Two major themes emerging from the findings will be discussed in this paper: the biological and heterosexual focus of sexual health information from trusted sources; and the lack of information on practical skills for ensuring safe and pleasurable sexual experiences.
Biological reductionism and heteronormativity
Adolescents in this study received considerable information on biological aspects of heterosexual sexuality and reproduction as it related to pregnancy and STIs. Although this is an important part of their sexual health knowledge, the potentially negative effects of this overriding focus on biological and heterosexual sexuality are worth exploring.
When appraising the content of the biologically focussed sexual health information, it becomes clear that adolescents are expected to take rational decisions based on being cognitively aware of negative biological outcomes of unprotected sex. Focussing on biological sexuality without also discussing the emotional/relational aspects of sexuality effectively separates the mind from the body, and the individual from their social context. This artificial separation fails to take into account the emotional and physical impulses that drive sexual attraction, nor does it account for the social forces, gender inequalities and power relations that influence a person's ability to initiate positive health behaviours [
28].
To underline this rational decision-making process, fear arousal was a tool utilized by both teachers and parents to warn adolescents about risks and consequences of unprotected sex. However, this information was rarely paired with practical explanations of how to access and use contraception, nor how to negotiate safe sex with a partner. Research has shown that utilization of fear arousal techniques may be counter productive, leading to risk denial
(it won't happen to me) [
29], particularly exacerbated in adolescence by a belief in their own invulnerability or invincibility [
1,
3].
This rational perspective also artificially separates the individual from their social context, disregarding the influence of peers, partners and parents on sexual decision-making. In this study negative peer pressure was exemplified though jokes and comments about virginity as well as discrimination of supposedly homosexual peers. This peer pressure may negatively influence sexual health decision making, as found in a South African study where peer pressure undermined health promotion information encouraging safe sex and HIV prevention [
30]. Conversely, peers may have a positive influence as seen in this study with the adolescent parents who described their role in promoting safe sex in their peers. When it comes to parents, a study from Cameroon found that perceived parental support for condom use had a strong association with actual condom use [
28]. Therefore it seems important that educators promoting safe sex behaviours also include discussions about peer, partner and/or parental attitudes that may greatly influence sexual decision-making.
Rationalization also fails to take into account the influence of conflicting messages from media, in particular pornography and erotic music. In this current study viewing pornography was described as normal for males and attitudes of towards pornography were gendered, consistent with previous research [
31]. The sheer extent of adolescent exposure to sexually explicit material on the Internet makes a strong case for broaching the topic of pornography with adolescents to raise their "media literacy" in understanding how media is produced and how to be critical of behaviours promoted through the media [
13,
32]. Adolescents in this study were already critical consumers of information on the Internet in general, therefore there is every reason to believe that through critical debate about pornography and other media eroticisation, adolescents can be encouraged to reflect on the conflicting messages between rational risks of unprotected sex and media eroticisation.
Another limitation of biological reductionism is the effect it has on adolescent understandings of sexual orientation. Although there were examples of adolescents whom had learnt about sexual diversity from the perspective of respect and non-discrimination, this approach was far from universal. With an overriding heteronormative, biological focus on prevention of pregnancy in the school setting, the topic of sexual orientation was commonly omitted or explained in biological terms as a hormonal disorder or "condition" making someone different. Additionally, medicalization in the form of referring suspected homosexual, lesbian or bisexual adolescents to psychologists and psychiatrists also supported an understanding of these orientations as conditions in need of medical support. This may further alienate youth with non-heterosexual orientations already at greater risk of poor health outcomes and bullying, whilst failing to explore with these adolescents the emotional and relation aspects of their developing sexuality [
33,
34]. Providing support for adolescents in the form of discussing same-sex attraction from a normality perspective focusing on feelings and attractions rather than biological differences may be important in preventing negative social and health outcomes [
33,
34]. This support could come from formal sources such as teachers or health professionals. Somewhat paradoxically, through the medicalization of sexual diversity, health professionals in this current study were given a point of contact to provide this emotional support for these youth.
A heteronormative focus may also distort the understanding adolescents have of the wide spectrum of sexual behaviours, regardless of sexual orientation. Adolescents learn about this spectrum of acts primarily from informal sources through conversations with friends and partners, Internet and pornography. In schools, adolescents learnt about the spectrum of sexual acts and particularly non-coital sex through anonymous question sessions. This reflects findings from a study from the United States that analysed the content of anonymous questions written by 795 pupils 11–12 years old and found three times as many questions related to non-coital sex, compared to vaginal sex [
35]. This trend indicates that adolescents see their teacher as an appropriate source of this information on diverse sexual acts, however the current taboo of the topic means they only ask in the context of anonymity.
The heteronormative nature of safe sex and abstinence messages were also discussed in the male university focus group where participants observed that many adolescents view oral and anal sex as both physically safe (avoiding pregnancy) and morally safe (maintaining virginity). The idea that oral and anal sex maintain virginity is not unique to the Chilean context, and may be influenced by conservative religious ideologies promoting abstinence and virginity [
36]. As these participants discussed, implications of this may include low perception of risk related to anal and oral sex, which could lead to reduced condom use and increased risk of STIs [
36]. A further serious implication may be an underreporting of sexual abuse not regarded by adolescents as either sex or abuse.
Another limit to this biological focus was the lack of information on emotional and relation aspects of sexuality in the home and in schools. In the home setting discomfort in talking about
afectividad was reflected in those parents who provided triggered, short, preventative messages linked to risk of pregnancy and contraception, without developing ideas of love, relationships, feelings, desire or sexual impulses. In schools the limited teaching of
afectividad in mainstream teaching was linked to the narrow educational and public health agendas focussing on pregnancy and STIs. This is of particular importance in light of results from a Chilean study showing that the main motivations for becoming sexually active described by adolescents are precisely love, emotions and pleasure [
17]. Therefore, in order to communicate effectively with adolescents about broad topics of sexuality beyond biology, both parents and teachers may need guidance in confronting their own sexuality, myths, cultural taboos and other barriers to communication on these topics [
37].
An interesting emerging finding about school sex education was that themes such as love and what one participant called the "
magic" of sexuality were often associated directly to religion classes. This raises the concern that non-religious adolescents may dismiss the value of learning about emotional and relational aspects of sexuality in school, if they only associate these teachings with religion. Similarly, by linking the idea of sexual abstinence only to religion, an important part of sex education, namely acknowledging the decision to wait to have sex until after marriage as a valid choice independent of religion, may be dismissed by adolescents and educators alike. In their study from the United States, Jones et al. [
8] found that adolescents had a range of definitions of abstinence and that that abstinence messages were often seen as compatible with contraceptive messages. This differs from findings in this current study where abstinence and contraceptive messages were described as mutually exclusive. Therefore, exploring the meaning of abstinence in contemporary Chile presents an interesting area for future research.
Finally, as seen in this study, the narrow public health and educational agendas focused on reducing the number of unplanned pregnancies and STIs meant that sexual pleasure was absent from formal sex education. The only exception was male masturbation, however the complete absence of the topic of female masturbation emphasises a gender disparity that denies female empowerment and entitlement to sexual pleasure [
38]. Fine and McClelland [
39] criticize the separation of risk and pleasure in formal school sex education, claiming that it distorts the way adolescents understand human relationships and desire. What both male and female adolescents in this current study showed through anonymous questioning in schools, conversations with friends and watching pornography, is that it is very often the topics of pleasure and desire that spark their curiosity.
A focus on the acceptable biological, heteronormative teachings across formal and informal sources is not unique to the Chilean context. Results from quantitative and qualitative studies from countries as varied as Brazil [
12], Norway [
40], New Zealand [
38], Vanuatu [
10], the United Kingdom and Australia [
37] describe similar situations, suggesting that the heteronormative, biological and risk focus is a tendency in a diversity of global contexts.
The theory-practice gap
A second emerging theme is the lack of focus on the practical aspects of ensuring optimal sexual health and sexuality. A number of adolescents criticized information from schools and parents for not adequately preparing them with tools to practice safe sex. To underscore the importance learning practical skills, an extensive systematic review of 83 school sex education programs claims that the most effective programs in delaying sexual debut and encouraging protected sex are comprehensive sex education programs that incorporate teaching skills related to partner communication and contraceptive use, as well building self-efficacy to be able to use these skills [
4].
Information about contraception was often provided by schools, parents and/or health professionals. Condoms were the primary form of contraception discussed, however the actual mechanism on how to put a condom on was only shown to one adolescent in school. Casas and Ahumada [
15] describe how practical teaching about condom use in schools touches on a sensitive nerve in the Chilean context, where there still exists a myth that teaching about contraception, and showing how condoms work will encourage early sexual activity. This myth has been dispelled by extensive evidence showing that comprehensive sex education is more effective than abstinence only sex education in delaying sexual initiation [
4,
5].
Another major contraceptive issue raised in this current study was the lack of morally neutral and medically correct information about the emergency contraceptive pill and how to access it. Adolescents had either not received information about the emergency contraceptive, or received vague information as to its efficacy, overshadowed by moralizing messages of guilt and responsibility. Although access is now guaranteed by law in Chile [
19], conflicting and ambiguous information about the emergency contraceptive, may impede an adolescent's ability to make an informed decision about its use. Chile is not unique in this respect, as debates on the function and legal status of the emergency contraceptive are common throughout Latin America [
41].
A core practical skill for promoting pleasurable and safe sex practices and preventing situations of coercion and miscommunication, is learning how to communicate effectively with a partner about sex [
5]. In this study the adolescents overwhelmingly discussed the importance of communicating with a partner on topics of sexual health and sexuality, however actual experiences were varied. These differences may be explained in relation to differing levels of self-efficacy felt by adolescents in power relations with their partners. Breakwell [
14] describes the link between the theory of self-efficacy and power, stating that effective communication helps set rules of engagement on when and where sex takes place. Conversely, infrequent partner communication, fear and/or perceived lack of ability to negotiate condom use has been shown to be directly associated with infrequent condom use [
42]. This supports the need for an increased focus on communication skills necessary for effective negotiation of consensual, safe and pleasurable sexual experiences.
The final skill relates to setting personal limits and learning to respect other's limits in order to prevent situations of violence and sexual coercion. Few participants in this study reported conversations with trusted adults about setting personal limits and partner violence, representing a gap in sex education. Globally, the majority of gender-based violence is perpetrated by men against women and most of the time this is by someone known to the victim, often their partner [
43]. Interestingly, a Chilean study surveying university students found males experienced more dating violence than females, however females were more likely to be physically hurt when exposed to dating violence [
44]. Few of these victims had talked with a friend about the violence and none had gone to the police, thus the authors advocate for open discussions with adolescents about partner violence, what it is, how the law can protect them and how to support friends that report violence [
44]. Alcohol and drugs may be involved in many coercive sex situations, and although their influence should not be overlooked, focussing only on what potential victims can do to reduce risks may merely perpetuate victim blaming rape myths. Thus it is important to engage both males and females in discussions on issues of respect, consent, personal limits and violence, so they can be respected and empowered in their sexuality. It is a human right to have a sexual life free from coercion, discrimination and abuse, therefore sex education that includes building skills for both setting and respecting personal limits represents a great opportunity to help break the current patterns of sexual violence in Chile.