taught through rehearsal or role-play of real-life situations that might put young people at risk.
Attitudes
Attitudes to sexual relationships, pregnancy and STIs includes: positive attitudes towards delaying sex, personal responsibility, condoms as a means of protection, parenthood, social attitudes such as confronting prejudice, multiple partners, different family systems including single parents, early marriage, divorce, and abusive relationships.
Motivational supports
A well-informed and skilled person needs to be motivated to initiate and maintain safe practices. A realistic perception of the young person’s own risk and the benefits of adopting preventive behaviour are closely related to motivation. Discussion with educated peers is effective as well as encouragement from parents who can reinforce the messages of the program.
Assertiveness
Understanding and practicing assertiveness is of particular relevance in sex education. It is basically about valuing and taking responsibility for ourselves, sticking up for our rights, and giving other people the respect that we want for ourselves. The aim is to be able to deal with situations without feeling or being too passive, aggressive or manipulative.
Who teaches sex education?
Significant adults in a young person’s life have roles to play in contributing and supporting a sex education program. The personal and intimate nature of this subject creates certain feelings in people and makes discussion difficult. Adults consequently debate who has ultimate responsibility for teaching young people about relationships and sex which may result in young people missing out on vital information altogether.
Parents.
They can be regarded as partners in this work by supporting at home a sex education program delivered by a medic or other professional. Further work with parents is outlined on pages.
Teachers.
Many areas of the school curriculum provide information and skills development that contributes to a holistic approach:Literature - discussion about the nature of relationships in books and their comparison with those of contemporary society.Biology - anatomy and physiology, body changes during puberty, pregnancy and older age.Moral education - effects of politics, religion, media, and youth culture on the family, society and young people’s lifestyles.Parenthood and family education - many aspects of a sex education program are contained within this subject area.Further work with teachers is outlined on pages.
Youth workers.
Youth workers interact with young people in an informal setting which is conducive to building the kind of relationships that promote a holistic approach to sex education. They tend to work from a young person perspective using opportunities to respond to individual needs as a matter of course during club sessions or on camps. With relevant information, basic training, and knowledge of referral to local medical and support services, youth workers are ideally placed to provide individual and group sex
education programs. Co-working with a medic could provide an ideal combination of skills, knowledge and approaches.
Medics.
Medics who have a role in sex education come from a variety of specialisms: gynaecologists, andrologists, paediatricians, venerologists and family doctors. In many countries, trained nurses both in a clinical setting and within young people establishments deliver a significant percentage of sex education work. Medics have the knowledge and information relevant to the physical and medical elements of a sex education program. They have the expertise of contraceptive methods, effects of disease and infection on the body as well as pregnancy and body changes. They specialise in treatment and have access to appropriate medical services. Medics usually see individuals in a clinical setting which relies on clients having the courage to seek support. Those working in the field of family planning are well aware of the consequences of lack of sex education programs with young people and acknowledge the essential role of prevention and health promotion work. As a result, many medics are valuing the role of an ‘outreach’ specialist that provides vital information to healthy young people in other environments such as schools, camps and youth clubs.
Peers.
Trained young people called ‘peer sex educators’ deliver some sex education programs. The initial barriers to communication often experienced by older professionals may not exist among peers as certain young people relate positively to education from individuals who are similar to them in age and life experience. Peer educators are specialists in education and prevention; they are trained to refer young people to medical specialists for individual consultation and treatment. Medics can provide information on the training courses for peer educators and support the programs by offering specialist consultations for referred young people.
How is sex education taught?
Sex education courses can be categorised into two main types: ‘core’ programs and ‘tailor-made’. A ‘Core’ program is a fixed repeated course following the same format with groups having similar characteristics such as age or profession. It will have a limited time lasting as little as one session or up to one full week. A ‘Tailor-made’ program is a course designed according to the needs of the group members. It demands prior discussion with members to identify what is important and assess what is required. This course is usually a series of sessions over a period of time.
Sex education programs should be well designed, use a variety of techniques and activities over a consistent period of time, and consist of 6 to 10 sessions.However, the teaching of sex education programs relies on several factors;
• The environment in which it takes place (clinic, youth club, camp, and school) will impact on the approach, methodology and activities possible.
 • The amount of time allocated or negotiated with the establishment for each session and the number of sessions available determines the priority subject areas.
• The skills and comfort level of the medic will determine whether young people are consulted individually or taught in a group. Experience and confidence will determine how the group is taught.
• The size of the group determines the type of approach and activities: workshop (up to 20 people), or seminar (unlimited numbers).
• Sensitive areas of work specific to gender, influences work with single sex groups only. Here, staffing is an issue due to a shortage of trained male specialists in sex education. The reality is that female specialists may have to take on this role with young men’s groups.
• Mixed gender groups have advantages and disadvantages. It is often useful for both genders to know how the opposite sex views relationships and associated problems. If activities are well planned young men and women learn together the skills that are important for effective communication and improved relationships. The disadvantages of this arrangement occur when a group is not sophisticated enough to deal with the subject areas, have strong personal feelings that inhibit working, or there is an imbalance of power between the genders.
Working with Staff in Young People Organisations
Young people do not generally attend clinics until they have a personal situation demanding attention or treatment. In order to undertake earlier education and prevention programs, it is vital for medical services to contact establishments and staff that work with young people. This may be happen in several ways • Schools and youth clubs contact the medic or department and request the work. • In smaller communities people have personal and professional contacts that make
communication easier and general concerns will be shared between them in an
informal as well as formal basis.
•  In larger towns, networking strategies must be developed to target those organisations that work with young people most at risk. This may involve asking managers and chief doctors to contact the following for information: youth and education services, non-government young people organisations, institutes and colleges.
• The medic requests responsibility from managers to undertake networking as part of the sex education program development.
Meeting with a key staff member
Initial contact is made by telephone and a meeting is arranged with the director or manager of the school or youth club. This meeting has several functions
• Both parties get to know each other.
• To provide a ‘contract’ in which to negotiate the specifics of the work such as content, amount of sessions etc.
• To discuss resources including whether the work is free or involves any payment.
• To identify a key member of staff who has ultimate responsibility for the program in the establishment, who knows the client group well, and acts as the main contact person for the medic regarding workshops, room allocation and any resources supplied by the establishment.

The following questionnaire highlights useful information and acts as a record of agreement between the two parties.