Comprehensive sexuality education in Italian secondary schools: the EduForIST national project

Comprehensive Sexuality Education (CSE) is defined by UNESCO as “a curriculum-based process of teach-ing and learning about the cognitive, emotional, physical and social aspects of sexuality. It aims to equip children and young people with knowledge, skills, attitudes and values that will empower them to realize their health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and understand and ensure the protection of their rights throughout their lives”. In recent years, a few studies have focused on understanding the landscape of Sexuality Education (SE) and CSE initiatives in Italy, particularly in school settings. These efforts have involved various stakeholders, including civil society organizations (CSOs), local health departments, and professionals from diverse fields, aiming to address the gap created by the absence of a national SE programme and shared standards (Fontana, 2018). Traditional SE activities tend to prioritise biological aspects, love, family, contraception, and protection from sexually transmitted infections (STIs), often overlooking key elements like consent, gender identity, human rights, pleasure and disability (Lo Moro et al., 2023). Most of these initiatives target primarily the prevention of STIs and provide information rather than education, with limited geographical coverage. Moreover, although many programmes declare that they perform evaluation, their results are rarely accessible or published (Chinelli et al., 2022). Only a few Italian studies published between 2000 and 2023 assessed SE programmes, finding increased knowledge but not necessarily safer sexual behaviours (Capuano et al., 2009; Bogani et al., 2015; Benni et al., 2016). According to the European Expert Group on Sexuality Education (Ketting et al., 2016), SE programme evaluation should encompass programme content, implementation processes and outcomes, informed by mixed methods approaches and educational theories. 

Firstly, the EduForIST Working Group (WG) was formed, comprising 17 representatives from institutional, academic and civil society organisations, as well as representatives from the Italian Ministry of Health and Ministry of Education (see Figure1). 

This group, overseen by a multidisciplinary team of 15 experts in sexuality education, relationships education and STI prevention, was responsible for developing the pilot intervention. The group analysed past educational approaches used in Italian experiences. These leaned towards liberal and critical viewpoints aimed at empowering students and deconstructing cultural norms. Based on the principles of CSE proposed by UNESCO (2018), the WG developed the pilot intervention during the course of online consultations involving Italian experts and stakeholders to identify the target population and intervention objectives. Focus groups then determined the structure of the intervention, including the frequency of sessions, the objectives and content and the methods for content delivery. A methodology consistent with that proposed by Ketting et al. (2016) was used to develop evaluation tools for the pilot intervention. Assuming a pedagogical perspective, the evaluation of the implementation process was reinterpreted as a source of information on the educational strength and weaknesses of the project. Qualitative analysis tools such as field journals and SWOT analysis were therefore proposed in order to critically understand educators' actions, their 'life of mind', and also the reflections and feelings that emerged during the implementation of the pilot intervention with their students. As far as the students were concerned, short-term outcomes were assessed by means of pre/post-tests on the knowledge acquired and satisfaction level surveys were conducted. 

The co-construction process aimed to develop a CSE pilot intervention promoting scientifically accurate, age-appropriate and culturally relevant knowledge as well as positive attitudes on sexuality for 14-16 year-old students. This process resulted in five learning objectives for the EduForIST project divided into interactive modules addressing various dimensions of sexuality. The modules of the EduForIST intervention covered the following 4 dimensions: A) changes in adolescence, B) development of sexual identity, C) first sexual experiences, D) STIs and the prevention of unintended pregnancies. Each module consisted of theoretical and practical sessions, employing participatory tools like role-playing and group activities to engage students. The implementation of the pilot interventions commenced in four Italian regions (Lazio, Lombardy, Puglia and Tuscany), thus ensuring geographical diversity. Educators from CSOs planned activities in schools, aiming for geographical representation across urban and rural areas within each region. Educators from different organisations conducted interventions in teams of two to facilitate skills sharing, cross-fertilisation and standardisation. School managements approved the intervention, often integrating it into existing educational programmes after having received the parents' formal approval. Teachers played a key role, coordinating activities and facilitating discussions in classrooms, although they were usually not present during interventions to ensure that students felt comfortable. Efforts were made to involve families by means of pre/post-intervention meetings, although parental participation varied across schools. Feedback sessions were held post-intervention to evaluate the experience, with some parents expressing interest in receiving additional support to help them with their communications with adolescents about sexuality. 

In total, 585 students initially responded to the pre-intervention questionnaire, with 508 completing it post-intervention. Table 1 shows the percentage changes and level of significance for each item examined.

According to our results, male students were less likely to answer several of the items correctly in the post-test, especially those related to STI prevention. Additionally, living in a northern Italian region was associated with a reduced probability of a correct response to specific items. Previous exposure to CSE topics in school activities increased the likelihood of a correct response to certain items, as did teacher participation in pilot activities and favourable paretal attitudes towards the intervention. Moreover, par-ental attendance at meetings positively influenced responses to certain items. Regarding satisfaction, 569 students completed the questionnaire and indicated a high level of interest in discussions on STIs and their prevention. However, less interest was shown in topics concerning gender identity, sexual orientation and gender roles, with a considerable portion of students expressing indifference toward these items.

The EduForIST project has facilitated the development, implementation and evaluation of sexuality education interventions in upper secondary schools across Italy, following the CSE approach recommended by international guidelines (Eisenberg et al., 2008; UNESCO, 2018; Goldfarb & Lieberman, 2021). While students exhibited good baseline knowledge of certain topics such as adolescent changes, they demonstrated a poor understanding of sexual identity and prevention measures for STIs and unintended pregnancies. This suggests ongoing gaps in addressing key themes in sexuality education within the country. The pilot interventions spanned various regions and revealed geographical differences in knowledge levels. These were higher in northern and urban areas than in southern and rural areas. Gender disparities were also revealed, with girls generally exhibiting higher competencies and being better informed, especially regarding prevention. The gap could be ascribed to some protective factors with respect to girls, such as the fact that they tend to seek more sexual health services/advice than boys, or that they have been placed at the centre of Italy’s HPV vaccination campaigns, which have only recently been extended to include boys (Donati et al., 2000; Psaroudakis et al., 2020; Brunelli et al., 2022). This highlights the need to involve male adolescents more actively in sexual health care and education. Overall, the study underscores the importance of integrating CSE programmes into the Italian school curricula to foster not only personal sexual and reproductive health awareness but also non-discrimi-natory attitudes towards marginalised communities, including those living with HIV/STIs or LGBTQIA+ persons. The results reported in this article show how the EduForIST pilot intervention, including the evaluation tools, could provide a model for future implementation of CSE educational interventions and potentially be scaled-up and transferred to different regions and secondary schools in Italy.