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Learning about sexual and reproductive health is critical to making responsible decisions about sexual behaviour—whether this means deciding to delay or abstain from sexual activity or taking precautions to prevent unwanted pregnancies and sexually transmitted infections. Access to effective, broadly based sexual health education represents an important source of information for Canadian youth and has been shown to decrease young people’s tendencies to engage in risky sexual behaviour.
Progress has been made in recent years on several key indicators of adolescent sexual and reproductive health. The teen pregnancy rate, for example, stands at an all time low: the pregnancy rate for 15- to 19-year-olds declined from 48.8 per 1,000 in 1994[1] to 30.5 in 2004.[2] In addition, the average age of first intercourse, another important indicator of adolescent sexual health, has increased over time. The proportion of teenagers (aged 15 to 19) who report that they have had sexual intercourse at least once declined from 47% in 1996 to 43% in 2005. Over the same period, the proportion of teenagers who reported having their first experience of sexual intercourse before age 15 declined from 12% to 8%.[3]
Despite these encouraging trends, risky sexual behaviours are not uncommon among Canadian teenagers. For example, in 2005, one-third of sexually active teens reported having multiple partners in the past year. As well, many teens do not use condoms on a regular basis. Between 84% and 90% of sexually active students in grades 9 and 11 report using some form of contraception during intercourse, but a recent study found that only 64% of sexually active Grade 11 females used a condom at last intercourse.[4]
One of the main reasons cited for not using a condom is the use of some other method of birth control, most often oral contraceptives.[5] While “the pill” is a reliable method of birth control, it does not provide any protection against sexually transmitted infections (STI), which are on the rise among Canadian teenagers.[6]
In Canada, more than two-thirds of reported cases of chlamydia, the most common reportable STI, occur among young people aged 15 to 24. Between 1997and 2004, there was a 55% increase in the rate of reported chlamydia infections among 15- to 19-year-olds and a 77% increase among 20- to 24-year-olds (which represents only a fraction of the true rate, as the majority of cases are asymptomatic and go unreported).[7] Reported rates of gonorrhea and syphilis are also increasing.
The research reveals a number of knowledge gaps pertaining to sexual health among adolescents. According to a 2005 survey of adolescents aged 14 to 17, only 66% of girls and 51% of boys had heard of chlamydia. In addition, 17% of adolescents were not aware that oral sex was a means of transmitting STIs, while 23% of teens (and 21% of their mothers) believed that poor hygiene can lead to STIs. In addition, teens demonstrated little knowledge of the possible health consequences of STIs. [8]
A report published by the Public Health Agency of Canada has identified the following informational barriers to learning about sexual health:
In addition to informational barriers, adolescents also encounter other barriers to responsible sexual behaviour. For example, when asked about their use of contraceptives, adolescents acknowledge that shyness with their partners or embarrassment around the process of acquiring contraceptives, rather than lack of knowledge, prevents them from acting responsibly.[9]
Although most Canadian adolescents have access to sex education in their schools, this education may fail to adequately prepare them for the realities of sexual decision-making they face. For example, in a large proportion of teen pregnancies, the male partner is substantially older than the female partner: in the United States the pregnancy rate is 3.7 times higher among girls whose partners are six or more years older, compared to girls whose partners are no more than two years older.[10] As well, girls who have sexual relationships with older males are more likely to contract STIs,[11] at least partly because they are less likely to use contraception. Among girls whose partner is older, for each year older the likelihood of consistent contraception use decreases by 11%.[12] In short, age discrepancies carry important implications in adolescent sexual relationships, yet age discrepancies are rarely discussed in sex education programs.[13]
The World Health Organization acknowledges that any definition of sexual health is “a heavily value-laden concept”[14] and agreement concerning definitions of sexuality and sexual health is difficult to achieve. The Pan American Health Organization suggests that:
As well, adolescents express some dissatisfaction with the topics covered in their sex education classes. Widely accepted definitions of sexuality and sexual health encompass far more than the physical and biological aspects of sex. Adolescents are sensitive to the fact that sexuality is not simply a biological function and they want to learn about the broader concepts of sexuality. When surveyed, many teens indicate that they want their sexual education to include information about engaging in healthy, sexually fulfilling relationships, not just information on physical sexual health.[16]
In addition to the exclusion of important topics, the sex-education programs generally delivered in Canadian classrooms fail to address motivational factors and behavioural skills.[17] By itself, information about sexual health is insufficient to affect changes that will lead to improved sexual health. Successful sex education programs also motivate students to engage in responsible sexual behaviour by helping them understand the consequences of their choices and teach them the behavioural skills they need to implement responsible decisions (e.g., how to negotiate condom use with a partner). Students must be motivated to make responsible decisions and possess the skills to carry out those decisions.
Few Canadian teachers receive formal training on how to deliver effective sex-education programs. A 1999 survey on teacher training in sexual education revealed that only 15% of elementary education, 10% of secondary education, and 24% of physical and health education Bachelor of education programs in Canada provide pre-service teachers with compulsory training in sexual health education.[18]
Strong evidence indicates that sexual health education can reduce the risk of unwanted pregnancies and STI/HIV infection among adolescents. Studies also show that well-designed sex-education programs can substantially reduce risky sexual behaviour in young people. A recent review of 48 studies of comprehensive sex-education programs concluded that effective programs can reduce the incidence of risky sexual behaviours (e.g., unprotected sex) by one-third to one-half.[19] For example, an evaluation of Safer Choices (an educational program designed to reduce sexual risk behaviours) found that rates of intercourse without a condom decreased by 37% among students in the program.[20]
According to the research, adolescents and their parents agree that schools should provide broadly based sexual health education—covering a wide range of topics including puberty, reproduction, healthy relationships, STI/HIV prevention, birth control, abstinence, sexual orientation and sexual abuse.[21] In order to ensure that the sexual education provided in schools is as effective as possible, two key elements should be incorporated:
Key components of effective sexual health-education programs
Learning about sexual health extends beyond the classroom: when couples, parents and communities have the necessary information, motivation and behavioural skills to enhance their own understanding of sexual health, they contribute to building environments conducive to sexual health. Parents and teachers believe that responsibility for sex education should be shared by schools and parents,[25] and most adolescents agree with them.[26] In addition, the medical community, as well as public health, legal and social welfare institutions all have an important role to play in equipping young people with the knowledge and abilities needed to engage in responsible sexual behaviour.[27]
Classroom-based sexual health education can be supplemented with sexual health resources and programs that link students and schools with their wider communities. Several such initiatives are in place across the country and the research indicates that, when these health services are convenient and youth-friendly, access and use of these services increases. [28]
In Manitoba there are currently three school-based health centres with approximately five more currently in development. The clinics are administered through a partnership between the primary care provider (usually a community health clinic or regional health authority), the school and the funders (the provincial government through Healthy Child Manitoba, regional health authorities and community health centres). Ontario's Windsor-Essex County has a number of school-based health clinics offering sexual health services. In one case, a community health centre operates out of a school.
The Halifax Regional District School board has Youth Health Centres (YHC) in all 18 high schools. There is a full-time co-ordinator for each YHC who has responsibility for one high school and its junior-high feeder schools.
Saskatchewan Teen Wellness Centres have been developed in various locations (several in schools) throughout the province to improve the health and wellness of youth and to provide education, information and services around a variety of topics and issues, including sexual health.
In B.C., the Parkgate Sexual Health Project was piloted in the Seymour area of North Vancouver in 2003 and 2004. Older teens were trained to work with their younger counterparts, instructing them on sexual health issues. The primary recipients of the program were teens aged 13 to 18, with youth workers and parents as secondary targets. The project will be extended across the region to promote improved sexual health and to address other teen health issues.
In addition to the learning about sexual health at school, young people, their parents and teachers can also turn to the internet for additional information and resources. A number of websites promoting learning around sexual health exist for teenagers, as well as their parents and teachers.
Improving the sexual health of Canadian youth requires a concerted effort on the part of educators, the health community, parents and communities. Broadly based sex education in schools and beyond the classroom can help to equip young Canadians with the information, motivation and skills they require to engage in responsible sexual behaviour.
[1] Statistics Canada, "The young and the reckless," from Canada Year Book 1999 (Ottawa, 1999). Accessed June 10, 2009.
[2] Statistics Canada, "Teen pregnancy, by outcome of pregnancy and age group, count and rate per 1,000 women aged 15 to 19, Canada, provinces and territories, 2003 to 2004" Health Indicators 1, no. 1 (2008). Catalogue no. 82-221-X. Accessed June 10, 2009.
[3] M. Roterdam, "Trends in teen sexual behaviour and condom use," Health Reports 19, no. 3 (2008). Statistics Canada Catalogue no. 82-003-X. Accessed June 11, 2009.
[4] W. Boyce et al., Canadian Youth, Sexual Health and HIV/AIDS Study: Factors influencing knowledge, attitudes and behaviours (Toronto: Council of Ministers of Education, Canada, 2003).
[5] W. Boyce et al., "Sexual health of Canadian youth: finding from the Canadian Youth, Sexual Health and HIV/AIDS Study," The Canadian Journal of Human Sexuality 15, no. 2 (2006).
[6] G. Jayaraman et al., Brief Report on Sexually Transmitted Infections in Canada: 2006 (Ottawa: Public Health Agency of Canada, 2009). Accessed June 11, 2009.
[7] Public Health Agency of Canada, 2004 Canadian Sexually Transmitted Infections Surveillance Report (Ottawa: Health Canada, 2007).
[8] J-Y Frappier et al., "Sex and Sexual Health: a survey of Canadian youth and mothers," Paediatric Child Health 13, no. 1 (2008).
[9] L. Archibald, Teenage Pregnancy in Inuit Communities: Issues and Perspectives, prepared for Pauktuutit Inuit Women’s Association (Ottawa: 2004). Accessed June 11, 2009.
[10] M. Males, "Teens and older partners," (Resource Center for Adolescent Pregnancy Prevention, May-June 2004), (accessed June 11, 2009).
[11] J. Manlove, E. Terry-Humen and E. Ikramullah, "Young teenagers and older sexual partners: correlates and consequences for males and females," Perspectives on Sexual and Reproductive Health 38, no. 4 (2006): 197–207.
[12] J. Manlove, S. Ryan, and K. Franzetta, "Patterns of contraceptive use within teenagers’ first sexual relationships," Perspectives on Sexual and Reproductive Health 35, no. 6 (2003): 246–255.
[13] Best Start and Sex Information and Education Council of Canada, Update Report on Teen Pregnancy Prevention (Toronto: Best Start, 2007). Accessed June 11, 2009.
[14] E. Coleman, "Promoting sexual health and responsible sexual behaviour: an introduction," Journal of Sex Research 39 no. 1 (2002): 3–6.
[15] Pan American Health Organization and World Health Organization, Promotion of Sexual Health: Recommendations for Action, proceedings of a regional consultation held in Guatemala in May 2000 (2000). Accessed July 7, 2009.
[16] S. Flicker et al., Sexpress: The Toronto Teen Survey Report (Toronto: Planned Parenthood Toronto, 2009).
[17] A. McKay et al., "Adolescent sexual health education: Does it work? Can it work better? An analysis of recent research and media reports," The Canadian Journal of Human Sexuality 10, no. 3–4 (2001): 127–135.
[18] A. McKay and M. Barrett, "Pre-service sexual health education training of elementary, secondary, and physical health education teachers in Canadian faculties of education," The Canadian Journal of Human Sexuality 8 (1999): 91–102.
[19] D. Kirby, Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases (Washington, D.C.: National Campaign to Prevent Teen and Unplanned Pregnancy, 2007). Accessed July 16, 2009.
[20] K. Coyle et al., "Safer Choices: Reducing teen pregnancy, HIV, and STDs," Public Health Reports, 2001 Supplement 1 116 (2001): 82–93.
[21] A. McKay, "Adolescent Sexual and Reproductive Health in Canada: a report card in 2004," The Canadian Journal of Human Sexuality 13 (2004).
[22] A. McKay et al., "Adolescent sexual health education: Does it work? Can it work better? An analysis of recent research and media reports," The Canadian Journal of Human Sexuality 10, no. 3–4 (2001): 127–135.
[23] J. D. Fisher et al., "Information–motivation–behavioral skills model-based HIV risk behavior change intervention for inner-city high school youth," Health Psychology 21 (2002): 177–186.
[24] W. A. Fisher and J. D. Fisher, "Understanding and promoting sexual and reproductive health behaviour: theory and method," Annual Review of Sex Research 9 (1998): 39–76.
[25] A. D. Weaver et al., "Sexual heath education at school and home: Attitudes and experiences of New Brunswick parents," Canadian Journal of Human Sexuality 11 (2002): 19–32.
[26] E. S. Byers et al., "An adolescent perspective on sexual health education at school and at home: I. High school students," The Canadian Journal of Human Sexuality 12, no. 1 (2003): 1–17.
[27] Public Health Agency of Canada, Canadian Guidelines for Sexual Health Education (Ottawa: Population and Public Health Branch, Health Canada, 2008). Available at www.publichealth.gc.ca/sti. Accessed June 11, 2009.
[28] D. McCall, and A. McKay, "School-based and school-linked sexual health education and promotion in Canada," Society of Obstetricians and Gynaecologists of Canada 13 (2003).