Sex education for adolescents: Indonesian nurse educators’ experience as parents
Article Category: Original Article
Publié en ligne: 09 oct. 2022
Pages: 303 - 310
Reçu: 17 févr. 2022
Accepté: 08 mars 2022
DOI: https://doi.org/10.2478/fon-2022-0039
Mots clés
© 2022 Alvin Salim et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
Many adolescents lack in knowledge of sexual and reproductive health in various countries in the world. Adolescents lack in knowledge of sexual transmitted infections (STIs) other than Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS), and other ramifications of risk-taking sexual behavior.1,2,3 This leads to poor health outcomes and death among adolescents.4 The Directorate General of P2P, Indonesia Health Ministry, dated 29 May 2020 reported the cumulative number of HIV/AIDS cases placing West Java region in the fourth rank of HIV/AIDS cases nationally.5 Moreover, maternal and infant mortality rates in Indonesia are high, which are exacerbated by early marriage, early pregnancy, STIs, pre-marital sex, and abortion.6
Studies have shown that sex education is a pivotal need for adolescents7 and have been shown to have many benefits for adolescents. It was recognized as a fundamental human health right and an important quality-of-life health issued by the World Health Organization.1 Specifically, the topics may include human sexual anatomy, reproduction, sexual intercourse, reproductive health, emotional relationships, reproductive rights and responsibilities, and other aspects of human sexual behaviour.8 The WHO (2021) has reported the advantages of sex education such as postponing sexual activity, reduction in the number of unintended early pregnancies, and the difficulties associated with them. There will be fewer unplanned pregnancies, and the likelihood of sexual exploitation and abuse will be reduced. It also helps reducing the use of abortion and the risks associated with unsafe abortion. Nevertheless, it stops the spread of HIV and other sexually transmitted illnesses and reduces risk-taking behavior.9
It is vital that children receive sex education early from family, rather than from untrusted sources.10 Parents should be active in conducting sex education to their children by seeking and giving information regarding sexual health.11 However, some parents might think that giving sex education is talking about intercourse only, but actually it is more to give understanding about sex organs and its functions.12 Moreover, conducting sex education itself is one of the problems that happen in eastern countries. Sexuality is a private matter, which is not discussed openly regarding to eastern culture;13 people who ask and talk about sex are considered to have dirty mind.14 Teachers in high school as educators considered sex education as a problem and taboo because talking about sex would make them feel uncomfortable in respect of the culture.15 Even nursing educators have the same problem when conveying sex education due to social and cultural considerations,16 although they are one of qualified persons to provide sex education.
While sex education remains the most controversial subject due to the various thoughts and ideas of different values present in society, educators must be the center of influence to promote sex education both in the family and school.17 One essential thing is exemplification by nurse educators as parents who must provide sex education to their children18 because they do have the knowledge about reproductive health and issues compare to other parents. Therefore, the present study aimed to explore the experience of parents in eastern country, with a nurse educator background and who reside in Indonesia to be exact, which will give insights to other parents on how to convey sex education to their children.
This present study employed a phenomenological qualitative design because it does not attempt to delve into the data in any interpretive depth and instead prefers to give thorough summaries of phenomena.19 Parents’ philosophy and children's psychology about conveying sex education were explored without any experiments. In addition, this design tends to be eclectic and founded on naturalistic inquiry premises.20
This study was undertaken at the private nursing school located in Bandung, West Java, Indonesia. In this university, many researchers conduct learning and teaching activities, so it will be easier to get permission for conducting the study. Six nursing faculty members who fulfilled the following criteria were recruited: male and female nursing faculty aged 40–65 years, has 10- to 18-year-old adolescent child/children, and has given sex education to them. Data saturation was achieved in the 6th participant; as the suggested number of participants in this type of research is 3–10, preferably at least 6, another sample was required for qualitative research.21 The participants approached by personal communication via telephone to confirm participation. There were 2 people who refused to participate for exclusion criteria consideration. The informed consent was obtained prior to scheduling the interview based on interviewee availability. Both researchers and participants were at their own places during the interview since it was conducted via online.
The researchers conducted semi-structured interviews by utilizing an interview protocol to remind them to communicate important bits of information19 and also allowed interviewers to probe additional details from interviewees. The interviewer was a nursing student, and the interview was supervised by a qualified lecturer in the same university, which already had an existing rapport with the interviewees. In the interviews conducted online in Zoom, and the interviews proceeded with the following general questions: (1) Based on your experience as a parent, how you communicate sexuality issues to your adolescent child/children; (2) what sexuality issues would you consider to discuss with them? Probing inquiries were asked if more information or clarification was required. The duration of the interviews ranged from 40 min to 50 min. The interviews were recorded with consent. The interviews were immediately transcribed verbatim in Indonesian, and subsequently, the rough transcribed data were referred back to the participants for correction. The whole verbatim was not translated into English, and only part of verbatim needed by manuscript was translated and validated by researchers. Data collection took place between July and August 2021.
The data collection and analysis were simultaneously carried out. The conventional content analysis suggested by Creswell (2018) was used to analyze the data. In this method, the steps are from specific to general and involve multiple levels of analysis conducted to (1) organize data and data analysis, which involved transcribing, scanning, typing notes, cataloging visual materials, and sorting and arranging data, (2) read and analyze data to shape ideas, (3) start coding all the data, (4) generate descriptions and themes, and (5) represent the description and themes. All the data were analyzed manually using the Creswell method.
Participants gave informed consent prior to participating in the study. They were guaranteed confidentiality, and the purpose of the audio-recording was conveyed to them. The transcripts of the researchers’ interviews were kept in a protected file and stripped of all identities by the corresponding author. The importance of voluntarily participating in the study and the possibility of declining to withdraw at any time was explained. The interviews were performed one on one in private using the Zoom meeting platform at the participants’ preferred time.
Trustworthiness of a study refers to the degree of confidence in data interpretation and methods used to ensure the quality of a study. The rigor of this study was maintained through the principles of credibility, transferability, dependability, and confirmability. Data credibility was established by immersion on the data and member checking. Transferability was achieved by providing a bold description of the study to equip the readers for using the result of research study. Dependability was considered through a stepwise replication approach to enable future researchers to use the work. Last, all steps were documented to meet the confirmability criterion so that other researchers may check the codes and categories.
Demographic data of participants are presented in Table 1. This study included six participants, one male and five females. On range, the participants were from 41 to 53 years of age. All participants have completed master's degrees in nursing education and are Adventist Christians. The participants have various cultural backgrounds, which are Batak (66.67%), Manado (16.67%), and Toraja (16.67%). As displayed in the table, the majority of participants were female with similar education and religious backgrounds but various ethnic backgrounds. Essentially, all participants were from Indonesian culture as part of eastern country, have adolescent children aged 10–18 years, and have conveyed sex education to them.
Demographic data of participants.
| Participant's classification | N | % |
|---|---|---|
| Male | 1 | 16.67 |
| Female | 5 | 83.33 |
| Magister | 6 | 100.00 |
| Bataknese | 4 | 66.67 |
| Manadonese | 1 | 16.67 |
| Torajanese | 1 | 16.67 |
| Only male | 3 | 50.00 |
| Only female | 1 | 16.67 |
| Male and female | 2 | 33.33 |
| Adventist Christian | 6 | 100.00 |
In the initial data analysis, 55 primary codes were extracted. The codes were classified into 3 themes and 13 subthemes. Each theme with its subthemes is shown in Table 2.
Theme and subtheme.
| Theme | Subtheme |
|---|---|
| I. Parents’ approach |
Gender match Parent–child closeness Media Attitude |
| II. Sex education topics |
Bodily autonomy, consent, and healthy relationship Health and safety Male and female reproductive anatomy Puberty-related changes How to maintain healthiness |
| III. Children's reaction |
Uncomfortable Questioning Acknowledging Laughing |
Parents’ approach refers to the overall experiences of parents, with a nurse educator background, while conveying sex education to their child/children.
The subthemes include gender match, parent–child closeness, media, and attitude.
The participants of different genders do not talk much about sexuality matters to their adolescent children. The child/children will look for the parents of the same gender to discuss that since the same-gender parent had the experience to explain it to them. An experienced parent depicts this situation as follows:
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All participants have a close relationship with their children. In other words, rapport is built by often having family activities to strengthen the bonding within the family, especially between parents and children. By utilizing the closeness and activities, sex education can be conveyed during family time, including routine in the religious activity of the family. This experience was articulated by them.
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Using media will be helpful to explain sexuality material to children. Most of the respondents will use media in situational case so that they can explain more. The media that are usually used are YouTube, pictures, textbooks, or television. The sample of participants’ statement is quoted as follows:
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Most of the time, respondents would like to convey this education in a relaxed environment. Sometimes they need to talk in private since the topic is sensitive to others. Parents have to adjust their attitude while conveying it to their children.
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Keeping their children safe is what all parents want. The participants taught their children to recognize and know what they should do when they are sexually abused. This subtheme is also included in healthy romantic relationships and attitudes toward different genders.
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This subtheme is related to contraception and sexually transmitted diseases. Most participants taught their children the general overview of sexually transmitted diseases. Some participants explained about contraception, but there is a warning to not use it before marriage, according to eastern culture.
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All participants taught their children to differentiate both gender, male and female. This topic is important to form the sexual identity of the children. It will also let them acknowledge that there is another gender aside from theirs.
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All participants explained to their children about the physical changes that happen when they reach puberty. This topic explains about the changes of appearance and physiology of the body. The action to certain changes is also included.
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All participants taught their children how to keep their genitals in a hygienic state. Adolescents should pay attention to keep their body clean since hormonal changes will increase sweat production. Bathing and changing the sanitary pad while menstruating will be necessary.
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Children reaction refers to the overall experiences of parents, who are nurse educators, while conveyed sex education to their child/children. Children reactions to the sex education conveyed by their parents concluded the subthemes of uncomfortable, questioning, acknowledging, and laughing.
Some children might be uncomfortable at the beginning when parents initiate discussion on sex education. They considered it as a sensitive topic and weird to be discussed with parents. Rejection might happen when this feeling exists.
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Some children were more questioning since they were curious. They wanted to know more from their parents about what happened or will happen to them in their development. This was a good sign that they are comfortable with the discussion and willing to improve their knowledge.
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Some children will absorb the information calmly, or they will just acknowledge since school already taught them about that. They are not ignorant about this conversation but absorb it to have deeper knowledge about sexuality.
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Some children laughed while parents talked about sexuality. It was related to parents’ attitude on how they convey sex education because some parents started the conversation with humor. Humor relaxed the situation to convey sex education successfully.
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This study aimed to explore the experience of parents, with a nurse educator background to be exact, on how they convey sex education to their children. The study revealed that conveying sex education has 3 areas of parent and children experiences, namely, parents’ approach, sex education topics, and children's reaction. In approaching children, same gender between parents and children are preferable because the both parties can relate to the discussion about sex since they have similar body parts and/or experiences.21 Parents need to build close relationships with their children as this closeness is important in developing healthy habits,22 healthy sexual habits in this case. When family bonding is strong, sex education can be conveyed anytime, including in family activity. Using media will be helpful for parents if needed because not all parents will have related media for the explanation. Parents can use humor in conveying sex education, but sometimes, seriousness and privacy are also needed depending on the topic and situation. Appropriate talking is needed in certain conditions to diminish embarrassment and anxiety, while using humor needs to be considered since it can help or be a hindrance in conveying sex education.23
From our findings, all respondents explain gender differentiation between male and female to their children. It is important to build their knowledge that will affect their attitude to their same and opposite gender in social relationships. Parents then will focus on explaining their children's bodies based on the children's gender, both for anatomy and physiology, especially the changes that happen during puberty. Both topics of gender differentiation and anatomy are similar to those used in the study conducted by Cameron and Bunoti.22,24 Since the changes will increase sweat and fat glands of the body, explanation about maintaining body's hygiene, especially the genital area, is necessary. This topic about genital hygiene is aligned with the study of Astuti.25
Contraception and sexually transmitted disease topics are important to achieve health and safety of reproductive organs.26 Research in Britain stated that these topics will protect adolescents for having sexual competence in their first intercourse in future, which can prevent STIs and unplanned pregnancies.27 However, the explanation needs to be adjusted with the culture because eastern culture does not allow sex before marriage, considering it is forbidden and a cause for shame for family.28 Parents can explain that contraception can be used to prevent pregnancy after marriage. Last but not least, children need to be taught about how to recognize sexual abuse so that they can protect themselves from it.25 This topic is important, considering child sexual abuse happened to 118 from 1000 children and will cause negative holistic health consequences to them.29
Children might have various reactions during sex education when conveyed. It is not surprising that some children might be uncomfortable since we are talking about private parts of the body, which they understand since they have learned in school. It is normal, and they can be comfortable if parents approach them in the right way or have built a strong bonding with them. When the bonding is strong enough, children will usually acknowledge the information conveyed by the parents. Aside from strong bonding, another factor that can make children comfortable with sex education is both children and parents have high knowledge on that topic.30 Some children will also ask more questions since they are curious and want to have better understanding about sex. Parents are encouraged to answer the questions of children in discussion to make sure children's voices are heard to provide opportunity for future discussion.31 In some cases, children might laugh about it when parents approach using humor in explaining the topics.
Moreover, the content, messages, and approaches used to provide sex education differ across countries.32 Sex education is a sensitive topic in public health and education policy in western Chinese culture for a variety of reasons. First, it is a deeply ingrained idea of sex as a “taboo” in Asian countries.33 Some doubters claim that sex education fosters juvenile promiscuity and that this topic should be ignored in order to avoid “awakening the sleeping bear.” While policy makers, educators, and parents have observed that adolescent sexual behavior is “out of control,” they disagree on how to reduce young people's problematic sexual behaviors.34 Yet, Indonesia research finding on improving sex education awareness in community service concluded that it is critical to provide sex education at an early age of children. This is a prevention strategy for providing children with the information they need about their sex and sexuality.35
Sex education is a great weapon to prevent young generation discover sexuality in a wrong way. Parents need to approach their adolescent children appropriately by gender match and form strong bonding with them, using related media and positive attitude. Gender differentiation, male and female reproductive anatomy, puberty-related changes, sexual transmitted disease (STD), contraception, genital hygiene, and safety from sexual abuse are important topics of sex education. These topics may be sensitive in eastern culture, but all are important to improve children's knowledge about themselves. Children's reaction is also varied, which depends on the parents’ approach and bonding level.
The findings of this study may provide nurses and nursing students a picture in conveying sex education to adolescents. They also will be able to educate parents on how to do it themselves as a family. Thus, providing sex education to adolescents at home should not be considered taboo by parents. It is predicted that if adolescents have sufficient understanding of sex education, they will no longer engage in dangerous sexual activities, allowing the harmful effects of free sex to be avoided or at least mitigated.