|Year : 2019 | Volume
| Issue : 2 | Page : 97-104
Impact of educational intervention on common beliefs about sex among adolescent health sciences students
Nishant Ohri1, Amandeep Gill1, Ganpat Vankar2, Aditi Patel1, Aditya Dubey1
1 Department of Psychiatry, Sri Aurobindo Medical College and PGI, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India
2 Department of Psychiatry, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Submission||22-Jan-2019|
|Date of Decision||14-Feb-2019|
|Date of Acceptance||01-Mar-2019|
|Date of Web Publication||18-Dec-2019|
Dr. Nishant Ohri
70, Gandhi Nagar, Sigra, Varanasi - 221 010, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: A majority of educational programs place emphasis on sexually transmitted diseases, abortion, and contraception but ignore the broader questions of sexual experience, anatomy, and cultural myths. The aim of the present study was to explore the impact of our intervention on these ignored domains. To ascertain the sex-related knowledge of students and note gender-wise differences. To explore which domains were affected least by educational intervention and which the most. Methods: Nine lectures were delivered to a total of 488 students. They filled the Knowledge Subscale Derogatis' Inventory (21 items; dichotomous) before and 2 h after the lectures, responses were anonymously collected in a ballot box. The lecture was of an hour and followed by 20 min of Q/A sessions. Emphasis was placed on sexual response cycle, interpersonal relationships, sexual fantasies, and prevalent myths. Results: There were 450 respondents pretest, and 414 in the posttest. In both groups, girls were in majority (69.6% and 73.9%). The mean knowledge scores of both groups were 7.88 (sd3.26) and 15.70 (sd3.42). The difference was significant (P < 0.0001). Boys had significantly higher scores than girls at pretest (t = 9.274; P < 0.0001), but at posttest a greater improvement in scores of girls, mitigating the initial difference (t = 0.339; P = 0.734). Statistically significant improvement was found in every item. Yet, significant gender-related differences persisted in a few items. Conclusions: Poor knowledge regarding sex among adolescent students in apparent is the study. Girls have a significantly lesser knowledge. The lectures mitigated the difference in knowledge between both the genders. Human sexuality training programs in India must include the domains of a knowledge deficit.
Keywords: Health science students, India, intervention, sexuality education
|How to cite this article:|
Ohri N, Gill A, Vankar G, Patel A, Dubey A. Impact of educational intervention on common beliefs about sex among adolescent health sciences students. Ann Indian Psychiatry 2019;3:97-104
|How to cite this URL:|
Ohri N, Gill A, Vankar G, Patel A, Dubey A. Impact of educational intervention on common beliefs about sex among adolescent health sciences students. Ann Indian Psychiatry [serial online] 2019 [cited 2020 Feb 29];3:97-104. Available from: http://www.anip.co.in/text.asp?2019/3/2/97/273373
| Introduction|| |
Psychiatrists and sexologists consider poor knowledge regarding sex to be an important factor that underlies the insecurities and apprehensions of patients who present with sexual dysfunction. The dissemination of scientifically informed knowledge is hampered by the taboo sex carries, conservative values, and lack of political will. It is not surprising then that misinformation and myths regarding sex continue to proliferate. In 2007, the National Council of Educational Research and Training recommended sex education to be structured into the existing school curriculum, but it met with strong opposition from conservative political groups. Eventually, a number of states (including Madhya Pradesh) banned sex education in schools, giving in to the idea that Indian values were incompatible with sex education and that it would lead to “corrupting” children's minds.
The avenues for well-guided knowledge about sex are limited. Adolescents do not prefer parents as their primary source of such knowledge; they rely chiefly on friends and media (including TV and internet pornography) and the ideas conveyed by such sources may be dubious and may lack empathic discourse toward sexual relationships and activities. Poor knowledge about sex has also been linked to sexual violence. For instance, the sexuality education program designed by UNESCO emphasizes “consent” and “refusal skills” as key ideas in the context of sex and relationships. The immediacy of launching similar programs in India cannot be overlooked considering the increasing incidence of sexual violence in the country.
One survey study of 738 adolescents in Haryana state in India found that a majority of students (91%) considered health-care professionals as reliable sources of information regarding sex, followed by teachers. In the present study, we endeavored to find out the status of sexuality knowledge in health-care students and how a simple educational intervention affects it. In our sexuality education intervention, we have not focused on the preventive aspects (contraception, abortions, and sexually transmitted infections); instead, we chose to address myths and misconceptions associated with sexual behavior.
| Methods|| |
The study was approved by the Institutional Ethics Committee of Sri Aurobindo Medical College and PG Institute, Indore which is leading institute in Central India. It is a tertiary care center to which Physiotherapy College and Nursing College are affiliated. The Principals of the Physiotherapy College and Nursing College gave permission to conduct the study. The study was conducted over a 3 months' period, in a classroom setting, involving nursing and physiotherapy students. The students were explained the purpose of the study. There was no classroom attendance, and the participation was voluntary. It was mentioned that they could leave the classroom at any point of time during the sessions. Although none of the students left the classroom and completed the survey.
The knowledge inventory was a modification of Derogatis Sexual Functioning Inventory Knowledge Subscale (Derogatis, 1976) with an added question about Dhat Syndrome and covered the following domains: knowledge regarding reproductive anatomy and physiology, sexual response cycle, sexuality in lifespan context, myths regarding sex, and sex and interpersonal relationship. Each item was a statement to which the respondent gave true/false responses. The maximum attainable score was 20. Questionnaires were distributed and anonymously collected, before and after the intervention.
The intervention consisted of 1 h interactive presentation followed by 20 min of question and answer sessions. Emphasis was placed on providing the knowledge of sexual response cycle, interpersonal relationships and sex, sexual fantasies, and discussing prevalent myths and summarizing empirical studies that dispelled them.
| Results|| |
A series of nine lectures were delivered to a total of 450 students in batches of 50 students pursuing courses in nursing and physiotherapy.
The total number of participants in the prelecture group was 450 and 414 in the postlecture group. In both groups, girls were in majority-69.6% and 73.9%, respectively. The average age was 19.52 years in the prelecture group and 19.48 years in the postlecture group. The participating students were pursuing undergraduate degrees in nursing (60.2% and 58.7%) and physiotherapy (39.8% and 43.5%).
There was an overall significant improvement in the total mean scores, and both groups, boys and girls, showed significant improvement of scores after the lectures [Table 1].
The prelecture mean score of boys was significantly greater than that obtained by girls (t = 9.274; df = 449; P < 0.0001), but after the lecture there was a greater improvement in the mean score of girls that mitigated the initial difference in the two groups (t = 0.339; df = 412; P = 0.734).
Impact of intervention: Item-wise analysis
The postlecture changes in response for each of the 20 items were statistically significant [Table 2].
|Table 2: Item-wise analysis of responses before and after the intervention|
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Gender-wise analysis of scores
Gender-wise analyses of scores for each item showed poorer knowledge among girls in the prelecture group, but the scores after the lectures were statistically comparable between the two groups [Table 3] for gender-wise analysis of selected items].
|Table 3: Gender-wise analyses of the items before and after the intervention|
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In the pretest girls scored lower in questions regarding female sexual anatomy and sexual response cycle, for instance, 51.5% of girls thought that women are not as desirous of sex as men, while 75.9% of boys agreed that girls are (χ2= 29.06; P = 0.0001). As high as 57.9% of girls did not agree that women could achieve multiple orgasms in a single sexual act, while 77.3% of boys were correctly informed that women could (χ2= 47.38; P = 0.0001). More boys than girls correctly answered that like erection in men vaginal lubrication in females was an indication of sexual arousal (84.6%, vs. 68.6%, respectively) and the difference was statistically significant (P = 0.0004).
The erroneous belief that larger breast size is an indication of more sexual desire in women was endorsed by 70.9% of boys and 62.7% of girls (P = 0.093). A significantly more number of girls compared with boys responded that fantasizing about someone other than the partner during sex was an indicator of poor sexual relationship (87.3% vs. 78.2%, respectively) (P = 0.014). Furthermore, 70% of girls and 63.3% of boys believed that a higher frequency of sex indicated a better-married life.
| Discussion|| |
As mentioned before, a majority of studies covering “sex education” or “family life education” overlook individual sexual experience and knowledge in favor of topics related to primary prevention. The present discussion will emphasize the poor knowledge of the sexual response cycle, the prevalence of myths, and the ill-perceived effects of certain sexual behaviors on relationships.
About 56% of all students in the pretest had the opinion that women are as desirous of sex as men. More male responders answered correctly (75.9 vs. 48.5 women; P < 0.0001). In contrast, a survey by Tejas et al., in Ahmedabad, found the correct response in 71.3% of students. As the lectures were interactive, it was pointed out by the students that they perceived “desire” (“Chahana”) as a show of readiness for sex, which was equated with behaviors such as eve teasing and staring that are commonly associated with men. “Desire” was not seen as an internal, subjective construct at first. In posttest, 91.5% of girls and 87.0% of boys answered correctly (P = 0.1768).
The girls had significantly poorer knowledge regarding sex in general. Not only that, they had poor knowledge regarding female sexual cycle and myths. For instance, 57.9% of girls did not know that women could achieve multiple orgasms in a single sexual act, while 77.3% of boys answered correctly that women could. In comparison, the survey study of medical students in Ahmedabad found 77.6% of students giving the correct response. Compared with just 15.4% of boys 31.4% of girls were not aware that vaginal lubrication was one of the indicators of arousal. In Tejas's et al. survey 21.9% of medical students were not aware of this. Furthermore, both believed that it was important to achieve orgasms simultaneously (55.5% boys vs. 42.5% girls; P = 0.011). In the above-mentioned survey of medical students, this myth was present in 45.1% of respondents. The posttest responses to these questions improved significantly, with the girls catching up on their knowledge so as to render the scores statistically similar. However, the question regarding simultaneous orgasms took an exception, and the students were not convinced postlecture. It should be noted that in the survey by Tejas et al. about 70% of respondents were male, while in our study 70% were female. It has already been seen that the pretest knowledge of girls was poorer. Furthermore, the average age of their study was 21.7 years compared with 19.4 years in ours, indicating relative sexual inexperience. This should explain the differences in the findings of the two studies to some extent.
The students were fraught with erroneous ideas regarding sex. In our study, not only 71.6% of boys but also 71.6% of girls too had the opinion that masturbation leads to health problems. Only 16.9% of medical students in Tejas's et al. survey believed so. The figure is also higher compared to 43% (responses from boys only) in Sathe and Sathe's study. Further Ramadugu et al. reported that 57.4% of boys and 79.9% of girls had poor knowledge about masturbation. In addition, 70.3% of the students in our study thought that masturbation indicated sexual dissatisfaction with the partner in married life. All these misconceptions were adequately resolved after the lecture. The improvement in scores was statistically significant.
The myth of Dhat was prevalent as anticipated from clinical experience. In all 85.5% of boys believed that flow of Dhat leads to impotence; the belief was prevalent among girls too with 78.3% endorsing it. The significant reversal in scores was seen after the lecture (χ2= 342.91; P < 0.0001), with 80.5% of boys and 84.6% of girls learning of the falsity of their earlier belief. Studies on ideas about Dhat in nonpatient groups are few and far in between. Barot and Mangla reported that all of the 50 patients in their study attributed their weakness to passing of Dhat. The high fall out rates in prospective studies on Dhat syndrome conveys how recalcitrant the idea is., In the survey of medical students by Tejas et al., only 32.9% had such view.
The students held a similar attitude towards nocturnal emission - 81.1% boys and 78.3% girls thought that it led to bodily weakness. The percentages reduced to 13.0% and 19.7% respectively after the lecture (χ2= 32.61; df = 1, P < 0.0001). The clarification regarding the meaning of “nightfall” was asked by girls in most of our lectures. In Tejas's et al. survey, only 19.4% of medical students believed so. Kushwah and Mittal reported that 53.4% out of 287 adolescents in their study believed that night emission was not a natural process. Data from an IIHMR study in Rajasthan also revealed the same attitude in 46% of adolescents.
Among other prevalent culturally propagated myths were that larger breast-size was indicative of more sexual desire in women, larger penis size provides more sexual satisfaction and that sex is not advisable during menstruation. Boys and girls scored equally badly. As many as, 79.5% of students believed that bigger size of the penis was important for sexual satisfaction. In contrast, 71.3% of medical students did not believe in the size myth in Tejas's et al. survey of medical students. As for the breast size and desire question, 70.9% of boys had incorrect response, but surprising still was that 62.7% of girls also were wrong. Sex during menstruation was perceived as inappropriate by 82.5% of students. Responses to these questions saw a strong and significant change posttest, with more than 80% of students agreeing that size of breasts is not indicative of desire or that larger size of penis guarantees satisfaction (P < 0.0001 in all three questions).
Dubious sources of knowledge are an important factor in keeping such myths alive.
In studies by S. Ramagudu and Sathe, friends were the chief source of knowledge (42 for girls and 54 for boys). Considering the present level of knowledge such a source is clearly misleading. Knowledge of adults is also suspect. Data from a Delhi based NGO, TARSHI, revealed that 70% of the 59,000 phone calls on their sexual health helpline were made by people of age range between 24 and 30 years, enquiring about sex-related anatomy and physiology. Kumar et al. in their survey of 743 adolescents reported that 91% of students preferred a health-care worker as their primary source of knowledge regarding sex, followed by school teachers. Students pursuing nursing, physiotherapy and occupational therapy comprised our study population, and their knowledge was poor and inadequate to meet the demands of questioning adolescents.
Marriage, relationships, and sex
The idea that higher frequency of sex indicated better married life resonated with 63.6% of boys and 70% of girls, and this was relatively resistant to the lecture as more than 33% of both genders in the posttest gave incorrect responses. A relatively higher number of boys believed that masturbation indicated poor satisfaction in marriage (81.8% vs. 65.2% girls; P = 0.0004). After the lecture, the scores improved significantly and more than 80% of students agreed that it did not matter.
Fantasizing about another person during sex was disagreeable to 84.5% of students. Although the postlecture saw significant improvement in scores, but 31.9% still disagreed (χ2= 227.23; P < 0.0001). In Tejas's et al. survey, 43.9% of medical undergraduates also believed so. A number of studies have pointed out a positive correlation between sexual satisfaction and sexual fantasies, especially in women., In our study, significantly higher number of girls (87.3%) believed that having such fantasies indicated poor relationship or sexual dissatisfaction. During the interactive session, the students found this hard to grasp and saw this fantasy almost equivalent to infidelity, which may be important as a few studies have suggested that relational variables such as love and cohabitation predict positive sexual satisfaction in women. On being provided with evidence form past sex surveys, the students agreed that exploration of fantasies may lead to better satisfaction and not the contrary.
Overall, 66% of students thought that homosexuality was a disease. This is considerably more than what Banwari et al. found in their study on medical interns where the attitude was predominantly neutral, and Tejas's et al. survey (38.8%)., Banwari et al. also observed that knowledge about homosexuality was the strongest predictor of positive attitude. Although there was a significant improvement in responses in posttest (χ2= 91.75; P = 0.0001) 34.1% still considered homosexuality a disease. A study from Bengaluru explored the attitudes of nurses towards sexuality and found that 69.1% of nurses confessed that they would be uncomfortable around homosexual patients.
Furthermore, a high number of students (74.7%) felt that one loses interest in sex by the age of 60 years. Lecture had an amenable effect on this opinion with 78% answering correctly.
Although our lectures had a positive impact, they were not based on recommendations by any statute body such as Rutgers WPFs The World Stars With Me, or UNESCO's International technical guidance on sexuality education. Our strategy included discussing the correct answers for each of the 20 items on the inventory based on knowledge subscale of the Derogatis Sexual Functioning Inventory, along with imparting a comprehensive understanding of the sexual response cycle, presentation of objective data from various landmark studies on sexual behavior, and an interactive feedback session addressing queries.
We also regret that the study evaluated knowledge change an hour after the lectures. If a follow-up were done after interval of 6 months, for example, we would be more sure about the enduring positive impact. Quantifying the long-term effects of dissemination of information through peer-education could have made the study stronger. On similar lines, Parwej et al. had compared the effectiveness conventional education strategies and peer-group education among students in Chandigarh and found both approaches to be equally effective, though the peer approach was less time-consuming.
| Conclusions|| |
The study demonstrates an overall lack of knowledge about sex in both genders, but more so in girls. Students not only lacked basic anatomical knowledge but also had highly misguided ideas regarding sexual desire, fantasies, orgasm, and the act of sex itself. Masturbation was understood to lead to weakness, and breast-size was taken as an indicator of desire.
The lectures led to significant improvement in the knowledge of the students and mitigated the wide gap in the knowledge of the boys and the girls. The beliefs about sex did not seem to have any scientific ground but were rather based on hearsay and prevalent cultural myths. Madhya Pradesh government's decree banning sex education for high school students would result in proliferation of such myths at best. There was unanimous agreement among the students that such interactive lectures on sex cleared many of their misconceptions and insecurities regarding the subject.
This study was approved by Institutional Ethics Committee with reference number SAIMS/SS/12//702 obtained on 31st January 2015.
Declaration of Patient Consent
Patient consent statement was taken from each patient as per institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results / clinical information /image without revealing their identity, name or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]