Journal of Adolescent Health 67 (2020) 245e252

www.jahonline.org

Original article

Unmet Needs in Sex EducationdWhat Adolescents Aim to

Understand About Sexuality of the Other Sex
Max Bauer a, Silvan Hämmerli, M.D. a, and Brigitte Leeners, M.D. a, b, *
a
Department of Reproductive Endocrinology, University Hospital Zurich, Zurich, Switzerland
b
University of Zurich, Zurich, Switzerland

Article history: Received July 17, 2019; Accepted February 7, 2020

Keywords: Sex education; Sexual health; Puberty; Sexuality; Psychosexual development; Education

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: Sex education programs need to modify their focus in light of changing societal norms
and increasing exposure to pornography. This study investigates what adolescents want to know
This study shows that ad-
about the sexuality of the opposite sex. This will allow practitioners to adjust sex education olescents' interests go
curricula to the needs of adolescents, thereby supporting the establishment of healthy, respectful, beyond reproductive
and sexually fulfilling relationships. health, which is the cur-
Methods: Two thousand three hundred forty-three adolescents from the age of 11e19 years (123 rent focus in sex educa-
classes) were asked to formulate questions addressed to the opposite sex as part of peer-led sex tion. To increase
education classes, where girls and boys were divided into separate groups. Groups of 10e12 in- competence in esatablish-
dividuals each formulated about 11 questions, resulting in a total of 2,625 questions. The questions ing fulfilling relationships,
were categorized using content analysis. sex education must pro-
Results: The largest portion of questions addressed sexual interaction (35.8%), with many ques- vide information on all
tions further addressing sexual preference (e.g., oral sex, sex positions) and the logistics and topics adolescents want to
qualitative aspects of first-time sexual intercourse. Adolescents were also interested in questions talk about and include the
about the body (e.g., anatomy, body hair, 15.2%), relationships (e.g., love, dating, 13.9%), ideal pleasure and desire as-
characteristics of men/women (10.5%), masturbation (10.1%), and pornography (7.3%). pects of sexuality.
Conclusion: Adolescents show a high degree of interest in understanding the feelings and per-
ceptions of the opposite sex. Acquiring this knowledge could be beneficial in building emotionally
and physically fulfilling relationships. To increase adolescents' sexual and relationship competence,
sexual education curricula should encompass pleasure and desire aspects of sexuality, initiating
and managing relationships, societal ideals, and addressing pornography, in addition to sexual and
reproductive health knowledge.
Ó 2020 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.

Sexuality contributes significantly to a happy and healthy life
[1]. As comprehensive sex education (CSE) in schools has proven
to be effective in improving sexual knowledge and lowering
Conflict of interest: M.B. was an active member of the peer-led CSE program
"Achtung Liebe." The other authors have no conflicts of interest to disclose.
* Address correspondence to: Brigitte Leeners, M.D., Department of Repro-
ductive Endocrinology, University Hospital Zurich, Frauenklinikstr. 10, CH-8091
Zürich, Switzerland.
E-mail address: Brigitte.Leeners@usz.ch (B. Leeners).
sexual risk behavior [2e8], it has become part of the national
curriculum in most European countries [9,10]. CSE becomes more
effective if adolescents participate actively in knowledge ex-
change, and the impact of teaching programs is proven to be
higher when the content meets participants' needs [11,12].
Today's sex education programs focus most often on sexual
and reproductive health (SRH), with the aim of lowering sexual
risk behavior [9,13e16]. Although sexuality and relationships
represent key topics for quality of life, the teaching of skills such

1054-139X/Ó 2020 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.
https://doi.org/10.1016/j.jadohealth.2020.02.015
246 M. Bauer et al. / Journal of Adolescent Health 67 (2020) 245e252
as discussing intimate topics or initiating and shaping relation-
ships is not a standard element of CSE [13,14,17]. In addition, the
increasingly easy access to pornographic material [18e21] ex-
poses adolescents to sexuality-related gender roles, which often
stand in contrast to respectful relationships. Despite this, ado-
lescents generally succeed in differentiating between porno-
graphic material and real-life sexuality [22,23]; this competence
remains important and should be addressed continually to
reinforce the conditions for fulfilling relationships. Nonetheless,
the topic of pornography is largely neglected in sex education
programs [9,13e16].
During puberty, adolescents are challenged with changing
bodies, identities, and often intense sexual desire. Providing
guidance during this challenging period is critical to increase
sexuality-related self-confidence and nurture positive attitudes
toward oneself and others [24]. This study of questions posed
by adolescents to the opposite sex in peer-led CSE classes
carries great potential for learning about adolescents' needs
and interests in sexuality. The resulting findings can be used to
adjust the content of teaching programs to the needs of ado-
lescents, to improve motivation and participation in sex edu-
cation classes. Therefore, this study aims to investigate (1) what
adolescents want to learn from the opposite sex in sex educa-
tion classes and (2) how sex and age relate to the questions
they raise.
Methodology
This investigation was designed as a prospective cohort study.
Questions addressing the opposite sex were systematically
collected from January 2014 to September 2015 in all 123 classes
(1,158 boys and 1,184 girls) from 82 schools that offered CSE
within a peer-led sex education program in the Canton of Zurich,
Switzerland. By law, Swiss schools are obliged to offer CSE
annually to adolescents above the age of 11 years. However, the
methodology and the duration are not clearly defined: teachers'
motivation, capability, and priorization determine how to assign
this topic. Teachers can give sex education classes themselves or
invite external sex education services [10], such as the peer-led
program presented here. The questions evaluated in this study
were collected within a specific peer-led CSE program conducted
by students aged 20e27 years at the University of Zurich and
participating voluntarily [25]. Before teaching sex education
classes, the university students were required to participate in a
standardized training program. This included obligatory atten-
dance at lectures given by medical experts, sexual therapists, and
senior members of the program. The training was designed to
convey SRH knowledge, course structure, and teaching meth-
odology. A male and a female sex educator taught four to five
hours of sex education in two blocks of two to two and a half
hours. Pre-selected topics were anatomy, sexually transmitted
diseases (STDs), contraception, love, relationships, sexual orien-
tation/identity, and pornography. All subjects were taught
interactively, including practical skill learning such as condom
use or relationship-oriented role-play followed by group dis-
cussion. The last 45 minutes of a CSE class were held within sex-
separated groups led by sex educators of the same sex in two
different rooms, with the aim of addressing gender-specific
topics such as gynecological examinations or breast and testic-
ular cancer. At the end of these sessions and after a brief period of
reflection, the groups were asked to formulate ten questions to
be addressed to the opposite sex. The questions were chosen in
open discussions and, after the exclusion of inappropriate
questions (e.g., “Who is the most attractive girl/boy in the
class?”), written down by the sex educator (examples in Table 4).
The sex educators tried to minimize the influence of group dy-
namics by giving every individual the possibility to ask questions
and by supporting the active participation of each adolescent.
Then the questions were exchanged, and the groups addressed
formulated their answers. Finally, the class was reunited, and the
answers were presented to the whole class by the sex educators.
The questions were collected and used for the present study.
The data were digitalized, and the questions were assigned to
different categories using inductive category formation through
content analysis [26]. Therefore, coding steps were based on
grounded theory, and the resulting categories emerged from the
analysis of the data. Questions were labeled systematically, and
categories were revised and further refined continuously
throughout the process.
The resulting categories were analyzed quantitatively and
qualitatively and were compared using cross tables. Chi-squared
testing was used to evaluate significant differences among cat-
egorical variables. A p value of less than .05 was considered
statistically significant. For statistical tests, IBM SPSS, version 24
(IBM Corp, Armonk, NY), was used.
Questions were developed in a group setting, and apart from
age and sex, no individual information on study participants was
collected; therefore, the data were completely anonymous. The
study was carried out in accordance with the Declaration of
Helsinki 1964, as revised in 2013, and in agreement with the
regulation of the local ethics committee [27]. At the end of the
teaching block, the adolescents agreed to collect and evaluate the
content of the questions generated.
Results
Altogether, 2,625 questions from 123 groups of boys and 123
groups of girls were evaluated, with an average of 11 questions
per group. (10.7
2.38 questions per group [girls 11.1
2.97,
boys 10.3
1.74]). The numbers of questions asked by different
sex and age groups are presented in Table 1.
Table 2 presents how often different topics were addressed
overall and by sex. Adolescents asked most frequently about
sexual interaction (35.8%), specifically showing curiosity in un-
derstanding gender-specific differences in sexual preferences,
first sexual intercourse, or arousing stimuli. Furthermore, they
wanted to know about the body (15.2%), asking the opposite sex
how they experience their genitalia and if and how they should
shave their body hair. Questions on relationships (13.9%)
regarding love, dating, and differing views and expectations
Table 1
Distribution of questions raised by youth to the opposite sex in sex education
classes
Variable No. of questions %
(N ¼ 2,625)
From girls (123 groups) 1,359 51.8
From boys (123 groups) 1,266 48.2
11e13 years 819 30.9
14e16 years 1,355 51.6
17e19 years 239 9.2
Special education classes with mixed ages 41 1.7
Missing data on age 171 6.5
 M. Bauer et al. / Journal of Adolescent Health 67 (2020) 245e252 247

Table 2
Topics addressed in questions on sexuality of the opposite sex, as developed by separate groups of girls and boys

Main category Subcategory Overall Girls Boys p value

N % N % N %

Sexual interaction 940 35.8 424 31.2 516 40.8 <.001*

Sexual preferences 355 37.8 131 30.9 224 43.4 <.001*
First sexual intercourse 269 28.6 136 32.1 133 25.8 .026*
Arousal 124 13.2 56 13.2 68 13.2 .989
Sexual orientation 61 6.5 25 5.9 36 7 .503
Kissing 51 5.4 33 7.8 18 3.5 .004*
Experiences with sexual activity 42 4.5 23 5.4 19 3.7 .198
Contraception 34 3.6 19 4.5 15 2.9 .200
STDs 4 .4 1 .2 3 .6 n.v.a
Body 400 15.2 167 12.3 233 18.4 <.001*
Male anatomy 167 41.5 101 60.1 66 28.2 <.001*
Body hair 117 29.1 42 25 75 32.1 .127
Female anatomy 70 17.4 4 2.4 66 28.2 <.001*
Othersb 46 12 20 12.5 26 11.5 .801
Relationships 365 13.9 258 19.0 107 8.5 <.001*
Love 106 29 84 32.6 22 20.6 .022*
Ideal relationship 92 25.2 62 24.0 30 28 .644
Dating 51 14 36 14.0 15 14.0 .987
Family 43 11.8 26 10.1 17 15.9 .091
Gender roles 18 4.9 15 5.8 3 2.8 .227
Othersc 55 15.1 35 13.5 20 18.7 .213
Ideal characteristics of men/women 276 10.5 190 14.0 86 6.8 <.001*
General 175 63.4 110 57.9 65 75.6 .005*
Physical traits 77 27.9 66 34.7 11 12.8 <.001*
Character traits 24 8.7 14 7.4 10 11.6 .245
Masturbation 264 10.1 130 9.6 134 10.6 .386
Ever masturbated 143 54.2 25 19.2 118 88.1 <.001*
Frequency of masturbation 66 25 59 45.4 7 5.2 <.001*
Technique of masturbation 29 11 24 18.5 5 3.7 <.001*
Experiences 26 9.8 22 16.9 4 3 <.001*
Pornography 191 7.3 89 6.5 102 8.1 .137
Ever consumed 122 63.9 35 39.3 87 85.3 <.001*
Frequency of consumption 26 13.6 26 29.2 0 0 <.001*
Favorite pornographic genre 19 9.9 13 14.6 6 5.9 .044*
Othersd 24 12.6 15 16.9 9 8.8 .095
Nonsexual behaviore 145 5.5 63 4.6 82 6.5 .039*
Communication 44 1.7 38 2.8 6 .5 <.001*
Total number of questions 2,625 100 1,359 51.8 1,266 48.2

p value comparing female and male groups using chi-squared test, p<.05 was considered as significant. Significant differences are bold and marked with an asterisk.
a
No value, chi-squared test is not viable because the expected cell count is <5.
b
Self-evaluation, nudity, hygiene, cosmetic surgery, pain.
c
Flirting, relationship status, cheating, breaking up, violence, nonromantic relationships.
d
Age of first contact, opinion about pornography, participation in a pornographic movie, motivation to watch pornography.
e
Clothing, sports, drugs, video gaming, going to the toilet.

were asked frequently and a substantial amount of interest was
also given to ideal characteristics of men/women (10.5%).
Boys were more interested in the categories sexual interac-
tion (40.8% vs. 31.2%, p <.001) and body (18.4% vs. 12.3%, p <.001),
whereas girls asked more questions about relationships (19% vs.
8.5%, p <.001) and ideal characteristics of men/women (10.5% vs.
6.8%, p <.001). Male anatomy was addressed more than twice as
often as female anatomy, resulting from girls' asking almost only
about male anatomy (60.1% vs. 2.4%), whereas boys asked the
same amount of questions about male and female anatomy
(28.2% vs. 28.2%). The categories masturbation and pornography
did not show a significant difference by gender in the number of
questions but differed strongly by gender in the way the topic
was addressed. Boys asked more about ever masturbated (88.1%
vs. 19.2%, p <.001) and ever consumed (pornography) (85.3% vs.
39.3%, p <.001), whereas girls were more interested in frequency
of masturbation (45.4% vs. 5.2%, p <.001), technique of mastur-
bation (18.5% vs. 3.7%, p <.001), frequency of pornography
consumption (29.2% vs. 0%, p <.001), and favorite pornographic
genre (14.6% vs. 5.9%, p ¼ .044).
Table 3 shows a further differentiation of subcategories that
were addressed through the questions more than 100 times.
Within the category of sexual preferences, we found a large di-
versity of topics with few significant differences by gender. Girls
were more interested in ideal conditions for intercourse (16.8%
vs. 8.5%, p ¼ .019) and sexual fantasies (14.5% vs. 6.7%, p ¼ .016),
whereas boys asked more about sex toys (13% vs. 1.5%, p <.001).
In addition to direct questions related to the use of pornography,
many detailed questions seemed to be inspired by pornographic
material (e.g., aimed to clarify interest in unusual locations for
intercourse, ejaculation on the partners body [cum shots], group
sex, or anal sex). In the category male anatomy, boys were most
concerned about size/shape of penis (74.2% vs. 16.8%, p <.001)
and girls wanted to know about experiences with penis (48.5%
vs. 13.6%, p <.001) and habits regarding penis (27.7% vs. 1.5%, p
<.001). That is, boys asked what girls think about their genitals
248 M. Bauer et al. / Journal of Adolescent Health 67 (2020) 245e252

Table 3
Differentiation of subcategories mentioned >100 times in questions asked by groups of adolescents to the opposite sex

Subcategory Sub-subcategory Overall Girls Boys p value

N % N % N %

Sexual preferences 355 131 224

Oral sex 64 18 28 21.4 36 16.1 .217
Ideal conditions for intercourse 41 11.6 22 16.8 19 8.5 .019*
General questions 40 11.3 11 8.4 29 13 .186
Sex position 36 10.2 16 12.2 20 9 .329
Sexual fantasies 34 9.6 19 14.5 15 6.7 .016*
Sex toys 31 8.8 2 1.5 29 13 <.001*
Ejaculation on body (cum shot) 19 5.4 4 3.1 15 6.7 .139
Location for intercourse 18 5.1 5 3.8 13 5.8 .321
Group sex 17 4.8 4 3.1 13 5.8 .238
Anal sex 15 4.2 2 1.5 13 5.8 .052
Prostitution 12 3.4 6 4.6 6 2.7 .343
Othersa 27 7.6 12 9.2 15 6.7 .561
First sexual intercourse 269 136 133
Appropriate age for first intercourse 105 39 49 36 56 42.1 .307
Virgin status 91 33.8 42 30.9 49 36.8 .302
Expectations toward first intercourse 52 19.3 30 22.1 22 16.5 .252
Othersb 21 7.8 15 11 6 4.5 .046*
Arousal 124 56 68 124
Arousing stimuli 85 68.5 32 57.1 53 77.9 .013*
Sexual thoughts 39 31.5 24 42.9 15 22.1 .013*
Male anatomy 167 101 66
Size/shape of penis 68 39.5 17 16.8 49 74.2 <.001*
Experiences with penis 58 34.7 49 48.5 9 13.6 <.001*
Habits regarding penis 29 17.4 28 27.7 1 1.5 <.001*
Othersc 14 8.4 7 7 7 10.6 .402
Body hair 117 42 75
Shaving behavior 54 46.2 15 35.7 39 52 .090
Shaving necessity 40 34.2 16 38.1 24 32 .505
Presence of body hair 23 19.7 11 26.2 12 16 .185
Love 106 84 22
Being in love 56 52.8 39 46.4 17 77.3 .010*
Behavior when in love 31 29.2 27 32.1 4 18.2 .200
Othersd 19 17.9 18 21.4 1 4.5 n.v.e

p value comparing female and male groups using chi-squared test, p <.05 was considered as statistically significant. Significant differences are bold and marked with an
asterisk.
a
Sadomasochism, moaning, foreplay, duration of intercourse, preferred daytime for intercourse.
b
Fear of first sexual intercourse, experiences with first sexual intercourse, requirements for first sexual intercourse.
c
Sperm, attitude toward penis, pictures of penis.
d
Romanticism, jealousy, turning someone down, lovesickness.
e
No value, chi-squared test is not viable because the expected cell count is <5.

(e.g., importance of penis size), while most girls did not ask about
boys' reactions to their genitals but were much more interested
in experiences with the penis (e.g., have you ever had an erection
in school?).
Figure 1 presents the main categories of questions differen-
tiated by age group. Groups aged 11e13 years were more inter-
ested in relationship (11e13 years: 18.2% vs. 14e16 years: 11.5%
vs. 17e19 years: 10.5%, p <.001) and body (17.7% vs. 15.7% vs.
8.9%, p ¼ .004). In the age group 14e16 years, the category
masturbation was addressed more frequently (8.2% vs. 11.5% vs.
9.3%, p ¼ .037), and for adolescents aged 17e19 years, questions
about sexual interaction were more important (29.7% vs. 36.9%
vs. 46.4%, p <.001). No significant difference was found with
regard to pornography (7.2% vs. 7.3% vs. 8.4%, p ¼ .801).
Regarding questions on sexual interaction, groups aged 11e
13 years were more interested in the subcategories kissing (13.8%
vs. 2.3% vs. .9%, p <.001) and contraception (6.1% vs. 2.5% vs. 1.8%,
p ¼ .036) (data not shown). In groups aged 17e19 years, ques-
tions about sexual preferences were more important (25.9% vs.
40.4% vs. 49.5%, p ¼ .005). No significant difference was found
with regard to first sexual intercourse, arousal, sexual
orientation, experiences with sexual activity, and STDs.
Regarding questions on relationships, groups aged 11e13 years
asked more frequently about love (38.3% vs. 23.9% vs. 8%, p ¼ .02).
No significant difference among age groups was found with re-
gard to ideal relationships, family, others (flirting, relationship
status, cheating, breaking up, violence, nonromantic relation-
ships.) dating, and gender roles.
Table 4 clarifies the classification of different categories by
providing definitions and examples of questions.
Discussion and Implications
For many years, some have criticized the limited focus of sex
education in reducing sexual risk behavior, while neglecting
treatment of the pleasure and desire aspects of sexuality [28e
30]. They concluded that concentrating on risks and negative
aspects associated with sexuality, especially of the female sexual
anatomy, seriously compromised the development of healthy
sexuality for both girls and boys. Extensive research has been
conducted in the last decades, showing increasing evidence of
the benefit of sex education [2e8], which led to the inclusion of
 M. Bauer et al. / Journal of Adolescent Health 67 (2020) 245e252 249

Table 4
Definition of the categories developed through content analysis from questions posed by groups of adolescents to the opposite sex including related examples

Category Definition (Questions about/on.) Example questions raised by youth (marked for girls with f,
for boys with m, no mark if question was raised by both
groups)

Sexual interaction
Sexual preferences .different sexual preferences such as oral sex, anal sex, Does your sex partner have to be a virgin? f
optimal setting, sex toys, fantasies, sex positions, group Do you want to have a threesome? f
sex Do you think oral sex is disgusting? m
Which sex positions do you want to try?
Where on your body is it ok to ejaculate? m
First sexual intercourse .virginity or specific aspects of the first sexual intercourse How do you imagine the first sexual intercourse?
At what age do you want your first sexual intercourse?
Who already had his/her first sexual intercourse?
Arousal .what sexually arouses someone and if one has sexually Do you have naughty thoughts?
arousing thoughts and/or is aroused How does a girl get horny? m
Sexual orientation .attitudes on own sexual orientation and sexual Is someone lesbian? m
orientation of other groups What's your opinion on homosexuality? f
Kissing .expectations and experiences with kissing Have you ever kissed someone on the mouth?
Have you ever had a French kiss?
Experiences with sexual activity .experiences with sexual activities Have you ever seen two people having sex? m
Has someone touched another person's genitals? f
Contraception .attitudes, preferences and experiences with Does the man or the woman take care of contraception? f
contraception Which method of contraception would you use?
STDs .experiences and emotions about STDs Are you afraid of STDs? f
Does anyone have experiences with STDs? m
Body
Male anatomy .the male genitals regarding form, experience, habits with When did you have your first erection? f
penis or sperm How big is the penis at your age? f
Do you look at your penis in the mirror? f
Body hair .if one has body hair, if and where one shaves and if one Do you already have pubic hair?
should shave the body hair Do you shave your genitals?
Should a man shave his genitals? m
Female anatomy .the female genitals, breasts and menstruation How does it feel to have a vagina? m
Who has begun their period? m
How does it feel to menstruate? m
Other .small subcategories such as self-evaluation, hygiene, pain, What do you think is positive, what is negative about your
cosmetic surgery, nudity or body weight body?
How many times a week do you shower? f
Which part of your body hurts most? m
What do you think of cosmetic surgery? f
Relationships
Love .if someone is in love, romance and how someone behaves What does romance mean to you? f
when in love Is anyone in love right now?
How can we know if you are in love? f
Ideal relationship .what is important in a relationship Do you think a relationship without sex is ok? f
What do you expect from a relationship?
Dating .first dates, best location for dates and experiences with What is the perfect first date?
dates What is a good location for a date? m
Family .marriage and on if and how many children one wants Do you want kids? How many?
Do you want to marry some day?
Gender roles .gender roles Is the household a women's issue? f
Why do you think that only women are moody? f
Other .small subcategories such as friendship, violence, cheating, Have you ever been hit by a woman because you tried to flirt
fear, who should do the first step in a relationship with her? f
What are you most afraid of in a relationship?
Should the boy or the girl take initiative to start a
relationship? m
Ideal characteristics of men/women
General .general ideal characteristics What's important for a woman? f
What makes a boy attractive? m
Physical traits .specific ideal physical features Does a man have to have big muscles to be attractive? m
Character traits .specific ideal character features What do you think about jealous women? f
Masturbation
Ever masturbated .asking if one has ever masturbated Did you ever masturbate?
Frequency of masturbation .asking how many times one masturbates How many times do you masturbate per week?
Technique of masturbation .what is used to arouse one during masturbation What do you think about while masturbating? f
Experiences .such as what age did you start to masturbate, if one has Have you ever masturbated in school? f
been caught masturbating or why someone masturbates Have you ever been caught masturbating? f
How old were you when you first masturbated? f
In which situations do you masturbate? f
(continued on next page)
250 M. Bauer et al. / Journal of Adolescent Health 67 (2020) 245e252

Table 4
Continued

Category Definition (Questions about/on.) Example questions raised by youth (marked for girls with f,
for boys with m, no mark if question was raised by both
groups)

Pornography
Ever consumed .asking if one has ever seen pornographic content Have you ever watched pornography?
Frequency of consumption .asking how many times one consumes pornography How many times a week do you watch pornography? f
Genre .which pornographic genre one prefers Which genre of pornography do you like most? f
Other .small subcategories such as first consumption, why one When did you first consume pornography? f
consumes pornography or if one would participate Would you participate in a porn movie? m
Nonsexual behavior .non-sexual behavior such as clothing, sports, drugs, video Which clothing style do you like best? f
gaming, going to the toilet What's your favorite sport? m
Why do girls go to the toilet in groups? m
Communication .what and how males and females communicate Do boys talk about girls with friends? f
Why do girls say ‘no’ but mean ‘yes’? m
Do you speak about your problems? f

sex education in public school curricula in many different
countries [9,13e16]. However, research has been focused mainly
on the effects of sex education regarding sexual risk behaviors
[2e8], and sex education programs worldwide are still limited to
SRH content with the aim of reducing sexual risk behavior [9,13e
15,17]. By providing a definition of sexuality that is limited to
unhealthy aspects, this approach neglects the context of ado-
lescents' everyday life. Consequently, recent studies evaluating
adolescents' perspectives show that adolescents generally
perceive the content of current sex education as boring and
inadequate for their needs [13e15,17]. In contrast, presenting
sexuality as a positive and healthy aspect of life increases ado-
lescents' ability to make beneficial sexual health decisions in
real-life situations [15,29]. Therefore, new forms of sex education
programs with greater reciprocity between sex educators and
adolescents covering more than just SRH knowledge present an
opportunity to increase participation in classes, thus leading to a
greater impact [11]. For these reasons, finding out about ado-
lescents' concerns is important to improve the impact of future
CSE interventions by covering all sexual healtherelated topics
important to adolescents. The present study provides detailed
insights into the context of adolescents' sexuality and can be
utilized to identify relevant topics to be added to future sexual
health programs.
Many of the questions collected for the present evaluation
addressed specific sexual behavior and experiences of the other
sex: knowledge that increases sexual competence and adapts
behavior to potential partner expectations and needs. The
apparent interest in questions on the appropriate age to initiate
sexual activity demonstrates the insecurity of adolescents
regarding this topic. Questions revolved around not only part-
nered sexuality but also masturbation and pornography. Ado-
lescents were particularly interested in topics where
discrepancies between male and female behavior might be ex-
pected, outlining an unmet demand for knowledge about sexual
behavior of the opposite sex. The questions partly confirmed
expected stereotypes, such as boys' interest toward girls'
perception of their genitals, especially regarding penis size.
Although our study design does not allow for an evaluation of the
adolescents' motivation for participating and formulating ques-
tions (just wanting to understand or actively using this knowl-
edge to initiate and/or maintain sexual relationships), they seem
to be motivated to find out about a partners' feelings and views.
We found one comparable study examining questions raised by

50%

40%

11-13 years 14-16 years 17-19 years

30%

20%

10%

0%
al *
Sexual Body * Rela onships * Ideal Masturba on * Pornography Non-sexual Communica on
interac on characters cs of behavior
men/women

Figure 1. Relative frequency of addressing different topics in questions posed by groups of adolescents to the opposite sex in relation to age. Percentage was calculated
from 2,413 questions (11e13 years: 819, 14e16 years: 1,355, 17e19 years: 239), excluding 212 questions with missing data on age or mixed ages. Chi-squared test was
used to calculate p values, p <.05 was considered as significant. Categories with significant differences between age groups are marked with an asterisk.
 M. Bauer et al. / Journal of Adolescent Health 67 (2020) 245e252
individual sixth graders in sex education classes [31]. Despite
these methodological differences, results were similar to our
study, i.e., questions on sexual activity and behaviors, anatomy,
and relationships were asked most frequently.
Questions about relationship building, love, expectations
toward a partner, and the perception of ideal relationships were
identified as other relevant topics. Again, the resulting answers
to the questions allow for better adjustment of individual
behavior toward partners, and they may consequently increase
the likelihood of well-functioning relationships. Adolescents
also used the opportunity to clarify delicate topics, for example,
whether a boy would agree to a relationship without sexual
activity. Questions related to the initiation of relationships
(e.g., how to know if someone is in love, how to approach
dating, and how to initiate sexual activity) show the tension
among the reflections of adolescents, societal norms, and
experienced reality. Being sexually active at a relatively young
age might result in being unprepared or being labeled as pro-
miscuous, while having first intercourse at a higher age might
result in being identified as unattractive or insufficient as a
partner or lover. Altogether, adolescents seek specific guidance
on how to initiate and maintain relationships. CSE adjusted to
foster the acquisition of such competences could help to reduce
the psychological burdens related to this important develop-
mental step toward adulthood [32].
During puberty, physical appearances change significantly,
and adolescents have to find their role as sexual beings; this
includes developing a concept of attractivity within a social and
cultural context with specific norms on adequate looks [33]. This
is reflected in the large proportion of questions about the body
and the ideal characteristics of women and men. Questions about
preferences regarding body hair were asked remarkably often by
all groups. As body hair is a modifiable and visible anatomical
feature and is subject to fashion trends, adolescents generally
experience pressure toward conforming to beauty ideals. These
findings indicate that providing the opportunity to reflect upon
and contextualize societal ideals (e.g., with body hair as an
example) within CSE classes could help meet adolescents' needs
and reinforce self-confidence when confronted with such issues.
The interest in pornography was independent of age and
gender. However, the formulation of questions regarding
pornography and also masturbation differed strongly between
boys and girls (Table 2). Boys mainly asked “Have you ever.?”
questions, whereas girls asked about more detailed aspects, such
as frequency of masturbation and pornography consumption, to
what boys masturbate, or which pornographic genres they pre-
fer. These differences can probably be attributed to the broader
portrayal of male sexuality in the public realm. In contrast, fe-
male sexuality is often portrayed with a focus on menstruation
and pregnancy, while the clitoris and its function receives only a
little attention in school-based sex education and biology books
[28e30]. Thus, sex educators should pay special attention to
discussing male and female sexuality in an equitable manner to
avoid neglecting the female sexual anatomy as an organ of sexual
desire.
The overall interest in pornography, in agreement with other
studies that have examined adolescents' exposure to pornog-
raphy, suggests that both boys and girls are confronted with
pornography from early adolescence [18e21]. Consequently,
they need to acquire skills enabling them to contextualize these
experiences and differentiate between pornography and real-life
sexual activity. Current sex education programs generally do not
251
seem to address this issue [9,13e17]. Open discussions about
pornography could support adolescents in the appropriate
handling of pornographic material and should therefore be
included in CSE practice.
Even though our results show that the interest in topics
addressed within CSE classes varied by age group, all the main
categories received substantial attention from all age groups, i.e.,
all topics generally seem to be relevant for any age group. Sig-
nificant differences were found regarding the topics sexual
interaction, body, relationships, and masturbation; in light of
this, CSE programs might be adjusted by slightly shifting the
focus of the topics discussed to reflect our findings about ado-
lescents' interests. However, as these differences were minor, the
general inclusion of topics in which adolescents are interested is
more important than the precise attention given to each topic.
Studies show that high relationship satisfaction, good
communication, and sexual assertiveness correlate with higher
sexual satisfaction [34e36], and a fulfilling sex-life is shown to
lead to better physical and psychological health, overall well-
being, and quality of life [37e39]. Our findings underline the
desire of adolescents to talk about qualitative aspects of sexu-
ality, e.g., pleasure and desire aspects of sexuality, from the age of
11 years on. They are curious about sexual practice and rela-
tionship building, i.e., initiating and managing relationships, as
well as societal ideals and pornography. Adding these topics to
CSE programs will increase content relevance, improve the
application of conveyed SRH knowledge in real-life situations,
and empower adolescents with a positive, responsible attitude
toward sexuality.
Strength and limitations
To the best of our knowledge, this is the only study that
qualitatively evaluates how adolescents use the opportunity to
ask the opposite sex questions about sexuality. As the develop-
ment of questions was part of a standardized school-based sex
education program, adolescents had adequate conditions (time
and support by experienced peer sex educators) to define the
topics in which they were really interested. Group dynamics and
previously transmitted knowledge may have influenced the
choices of questions. But, despite being part of the curriculum,
the topics STDs, contraception, and sexual orientation were
rarely put on the list of questions, while pornography and re-
lationships were addressed in most classes. Therefore, adoles-
cents selected their questions at least partly independently from
the content of the teaching program. Also, as the questions were
developed in a group setting, we cannot tell on an individual
level if a question was rated as important.
The level of sexual experience of the adolescents at the time
of the study, e.g., whether they had ever had sexual intercourse,
likely influenced the types of questions they raised. However, we
did not collect this background information and consequently
were unable to assess the type and degree of association be-
tween an individual's level of sexual experience and the ques-
tions they raised.
The choice to invite a peer-led sex education program by
schools might have resulted in selection bias. On the other hand,
the format of open discussion, one of the main characteristics of
peer-group education programs [40], provides an ideal oppor-
tunity to learn about the needs of adolescents.
As gender-separated teaching sessions did not include further
differentiation by sexual orientation or identity, interests of
252 M. Bauer et al. / Journal of Adolescent Health 67 (2020) 245e252
homosexual or transgender adolescents might have received
insufficient attention. Nonetheless, discussions were open to any
questions and the teaching program carefully addressed sexual
orientation and identity.
CSE programs should increase competencies regarding
sexuality and relationships by addressing specific sexual activ-
ities and relationship building in addition to current reproduc-
tive health topics. Adjusting curricula to adolescents' needs will
likely increase not only their participation in sexual education
programs but also have a positive impact on their future sexual
health decisions.
Acknowledgments
The authors thank all participating adolescents for contrib-
uting to this study.
Funding Sources
None.
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