Madeline King, PharmD, BCIDP
Myriam Shaw Ojeda, PharmD
At the end of this case, students will be able to:
- Consider cultural and social perspectives regarding sex education
- Describe ways to educate multi-generational patients from different cultures about sex education
- Illustrate how to use culturally sensitive communication in high stakes conversations
- Create a communication plan using personal knowledge and community resources to provide sex education
Education on sexual practice varies widely in different countries, nations, cultures, and religions. Sexuality is often tied to morals and personal values, in addition to its status as a health topic. Whether a person sees sexuality as natural versus sacred may determine how they view sex education. Under a natural framework, sexuality is a factor of the human experience equal to any other bodily function and should be taught with the same emphasis. When seen as a sacred function, sexuality is placed differently compared to the education of other aspects of bodily function. While this sacredness is widely respected, it may render the subject taboo or limited in educational discussions.
Comprehensive sexual education includes the physical, emotional, intellectual, and social aspects of sexuality and interpersonal relationships/connections, and not just the physical act of sex.1 Government leaders and parents, in some cultures, believe that early sexual education will lead to earlier sexual activity. However, it is more common that countries with more structured sexual education teaching have lower rates of teenage pregnancy.2,3 In some countries, sexual education is taught extensively in schools, whereas in others, the subject is not allowed in schools. For instance, in the United Kingdom, sexual education is mandatory, but each school varies in how they approach the subject. The emergence of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in the 1980s in the United States increased demand for sex education beyond abstinence; however, there is still not a federal mandate for sexual education.4,5 In Belgium, there is a sexual education website curated for youth that children as young as seven years old can view and understand,6 however, there are other countries where sexual education isn’t allowed in schools. In India, sex education is not mandatory in schools, but the Youth Parliament Foundation established in 2002 is increasing information availability, including through one of their campaigns, “know your body, know your rights” (KYBKYR).7,8
There are many socio-cultural challenges to sexual education around the world. One important concern is that in countries where sex education is not taught thoroughly or is not the same between different schools, some young people may not be able to recognize signs of sexual abuse. Education on sexual health is encouraged by the United Nations, which has a health agency dedicated to sexual and reproductive health.9-11 For example, child marriage and female genital mutilation (FGM) are practiced in many countries globally and are particularly harmful to women. The United Nations Population Fund (UNFPA) has noted that the COVID-19 pandemic has the potential to increase the prevalence of these practices, resulting from the lack of in-person school and extra-curricular activities, economic hardships, and lack of access/funding for health programs. They also state that while legislation and guidelines are helpful, changing social norms is the key to achieving gender equality and eliminating these harmful practices.10
The Demographic and Health Surveys (DHS) Program under the US Agency for International Development (USAID) conducts surveys and analyzes data on health, HIV, and nutrition in countries worldwide.11 Based on their estimates, as of 2014, an estimated 225 million women in developing regions had an unmet need for modern contraception.12 This unmet needed is defined per the DHS to include woman of reproductive age (15-49 years old) who are: (1) married or unmarried and sexually active, (2) not using any method of contraception, either modern or traditional, (3) fecund (fertile), or (4) those who do not want to have a child (or another child) in the next two years or at all.11,12
The overarching goal of sexual education should be to present sexuality and relationships as a natural and healthy part of life, and to reduce negative outcomes such as unwanted/unintended pregnancy, sexually transmitted infections, or abuse, in addition to ensuring that people have the knowledge to make healthy sexual decisions. There are many organizations focused on fighting gender inequality, harmful sexual practices, and encouraging sexual education for youth. Learning how to communicate this vital information in a culturally sensitive manner is important for healthcare providers to be able to move forward.
Case and Questions (part 1)
You are part of a medical mission trip to Jaipur, India. A multigenerational family visits your health clinic where you are providing health education. The family consists of GM (the grandmother, 50 years old), MM (the mother, 34 years old), and two daughters (DM and EM, 18 and 16 years old). MM has an obstetric history of G9-P7-A2. During your session, she mentions that she no longer wants any more children. Upon further discussion, you learn that the patient does not currently use any form of contraception, and she mentions that her family is traditionally against using contraceptives for religious reasons.
1. How would you plan to educate MM on contraceptive options, including any relevant pharmacologic and non-pharmacologic options?
2. How would you better your own understanding about the patient and her family’s belief systems regarding contraception?
3. How would you use culturally-appropriate methods to communicate with the patient?
Case and Questions (part 2)
After discussing contraceptive options, DM shares that she has also encountered issues with her menstrual cycle. She expresses frustration at the limitations she experiences when she is on her period. Her mother does not let her enter the kitchen for fear of bringing bad luck. Additionally, EM shares that she does not have a consistent supply of hygiene products. She asks if the clinic can provide any sanitary pads.
4. What are some resources you can use to help EM access menstrual hygiene products?
5. What are some cultural beliefs and practices that exist regarding menstrual cycles in different cultures?
Case and Questions (part 3)
You take the time to address both DM and EM’s questions about sex education and her menstrual needs. In the middle of your discussion, GM, the grandmother cuts you off and begins to accuse you of “westernizing her grandchildren.” She states that sex education will only push them to be sexually active before the time is right. Since she does not speak English, your interpreter, a local resident, quickly steps in to translate.
6. What methods can you use to prepare your interpreter to act as a bridge for effective communication as you quickly respond to this question? How will you prepare for the session with the translator?
7. Describe ways you can respectfully respond to GM’s concerns, simultaneously showing respect for the patient’s family culture while sharing evidence-based sex education.
Sex education is crucial as it allow individuals to knowledgeably care for themselves and make decisions about their healthcare. Pharmacists have a powerful opportunity to combine medication knowledge with communication tools to open an avenue for quality communication that meets the support and resource needs of menstruating individuals. Intercultural patient care can be fraught with miscommunication pitfalls. But a respectful and curious attitude can help healthcare providers create a safe and open space for honest discussion. Additionally, taking the time to understand cultural and religious beliefs can help providers understand why patients have certain beliefs about menstruation and sex education.
Healthcare providers have a unique opportunity to address systemic issues of inadequate sex education. They are also given the ability to speak to beliefs that are not based on fact. Gently correcting myths or adding factual background to existing beliefs can empower women to fully manage their personal health. This type of education can help address larger issues related to inequity in healthcare decision making, sexual based mistreatment, and a lack of access to menstrual hygiene products.
Patient Approaches and Opportunities
Communication across cultures can be challenging to navigate. Discussion of subjects that may be considered sensitive or even taboo can create tension early in the conversation. Care must be taken to communicate clearly. Unfortunately, certain societies’ cultural and social norms have restricted essential education in subjects like sex, feminine hygiene, and reproduction. Individuals living with these societal norms often believe that sex education may lead younger generations to be promiscuous. However, the opposite is more often true.5 When young people are educated about sexuality in a healthy way and understand safe sexual practices, they are less likely to get that information from friends or inaccurate sources.
Pharmacists have a unique ability to address the challenges stated above because they are often accessible to people even in rural areas. Counseling patients on their medications can often open the door to crucial conversations about taboo medical subjects. Incorporating culturally sensitive tools of communication can create a high level of impact and improve the dialogue between the pharmacist and patient. Patients will be able to find a safe and open environment to address medication related questions but also extremely important sex education queries. Pharmacists have a pivotal role in global health and patient communication. Using pharmacist-specific communication skills may be the answer to the disparities seen in sex education globally.
Related chapters of interest:
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- Ethical decision-making in global health: when cultures clash
- Hormonal contraception: from emergency coverage to long-term therapy
- From belly to baby: preparing for a healthy pregnancy
- Digging deeper: improving health communication with patients
- Uncrossed wires: working with non-English speaking patient populations
- World Health Organization. Sexual and Reproductive Health and research (SRH), including the Human Reproduction Programme (HRP).
- UN Women.
- UN Population Fund. International Technical and Programmatic Guidance on Out-of-School Comprehensive Sexuality Education (CSE).
- World Health Organization. 2016 WHO medical eligibility criteria for contraceptive use.
- Journal articles:
- Morales A, Garcia-Montaño E, Barrios-Ortega C, Niebles-Charris J, Garcia-Roncallo P, Abello-Luque D, et al. Adaptation of an effective school-based sexual health promotion program for youth in Colombia. Soc Sci Med 2019;222:207-215.
- Mwaria M, Chen C, Coppola N, Maurice I, Phifer M. A culturally responsive approach to improving replication of a youth sexual health program. Health Promot Pract 2016;17(6):781-792.
- Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician 2014;90(7):476-80.
- Hadziabdic E, Hjelm K. Working with interpreters: practical advice for use of an interpreter in healthcare. Int J Evid Based Healthc 2013;11(1):69-76.
- Latifnejad Roudsari R, Javadnoori M, Hasanpour M, Hazavehei SMM, Taghipour A. Socio-cultural challenges to sexual health education for female adolescents in Iran. Iran J Reprod Med 2013;11(2):101-10.
- Saewyc EM, Poon CS, Homma Y, Skay CL. Stigma management? The links between enacted stigma and teen pregnancy trends among gay, lesbian, and bisexual students in British Columbia. Can J Hum Sex 2008;17(3):123-39.
- Guttmacher Institute. Review of key findings of “Emerging Answers 2007” report on sex education programs. February 2016. . Accessed January 29, 2021.
- Donovan P. School-based sexuality education: the issues and challenges. Fam Plann Perspect 1998; 30(4):188-93.
- Landry DJ, Kaeser L, Richards CL. Abstinence promotion and the provision of information about contraception in public school district sexuality education policies. Fam Plann Perspect 1999;31(6):280-6.
- Study International. Sex education around the world: how were you taught? November 2017. . Accessed January 29, 2021.
- Advocates for Youth. The future of sex education. . Accessed January 29, 2021.
- Know Your Body, Know Your Rights. The YP Foundation. 2020. . Accessed January 29, 2021.
- United Nations Population Fund. Sexual and reproductive health. 2020. . Accessed January 29, 2021.
- United Nations Population Fund. Comprehensive sexuality education. . Accessed January 29, 2021.
- The DHS Program, Demographic and health surveys. . Accessed January 29, 2021.
- Singh S, Darroch JE and Ashford LS. Guttmacher Institute. Adding it up: the costs and benefits of investing in sexual and reproductive health, 2014. . Accessed January 29, 2021.