updated 25 March 2003
In Swedish society, a positive social approach to sexuality is prominent in conceding the adolescents' claim for sexual pleasure without the feelings of shame, guilt, or fear, and in respecting young people's rights to free access to information on the prevention of STIs and unwanted pregnancy. This notion is evident in the long history of school-based SE that is, in the national curriculum, labeled as 'Education on sexuality and personal relationships'. The aims, contents and methods of schoolwork on sexuality and sexual health have been changing during the last 50 years, continuously affected by the course of public debate on sexual matters. When in 1956 SE in schools was made compulsory, Sweden became the first country to mandate the provision of this school subject. In that time, goals were set in terms of eliminating negative outcomes that could be caused by ignorance or social prejudices concerning body and sexuality. Schools were expected to provide teaching primarily in the area of physiology, reproduction and contraceptives (Lennerhed, 2000; Meredith 1989).
During the next decades, the transparency and systematic quality of developmental procedures, as well as the permanent scientific elaborations and evaluations of the national program, have resulted in one of the most comprehensive manuals on the implementation of SE in schools - 'Education in Personal Relationships' - published by the National Board of Education in 1977. This extensive teaching-guide, based on 10 years of research and investigation, involves the argumentation of the fundamental principles and objectives of SE as consonant with the underlying social values of equality, tolerance and the right to personal integrity. This approach to SE departs from ethical pluralism, respecting different moral and value systems of particular ethnical, religious and sexual minorities, while, at the same time, argues for the above-mentioned fundamental, 'common', social values. In teaching practice, among other school tasks, this means advocating for gender equality, promoting tolerance to different sexual choices, and addressing the issue of sexual violence (Meredith, 1989). The manual also includes detailed methodological instructions, together with relevant information and facts about (adolescent) sexuality, as well as teaching strategies for addressing value-sensitive issues such as homosexuality, abortion, and masturbation. Educational methods and contents are adapted to pupils' age/developmental stage, and whereas a dialogue is one of the recommended teaching methods, a strong emphasis is also put on the importance of transmitting the factual knowledge. In general, the manual from 1977 holds a positive attitude to sexuality, which is presented as the integral part of human life, linking identity and society.
In the next period, along with the changes of relevant policies, educational focus in the area of sexuality and personal relationships kept shifting from the affirmation of sexuality to the prevention of STIs, from the emphasis on sexist language and sexual violence to the detected lack of gender equality perspective. This last concern was given particular attention in the quality assessment of SE implementation in schools, carried out by the National Agency for Education in 1999. A total of 80 schools were inspected regarding teaching in 'Sexuality and personal relationships' as one of the school health-work themes intended to be implemented as interdisciplinary areas of knowledge and integrated in other subjects' teaching (Nilsson & Norgen 2001; Nilsson & Sandstrom 2001). Reforms of the Swedish educational system during the Nineties were characterized by the move from a centralized system with detailed regulations to a system where schools are directed through goals and results. The new national curricula (1994 and 1995) lay down the educational system's basic values and overall tasks, and by stating 'the goals to strive towards' provided a framework for the teaching of various subjects and knowledge areas, including the aspects of health education (Garcia-Sanchez et al, 2002; Centerwall, 2000a; Lennerhed, 2000). The only direct reference to sexuality and personal relationships, to be found in the Swedish national curricula, is in the context of the principal teacher's duty for ensuring that education in this area is implemented as the cross-subject field of knowledge (Centerwall, 2000a Nilsson & Norgen 2001; Nilsson & Sandstrom 2001). This indicates that the various aspects of sexuality (social, emotional, ethical, psychological, anthropological) need to be presented, and that teaching in this area should be integrated into school subjects such as biology, psychology, civic education, Swedish language, religion and social science. Moreover, a promotional approach, stipulated in curriculum as the general point of departure for teaching certain subjects, requires that education on sexuality and personal relationships should find ways to address the positive aspects of sexual relations (pleasure, love, self-esteem, friendship), not only to highlight possible negative outcomes like STIs, unwanted pregnancies and violence.
Without the curriculum-specified teaching goals or a syllabus at the national level, the quality and the extent of SE provision are determined by each school's priorities. The very broad descriptions in the national curriculum, and the decentralized educational system provide an opportunity for a particular school to formulate objectives and develop SE programs that cater the best to the requirements and needs of their pupils. On the other hand, the lack of more explicitly defined concept of sexuality and personal relationships, as well as the lack of clear directions in assigning the responsibility for teaching on this theme could, in some school environments, present obstacles to the effective cross-curricular implementation of SE, as in accordance with the goals expressed in the national curriculum. With the objective to support interdisciplinary approach to school health-work, and to assist teachers in the implementation of the particular aspects of healthcare and education, Sweden's National Agency for Education has developed and published a series of references materials concerning various health-related issues, and focusing on pupils' perspective (Nilsson & Norgen 2001). A body of reference material intended for use in sexuality and personal relationships education, which was commissioned by the Swedish government to replace the manual from 1977, was published in 1995 as 'Love! You can really feel it, you know: Talking about Sexuality and Personal Relationships in School', and two years later was awarded as the best SE program by the World Association for Sexology (Centerwall, 2000a). This 'collection of facts and opinions' gives a clear youth perspective by using examples from adolescent life and emphasizes the importance of dialogue and discussion, reflection and argumentation, as a means of teaching and acquiring knowledge. In relation to its contents, the reference material discusses the role of a teacher as a guide; addresses issues often regarded as sensitive-to-teach (homosexuality, masturbation, abortion, pornography, sexual violence); provides different accounts of young people's psychosexual development; gives the most recent research insights and statistics concerning adolescent sexuality; and presents educational methods that highlight communication and conversation as basic tools for work in the area of sexuality and personal relations.
Learning perspective ('reflection or information') was one of the criteria used to evaluate schoolwork in the area of sexuality and personal relations in the already mentioned 1999 quality assessment (Nilsson & Norgen 2001; Nilsson & Sandstrom 2001). The other perspectives that served as instruments to assess the quality of teaching were 'gender equality', 'risk/promotion', and 'pupil/adult' perspectives, to which findings (on goals, the head teacher's responsibility for cross-curricular themes, content, work methods, school environment) were compared. The report indicates that the quality of SE provision varies not only between, but also within schools. The cross-subject implementation of these issues proved to be difficult in the schools without formulated written goals at the local level, and in the environments where principal teachers do not actively direct teaching. Another conclusion from the assessment concerns difficulties in providing a balance between the risk, and the promotion perspective. It is important to note that in the cases where the emphasis in teaching was put on the biological and physiological aspects of sexuality, educational discourse was dominated by the risk perspective, highlighting potential negative outcomes. Moreover, the report points that education strategies in those cases tend to be orientated more towards the transmitting of factual knowledge and 'informing' pupils. On the other hand, the good examples of SE lessons are characterized by using pupils' perspective and experiences as the starting point, as well as by giving young people opportunities for discussion and reflection, and by employing guided dialogue as a general way of working. Likewise, successful SE classes create affirmative atmosphere in which the positive aspects of sexuality are promoted, and adolescents' self-esteem is supported (Centerwall, 2000a; Nilsson & Norgen 2001; Nilsson & Sandstrom 2001).
The quality assessment of the gender equality component in SE school practices departures from the premise that all schoolwork on sexuality focuses not just on 'young people' or 'pupils', but significantly positions children and adolescents as 'boys and girls', as 'young women and young men', the members of a particular social and cultural gender system. The report argues that while there is a need to present more explicit and transparent links between sexuality and identity, at the same time, to over-emphasize gender differences could result in reproduction of stereotypes regarding 'male' and 'female' sexuality. The other concern was raised in relation to a tendency that SE lessons are being delivered more in line with girls' needs and requirements, whereas frequently neglecting the specificity of boys' psychosexual development. This notion goes hand in hand with schools focusing their support networks on female adolescents, who are often perceived as 'the victims of aggressive perpetrators' - their male peers - who mostly lack counseling services that would be suited to their needs for honest, personal, and concrete advice. In addition, the quality assessment of working methods stresses that teaching in single-sex groups, without providing the opportunity for a dialogue between girls and boys, contributes to the hardening of gender stereotypes, which often result from the lack of understanding and insights about the other gender's point of view. The collected findings from the inspection were distributed to all head teachers nationwide, with the objective to facilitate further developments in schools' health work in general, and in the area of sexuality and personal relationships in particular (Centerwall, 2000b; Nilsson & Norgen 2001; Nilsson & Sandstrom 2001).
In Sweden, school-based SE is also addressed through the National Action Plan for Public Health and the National Policy for Prevention of HIV/STIs (1995) developed by the National Institute of Public Health. These documents additionally underline the promotional perspective in schoolwork on (sexual) health, and emphasize a communicative approach that aims to stimulate reflection and discussions around issues such as body, sex, identity, self-esteem, and contraceptives. Sexual health is defined in positive terms as 'sexual enjoyment and emotional togetherness', and as 'safe sex-life without STIs and unwanted pregnancies', and in that way incorporates both the promotional and the preventive approach. Moreover, these documents state that all health promotion and prevention efforts should also consider wider aspects of sexuality and relationships, and should include gender equality perspective as well (Garcia-Sanchez et al, 2002; Nilsson & Norgen, 2001).The effectiveness of Swedish approach to work on young people's health is also the result of a developed collaboration between educational and health authorities and organizations at the national, regional, and local level. The 'Health-promoting school' project, initiated by WHO in 1995, has been elaborated and managed by the National Institute of Public Health, and today includes a network of 600 schools. Today, there are also around 200 Youth Counseling Centers, established through youth policy programs, and serving as 'easily accessible preventive community resources'. These 'forums' - where support, advice and help for both 'body and soul' are offered to young people free of charge - are functioning as divided responsibility of the County Councils and the municipalities/rural districts. The work at the Centers consists of primary and secondary preventive care, individual consultations, free distribution of condoms, examination and early treatment, and outward activities, such as lectures and group discussions with youth and parents. Another important part of their exterior work is an active participation in school-based education on interpersonal relationships and human sexuality, with the objective to influence schools to further develop and expand their SE programs (Garcia-Sanchez et al, 2002).
LAFA (the Stockholm County Aids Prevention Center) is a unit within the Stockholm County Council's public health department. The implementation of this preventive health program, targeting youth, men who have sex with men, immigrants and refugees, is facilitated in a close co-operation with schools, youth clubs, and youth clinics. Besides its main task - the prevention of HIV and other STIs, and unwanted pregnancies - LAFA also carries out its own research in the field of sexuality and personal relationships, and acts as a methodology and knowledge resource center to promote sexual well-being through safer sex and wider awareness of sexual matters. Services offered by LAFA include educational courses and trainings for teachers, head teachers, school nurses, and social workers; counseling, monitoring and support; information center with statistics, reports, and documentations; methodology material 'Main Thread'; youth magazine on HIV, sexual health and SE; and free condoms (Garcia-Sanchez et al, 2002).
The leading organization in Sweden in the area of sexual and reproductive health and rights is the Swedish Association for Sex Education (RFSU), founded in 1933, when its first program task was focused on introducing SE in schools starting at the age of seven in the first grade. For the past seventy years RFSU has been promoting programs for sexual and reproductive health and rights, organizing clinics, providing counseling, selling condoms, and successfully fulfilling its main objectives: access to contraceptives and counseling services; safe and legal abortion; and SE and family planning as the specific human right. In addition, RFSU actively advocates the implementation of the Cairo Platform of Action; has developed the model of institutional collaboration and multi-sectoral approach that resulted in many legislative changes; offers technical assistance regarding sexuality and SE in Sweden and internationally; and produces material that illustrates the Swedish experiences and the Swedish model of working with sexual and reproductive health and rights (Garcia-Sanchez et al, 2002; Lennerhed, 2000).
In summary, the Swedish approach to school-based SE is pragmatic, taking girls and boys and their needs as the point of departure, with the primary goal of supporting and helping young people in their psychosexual development. The educator's role is to present different value perspectives and to facilitate group discussions, while adolescents themselves make conclusions and acquire knowledge through dialogue and reflection. The basic concept underlying Swedish SE is that promoting positive perspective on sexuality gives rise to strengthened self-esteem and greater capacity to have control and make decisions about one's own sexual life, which in turn assists to prevent unplanned pregnancies, abortions, and STIs. The efficiency of Swedish SE results from a successful integration in the educational system and a close co-operation with the health sector, as well as from the approach that takes into account the social reality of young people's sexuality.