Introduction

During adolescence (age 10–19 years old), young people experience a critical time of transition. Hence, they are susceptible to a myriad of health risks, including sexual health issues (World Health Organization, 2018a). Adolescents may often lack knowledge of sexual health and are vulnerable to sexual ill health, such as sexually transmitted diseases (STDs), sexually transmitted infections (STI), human immunodeficiency virus (HIV), unintended pregnancy, unsafe abortion, abusive or exploitative sexual relationships (Berglas et al., 2014).

School-based sexual health education (SBSHE) has the potential to reach many adolescents from diverse backgrounds (Sundaram et al., 2016). It is an important platform to educate adolescents on sexual health (e.g., education on STD) and enhances their well-being (e.g., communication, body image, development of healthy relationships, and understanding of consent and sexual rights). There are four main approaches to SBSHE: abstinence, comprehensive, rights-based, and relationship-based sexual health education. These models have one component in common; educating adolescents about the risk of sexual activities (HIV, AIDS, unwanted pregnancies); however, their approaches remained different. Abstinence-based SBSHE encourages restraint from sexual activity outside of a committed adult relationship (notably marriage), and comprehensive SBSHE, often relies on harm reduction or disease prevention that promotes abstinence while also promoting safe sexual practices for sexually active adolescents (Berglas et al., 2014). In recent years, two other SBSHE (relationship-based and rights-based SBSHE) has been developed. Rights-based SBSHE reinforces the sexual rights of adolescents, gender equality, and sexual and reproductive health, to enable them to deal with their sexuality in a responsible way (Berglas et al., 2014). Relationship-based SBSHE emphasized sexual communication, trust, intimacy, and sexual pleasure as important elements in aiding adolescents to assess their readiness for sex, evaluate the benefits and risks associated with different types of sex, and use methods to prevent sexual health issues (Hensel et al., 2018). Prior research has found that more SBSHE across countries, including those in low- and middle-income countries, are shifting from abstinence-based SBSHE to other approaches (Berglas et al., 2014). Despite the developments of SBSHE, current research has shown that adolescents’ needs for sexual health knowledge remained unmet (Waling et al., 2020, 2021). Findings from a recent Cochrane review showed that SBSHE improved knowledge of sexual health and reduced risk-taking behavior; however, it is unknown whether there is an association between SBSHE and the number of STI or unintended pregnancies among adolescents (Mason‐Jones et al., 2016). Additionally, findings from other qualitative studies reported that adolescents felt deprived of opportunities to learn and discuss sexual health openly and felt that SBSHE was unrealistic (Hilton, 2003; Hirvonen et al., 2021; Zanatta et al., 2016).

To support adolescents’ sexual health, a thorough understanding of their experiences and perspectives on SBSHE is warranted. However, only one qualitative review on SBSHE was published five years ago (Pound et al., 2016). This review examined the SBSHE experience of children and young adults aged 6–25 years, and most of the included studies were from high-income countries. There is a need for a qualitative systematic review solely on adolescents as they are vulnerable to poor sexual health, and they have a right to sexual health information that allows them to make autonomous decisions on their sexual health and well-being. Therefore, this qualitative review will focus on adolescents and their views of SBSHE. This can help give context, nuances, and an opportunity to understand their experiences through their voices. Involving the views of those who received SBSHE, and employing their ideas are considered good policy-making practices that can pave way for sexual health education that is tailored to the needs of adolescents and appropriate for their age group (Setty & Dobson, 2022).

Method

Aims

This review aims to consolidate the available evidence on perceptions, experiences, and needs of adolescents on SBSHE.

Search Strategy

Both published and unpublished studies were identified by utilizing the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) (Fig. 1) and reported according to the PRISMA Checklist (Supplementary File 1). To obtain the relevant studies, a three-step approach was adopted: (1) systematic search of selected electronic databases, (2) manual search of reference lists of relevant studies, and (3) discussion and mutual consensus among reviewers. Firstly, a preliminary search was conducted on PubMed. After this search, the strategy was reviewed by a university librarian and then applied to six electronic databases: CINAHL, PubMed, Embase, PsychINFO, Scopus, and Mednar (gray literature) from inception until June 2022 (Supplementary File 2). Results from this search strategy were imported into Endnote Software, and duplicate studies were removed using the software’s in-built functions. Subsequently, two reviewers (CC and SS) screened the titles and abstracts, followed by the full texts for eligibility. The reference lists of the included studies were manually searched for relevance. Lastly, any discrepancies that arose were discussed between the two reviewers until a consensus was reached. This review was registered on the International Prospective Register of Systematic Reviews (PROSPERO): CRD42021236507.

Fig. 1
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PRISMA flow diagram

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Inclusion and Exclusion Criteria

The inclusion criteria for this review were: (1) studies exploring the perceptions, experiences, or needs of school-going adolescents aged 10 to 19 years old; (2) studies evaluating the intervention of any SBSHE, and (3) studies of qualitative design or mixed-method studies with qualitative content that can be extracted. Due to logistical constraints, only studies written in English were included. Studies were excluded if: (1) participants were not adolescents, or were not school students at the time of the data collection (2) participants did not receive SBSHE, and (3) they were not qualitative or mixed-method studies.

Quality Appraisal

The two reviewers (CC and SS) performed the quality assessment for the included studies using the 10-item Critical Appraisal Skills Program (CASP) checklist to comprehensively appraise the: (1) aims and objectives, (2) methodology, (3) study design, (4) sampling method, (5) data collection, (6) reflexivity of the research, (7) ethical considerations, (8) data analysis, (9) rigor of results, and (10) significance of the studies. By rating each item using “Yes” (three points), “Can’t tell” (two points), and “No” (one point), the maximum score attainable was 30 points. The score of the included studies ranged from 24 to 30 points and had an average of 27.9 points (Supplementary File 3) and interrater reliability of 92.7%. The purpose of CASP was not to assign meaning to the score but to increase the rigor of synthesis (Sale & Hawker, 2005). Therefore, all studies were included in this review regardless of their CASP score. Overall, the majority of the studies used the appropriate measures for most of the items on CASP. However, reflexivity, which is the relationship between the researcher and the interviewed participants, remained unclear in many of the included studies.

Data Extraction

The authors developed a data extraction table that was used to extract details (e.g., study aim, methodology, and findings) (Table 1). Additionally, both first-order constructs (e.g., the quotations of adolescents) and the second-order constructs (e.g., primary authors’ interpretations of findings) were extracted from each study. The two reviewers (CC and SS) conducted the data extraction independently. Any discrepancies were resolved between the two reviewers until consensus was achieved.

Table 1 Characteristics of the included studies
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Table 2 Themes and subthemes
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Synthesis

Data synthesis, including meta-summary and meta-synthesis, was completed using Sandelowski and Barroso’s two-step approach (Sandelowski & Barroso, 2007). Meta-summary was done by extracting, separating, grouping, and abstracting text findings and quotations in the study into summarized statement sets. Similar statements were then combined into codes. Next, a meta-synthesis was performed. The codes consisting of adolescents’ perceptions, experiences, and needs were inductively grouped into main themes and subthemes by comparing them across included studies using thematic analysis by the two reviewers, independently. Then, the themes were further meta-synthesized into more comprehensive and higher-order novel concepts with deeper insights into SBSHE among adolescents. Triangulation was maintained throughout the synthesis by comparing synthesized themes with each study to unravel a novel understanding of SBSHE among adolescents.

Results

Characteristics of the Included Studies

As depicted in the PRISMA flowchart (Fig. 1), 17,529 articles were retrieved. Duplicates (n = 7082) were removed using Endnote. Following the screening of the titles and abstracts from the remaining 10,439 articles, 225 articles remained for full-text assessment; this subsequently resulted in the inclusion of 43 studies. After the addition of another eight studies from these included studies, 51 studies were included. Forty-seven studies were unique, while four studies had repeated participants; they were included as they provided different analyses and insights (Hilton, 2003, 2007; Waling et al., 2020, 2021). The majority of the included studies were qualitative study designs, while the remaining two were mixed-method study designs (Hirvonen et al., 2021; Jarpe-Ratner et al., 2022). These studies were conducted in North America (n = 18; the USA and Brazil), Africa (n = 15; Uganda, Tanzania, Kenya, Nigeria, Zambia, and other provinces in Africa), Europe (n = 10; UK, Ireland, Germany), Asia (n = 3; Yemen, Philippines, and Iran), and Oceania (n = 5; Australia and New Zealand) (Table 1).

Findings were meta-synthesized to identify three main themes: (1) teachings of SBSHE and its impact, (2) adolescents’ preferred approach to SBSHE, and (3) importance of engaging and safe SBSHE.

Teachings of School-Based Sexual Health Education and Its Impact

SBSHE provided to the adolescents in this review was not in-depth across different regions. Many participants were misinformed, and more adolescents wanted to learn about contraception. The topic of unwanted pregnancies was often geared toward female students, and they wished that their male counterparts were more involved.

Content Coverage and Mixed Views on School-Based Sexual Health Education

Human Biology and Reproduction

Adolescents, in this review, regardless of region, reported learning about human biology and reproduction (Achora et al., 2018; Chirwa-Kambole et al., 2020; Kemigisha et al., 2019; Merrill et al., 2018) being covered in the SBSHE. Yet, not all were knowledgeable about human development (Adams Tucker et al., 2016; Djuwitaningsih & Setyowati, 2017; Hirst, 2004). Several adolescents were also misinformed, with one student reporting that “dating someone who is 10 years older than you” would cause “damages in your womb” (Adams Tucker et al., 2016).

Understanding of Sexually Transmitted Diseases

From the included studies, many struggled to identify the differences between HIV and AIDS (Lupton & Tulloch, 1996). Students verbalized the lack of knowledge about STIs as highlighted by one such student “Any sex education we received at school was purely about diseases…don’t know very much about STIs…” (Ezer et al., 2019). There was also confusion on the modes of transmission between STIs, HIV, and AIDs (Adams Tucker et al., 2016; Lupton & Tulloch, 1996; Waling et al., 2020), or where to get tested (Smith et al., 2011). Furthermore, some adolescents had misconceptions, with one student stating that having sex “on your period” may lead to “guys get[ting] certain diseases” (Adams Tucker et al., 2016).

Consequences of Unwanted Pregnancies

It was common for adolescents in this review to recall learning about strategies to prevent unwanted pregnancies (e.g., abstinence or practicing safe sex). Focus on preventing such pregnancies was especially common in SBSHE conducted in Africa, given the high number of unwanted pregnancies reported in these areas (Achora et al., 2018; Adams Tucker et al., 2016; Chirwa-Kambole et al., 2020; Kemigisha et al., 2019; Likupe et al., 2021; Malinowski & Stamler, 2003; Manda et al., 2021; Mturi & Bechuke, 2019). Understanding the consequences of pregnancy such as greater health risks and parenthood responsibilities has also “changed other people’s decisions” and “keep them in school” (Achora et al., 2018). As women traditionally bear the brunt of childrearing, adolescents felt that the emphasis on unwanted pregnancies was often targeted at girls. They hoped that their male peers would be equally involved as unwanted pregnancies were “not just one person’s responsibility” (Malinowski & Stamler, 2003).

Awareness of Safe Sex

Some adolescents in Western and African regions in this review mentioned that SBSHE specifically increased their awareness of condoms, and contraceptive methods to prevent HIV and unintended pregnancy (Ezer et al., 2019; Layzer et al., 2014; Manda et al., 2021; Maticka-Tyndale et al., 2007; Merrill et al., 2018; Nelson et al., 2016; Smith, 2015; Ybarra et al., 2014). Conversely, many others displayed minimal knowledge of condoms or contraceptives (Abel & Fitzgerald, 2006; Djuwitaningsih & Setyowati, 2017; Hilton, 2007; Lester & Allan, 2006; Mturi & Bechuke, 2019; Rehm, 2011). Several adolescents recalled being advised to use condoms, but some were not educated on how to use them (O'Higgins & Gabhainn, 2010). Additional forms of contraception such as birth control or emergency pills were less discussed (Hilton, 2007; Rehm, 2011).

Timing and Sufficiency of School-Based Sexual Health Education

Adolescents in Western, African, and Asian regions in this review often felt that it was conducted too late (Ezer et al., 2019; Hirst, 2004; Javadnoori et al., 2012; Lester & Allan, 2006; Mturi & Bechuke, 2019; O'Higgins & Gabhainn, 2010; Strange et al., 2003; Waling et al., 2020) and some “already had sex” (Strange et al., 2003) before attending it. Overall, adolescents felt that punitive measures and general statements overly simplified their SBSHE. As aptly reported by a student, SBSHE enforced “don’t do it, and that was it” (Ezer et al., 2019), often disregarding the nuance and intricacies of sexual negotiation (Layzer et al., 2017; Maticka-Tyndale et al., 2007; Widman et al., 2016; Ybarra et al., 2014). However, many struggled with sexual negotiation, fearing negative reactions or sexual violence from their partners, with one adolescent sharing that “he [boyfriend] can still beat you if you say no…” (Maticka-Tyndale et al., 2007). Adolescents who had unanswered questions on sexual health sought information from peers (Ezer et al., 2019; Hirst, 2004; Lester & Allan, 2006; Smith, 2015; Waling et al., 2020, 2021), and with the rise of technology, many adolescents have turned to the Internet and social media (Djuwitaningsih & Setyowati, 2017; Ezer et al., 2019; Waling et al., 2021).

Adolescents’ Preferred Approach to School-Based Sexual Health Education

This theme highlighted the approach to sex education that adolescents preferred. Some adolescents raised concerns about enforcing sexual abstinence and using scare tactics in SBSHE. Others have provided broader topics for consideration, and they also hoped that SBSHE would be inclusive of all gender and ethnic categories (Table 2).

Controversies with Abstinence-Only and Scare Tactics in School-Based Sexual Health Education

Abstinence-only and scare tactics approaches were practiced across various countries. However, the adolescents in this review had opposing views on these approaches. Some adolescents felt that scare tactics through “disturbing” visuals were effective in deterring unwanted pregnancies (Lee et al., 2016; Smith, 2015). Others felt that SBSHE should not be “about scaring kids out of having sex” but should focus on “teaching them good healthy habits to have controlled, consenting sex” (Waling et al., 2020). Some participants felt that the enforcement of abstinence caused them to “think twice about having sex” (Chirwa-Kambole et al., 2020; Denner et al., 2005; Didion & Gatzke, 2004; Nwokocha et al., 2015; Ott et al., 2003; Ybarra et al., 2014). This sentiment was common among countries in South Africa or older studies conducted in the USA. However, according to studies published in recent times, more felt that “it wasn’t useful at all” (Ezer et al., 2019) as this approach assumed they would have sex after marriage (Ezer et al., 2019; Maticka-Tyndale et al., 2007; Mturi & Bechuke, 2019; Rehm, 2011; Waling et al., 2021).

Broader Topics for Considerations

Relationships and Sexual Negotiation

Adolescents in all regions often wished to learn more about intimate relationships and building healthy relationships with their partners (Abel & Fitzgerald, 2006; Allen, 2005; Didion & Gatzke, 2004; Hilton, 2007; Mturi & Bechuke, 2019; O'Higgins & Gabhainn, 2010; Smith, 2015; Waling et al., 2021). In addition, they would also like to learn how to improve their negotiation skills to seek consent, engage in safe sex, and get tested for STDs with their partners (Abel & Fitzgerald, 2006; Waling et al., 2021). Some adolescents wanted to know more about sexual practices and pleasures, as well as how to engage in these practices safely (Allen, 2005; Brüll et al., 2016; Hilton, 2007; O'Higgins & Gabhainn, 2010; Smith et al., 2011; Waling et al., 2021).

Dealing with Peer Pressure

Others requested help to navigate peer pressure that emphasized sexual relations to “prove’ themselves (Abel & Fitzgerald, 2006; Likupe et al., 2021; O'Higgins & Gabhainn, 2010; Smith et al., 2011). For example, male adolescents in this review were conscious of how much their sex is influenced by the prevailing masculinity culture. They wanted strategies for saying no, in a sense that allowed them not to appear foolish or ‘chicken’ (Hilton, 2007). Overall, many adolescents in this review wanted to learn about consent, and understand what constitutes healthy and unhealthy relationships (e.g., topics surrounding sexual abuse and partner violence) (Ezer et al., 2019; Manda et al., 2021; O'Higgins & Gabhainn, 2010; Waling et al., 2021).

Importance of Diversified School-Based Sexual Health Education

The adolescents highlighted the need to diversify SBSHE by including practices from different sexualities and cultures surrounding sexual health education. Many LGBT participants expressed their frustrations with the heteronormativity of their SBSHE. The exclusion of LGBTs limited their knowledge of engaging in safe sex thus causing them to ignore “safe sex” precautions (Ezer et al., 2019; Jarpe-Ratner et al., 2022). Cultural minorities were also disheartened that they were not adequately represented in SBSHE (Hirst, 2004; Waling et al., 2021). As one African-American adolescent expressed: “Never ever [have I seen any African-American people featured in sexual [ity] education]…They're always White.”(Hirst, 2004). This strong emphasis on diversity among gender identity and ethnicity is common in the Western context (e.g., in the USA and Australia).

Importance of Engaging and Safe School-Based Sexual Health Education

The use of engaging elements for SBSHE was important for participants. Additionally, having a safe space to learn with competent educators was essential. Outside experts, more visuals, and narratives for immersive learning were welcomed.

Engaging and Up-To-Date Sessions

More Discussions and Interactions

Adolescents, regardless of gender, enjoyed “more discussion in class” (Allen, 2005) and small discussion groups with friends (Allen, 2005; Strange et al., 2003), families, and educators (Allen, 2005; Cornelius et al., 2012; Hilton, 2003; Merrill et al., 2018; Nelson et al., 2016; O'Higgins & Gabhainn, 2010; Strange et al., 2003). Both young and older adolescents felt that interacting or listening to personal stories from those affected by HIV or unwanted pregnancies were deemed to convey a stronger message (Adams Tucker et al., 2016; Ado & Mensah, 2015; Allen, 2005; Lupton & Tulloch, 1996; O'Higgins & Gabhainn, 2010; Rehm, 2011; Smith et al., 2011).

Engaging Visuals

Others would like SBSHE to be less repetitive and more engaging through visuals such as prints, videos, diagrams, and slide shows (Al-Iryani et al., 2013; Hilton, 2007; Nwokocha et al., 2015; O'Higgins & Gabhainn, 2010). In recent years, studies conducted in the USA have incorporated technologies such as animations and video games were incorporated into SBSHE since they were deemed visually appealing or entertaining (Layzer et al., 2017; Pendergrass et al., 2016; Widman et al., 2016). Similarly, other high-income countries had incorporated the use of anonymous text messaging, avatar-based games (Brüll et al., 2016; Widman et al., 2016), computer-based learning, or game-based learning which has gained popularity among the participants (Allen, 2005; Cornelius et al., 2012; Haruna et al., 2018; Nwokocha et al., 2015). Adolescents who received only text-based SBSHE highlighted that face-to-face interactions were still important (Cornelius et al., 2012).

Availability of a Safe Space to Learn Sexual Health Education

Ability to Freely Express Themselves

Adolescents in this review wanted to receive SBSHE in a private (Allen, 2005; Brüll et al., 2016; Hilton, 2003; Lester & Allan, 2006; Maticka-Tyndale et al., 2007; Merrill et al., 2018; Pendergrass et al., 2016; Widman et al., 2016; Zanatta et al., 2016) and safe (Adams Tucker et al., 2016; Chirwa-Kambole et al., 2020; Jarpe-Ratner et al., 2022; Merrill et al., 2018; Smith, 2015; Waling et al., 2020) environment. They would like to “feel free” to express themselves without the fear of judgment (Chirwa-Kambole et al., 2020).

Relaxed and Respectful Environment

Adolescents enjoyed SBSHE in a relaxed and informal setting (Adams Tucker et al., 2016; Manda et al., 2021; Merrill et al., 2018; Mturi & Bechuke, 2019) as it made learning “easier than other courses” (Haruna et al., 2018) without having to “stress yourself” (Adams Tucker et al., 2016). Safe space to learn sexual health education was jeopardized by disruptive adolescents who “laugh[ed] and giggl[ed]” (Haruna et al., 2018), “made jokes” or disrespected others (Adams Tucker et al., 2016; Didion & Gatzke, 2004; Haruna et al., 2018; Lupton & Tulloch, 1996; Mukoma et al., 2009; Smith, 2015; Smith et al., 2011; Strange et al., 2003). Disruptions in SBSHE were often caused by rowdy male students as a means of publicly demonstrating their masculinity with jokes about sexuality (Hirst, 2004; Lupton & Tulloch, 1996; Mukoma et al., 2009).

Having Competent Educators

To provide a safe space, the types of SBSHE educators mattered as well. While some adolescents felt that peer educators were more relatable (Ezer et al., 2019), others preferred unfamiliar adults so that adolescents could receive non-biased information and could freely ask questions (Chirwa-Kambole et al., 2020; Lester & Allan, 2006). Many adolescents in this review were uncomfortable when they were taught by familiar faces (Allen, 2005) as they felt that their existing relationships with their educators were “too close” (Allen, 2005). Doctors, nurses, and qualified counselors were preferred by the participants in various regions, and among both young and older adolescents. This was because professionals were deemed more knowledgeable, and more likely to uphold confidentiality (Achora et al., 2018; Ado & Mensah, 2015; Brüll et al., 2016; Hilton, 2003, 2007; Javadnoori et al., 2012; Lupton & Tulloch, 1996; Mturi & Bechuke, 2019; Njue et al., 2009; O'Higgins & Gabhainn, 2010; Ramukumba et al., 2020; Waling et al., 2021). Adolescents benefited from SBSHE when educators were knowledgeable (Abel & Fitzgerald, 2006; Adams Tucker et al., 2016; Chirwa-Kambole et al., 2020; Ezer et al., 2019; Hilton, 2003; Jarpe-Ratner et al., 2022; Likupe et al., 2021; Lupton & Tulloch, 1996; Mturi & Bechuke, 2019; Nwokocha et al., 2015; Smith et al., 2011; Strange et al., 2003; Waling et al., 2020) and confident to teach about sexual health (Adams Tucker et al., 2016; Ado & Mensah, 2015; Ezer et al., 2019; Javadnoori et al., 2012; Likupe et al., 2021; Njue et al., 2009; Smith, 2015; Strange et al., 2003; Waling et al., 2020).

Having Educators That They Can Trust

Regardless, participants were more receptive to educators that they “can trust” (Hilton, 2007), which was important in ensuring a safe space. Key factors to upkeep trust include keeping confidential information and refraining from gossip (Adams Tucker et al., 2016; Didion & Gatzke, 2004; Hilton, 2007; Lupton & Tulloch, 1996; Merrill et al., 2018; Njue et al., 2009; Sorhaindo et al., 2016; Waling et al., 2021; Yoo et al., 2004). Adolescents wished to be “treated with respect” and not “belittled” by their educators (Adams Tucker et al., 2016; Chirwa-Kambole et al., 2020; Lester & Allan, 2006; Smith et al., 2011; Sorhaindo et al., 2016; Yoo et al., 2004). Conversely, adolescents in this review felt judged or punished by their educators when their educators were deemed not trustable and had their thoughts “repeated to their parents” (Adams Tucker et al., 2016; Hilton, 2003; Hirst, 2004; Njue et al., 2009; Smith, 2015; Yoo et al., 2004).

Discussion

This review consolidated the adolescents’ perceptions, experiences, and needs about SBSHE, and the findings were represented in three main themes: (1) teachings of SBSHE and its impact, (2) adolescents’ preferred approach to SBSHE, and (3) importance of engaging and safe SBSHE. The types of SBSHE and students’ experiences and needs of SBSHE are highlighted in this discussion.

The adolescents’ expectations of sexual and reproductive health from the included studies indicated that they yearned for a holistic sexuality education approach that promotes conscious, healthy, and consensual choices in relationships and sexuality. Yet, many adolescents from the included studies were frustrated with their SBSHE which did not address these topics. Hence, despite the global increase in policies that promote comprehensive sex education, the experiences described by the adolescents in this review were not in line with United Nations Educational Scientific and Cultural Organization (UNESCO) SBSHE guidelines (UNESCO, 2018). These significant gaps between policies and practical implementation need to be addressed. It is also noteworthy that despite the highest number of HIV-positive cases among adolescents from regions such as Africa, Asia, and Latin America (Chi et al., 2011), available studies from these regions were limited. Hence, future research should strive to provide a global representation of adolescents’ perspectives on SBSHE.

Our review found that the recently included studies, those published after 2015, had sought to address broader topics ranging from mutual consent to sexual contact, sexual abuse to partner violence. This is a commendable move toward UNESCO’s guidelines to provide a more comprehensive SBSHE for adolescents (UNESCO, 2018). However, many participants expressed that SBSHE had often remained superficial and missed the intricacies of relationship building. Similarly, Burkett and Hamilton (2012) (Burkett & Hamilton, 2012) reported that SBSHE did not provide realistic accounts of relationships and negotiations in terms of sexual encounters. Hence, due to the complexity of adolescent relationships, the future SBSHE needs to move past the simplistic notions of “just say no” (Maticka-Tyndale et al., 2007) and include applicable topics on relationship building, sexual consent, sexual abuse, and partner violence (Coy et al., 2016). SBSHE guidelines by UNESCO recommend that adolescents be taught to be able to distinguish between healthy and unhealthy sexual relationships, and the different ways of expressing love as one matures (UNESCO, 2018). Recent studies have reported that critical in-class discussions during sexual health education can provide opportunities for discussions and educate youths about unfamiliar and sensitive content (Malo-Juvera, 2012; Osman, 2021). For example, the use of “young adult literature” during English and Language Arts lessons had been shown to successfully teach adolescents a variety of skills, including understanding sexual health topics related to sexual consent, sexual abuse, and partner violence (Palmer & Hirsch, 2022). The findings suggested that the learned skills and knowledge promoted critical thinking and thus could enable adolescents to navigate their relationships in the future (Malo-Juvera, 2012; Palmer & Hirsch, 2022).

UNESCO guideline recommends that SBSHE be diversified and includes teachings about gender identity and respect for different identities (UNESCO, 2018). However, the findings of our review emphasized that SBSHE was not comprehensive and inclusive for adolescents who were LGBT and/or ethnic minorities. This coincided with a recent survey, reporting that 44% of non-heterosexual young women found their SBSHE not useful (Sundaram et al., 2016). Like another study (Harrison et al., 2016), the adolescents in this review raised the need for gender inclusivity in SBSHE. Research has shown that inclusive sexual health education reduces homophobic bullying and harassment and increases the perception of safety among LGBT students (Goldfarb & Lieberman, 2021). This is supported by a 2015 survey of 1232 gay and straight adolescent students in the USA which found that inclusive SBSHE was associated with a higher perception of safety and lower levels of harassment (Snapp et al., 2015). Another study has also demonstrated that this approach reduces homophobic and transphobic bullying (Gegenfurtner & Gebhardt, 2017).

Unique to our review, the adolescents highlighted that the SBSHE must also be taught within the larger context of intersectionality and transcend beyond gender identity and also racial and ethnic/cultural groups. Hence future SBSHE curricula could consider including and evaluating these suggestions.

Adolescents from this review valued having a “safe space” to learn about sexual health and sexuality. They emphasized the need for a trusting relationship with the educators. Conversely, adolescents were less receptive when they felt judged, punished, or had their confidentiality breached. These highlighted the need for future SBSHE to take into consideration program content, program venue, and the training of educators. Previous literature has also reported the need to set ground rules to build trust with students so that they can participate freely in conversations on sexual health (Goldfarb & Lieberman, 2021). To ensure confidentiality, educators could consider using anonymous question boxes, online polls, or forums to receive questions that adolescents may find embarrassing or unsafe to ask openly in a classroom (Green et al., 2015; World Health Organization, 2018b). While adolescents in this review have shown preferences for “outside experts” to conduct the SBSHE, not all schools have the resources to acquire professional services in this aspect. Hence, having dedicated teachers (e.g., specialist sexual health education teachers) who are certified and trained in teaching sexual health, and do not have a direct student–teacher relationship with adolescents could be a cost-saving and viable solution (Pound et al., 2016).

There is a myriad of teaching methods developed for SBSHE. Congruent with other research, the studies in this review reported that interactive approaches were utilized in SBSHE to promote sexual health (Leung & Lin, 2019). From our review, it is evident that these interactive components (e.g., group discussions, storytelling, and game-based learning) were compelling for the youths in this review. Rather than having teachers as the ‘directors’ of the learning process in SBSHE, UNESCO recommends that future SBSHE should develop interactive strategies to engage the learners. This can encourage active participation and allow adolescents to critically think about their own lives and sexual health (UNESCO, 2018). Some SBSHE in this review included technology-based approaches (e.g., text messaging or avatar-based games). These approaches can conceal the identities of users, thus providing adolescents with a “safe space” to discuss and ask questions on sexual health anonymously without the fear of judgment. However, the use of technology needs to be carefully monitored by schools to ensure that the sexual content is age-appropriate for adolescents, factual, and controlled (McCarty-Caplan, 2013).

Limitations

This review has some limitations. Firstly, only studies written in English were included; hence, relevant studies in other languages may have been excluded. Secondly, in many of the included studies, the relationship between the researcher and their participants was rarely mentioned, questioning the rigor of the included studies. Lastly, most of the included studies were conducted in North America, Africa, and Europe, with limited studies in countries like Asia and Latin America. Despite these limitations, the findings of the review have provided in-depth insights into the students’ experiences and needs of SBSHE, complementing existing quantitative research and paving the way for a higher quality SBSHE for adolescents.

Future Implications

For a global representation, future research should examine the SBSHE in other countries, especially those with a high prevalence of HIV-positive adolescents beyond Africa (e.g., Asia and Latin America). There is also a need for diverse and inclusive teachings on mutual consent, sexual abuse, and partner violence in the SBSHE curricula. Moreover, intersectionality, crossing gender identity, racial groups, and ethnic/cultural groups should also be considered during these sessions. Educators must also be educated to provide a safe and trusting environment for adolescents. Additionally, our review adds to the growing number of research that has highlighted the importance of interactive approaches to appeal to youths. Align with this, future SBSHE should consider implementing interactive and technology-based pedagogies when teaching sexual health. Future research should explore the use of different educators in providing SBSHE (e.g., peers, and healthcare providers). Lastly, future research should also triangulate the perceptions of teachers, peer educators, and administrators with adolescents’ views, which would provide a more holistic understanding of SBSHE.

Conclusion

This review consolidated qualitative evidence around the experiences, perceptions, and needs of adolescents about the SBSHE. To fulfill the requirements of adolescents, the SBSHE curriculum needs to cover aspects such as consent, and sexual violence. Furthermore, SBSHE must also be inclusive and equipped with well-trained educators. Areas of future research should also extend to evaluating the effectiveness of different types of educators, and conducting more research in countries like Asia or Latin America. By taking into consideration the experiences and needs of adolescents, we can better develop the SBSHE that is useful and relevant to them.