Sex education has been widely recognized as a means to inform young people of the negative consequences of premature sexual activities (Tabatabaie, 2015). Global research efforts have demonstrated that sex education programs (SEPs) have contributed to the prevention of risky sexual behaviors and negative sexual outcomes such as sexually transmitted infections, unintended pregnancies, sexual coercion, abuse and exploitation, while improving their quality of life, health, and general well-being (UNESCO, 2009; WHO Europe, 2010). However, understanding the impact of programming could be challenging due to issues measuring future outcomes, such as changing HIV-related behaviors and HIV case reduction (Fonner, Armstrong, Kennedy, O’Reilly, & Sweat, 2014), preventing teenage pregnancies, or reducing premature sexual engagements in future years (Vilanculos & Nduna, 2017). In addition, many controversies regarding SEPs remain unresolved, such as (1) whether it should be delivered as a formal education component in an elementary school setting, (2) whether it should be a collaboration between school and family, (3) at what age children should start receiving sex education, and (4) which topics should or should not be included (Bale, 2011; Caputo, 2007; Goldman, 2013; Kurtuncu, Akhan, Tanir, & Yildiz, 2015). However, the target population is typically for adolescents focusing on diverse topics about sexuality, such as STD, HIV-AIDS, birth control, pregnancies, sex and ethics, and sexuality identity (Keogh et al., 2018; McKay, Vlazny, & Cumming, 2017). However, for preschool age children topics are mainly about child sexual abuse prevention or involvement of parents and health professionals in information sharing (Brown, 2017; Kurtuncu et al., 2015; Martin, Riazi, Firoozi, & Nasiri, 2018). The purpose of this study was to conduct a review of relevant literature on early SEPs that have been tested for their effectiveness for school-age children, particularly in elementary school years, in schools, social services, and other community-based settings.

While sex education is proven to be effective for adolescents, seldom do research studies use empirical data to test the effectiveness of formal sex education for pre-pubertal youth. When programs are designed for teens, sex has already been talked about as a popular peer-initiated topic during their pre-pubertal years. Even though educators recognize the importance of designing sex education curriculum for all children, the starting age is still debatable (Barr, Moore, Johnson, Forrest, & Jordan, 2014). In a study on the attitude toward sex education, students, parents and teachers expressed a wide range of starting ages between 5 and 25, with a mean of 10.97 (SD = 4.3) but many participants felt that primary school is the appropriate time to learn about abstinence from sexual activities (Fentahun, Assefa, Alemseged, & Ambaw, 2012). It is necessary to find data to support their intent and goal to deliver SEPs for elementary school-age children. Even though many SEPs have targeted school-age children, most programs are designed for children in middle or high school. This study aimed to analyze sex education curricula with a mission to educate pre-pubertal children and to find program designs for these children with evaluation data to support program implementation.

Method

This study reviewed research studies published between 2005 and 2019 that described the content, delivery methods, and data analysis for evaluating sex education programs that could target elementary school-age children. The year 2005 was the starting year for this study mainly based on a Scotland study by Buston and Wight (2004) who collected data from 25 schools. This Scotland study found that variations between classes would determine the most appropriate ways to present sex education materials to engage student participation. Their study stimulated research interest on international research studies of sex education that targeted elementary school students.

Research-based literature was searched based on an initial research question: “What are the components of SEPs that have been commonly delivered to elementary school students with evaluative outcomes across different countries?” Targeted studies were identified through a literature search in three electronic databases (Academic Search Complete, Education Source, and MedLine) with keywords “sex education,” “elementary school or primary school or grade school” and “prevention.” Inclusion criteria included: (1) SEPs with relevancy and implication to elementary school-age children; and (2) descriptions of the SEP including its design/programming and data generation methods, with discussions relevant to planning SEPs for elementary school students. Article titles, abstracts, and contents were first reviewed to determine content relevancy, data reliability and validity. If two or more similar SEPs were described for a specific country or location, only the newest article was selected to avoid duplication of information. The final selection included empirical studies, systematic reviews, and meta-analyses with recommendations to improve the SEP development targeting elementary school-age children.

Figure 1 is a PRISMA Chart with a summary of the article selection process with a literature search between 2005 and 2019. The research team consisted of two members to ensure reliability of the search process and content analysis. Keyword search generated a total of 435 articles, in which 300 articles were first excluded due to duplicated information from either the same article or same project. After reviewing the abstract and method section of the remaining 135 articles, only 67 articles had methodological descriptions. The team further reviewed 60 full-text articles on specific SEP details and excluded those without outcome design, evaluation, or not having enough details about their SEPs on design or curriculum topics. In two additional rounds, the researchers summarized the review results by examining the descriptions and the program outcomes of each selected SEP. The, 49 articles were excluded mainly because of a lack of implications on preteens. Finally, eleven studies were reviewed with a thematic analysis. The themes were then organized with information in three categories: (1) characteristics of the curriculum such as titles and educational approaches; (2) program evaluation design and methods; and (3) research questions, measures, and results. Data relevant to the research purpose were placed into three tables to be described in detail in the results section.

Fig. 1
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PRISMA chart

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Results

The analysis with results is reported by 11 SEPs in nine countries. These SEPs presented diverse approaches and covered various topics for sex education delivery. The original intent to organize a checklist of common elements across the programs could not be accomplished because of the diverse findings. Diversity is particularly evident in terms of program titles, program delivery methods, topics of instruction, and ways to involve family and community in agreeing to deliver SEPs. In addition, with the inclusion criterion that the SEP must be relevant for elementary school-age children, some programs that targeted children of all ages were not excluded. Even though the SEPs were designed to target school-age children inclusive of elementary school, only one study focused solely on 5th graders. Since the SEP delivery methods were diversely implemented, this review could not generate a standardized curriculum. These results were summarized in three tables to highlight the main components of these SEPs and to demonstrate that there was not a uniform set of delivery or evaluation methods across these programs. As a result of content diversity, three major findings related to curriculum development addressed the unduplicated efforts in design and delivery across SEPs: (1) curriculum approaches, (2) program titles and presentation topics, (3) diversity in program designs, and (4) child-centered outcomes relevant to elementary school-age children.

SEP Curriculum Approaches

Table 1 summarizes the curriculum approaches that led to a SEP being formally delivered. Typically, a program was designed to be one to nine sessions, with a length of about 45 min per session, 6 h to 24 months in duration. Methods of delivery included classroom presentations with interactive activities (videos, discussions, games) to keep children focused and interested in the program. Some used multiple means to engage the children, e.g., small group exercises and critical thinking case analyses (Constantine et al., 2015; Kim & Kang, 2017). One study mentioned the use of mass media information such as news of child sexual abuse (Kim & Kang, 2017). Another study taught sexual health in physical health classes (Erkut et al., 2013).

Table 1 Sex education approaches
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Program Titles and Presentation Topics

Table 1 also lists the “SEP Program Title” for each research study. “Sex education” was the most common SEP title, evidenced by its use in seven of these SEPs in Hong Kong, United States, Ireland, Chile, and China (Che, 2005; Erkut et al., 2013; Paul, Bell, Fitzpatrick, & Smith, 2010; Silva & Ross, 2003; Smylie, Maticka-Tyndale, & Boyd, 2008; Wang, Meier, Shah, & Li, 2006). SEP program titles were also used differently as reported in these studies by country: “sexual health education” in Scotland (Black, McGough, Bigrigg, & Thow, 2005), “sexuality education” in the U.S. and Japan (Constantine et al., 2015; Hashimoto et al., 2012), “sexual and reproductive health initiative” in South Africa (Mathews et al., 2015), and “child sexual abuse prevention education program” in South Korea (Kim & Kang, 2017). All programs used the word “sex,” “sexual” or “sexuality” as part of their program title. Among them, two programs used “sexual health” and one program used “sexual abuse prevention” as subtitles to highlight their specific focus on prevention.

In specific program topics, the most popular presentation topics were sexual relationship, sex, sexual abuse, family relationship, self-protection, puberty, reproduction, gender differences, safe sex, contraception, risk, diseases, sexually transmitted diseases, decision-making responses, and communication skills. More specifically, these topics were gender issues and sexual development (Constantine et al., 2015; Hashimoto et al., 2012), reproductive health (Black et al., 2005; Constantine et al., 2015), puberty (Black et al., 2005; Che, 2005; Hashimoto et al., 2012), safer sex (Black et al., 2005; Constantine et al., 2015), dating and relationship (Black et al., 2005; Che, 2005; Constantine et al., 2015; Hashimoto et al., 2012), sexually transmitted diseases including HIV/AIDS (Black et al., 2005; Che, 2005; Constantine et al., 2015; Hashimoto et al., 2012), pregnancy and/or birth control (Black et al., 2005; Che, 2005), sexual harassment (Che, 2005), sex and the media (Che, 2005; Constantine et al., 2015), sexual abuse (Che, 2005; Hashimoto et al., 2012), and sexual orientation (Che, 2005). Even though these presentation topics varied across programs and locations, based on how programming or implementation was designed in the country or region, the goal to deliver sex education was universally about sex and sexuality. Regardless of how it was titled, the main goal was to educate children about normal sexual health and development. Very few specified the negotiation or refusal skills of sexual relationships or advances.

Diversity in SEP Design

Table 2 shows diversity in SEP designs. Even though these studies had implications for younger children, most programs were delivered to adolescents. Their outcome-based evaluation designs were mostly pre-posttest design (n = 8, 73%), among which three with quasi-experimental groups and two were longitudinal for up to 2 years. In addition, three studies used a post-test-only design. Teachers were the main characters responsible for the SEP delivery. Typically, teachers assumed the most recognized role as SEP leader or facilitator. Specific findings showed that they included: (1) teachers who taught any subject (Black et al., 2005), (2) teachers who organized weekly meetings with educational psychologists to discuss various topics that could increase student interactions and discussions of how to deal with real-life situations (Silva & Ross, 2003), (3) teachers who were specifically appointed to coordinate SEPs (Che, 2005), and (4) instructors who taught subjects of health and physical education, home economics, and health sciences, working with those who developed the curriculum of health education (Hashimoto et al., 2012).

Table 2 SEP outcome research designs
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Other program deliverers included: SEP project staff (Constantine et al., 2015; Mathews et al., 2015; Wang et al., 2006), nurses (Black et al., 2005; Hashimoto et al., 2012; Kim & Kang, 2017), doctors (Black et al., 2005), peer educators (Paul et al., 2010), counselors (Wang et al., 2006), and volunteers (Constantine et al., 2015). However, social workers were not mentioned or described as prevalent leaders of sex education in these selected studies.

SEP Outcomes Relevant to Pre-Pubertal Children

Table 3 summarizes the evaluation results generated from these SEP studies, with a list of diverse research questions from these 11 studies to measure outcome effectiveness. The research questions in these studies were mainly about SEP program effectiveness. Additional questions were related to barriers and facilitators to SEP attendance, factors leading to sexual behaviors, and improvement in self-protection and communication skills. Beyond directly obtaining input from children, a study asked adolescents to recall their earlier experiences in sex education (Black et al., 2005). While adults were typically the SEP planners, parents were not involved in the planning stage. Parents were mentioned only when parent–child communication was a topic or an outcome variable (e.g., Constantine et al., 2015).

Table 3 SEP outcome research results
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These studies provided a mission or value about reducing resistance against sex education. The mission of these studies was reflected in the research questions, such as positively communicating with children about these topics: decision-making skills, attitudes and values of sex education, values of healthy sexual development, self-protection, negotiation skills, and attitude toward sex. However, none of these studies mentioned inviting children to provide input when planning a SEP. With a focus on outcome evaluation, these selected studies described ways to expand sex education as a partnership among a variety of adult stakeholders, including children’s families, teachers and social service communities, so that recommendations could be generated. For instance, in the United States, Erkut et al. (2013) specifically supported a logical, sequential curriculum with a family activity component to promote topic comprehension and enhance participant engagement. In Canada, representatives from various community groups served as educators for program delivery purposes (Smylie et al., 2008). In Chile, communication learning with adults was emphasized, with the idea that interpersonal communication was a key to successful prevention of sexual abuse (Silva & Ross, 2003). These activities were connected to a need for school educators to work collaboratively with each other, the social service communities, and the children’s families to support the function of a formal SEP for children.

Discussions

As an exploratory study, the initial search starting in 2019 aimed at finding evidence to produce a checklist of major tasks involved in the delivery of SEPs for elementary school-age children. This checklist could not be actualized due to the variations in SEP designs and delivery methods even though our target child was within elementary school-age in the study design or implications. The results must be interpreted with caution due to four shortcomings in the use of secondary sources: (1) the keyword to determine age specified in the studies was based on “elementary school, grade school, or primary school,” not a range of ages, which might have resulted in mostly school-based programs (except one) in the final selection; (2) some identified designs did not sufficiently provide a standardized list of SEP program contents; (3) evidence to support each of the SEP curricula was based primarily on pretest/posttest designs without the use of a control group; and (4) evaluation data might be connected with different meanings in reference to the cultural context of the country, even though it was also surprising to find SEPs in nine different countries within this search. In addition, even though the target population was elementary school-age children, two studies evaluated SEPs for both adolescents and younger children.

Despite these limitations, the summaries provided in these eleven studies captured information of these SEPs in terms of their curriculum development strategies, implementation formats, and their target participants that might include adolescents. A future study could focus more effort to locate SEPs in the world by checking research studies from international databases with a focus on sex education for elementary-school students, particularly those with a focus on preventing child sexual abuse. Nevertheless, the presented information demonstrated scientific merit and practical insights with relevance for improving the quality and image of sex education for the benefits of disseminating accurate information to young children.

Discussion and Application to Practice

Although the results could not generate a standardized SEP curriculum or a step-by-step checklist about how to deliver contents for young children, three practical insights could be used as a reference. These insights support the importance of planning activities for children to learn about sexual health while helping parents, schools, and the local communities work together to reduce stigma against sex education.

First, diverse SEP titles might be used to avoid social stigma against teaching young children about sex. However, the formal title of their specific curriculum still contained the two most commonly used words—“sex education.” The use of “health” in the program title adds a positive image to sex education as it connects to children’s well-being. The descriptions of these various titles supported the use of different titles to reflect program designs and, at the same time, to increase the acceptability of delivering sex education that could normalize the word “sex” on its program title.

While it is not clear if the alternative titles were used by other programs to normalize the education aspect of sex education, it is related to the stigma of sex education as a taboo topic to formally deliver in schools (Agbemenu et al., 2018). Cultural sensitivity must be considered when sex education is delivered to facilitate a better reception of the topic. In this study, “health education” refers to promoting children’s knowledge of their sexual development. An important question is: Do we need to avoid using “sex education” as the educational title to help reduce the taboo around sex? In these eleven studies with empirical data support, the term “sex education” has been used in six studies, specifically as the title of the SEP curriculum. Even though other terms may be used to help parents and children understand the health perspective of sex education, it is hoped that educators can work with families to deliver a positive image of sex education. It is important to normalize sex education as part of a school curriculum, as sex education is inclusive of knowledge about sex and gender, sexual development, sexuality, sexual health, sexually transmitted diseases, sexual orientation, and attitude toward discussions on sexual knowledge.

Second, it is essential to study how educators are selected and trained. The selected studies included the role of an educator with a specialization in sex education but did not combine the role of school social workers as sex education providers. Based on a recent study with interview data from children ages 3–11, a great challenge in school social work has been related to assigning social workers with the role of sex educator to support children with disabilities, with a concern that the social workers’ role is not well defined (Bolin, Rueda, & Linton, 2018; Rueda, Bolin, Linton, Williams, & Pesta, 2017). For future sex education development, if social workers are to be involved from the planning stage, it is essential for them to obtain recognized trainer credentials. They must be ready to deliver sex-related contents with an advanced level of preparation to be part of a sex education faculty. Just by reviewing the findings through these published articles, however, it is still unclear if social workers are considered a key member in a SEP team. Social workers’ coordinator role are not defined or confirmed.

Third, although the youth’s age range and average age were included in eight of the eleven studies, gender differences in topic coverage were not addressed. In other words, specific topics about sex and sexuality may not be linked to the youth’s gender and developmental level as their focus is on how to initiate sex education curricula but not to test the demographic differences in their design (Constantine et al., 2015; Hashimoto et al., 2012). SEPs tend to provide a generic curriculum for youth across a wide age range. In this review, the eleven programs targeted the youth between 9 and 18 years of age; only one study focused solely on children in the fifth grade while others targeted SEPs for older children.

Conclusion

This brief report highlights the importance of topic planning based on gender, age, and cultural differences when SEPs are designed for elementary school-age children. Since the SEPs reviewed targeted mainly on older children who tended to search the internet for information, it is important to deliver a school-based SEP curriculum in an earlier age when they need reliable sources to start their learning about themselves and sexual health (Liu, Van Campen, Edwards, & Russell, 2011). A surprising finding from these sex education programs was these nine programs did not mention the social workers’ role in leading or coordinating these educational efforts. It also does not mention anything about young children with special needs, such as with disabilities that put them into a high-risk group for sexual abuse and bullying, who should be a priority target for planning curricula on positive sexuality and relational health earlier for prevention purposes (Barr et al., 2014; Rueda et al., 2017; Silva & Ross, 2003). Future studies should have more in-depth discussions on integrating methods with interprofessional collaborations learned from the global efforts. SEPs must also explore how to engage the community to work with both parents and teachers in the process of designing, planning, and providing sex education for elementary school-age children in a formal way. As a first step, it is essential for school social workers to partner with teachers and nurses to form a team of trained sex education faculty to work closely with parents to formalize age appropriate SEPs in the school system.