Young Individuals’ Attitudes Towards Sex Education and Related Factors

: Objectives: To determine young individuals’ attitudes towards sexual education and related factors. Emotions, thoughts, and attitudes are as important as knowledge on sexual matters. For this reason, it is necessary to determine the attitudes of young people towards sexual education and the factors affecting these attitudes. Material and Methods: This is a cross-sectional and descriptive study. The study included university students and data were collected via ‘Google Forms’. The study sample is comprised of 501 undergraduate students. We collected the data in November-December 2021 using a Personal Information Form and the Scale of Attitudes towards Sex Education (SATSE). Results: The average SATSE score of the participants was 59.27±11.14. We found that 52.3% of the participants considered their sexual health knowledge level as sufficient, but 60.5% did not receive sexual health education. In addition, it was determined that more than half of the participants could not easily talk about sexual health issues with their families. Conclusion: The results of the research showed that the attitudes of the participants towards sexual education were generally positive. Several characteristics, such as the geographical region resided, father’s education level, being in a romantic relationship, and finding their sexual health knowledge level as sufficient affected their attitudes towards sexual education.

The foundations of sexual education should be laid in the family and maintained in schools. The most important reasons why families avoid talking about sexual education are the lack of information and the fact that the subject is considered a taboo. In addition, instructors in schools have insufficient training on the subject and the subject is not included in the curriculum 4 . One study also found that parents fear that talking about sexuality will encourage the kids to engage in sexual acts, that they did not have enough information to inform about sexual education, and that parents think their kids had certain knowledge on the subject 5 .
According to the Sexual Information and Education Council of the United States (SIECUS), sexual education programs have four main objectives: knowledge and attitudes, values and understanding, relationships and interpersonal skills, responsibility 6 . Sexual education has a positive effect on safer sexual behaviors and can delay the age of first sexual intercourse, contrary to the common misbelief that it encourages sexual activity 7 .
Family structure, education level, close environment, and culture are effective in the development of sexual attitudes and behaviors of individuals. Being a woman or a man, living in an urban or rural area, and socio-cultural characteristics, such as age, also affect attitudes and behaviors towards sexual education 8 .
Emotions, thoughts, and attitudes are as important as knowledge on sexual matters. For this reason, it is necessary to assess young people's attitudes towards sexual education and the factors affecting these attitudes. It is considered that, based on the present results, young individuals' attitudes towards sexual health education will be identified, and thus, important implications will be drawn for future studies.

Purpose of the research
The present study aimed to determine the attitudes of young individuals towards sexual education and related factors.

Research Design
The research is cross-sectional and descriptive.

Place and Time of Research
The research was carried out online via 'Google Forms' with young people studying at a university. The local ethics committee approved the study. After the data collection forms were uploaded to the Google survey system, the online link of the survey was shared on social media platforms (WhatsApp, Twitter, Instagram, Facebook, Pinterest, Snapchat, etc.).
The inclusion criteria were being in an age range of 18-24 years, being single, studying at an undergraduate program, being able to read and understand Turkish, and willing to participate voluntarily in the study. Data were collected between November and December 2021, and 501 young people participated in the study.

Data Collection Tools
Data were collected using a Personal Information Form and the Scale of Attitudes Towards Sex Education (SATSE).

Personal Information Form:
The following information was collected with the personal information form developed by the researchers: age, major, gender, class, employment status, place of residence during education, mother's education status, father's education status, mother's employment status, father's occupation, family income, sexual education status, the location where they spent most of their life.

Scale of Attitudes Towards Sex Education (SATSE):
It is a 15-item 5-point Likert-type scale developed by Turhan 9 to measure attitudes towards sexual education. The scale has two sub-dimensions, attitudes towards the benefits of sexual education and general attitude towards sexual health. Items 2,5,8,9,10,11,12,13,14,15 measure attitudes towards the benefits of sex education, and items 1, 3, 4, 6, 7 measure attitudes on sexual health. The score range is between 15 and 75. The higher the scores on the scale, the more positive the individuals' attitudes towards sexual education are. The scale's Cronbach alpha reliability coefficient is 0.865 9 .

Statistical analysis
Data analysis was made using IBM SPSS Statistics for Windows version 22.0. Number and percentage values were used in the analysis of the demographic characteristics data. Arithmetic mean, standard deviation, median, minimum, and maximum values were calculated for SATSE results. We used the Mann Whitney U Test for the mean of two groups, the Kruskal Wallis test was used to compare the mean scores of more than two groups, and the Spearman Correlation analysis for the relationship between age and class and mean SATSE scores. The significance level of the findings obtained from the study was evaluated at the 95% confidence interval and at p<0.05 significance level.

Ethical Approval:
The Non-Interventional Clinical Research Ethics Committee of the university approved the study. The purpose of the study was explained by sharing the link of the questionnaire with the young undergraduate students, and their consent was requested by informing that participation in the study was on a voluntary basis.

Results:
The mean age of the young people participating in the study was 20.56±1.382 years and the majority of them were women (n=375, 74.9%). It was found that 74.5% (n=373) of the participants were students of health sciences and the majority of them were not working (n=449, 89.6%). Almost half of the participants (n=214, 42.7%) lived in the Central Anatolia region in Turkey (Table 1). When the sexual health characteristics of the participants were examined, it was seen that most of them did not have a romantic relationship (n=363, 72.5%), and 52.3% (n=262) considered their sexual health knowledge level to be sufficient. However, it was determined that 60.5% (n=303) did not receive sexual health education. It was determined that 34.3% (n=172) of those who received sexual health education received the education most from school and 60.1% (n=301) would prefer to receive sexual health education from health professionals. It was determined that more than half of the participants (n=344, 68.7%) could not easily talk about sexual health issues with their families, and 55.1% (n=276) think that sexual health education should be given to male and female students together ( Table 2).  (Table 3). When the relationship between the participants' age (r=0. 16, p=0.000) and the grade level at school (r=0.13, p=0.003) and their mean SATSE scores was examined, a positive and significant relationship was observed. It was determined that the area of residence had a significant effect on the attitude towards sexual education (X2=16.794, p=0.010).
In further analysis, a significant difference was found between the SATSE total score means of the participants living in the following regions: Mediterranean region and Eastern Anatolia region (U=547.500, p=0.009); Central Anatolia region and South East Anatolia region (U=6524.000, p=0.035); Central Anatolia region and East Anatolia region (U=814,500, p=0.004); Aegean region and East Anatolia region (U=112.500, p=0.014); South East Anatolia region and Marmara region (U=626.500, p=0.010); and, Eastern Anatolia region and Marmara region (U=63.500, p=0.000). There was a significant difference the educational status of the father and the SATSE total score (X2=10.868, p=0.028). Further analysis found a difference in father's education status between: primary school graduates and university graduates (U=8232.500, p=0.004); secondary school graduates and university graduates (U=3559.500, p=0.006); and, high school graduates and university graduates (U=4840.000, p=0.031) ( Table 4).
There was a statistical difference between the following conditions and the participants' mean SATSE total scores: having a romantic relationship (U=20603,000, p=0.002); thinking that their sexual health knowledge level is sufficient (U=26950.000, p=0.007); status of receiving sexual health education (U=21335.500, p=0.000); preferred source of sexual health education (X2=10.574, p=0.032); the status of talking about sexual health issues comfortably with the family (U=20680.000, p=0.000); status of preferring sexual health education offered in schools (U=3197.000, p=0.000); and, preferring that sexual health education is given to male and female students together (U=21233.000, p=0.000). As a result of the further analysis, the difference between the preferred source of sexual health education and the SATSE total score was due to the following groups: teacher and websites (U=133.500, p=0.007), health professionals and websites (U=915.500, p). =0.004), web sites and family members (U=75.500, p=0.001), and web sites and psychological counselor/guidance teacher (U=391.000, p=0.019) ( Table 5).

Discussion:
Although more than half of the participants did not receive sexual health education, 52.3% of them considered their sexual health knowledge level to be sufficient. In the "Turkish Adolescent Profile" study conducted by the Turkish Ministry of Family and Social Policies in 7000 adolescents in 2013, it was stated that 25% of the participants did not receive any education about sexuality, but 41% could find adequate answers to their questions about sexuality 10 . In the study conducted by Bakır, Irmak Vural and Demir 2 in 364 undergraduate students studying in the field of health, it was determined that 72.3% of the students did not receive sexual health education. In a study conducted by Yanıkkerem and Üstüngorul 11 in 420 nursing students, 52.5% of the students stated that their level of sexual knowledge was sufficient.
Our study and other research results show that adolescents lack information on this subject. In addition, the fact that the students in the field of health made up the majority of the sample (n=373, 74.5%) in our study and they had received courses in which sexual health information was given as part of their curriculum may have caused the young people to perceive that their knowledge is adequate. The fact that young people get information about sexual health from the Internet, which was the second most common resource following school, may indicate that easy access to the Internet may have facilitated access to information in matters about sexual health.
More than half of the young people participating in the study preferred to receive sexual health education from health professionals, and they stated that they preferred to receive it from their families as a last resort. Similar to our research results, in another study conducted with young people studying at the Faculty of Education, 89.1% of the students stated that they wanted to receive sexual health education from a specialist doctor or nurse 12 . Parents should be the first source of direct sexual information to their children. This is a very important factor in the development of young people's attitudes and value judgments about sexuality. However, there are no programs for parents to develop skills in sexual education 13 . In Turkey, no official sexual education program is offered in schools by the Ministry of National Education. Subjects related to sexual education are included in the curriculum, mostly in science courses, and they are not given under the title of "sexual education" 3 .
In addition, parents may feel ashamed to talk about the subject, as well as not feeling knowledgeable about sexual education 14 . In line with these results, it is thought that the reason why the young people in our study prefer to receive sexual education less from their families is because their parents also went through the same education system and did not receive sexual education in schools.
More than half of the participants in the present study think that they cannot easily talk about sexual health issues with their families, and nearly half of them think that sexual health education should be given separately to girls and boys. Kurtuncu et al., 15 , Ceylan and Çetin 16 , and Tuğut and Gölbaşı 17 also found that parents could not easily talk about sexual education issues with their children. Young people are not comfortable approaching their parents for guidance on sexual matters, or they do not get satisfactory answers when approached. In the Turkish society, sexuality is still defined with expressions such as secret, shame, sin, and forbidden 18 . It is thought that this traditional approach prevents talking about sexuality in the family and with the opposite sex.
It was observed in the present study that the attitudes towards sexual education in the young people participating in our research were positive. Bakır, Irmak Vural and Demir 2 and Turhan 9 have also observed that students have a positive attitude towards sexual education. Our research result was found to be compatible with the literature. It is an important and positive finding of the study that students' attitudes towards the benefits of sexual education programs, which are not yet part of the education system in Turkey, were positive. It was determined that as the age and grade level of the young people increase, their attitudes towards sexual health education increase positively. It is an expected result that individuals' awareness of sexual health increases due to the increase in age and education level.
In our study, it was determined that the geographical region of residence had an effect on the attitude towards sexual education. It is seen that the average score of attitudes towards sexual health education decreases from the west to the east of Turkey. It is thought that this outcome may be due to the dominance of a patriarchal structure in the east of the country. It is expected that the attitudes towards sexual education in young people who grow up in this structure will be more traditional. In addition, it was determined that as the education level of the fathers of the young people in the study increased, their attitudes towards sexual health education were also more positive. Ceylan et al., 3 and Nyarko et al., 19 have reported that the attitudes towards sexual education in parents who graduated from higher education were more positive. In another study, it was determined that the level of education of the parents caused a significant difference in the general attitudes of parents towards sexual education and their attitudes towards sex education within the family 20 .
Regardless of the geographical location difference, the increase in the education level of the parents, who are expected to give the sexual health education that needs to start in the family, has revealed the necessity of sexual education and the result that it can be easily spoken within the family. It is a predicted result that the child raised in this family environment has a more positive attitude towards sexual education.
Young people in romantic relationships have more positive attitudes towards sexual education. Romantic relationship is an important component of personality, sexuality, and psychosocial development in young adulthood 21 . In the relationship evaluation model of Busby, Holman and Taniguchi 22 , it was reported that, in a romantic relationship, sexual attitudes and behaviors of individuals are important determinants of the satisfaction obtained from the relationship. The fact that young people have a romantic relationship may lead to the emergence of the need for information about sexual health, and thus, to seek sexual education. This may have positively affected the attitudes of young people with romantic relationships towards sexual health education.
In the present study, it was determined that young people who think that their sexual health knowledge level is sufficient have better attitudes towards sexual education. Öklü et al., 23 studied university students' perspectives on sexual myths, and found that students who considered their knowledge of sexuality as sufficient had lower levels of belief in sexual myths. Esen and Siyez 24 determined that a comprehensive sexual health education program they conducted in high school students had a positive effect on their attitudes towards sexual health. It is a predicted result that young people who find their sexual health knowledge level as sufficient have also positive attitudes towards sexual health education.
It was found that those who want to receive sexual education and those who prefer to receive this education from teachers, health personnel, family members, guidance and psychological counselors rather than the Internet had more positive attitudes towards sexual education. Turhan 9 argued that students want to get their sexual health information from educators at schools and that sexual education will increase their self-confidence in solving sexual problems. Kahyaoglu Sut et al., 25 found that the most frequently used sources of sexual information by students were schools, the Internet, and the media. Teachers, psychological and guidance counselors, and health professionals have an important role in accessing the right information about sexual health education, especially in societies where sexual issues cannot be talked about easily 26 . It is expected that young people with more positive attitudes towards sexual education want to receive sexual education from professionals rather than the Internet.
According to our study results, being able talk about sexual health issues with the family had a positive effect on participants' attitudes towards sexual education. Attitudes, beliefs, behaviors, and values related to sexual education are shaped from early childhood and with family participation 27 . A positive family approach to sexuality prevents young people experiencing sexual health problems, enabling them to develop conscious and healthy behaviors about sexual health and making respectful and conscious choices 18 . In addition, sexual health education should be continued throughout life in accordance with age so that young people can make conscious sexual choices, and to prevent early and unwanted pregnancies and protect themselves from sexually transmitted diseases 11 . This finding of the study can be interpreted as a positive result in terms of revealing the role of the family in developing attitudes towards sexual education.
The attitudes towards sexual education in young people who want sexual health education to be given in schools and together with boys and girls were found to be more positive. Fonner et al., 28 conducted a meta-analysis study involving 64 studies from low-and middle-income countries, and found that school-based sexual health education is an effective method in reducing the risk associated with HIV/ AIDS, and that students have more information about HIV/AIDS through education given in schools. In underdeveloped and developing countries, schoolbased sexual health education is not carried out in line with national policies and sexuality is still seen as a taboo. This, in turn, can affect young people's sexual knowledge and attitudes and increase their risk of engaging in risky sexual behaviors 29,30 .

Conclusion and Recommendations:
As a result, this study showed that university students generally have positive attitudes towards sexual education. The following characteristics affected their attitudes towards sexual education: the geographical region resided, the level of education of the father, the presence of romantic relationship, the belief of possessing sufficient sexual health knowledge, receiving sexual health education from professionals, being able to talk to the family comfortably about sexuality, and preferring sexual education to be offered in schools and together with girls and boys. Sexual health education should be considered in the family in the early period and then in the school curriculum and should be continued throughout life.
Especially in societies like Turkey where sexual education is considered taboo, schools play the role of educators for both students and parents. Thus, the parents of the future will be supported in terms of both knowledge and attitude, and negative attitudes towards sexual education will be prevented. Sex education plays an important role in the prevention of sexually transmitted diseases, adolescent pregnancies and voluntary abortions, which are increasingly important health problems in Turkey as well as in the rest of the world. This study has the feature of guiding future studies as a result of identifying the attitudes of young individuals towards sexual education and related factors. In future studies, it is recommended to focus on how sexual education prepared for young people will affect the attitudes of young people.

Funding information
The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Declaration of Competing Interest
Authors declare that they have no conflict of interests.