‘I tell them that sex is sweet at the right time’ – A qualitative review of ‘pleasure gaps and opportunities’ in sexuality education programmes in Ghana and Kenya

ABSTRACT

Pleasure is a key motivator for sex globally, while unsafe sex is the largest risk factor for young women’s mortality and the second for young men. However, framing of sex education and sexual health programmes continues to be around avoiding danger, death and disease, rather than striving for pleasurable, satisfying, and safe sexual experiences. Omission of pleasure and sex-positivity goes against growing evidence that shows that people with more positive views of sexuality are more likely to practice safer sex, use contraception consistently, have higher sexual self-esteem and be more assertive.

The Pleasure Project and Rutgers, with GH SRHR Alliance (Ghana) and SRHR Alliance (Kenya), conducted a qualitative pilot study of sexuality education under the Get Up Speak Out programme, analysing the extent to which they included sex-positive content, with recommendations to enhance sex-positivity. Data were collected through interviews with facilitators, focus group discussions with learners, observation of sessions, and curricula content analysis. Findings reveal possibilities of sex-positivity in restrictive contexts, illustrating ways for sexuality education to become more sex-positive and pleasure inclusive. This study enables the development of a new tool for a ‘pleasure audit’, with markers of high-quality, sex-positive and pleasure-inclusive sexuality education or sexual health programmes.

KEYWORDS:

• Pleasure
• sex-positive
• Comprehensive Sexuality Education (CSE)
• qualitative study
• Global South

Setting the scene: Motivations for sexual activity

People have sex (i.e. sexual activity, including sexual intercourse) for many individual, economic and societal reasons, including bonding relationships, love and affection, societal expectations, economic need, reducing stress and a social contract such as marriage and reproduction (Browning et al., 2000; Rye & Meaney, 2007). Amongst all these reasons, sexual pleasure is one of the primary motivating drivers for sexual behaviour (World Association for Sexual Health, 2008). The World Association for Sexual Health (WAS) and the International Planned Parenthood Federation (IPPF) both emphasise the importance of pleasurable, satisfying, and safe sexual experiences within their declarations on sexual rights (IPPF, 2008 & WAS, 2014) and the World Health Organisation (WHO) places a positive approach to sexuality and sexual relationships as essential to wellbeing, when defining sexual health (WHO, 2006).

In this article, we first lay out the theory and evidence on the problematic relationship between sexuality education programmes and the realities around sex vis-à-vis pleasure and danger. Most of the emerging literature on sex-positive or pleasure inclusive sexuality education comes from North America, Europe or Australia. While there are assessments and evaluations of sexuality education programmes in sub-Saharan Africa, Asia and Latin America, only few mention pleasure or sex-positive approaches. We discuss the limited literature we found using search terms such as ‘sexuality education’ + country name / region + ‘pleasure’ / ‘sex-positive’. We then provide the results of a qualitative pilot study, that was conducted in Ghana and Kenya, with the aim to develop a pleasure audit tool that will give operational application of a sex-positive approach to sexuality education which more accurately resonates with young people’s realities.

For the purposes of the study, we have used several definitions to form the basis for how we operationalised sex-positivity and pleasure in our study tools. We used the working definition of sexual pleasure developed by the Global Advisory Board on Sexual Health and Wellbeing that emphasises ‘self-determination, consent, safety, privacy, confidence and the ability to communicate and negotiate sexual relations’ as ‘key enabling factors for pleasure to contribute to sexual health and well-being’ (GAB, 2016) and the International Planned Parenthood Federation’s definition of sex-positivity, i.e. ‘ … an attitude that celebrates sexuality as a part of life that can enhance happiness, bringing energy and celebration. Sex-positive approaches strive to achieve ideal experiences, rather than solely working to prevent negative experiences [while acknowledging and tackling] the various risks associated with sexuality, without reinforcing fear, shame or taboo … ’ (IPPF, 2016). The pilot study looked at two sexuality education programmes, exploring the extent to which they were comprehensive and sex-positive, and made practical recommendations. It then explored how this can inform a future tool to be used globally to measure sex-positive sexuality education programmes and their effects.

Unsafe sex is the largest risk factor for young women’s mortality and the second biggest for young men, especially in Sub-Saharan Africa (Mokdad et al., 2016). There are about 1.2 billion 15–24 year olds in the world (UN DESA, 2019) and 80% of all HIV-positive young women (aged 15–24) live in sub-Saharan Africa in (UNAIDS, 2014). Social determinants of sexual health, including gender and cultural norms, poverty, lack of education, lack of sexual healthcare infrastructure and access, combined with the lack of access to Comprehensive Sexuality Education (CSE) results in unwanted pregnancies, sexually transmitted infections (STIs), unsafe abortions and sexual and gender-based violence (SGBV) among women and girls all over the world (UNESCO, 2018). In response to this situation, a more holistic approach and understanding of safer sex and sexuality education is needed, which takes physical and psychological satisfaction, self-determination, consent, safety, privacy, confidence and communication/negotiation into consideration (GAB, 2018).

Although pleasure, and more broadly well-being, is becoming more prominent on the global public health agenda in recent years (Ford et al., 2019), when talking about sexuality or when providing sexuality education, adverse outcomes remain the main focus, and the discourse around fear, death, disease and danger are still prevalent in sexual health programmes (Ingham, 2005; Philpott et al., 2006; Singhal, 2003). With regard to sexuality education, topics like risk, abstinence and disease are often used as ‘scare tactics’ in the classroom for young people (Alldred & David, 2007). Although these negative outcomes are the targets that we need to tackle in the domain of public health, no evidence of high reliability has shown that a sex-negative approach to education and safer sex promotion leads to safer sexual behaviours, and the approach has little effect on developing sexual responsibility and subjectivity among young people (Fine, 1988; Higgins & Hirsch, 2007; Knerr & Philpott, 2008).

Getting into the act: Learning about sex, sexual scripts and contexts

Despite the growing body of evidence and advocacy around sex-positive approaches to sexuality education around the world, programmes remain focused on pessimistic sexual narratives (Allen, 2007; Jones, 2011; Oliver et al., 2013), and positive expressions such as desire, intimacy and pleasure have been often absent from sexuality education curricula (Allen et al., 2014; Cameron-Lewis & Allen, 2013; Ingham, 2005). Beyond sexual education curricula, sexuality educators also play an important role in how sexuality education is delivered. In a research into the pre-service training for sexuality educators in Australia, Ollis (2016) argues that educators’ confidence, values, knowledge and skills towards sexuality have the power of bringing about sustainable change to sexuality education.

Sexuality education and sexual health programmes often tend to perpetuate and reinforce damaging sexual narratives and social injustice, including silencing and shaming diverse desires, sexualities and especially women’s pleasure-seeking. For example, some sexuality education programmes use stereotyped frames of men being predators and women being victims (Jolly, 2007). Gendered expressions of sexual motivations mean that men are more able to express pleasure as a reason to have sex, or not use a condom, whereas women express emotional reasons for having sex, such as commitment and love (Meston & Buss, 2007). Most sex education manuals talk about menstruation for girls and wet dreams for boys, which indicates that sexual pleasure is for boys, while girls only need to learn about managing fertility (IPPF, 2016).

Evidence from previous studies and practices has shown the effectiveness of sex-positive or pleasure-focused education in terms of improved attitudes and health outcomes, such as condom use and other safer sexual behaviours. Schalet’s (2008) study compared the sexual experiences of Dutch and American teenagers and found that Dutch teenagers showed higher levels of contraceptive use and lower incidence of STIs, unwanted pregnancies and abortion, compared to American teenagers. This is because, compared with American teens, Dutch teens were more likely to receive Comprehensive Sexuality Education, which focused on consent, pleasure and responsibility in relationships. Another study also argues that pleasure-inclusive counselling and sexuality education can increase young women’s agency and reduce the rates of STIs and unwanted pregnancy, drawing on their experience of working for a UK sexual health charity for young people (Hanbury & Eastham, 2016). Furthermore, a meta-analysis by Scott-Sheldon and Johnson (2006) examined the effectiveness of safer sex interventions with erotic components. It reviewed 21 studies of safer-sex promotion or HIV prevention, all containing at least one method of eroticising safer sex and the results provided rigorous evidence, through the measurement of participants’ knowledge, attitudes, condom use and sexual partners, that promotion and interventions that included pleasure could lead to reduced risky sexual behaviours. Other programmes also open a pleasure dialogue to increase people’s safer sex behaviour by using erotic images and videos and eroticising the use of condoms (Becasen et al., 2015; Hogben et al., 2015; Schalet, 2011).

Several studies from the Global South highlight the absence of open discussion in the classroom setting about sex and sexuality, relating this to teacher attitudes and skills as well as policy restrictions. Studies focusing on HIV/AIDS education in several eastern and southern African countries found that many teachers felt concerned about being embarrassed and vulnerable in HIV/AIDS lessons, for example when their own sexuality and sexual experiences were questioned by students and became a topic in class (Pattman & Chege, 2003; Helleve et al., 2011). Some teachers resorted to adopting a moralistic and didactic approach to make them feel they could assert their authority and protect themselves (Pattman & Chege, 2003). Studies from Uganda and South Africa have shown that many sexuality education teachers believed that good sex education was abstinence-only and based on negativity, scare tactics and medical facts on sexuality-related topics, with notions of pleasure, desire and fulfilment being largely absent (Francis & De Palma, 2014). Many of those teachers work in a school system that expects them to teach abstinence-only. Yet, in Uganda, one-third of interviewed teachers said they were teaching both abstinence and contraception, and these were mostly younger, male teachers (De Haas & Hutter, 2019). Still, many of those teachers were concerned that society would consider them immoral and that demonstrating condoms or other means of contraception, might be interpreted as approval for students to become sexually active (De Haas & Hutter, 2019). Similarly, evidence from South Africa and Tanzania shows confidence in teaching HIV/AIDS and sexuality education could lessen when teachers experienced that the content contradicted their own or others’ values (Helleve et al., 2009). This fear may then reinforce teachers’ perceptions that they should focus on what is considered moral behaviour and justify abstinence-only teachings and silencing issues of sex (De Haas & Hutter, 2019). Overall, there remains a gap in studies focusing on opportunities for education styles that are more sex-positive as well as their effects.

As sex-positive and pleasure-inclusive approaches to sexuality education and positive-narrative sexual scripts gain more recognition, there are some inspiring organisations and programmes promoting sexual health and pleasure, including, for example, Adventures from the Bedrooms of African Women (https://adventuresfrom.com/), Life and Love with HIV (https://www.lifeandlovewithhiv.ca/), Agents of Ishq (http://agentsofishq.com/), Love Matters (https://www.rnw.org/what-we-do/love-matters/), the International Planned Parenthood Federation (IPPF) and, of relevance to this study, The Pleasure Project and Rutgers. More recently, UNESCO has also embraced pleasure through its revised edition of the International Technical Guidance on Sexuality Education (2018), as has the Guttmacher-Lancet Commission’s integrated definition on sexual and reproductive health and rights (Starrs et al., 2018).

Responding to desires: Addressing young people's sexual realities

The qualitative pilot study that investigated the inclusiveness of a sex-positive approach in sexual health education programmes was conducted in Nairobi city in Kenya and in Tamale, Sagnerigu and East Mamprusi in Ghana in May 2019. In both countries, policies and frameworks put restrictions on the content of sexuality education messages that can be provided to in-school students.

In Kenya, sexuality education is currently not a stand-alone subject taught in schools. Aspects of sexuality education are included in the Life Skills Education Curriculum and divided over other subjects such as biology and Christian Religious Education. Integration of Comprehensive Sexuality Education (CSE) into other subjects can have the drawback that teachers more easily skip topics that they view as controversial (Keogh et al., 2018). The Life Skills Education Curriculum developed by the Ministry of Education in 2002, and revised in 2008, includes information on different topics and deals with behaviours related to sexual health outcomes such as avoiding premarital sex; preventing sexual coercion; not perpetuating harmful traditional practices and responding assertively to harassment, abuse, bullying and pressure (UNESCO & UNFPA, 2012). However, a recent review has stated that information on contraceptives, condoms, sex and sexual health is only superficially addressed and topics such as reproduction, STIs, abortion, access to condoms and sexual health services and sexual diversity are excluded. The syllabi also tend to approach sex in negative terms (Sidze, 2017). In addition, a recent study among secondary school teachers in Kisumu central sub-county in Kenya found that less than a quarter of teachers had been trained on CSE. Out of the trained teachers, less than half felt that the training addressed the educator’s values, biases and opinions, likely resulting in teachers restricting themselves to teaching topics they felt comfortable with (Ogolla & Ondia, 2019).

In Ghana, there is a supportive environment for delivering SRH education, the trajectory of its content and delivery to young people has been long established and informed by its supportive policies (e.g. The Adolescent Reproductive Health Policy) and strong willingness to adhere to international commitments in support of sexuality education (Awusabo-Asare et al., 2017; Panchaud et al., 2019). However, available syllabi focus heavily on the promotion of abstinence, using a negative approach, and do not adequately address gender, sexual diversity, rights and practical skills (Awusabo-Asare et al., 2017). The intention of the Ministry of Education to launch the National Guidelines for delivering Comprehensive Sexuality and Reproductive Health Education (CSRHE) in basic schools in Ghana triggered opposition in the fall of 2019.

Methodology and research questions

This study was small-scale and intended as a pilot to learn about comprehensiveness and sex-positivity of CSE programme implementation on the ground. Data were collected through 16 in-depth interviews (eight in each country) with CSE facilitators (young peer educators and teachers) as well as one focus group discussion with five young peer educators in Ghana. Focus group discussions (FGDs) were conducted with learners, six in Kenya with 26 respondents in all, four in Ghana with 28 respondents in all. In addition, in each country, one CSE session was observed and content analysis of some of the CSE curricula used for the programme in each country was done.

To select CSE teachers/facilitators as respondents for the pilot study, we used a Positive Deviance approach (Tufts University, 2010) whereby we asked the National Programme Coordinators of the GH Alliance in Ghana and the SRHR Alliance in Kenya – both implementing the Get Up Speak Out (GUSO) programme – to identify individuals whose uncommon, but successful behaviours and strategies have enabled them to use a sex-positive approach, despite them facing the same constraints and barriers to CSE as their colleagues. The ‘positive deviants’ were selected as respondents with an aim to learn from their uncommon behaviours and strategies. CSE facilitators and teachers with a less sex-positive attitude were also included in the study so as to better grasp the differences between facilitators’ sex education styles. Learners were identified by the Youth Country Coordinators¹ of both Alliances, in collaboration with the partner organisations. The criteria used for this purposive sampling was: learners who were receiving CSE in the GUSO programme, ensuring a gender balance, and a mix of in-school and out-of-school learners, with at least one group of learners from a marginalised or vulnerable population (in Kenya this was young people living with HIV, and in Ghana this was young people with hearing loss). Respondents were either invited to the place where they typically received CSE by their educators or programme managers, or were met in their schools, with the teachers and school authorities organising logistics. The interview and FGD guides had verbal consent forms attached, which were read out to all respondents, ensuring they understood their rights and the purpose of data collection. All respondents were provided transport costs for coming to the interview or FGD.

The data collection was done by a lead researcher from The Pleasure Project, with three young co-researchers in Kenya and four young co-researchers in Ghana. The young co-researchers were young people who had been involved in the programme themselves, and included the Youth Country Coordinators as well. The teams were trained by the lead researcher on interview techniques, reflection on quality of data and research ethics. Data were analysed in two phases. The first phase of analysis was done immediately following the data collection, through debriefing with the complete team and reflecting on key findings and observations; exploration of inconsistencies or questions not answered. These reflections helped to improve researcher skills and guide further interviews, ensuring gaps in the data were covered and inconsistencies followed up. Notes were made of these sessions to see early thematic areas. These were validated with the senior leadership of the country GUSO Alliance and further refined, which then informed the categories and labels for coding of interview transcripts and field notes in the second phase. This second phase analysis was carried out by the lead researcher and organised in a manuscript that answered the research questions (refer to box on Detailed study areas). Ethical approval was obtained in both countries from the Amref Ethics and Scientific Review Committee in Kenya; and the Navrongo Health Research Centre Institutional Review Board in Ghana.

The key research question was: To what extent are sexuality education components of the GUSO programme, as implemented by the GH Alliance in Ghana and the SRHR Alliance in Kenya, inclusive of the elements of a sex-positive approach?

Table

Detailed study areas

CSE curricula and IEC materials:

(1) How are messages that promote a sex-positive view, and that move beyond purely prevention of disease or biomedical descriptions, expressed in the sexuality curricula and IEC materials?

(2) To what extent are honest descriptions of what sex and safer sex entails incorporated?

For sexuality educators / teachers / facilitators:

(3) Do facilitators feel comfortable in discussing sex-positive topics of sexuality education, respond to learners’ questions on relationships, negotiations, consent and sex in a comprehensive way, and encourage learners to be responsible for their sexual wellbeing by examining and questioning the social and gender norms that govern these? If yes, how?

(4) Do sexuality education sessions provide learners with skills like self-determination, consent, safety and confidence? If yes, how?

For learners:

(5) Do learners feel more positively about their own bodies, and have more sexual self-esteem, are they able to express their sexual expectations and desires in a clear manner, and have they understood the concept of sexual health and sexual rights, as an effect of sexuality education classes? If yes, how did the lessons contribute to this?

The conceptual framework for the proposed pleasure audit tool and the pilot study derives from the ‘Pleasuremeter’ designed by the Global Advisory Board for Sexual Health and Wellbeing (GAB). This Pleasuremeter is designed for health care providers to implement the pleasure approach in sexual history taking (Braeken & Castellanos-Usigli, 2018). For this pilot study, we adapted the measure to analyse CSE content and delivery for a sex-positive approach. There are seven factors in this measure which are explained below:

1. Physical and psychological satisfaction/enjoyment – this refers to the level of satisfaction/enjoyment in relationships, and factors that affect this.

2. Self-determination – refers to the level of agency when engaging in sexual relationships or activities.

3. Consent – refers to the ability to arrive at consensual agreements about what you want or don't want, and how freely consent is given.

4. Safety – refers to aspects of a sexual relationship or encounter that make you feel safe or unsafe, methods of protection against STIs, including HIV, and contraception, substance use or other aspects that affect sexual safety.

5. Privacy – refers to factors that affect privacy, control over the level of privacy.

6. Confidence – refers to the ability to express yourself in a sexual encounter, thoughts around body image.

7. Communication/negotiation – refers to the ability to talk about what you want, articulate what you find pleasurable, propose new things.

Limitations

The time allocated for data collection was not enough to ensure that further respondents could be sought based on the information received. The research teams were not always able to speak to the learners of the CSE facilitators interviewed, or the CSE facilitators of the learners who were in the FGDs, as the respondents were pre-fixed, and due to the time constraints, more FGDs and interviews could not be done. In addition, to understand and demonstrate the impact on those who do receive sex-positive CSE, it would have been necessary to engage in case study analysis of some learners. Therefore, this study only provides us with a snapshot of what exists and points to areas that require further, focused research.

Findings

Themes that stood out most prominently from the data collected in both countries were: educators needing more support to speak out comfortably about sexuality, young people not getting enough information and seeking information elsewhere – including turning to porn – and how some CSE educators are able to provide sex-positive education but they are swimming against the tide. Amongst the CSE facilitators in Ghana and Kenya, some were comfortable with discussing sex and sexuality while others were not. The primary reason for discomfort was religious values and beliefs, particularly around masturbation and sexual diversity (i.e. they believed that these are sinful), and sexual activity among young people outside of marriage (i.e. that it should not take place, or that young people should abstain until marriage). For example, one female CSE teacher from Kenya said:

Students face dilemmas on relationships. We advise them on having friendships rather than having a sexual relationship. They share that they have sex for pleasure. The students ask questions about how they can abstain because they don’t know how to do without it. I tell them not to be in closed areas with the opposite sex or stay long with the opposite sex. These kids have done things I myself have not done.

In Ghana, safe abortion came up as an additional topic that was difficult to discuss. For those who found it easy and were comfortable in discussing these issues, it was because they had examined and rejected some of the socio-cultural beliefs they were brought up with, including gender bias and expectations. This was done through repeated trainings, ongoing discussions with like-minded persons – such as peers, supervisors or trainers – who were also positive about sexuality, and experience or observation of things like sexual desire and fulfilment, engaging in happy relationships, sexual violence, and/or teenage pregnancy and its consequences. Some of them also cited the support they were getting from their supervisors or trainers on addressing difficult questions from learners. Repeated training and the length of time that CSE educators were providing CSE were mentioned as important in overcoming shyness and becoming more confident in discussing sexuality-related issues. The combination of these factors seemed to impact the ability of the sexuality educator to re-examine their beliefs and socio-cultural norms in light of the principles and values of Comprehensive Sexuality Education, i.e. being rights-based, gender transformative, and sex-positive. A male CSE teacher from Kenya said:

You need to tell young people the truth about sex. If you tell them if you have sex you will get infected – this is wrong. Instead you have to tell them that if you have sex without a condom with an infected person then you will get infected. If you tell a child that sugar is bad for you, the day that child will dip his finger in the sugar and taste it, he will know it tastes good. You will be the liar. Don’t cheat them. Just give them the right information and guide them through. Give them freedom to make decisions after you have prepared them psychologically. Do not scare them.

Another female CSE educator from Kenya said:

They like to discuss healthy relationships and sex. I tell them that sex is sweet at the right time. There’s no right time but I tell them to have sex when they are ready and can handle the responsibilities that come with it. Parents not being open is a challenge as they don’t talk to their children. I stand in the gap between parents and children and talk to them about sex.

Finally, one male CSE facilitator in Ghana mentioned:

Certain religious teachings were misunderstood about sexuality. For example, we don’t allow girls from getting in contact with boys, to avoid immoral contact, but when they get CSE, they can behave decently with each other and it’s okay to put them in contact with each other. The cultural approach to certain issues was wrong.

However, the experience of one male teacher from Ghana shows how one’s own beliefs can continue to clash with values that underpin CSE. This male CSE facilitator said:

[Before being trained] I didn’t buy the [CSE] programme or the idea. I thought it was for grown-ups, but later I realised it was for all - those who were ready. It makes the students free and opens their minds. Now they’ve seen its benefits and it’s not a taboo anymore to mention some of the words like sex or sexual organs like penis and vagina in relation to sexuality.

This facilitator provided his initial learners with sex-positive CSE, including discussion on sexual enjoyment. However, over a period of time, he had changed his mind. He shared:

I realised it was not necessary [to talk about sexual enjoyment] so I told them not to do it. I told them not to involve themselves in that. They should abstain. One can only enjoy sex if you’re married. (…) If they are 18 and beyond, they can be involved. Don’t allow your body changes to deceive you. Don’t think that once you have started growing breasts or a penis you are ready to have sex. If you are combining sex and education - you will focus on sex.

This example shows the importance of continued support for sexuality educators in overcoming harmful socio-cultural norms on sexuality and gender biases.

What stood out in both countries is a need for more tools on how to use sex-positive language and how to address sensitive topics such as ejaculation, masturbation, hygiene during and after sex, and parent–child communication. A need for more tools was also highlighted at a school for learners with hearing loss where CSE facilitators struggled with the right signs for bringing across certain sexuality education messages. Finally, a need for materials focusing on the sexual and reproductive rights, needs and aspirations of young people living with HIV was expressed. All young people encountered in this study were enthusiastic about receiving CSE. They enjoyed the sessions, which were mostly interactive, with facilitators asking questions and encouraging discussion. Young people had many questions around sex (e.g. what it is, how it feels, engaging/not engaging in it, masturbation, ejaculation, contraceptives) and relationships (e.g. role of sex and money in relationships), yet they experienced that they had to ask many sex-related questions, otherwise educators would not bring it up. This was in part to do with the fact that the curriculum being used did not explicitly address certain issues, and sometimes, when providing CSE in schools, the government’s education guidelines on providing life skills prohibited educators from providing more explicit information on contraceptives and condoms, sex, and masturbation. Some of the more sex-positive educators found creative ways of dealing with these restrictions by gaining the trust of their learners, encouraging learners to ask questions that they could respond to (in cases where there were restrictions on bringing up the topic), not reporting all discussions conducted in the session, and using out-of-school options like a youth centre, youth-friendly services, or outreach programmes to provide condom demonstrations and/or contraceptive access. A male, CSE peer educator from Kenya said:

You might have come prepared to deliver a topic, but you may find what you’re teaching is going to another direction and you can’t stop them talking about it. You need to have that discussion. When there is sex in the curriculum, and someone is talking about sex between two girls then it becomes part of the curriculum. Sometimes you do these topics as a personal example, like I would say, “I had a girl who didn’t want it, but I was so ready. But since I’m a good boy and I respect her decision, so I masturbated instead. When you force a girl, it is rape.” I’m comfortable with these topics with my learners. I take them as my friends. I don’t want them to fear me like a teacher.

In general, it seemed that there was more space to discuss sensitive topics in out-of-school settings. Of course, the facilitator’s own level of comfort and values also to a large extent determined whether or not honest discussions took place on masturbation, abortion, sexual diversity, sex and pleasure. There were some learners who had received good orientation on sexual diversity but not so much on safe abortion. Among the older learners, some even brought up new information to the facilitators, for example on female masturbation and the clitoris, but this was not necessarily appreciated by the facilitators who sometimes felt challenged or threatened by information they were ill-equipped to handle.

Although the number of young people involved in this study is relatively small, there were clear distinctions when they spoke about what they had learned from CSE. Sometimes it was clear that sexual rights and gender had been covered well during CSE. One male learner from Ghana explained:

This education has changed my mind about certain roles at home. Now I help my female siblings to cook. Even when my female siblings were busy doing something, I felt that as a male I hadn’t got a role but now I know better and help with the cooking and washing. I help with domestic chores which I would never have done before CSE.

Other learners were still getting the message of abstinence and chastity. One young female from Ghana explained:

Avoid curiosity - when you want to know how sex feels like, as young as you are, you will want to venture into sex if you want to know how it feels like. So, if you keep away from curiosity then you keep away from sex. You can also contract an STI.

With regards to HIV, some learners in Ghana and Kenya said they learnt about how to live positively with HIV – including sexual and reproductive rights, and the needs and aspirations of young people living with HIV – while the majority said they only learnt about prevention of HIV.

Because of the challenges with CSE delivery – i.e. working in a setting that encourages abstinence-only education, and discomfort among some facilitators – some learners spoke about searching the internet and watching porn as alternative ways of seeking more information, like this in-school one from Kenya:

On TV, when there is a film where they are having sex and my parents tell me not to watch, so I’m curious and when I get a chance to get the mobile, I go online and look for sex and I get to pornography. We look for lesbianism and gayism online to learn more about it because we want to understand why they are doing it.

Those learners who had looked for more information outside of the CSE sessions they were getting were eager to share this with their peers. Some of them used WhatsApp or online blogs to do so. Despite young people’s access to the internet, many of them do not have the skills to distinguish reliable sources of information from unreliable ones. This is a skill that CSE should be providing too.

It is also clear that the evidence on abstinence-based messaging being ineffective hasn’t trickled down through to all programme managers and sex educators.

Discussion: Motivated for more

Many organisations are making efforts to break the barriers of negative discourses in sexuality education and the relevance of pleasure for sexual health is also gathering more and more attention from academia (Ford et al., 2019). However, several challenges are still in the way of giving more and sustained attention to sex-positive and pleasure-based approaches in sexuality education. This pilot study highlighted some of these challenges – as well as opportunities – focussing on the level of facilitators and learners. The findings of this pilot study will be used to develop a ‘pleasure audit tool’ that will support sexuality education programmes in different contexts, and over time, allow facilitators/learners to assess themselves on their level of sex-positivity and provide practical tools to step up their sex-positive approach.

Young people are certainly demanding more open, honest and explicit information as seen from the findings, where, when asked what more they would like to learn about, FGD respondents listed topics like masturbation, sex (what it feels like), contraception and condoms, porn, and relationships. They are also turning to other sources of information in the absence of reliable and relatable sexuality education that addresses their realities, including porn. Porn, although stigmatised, remains a key source of information on sex and sexuality for a number of young people around the world, including in African settings (Both, 2016; Cheney et al., 2017; Day, 2014). Unfortunately, most porn reinforces dangerous stereotypes about gender, race, body image, and sexuality. However, there is a huge potential for sexually explicit media to act as a means of sexuality education, to promote safer sexual behaviours and create empowering sexual scripts (Cheney et al., 2017; Philpott et al., 2017).

Like some previous studies conducted in eastern and southern Africa, this study found that sexuality educators need more support in developing and maintaining confidence and feeling comfortable to discuss sex and sexuality more openly, on framing messages in a sex-positive way and in reconciling their values with those that underpin effective CSE (De Haas & Hutter, 2019; Helleve et al., 2009). This was made clear through the fact that while many CSE facilitators were keen to empower young people with correct knowledge, they themselves had some deeply rooted attitudes that were against equal gender roles within relationships or masturbation, among other topics. Ongoing support is needed to enable CSE facilitators with this, as with limited training there is the risk that facilitators will slip back to previous beliefs and values and reinforce gendered sexual and social norms and exclusion through sexuality education (Le Mat, 2017).

There is an imperative need to focus on gender transformation through Comprehensive Sexuality Education. Gender transformative approaches stress the importance of critical reflection on gender and power and harmful gendered and sexual social norms. This critical reflection should lead to more inclusive and more gender-equitable practices and relations. CSE with explicit attention to gender and power is key to achieving results for young people, for example, increased self-esteem, especially among girls and young women, and more positive attitudes towards sexuality, as well as qualities like assertiveness. It could further engender better health outcomes and more satisfying sex lives (Horne & Zimmer-Gembeck, 2006; Rosser et al., 2002; Tolman, 2005).

The findings of this study show that despite a socio-cultural and legislative context that puts restrictions on the discussion of sex, condoms, contraception, and pleasure among young people, especially those in-school, it is possible to adopt a sex-positive and pleasure inclusive approach as seen through the ‘positive deviants’ we were able to identify in this study. This connects to findings from some studies that CSE facilitators could mix abstinence-only with more comprehensive teaching approaches; these ‘hybridised’ approaches and their potential as well as their effects on learners deserve further study (Francis & De Palma, 2014; De Haas & Hutter, 2019). In this study, besides repeated training, sex-positive CSE facilitators mentioned personal sexuality-related experiences and interpersonal relationships with other sex-positive people or supportive mentors or supervisors as factors enabling them to deliver sex-positive sexuality education. Such findings suggest that personalities and interpersonal relationships may drive or hinder sex-positive teaching styles in ways that are not immediately evident to the facilitators themselves or to the organisations they work for.

The Global Advisory Board for Sexual Health and Wellbeing proposes a triangle approach, linking sexual pleasure, sexual health and sexual rights (Gruskin et al., 2019). It is believed that if exercised within the context of sexual rights, sexual pleasure could positively contribute to sexual health and wellbeing. Based on the nature of sexual pleasure and the complex linkages between pleasure, sexual health and rights, more emphasis should be placed on the attempt to develop agency and self-esteem, especially for young women, through sexuality education, because this would influence their empowerment over other parts of their life (Holland et al., 1992). As sexuality is a socially constructed concept (Holland et al., 1992), pleasure is also constructed by macro-social elements such as society, culture, gender and politics (Boyce et al., 2007; Dowsett, 2003; Gammeltoft, 2002). Since expressions of sexual pleasure are diverse with different age, gender relations, social conditions, economic needs, cultures and histories, adjustments to different cultural settings need to be applied when integrating pleasure into sexuality education. We also found a lack of research that is rooted in a range of socio-economic contexts, especially in sub-Saharan Africa or contexts where risks of unsafe sex are higher.

‘Pleasure’ per se, or using a sex-positive approach, can seem challenging to discuss with young people. But, as observed in conversations with study participants, when broken down to the seven sub-components of the ‘Pleasuremeter’ tool, it makes it less confronting, easier to digest and to talk about. Using the seven components as the basis for the interviews and focus group discussions also gave the research team the entry point to understand learners’ need to know more about sex and pleasure, and educators’ abilities to discuss the same. In effect, if you do not ask about pleasure and desire, you do not easily find instances of its discussion. Therefore, pleasure should be incorporated into more studies and asked about rather than avoiding it due to anticipated negative reactions. Sex education programmers and educators have a responsibility to offer sex education that is relevant and effective, by including sex-positive narratives.

Acknowledgements

The authors would like to express their gratitude to the SRHR Alliances of Ghana and Kenya for their interest having their sexuality education programmes with the Get Up Speak Out (GUSO) Project reviewed. In particular, the National Country Coordinators, Kenneth Danuo (Ghana) and Johnstone Kuya (Kenya), the Youth Country Coordinators, Irene Siaw (Ghana) and Judy Amina (Kenya), and the young co-researchers – Martha Anabila, Maxwell Ayamber, and Amanfo Richard in Ghana; Annete Muchendiza and Dambalash Ermiyas in Kenya – worked tirelessly to ensure that the pilot study was conducted well.

Zihui Zhang, an intern for The Pleasure Project, worked on the content analysis of the CSE curricula that were analysed for the pilot study, and conducted a first cut of the literature review for this article. The conceptualisation of the pilot study was done with strategic contributions from Doortje Braeken, Global Advisory Board for Sexual Health and Wellbeing.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The funding for the study came from the Ministry of Foreign Affairs, Government of the Netherlands (Ministerie van Buitenlandse Zaken).

Notes

1 Get Up Speak Out (GUSO) is a five-year programme (2016–2020) developed by a consortium consisting of Rutgers, Aidsfonds, CHOICE for Youth and Sexuality, Dance4life, International Planned Parenthood Federation (IPPF) and Simavi. The programme is financed by the Dutch Ministry of Foreign Affairs under the SRHR Partnership Fund. The goal of the GUSO programme is that all young people, especially girls and young women, are empowered to realise their SRHR in societies that take a positive stance towards young people’s sexuality. The GUSO programme is implemented in seven countries: Ethiopia, Ghana, Indonesia, Kenya, Malawi, Pakistan and Uganda. In each country well-established SRHR organizations, including youth-led ones, work together in Alliances. Each Alliance has a National Programme Coordinator who works in partnership with a Youth Country Coordinator, a young person, to ensure meaningful youth participation in the programme and to demonstrate to Alliance members the importance of having young people in decision-making capacities.