SEX EDUCATION

2020, VOL. 20, NO. 6, 627–641

https://doi.org/10.1080/14681811.2020.1719480

Bhutanese trainee teachers’ knowledge, attitudes and

practices about sex and sexual health: exploring the impact of
intervention programmes
Ugyen Tshomoa, Kezang Sherab a
and John Howardb
a
Paro College of Education, Royal University of Bhutan, Paro, Bhutan; bNational Drug and Alcohol Research
Centre, UNSW Australia, Sydney, Australia

ABSTRACT ARTICLE HISTORY

Sex and sexual health remain taboo topics in Bhutan. Sexually Received 30 July 2019
Transmissible Infections (STIs) are still associated with social stigma, Accepted 19 January 2020
embarrassment and denial, and knowledge of sexual health among KEYWORDS
young people does not equate to safer practice. This study employed Knowledge; attitudes;
longitudinal survey method to explore the level of trainee teachers’ practice; sexual health;
knowledge, attitudes and practices about sex and sexual health at the trainee teachers; Bhutan
beginning (2015 – baseline) and end (2018 – post-intervention) of
a four-year training programme delivered in the two teacher training
colleges in Bhutan. Data were collected using a self-administered
survey questionnaire (baseline, n = 380 and post-intervention, n =
350) focused on knowledge about sex and sexual health, attitudes
towards sex and sexual health, and sex and sexual health behaviour/
practices of the trainee teachers. Findings showed an overall general
improvement in students’ knowledge, attitudes and practices after the
introduction of a compulsory non-credited comprehensive sexuality
education (CSE) module, the organisation of seminars, and the provi-
sion of health talks. However, there remain opportunities for further
improvement. These include a further review of the CSE module,
increased use of digital technology, and enhanced attention to social
media. Findings have implications for a wide range of college students,
not only trainee teachers, and not only for future work in Bhutan.

Introduction
In 2017, Bhutan had a population of about 735,553 (47.7% female), with a median age of
26.9 years, about 22% aged 10–24 years, and a growth rate of 1.3% per annum (National
Statistics Bureau 2017). In Bhutanese society, Sexually Transmissible Infections (STIs) are
still associated with social stigma, embarrassment and denial. Discussion of the health
risks associated with sexual behaviour remains taboo (Sherab et al. 2017; UNDP 2013).
There is anecdotal information from students indicating that some suffer from ‘embarras-
sing diseases’ and prefer not to visit clinics and hospitals, even in a context where testing
and treatment are offered free of charge. STIs including HIV present a serious challenge to
the health and wellbeing of Bhutan, especially since ‘STI prevalence and incidence are
worryingly and unacceptably high’. To address this, research indicates the need for

CONTACT Kezang Sherab kezangsherab@gmail.com

© 2020 Informa UK Limited, trading as Taylor & Francis Group
628 U. TSHOMO ET AL.

effective, evidence-informed sexuality education. It is important that such education does

not lead to fear of ‘sex’ and further stigmatise sexual behaviour, which should be
pleasurable, non-coercive and safe (Wood et al. 2019).
This study explores the knowledge, attitudes and practices of Bhutanese trainee
teachers in relation to sex and sexual health with a particular focus on their knowledge
and risk practices. Trainee teachers are a key population to target in relation to sex and
sexual health as, once they graduate, they are in a privileged position to influence the
young people they teach. Good quality teacher training can provide appropriate sexu-
ality-related knowledge and skills which can be utilised in school by teachers as ‘trust-
worthy sources in a trusting environment’ (Xong, Warwick, and Chalies 2019, 1). This study
is grounded in a broad, positive, holistic view of sexual health as:

. . . . . . . a state of physical, emotional, mental and social well-being in relation to sexuality; it is

not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive
and respectful approach to sexuality and sexual relationships, as well as the possibility of
having pleasurable safe sexual experience, free of coercion, discrimination and violence. For
sexual health to be attained and maintained, the sexual rights of all persons must be
respected, protected and fulfilled. (WHO 2006, 4)

Despite the plans and policies executed by the Bhutan Government, recent research
demonstrates the existence of emerging issues for young people such as sexual health
problems, substance use, mental health and violence (Dorji 2015; MoH and WHO 2017;
Sherab et al. 2017, 2019).
A recent study of college students’ sexual behaviour revealed a gap between knowl-
edge and practice (Gurung et al. 2016). Although students’ information and knowledge
on STIs was high (95% and 88%), only 75.3% of the sample reported condom use during
sexual intercourse. While 59% reported being worried about contracting an STI during
sexual activity, 32.6% indicated that they would have sex rather than avoid it due to the
unavailability of condoms. While a substantial percentage of college students (17.9%)
considered involvement in sexual activity a casual thing, about two thirds (62.2%)
believed that sexual activity should occur only in a serious relationship.
In response to the above concerns, a Comprehensive Sexuality Education (CSE) module
was introduced at Paro College of Education (PCE) in 2010, with support from UNFPA, to
create awareness and educate trainee teachers. The module covers ten core life skills –
growth and development, developing healthy relationships, sexuality, sexual behaviour
and sexual violence, understanding pregnancy and parenthood, STIs and HIV, Body Image
and Healthy Living, and Behaviour Issues (Royal University of Bhutan 2014). Later, in 2014,
CSE was designated a non-credit compulsory module in the three Royal University of
Bhutan (RUB) colleges.
CSE forms part of life skills education in schools of Bhutan which is taught as a subject
for two hours a month. The content of life skills education includes ten core life skill
values, healthy environment, growing and development, menstruation, sexual harass-
ment, healthy living, relationships, sexual rights and responsibilities, contraceptives,
pregnancy and responsible sexual behaviour.
To provide baseline data to aid evaluation and the future development of provision in
the teacher education context, a Knowledge, Attitudes and Practices a baseline survey was
conducted in 2015 among all first-year trainee teachers (n = 380) at the two Education
 SEX EDUCATION 629

colleges of the Royal University of Bhutan – Paro College of Education, which prepares
primary school teachers and Samtse College of Education, which prepares secondary school
teachers – soon after admission, to ascertain their knowledge, attitudes and practices in
relation to sexuality. Members of this group were then offered the 30-hour CSE module for
a semester in the first semester of their first year of study. Other intervention activities such
as an international seminar in 2015 at PCE on the theme ‘Let’s Talk about sex’, a national
seminar at SCE in 2016 on ‘Sexuality’, and health talks by a medical practitioner from Paro
District Hospital in 2018 were organised to enhance trainee teachers’ CSE knowledge.
Additionally, some trainee teachers participated in Y-PEER (Youth Peer Education) training
supported by UNFPA, where they learned about adolescent sexuality education.

Background
Knowledge
Research in the Bhutanese context has shown that more than 20% of young people
regard sex as a source of fun, pleasure and enjoyment (Dorji 2015). This may be lower than
in other countries, especially Western countries, and may reflect the morality-oriented
cultural norms in Bhutan and/or be an underestimate given probable reticence to
perceive taboo behaviours in a positive light. Adolescents can easily recognise the risks
associated with sexual behaviour but may be deficient in interpersonal and negotiation
skills and lack awareness of what might be available to assist them. They may also fear
rejection by services they perceive as adult-oriented and judgemental. They may be
correct in the view that many services treat adolescents and young people differently,
judge them, and even refuse services or insist that parents be involved in assessment and
interventions (WHO 2018).
There is evidence to show that the information about sex and sexuality provided to
young people is inadequate in Bhutan (Dorji 2015; Sherab et al. 2017, 2019). According to
Dorji (2015), in schools, the focus is largely on biological aspects of human sexuality.
Teaching tends to be didactic versus participatory, with an overemphasis on ‘risk, morality
and values’, rather than a more balanced, non-heteronormative approach recognising
pleasure. Rarely do teachers adopt a strengths-based approach which encourages critical
thinking. Of course, knowledge alone is not enough to change attitudes and practices,
social and cultural factors have an important role to play as part of sex and sexuality
education (Sherab et al. 2019; Tshomo 2016; Tshomo et al. 2018).
To help young people learn about sex, sexuality and sexual health, a variety of
resources in a variety of formats is essential. Millennials or Generation Y (Individuals
born between 1980 and early 2000s) are heavy Internet users and social networking has
been found useful in reaching diverse young people with important health information
(Dutt and Manjula 2017; Ralph et al. 2011), with Rizal and Dem (2018) noting the use of the
social media to enhance knowledge of sexual health in Bhutanese schools.
Parents or caregivers play a vital role in increasing knowledge and changing attitudes
and behaviour of their children (Guha 2013). With appropriate and respectful parental
monitoring, sexual initiation can be delayed, there is less frequent sexual intercourse, less
risky sexual behaviour, fewer sexual partners and pregnancies, and increased condom use
among young people.
630 U. TSHOMO ET AL.

Family values, culture and beliefs shape sexual attitudes and behaviours (Sherab et al.
2019; Tshomo 2016). Bhutanese society is male-dominated, with most power lying in the
hands of men and male notions of sexuality prevailing (The Bhutanese 01/03/2013). In
Bhutan, men can openly express their sexuality but woman must remain gentle, quiet and
shy. It is considered a social taboo to have sex before marriage or a child out of wedlock.
Openness to those of different sexual orientations remains limited.
Despite stigma and taboo surrounding discussion about sexual matters, the depiction
of the male sex organs is ubiquitous in Bhutan, especially during tsechu (annual religious
festivals) and on the walls of houses. The sale of wooden phalluses is popular and there is
even a fertility monastery (chimi lhakhang) with a well-attended phallus carrying cere-
mony for infertile woman (Tshomo 2016). Via these common beliefs and practices, the
very organ which can bring risk (and pleasure) is worshipped.

Attitudes
Attitudes are influenced by knowledge. Many young people hold favourable attitudes
towards having sex and discussing it openly. Attitudes can be influenced by tradition,
family beliefs and values (Dorji 2015; Sherab et al. 2019; Tshomo 2016). However, because
of tradition and culture, there is always a fear of being judged as a bad person by others in
the wider community when displaying a positive attitude towards an open and explicit
discussion of sexuality (Guha 2013).

Practices
Changing social and economic conditions in Bhutan poses new challenges, with potentially
negative social and health outcomes for young people (Dorji 2015). The rising teenage
suicide rate in the country is an indication that young people are vulnerable to a range of
pressures, including relationships and sexual and reproductive matters (Sherab et al. 2017).
The Bhutan National Health Survey (Ministry of Health 2012) noted more than 43% of
women aged between 15 and 49 reported having had their first pregnancy between 11
and 19 years of age. A recent school-based health survey found that of the 15% of
students who had sexual intercourse (23% male, 9% female), 50% of men and 47% of
women first had sexual intercourse before 14 years of age. About a quarter (24%) did not
use any form of contraception at last intercourse, and about 6% have had sex with
multiple partners (MoH and WHO 2017).
There is a significant positive correlation between the sexual behaviours portrayed in
the media and the sexual behaviours of the self and others (Dutt and Manjula 2017). Dutt
and Manjula (2017) note the positive relationship between greater knowledge and more
positive attitudes towards discussing sexuality. But greater knowledge does not necessa-
rily link to more active sexual behaviour (Weaver, Smith, and Kippax 2005).

Research question
Against this background, this study sought to explore what is the impact of comprehen-
sive sexuality education and other advocacy programmes on trainee teachers’ knowledge,
attitudes and practices with respect to sex and sexuality?
 SEX EDUCATION 631

Methods and materials

The study employed longitudinal survey method (Cohen, Manion, and Morrison 2011;
Cooksey and McDonald 2011) to explore trainee teachers’ knowledge attitudes and
practices about sex and sexual health at the beginning (2015 – baseline) and end
(2018 – post-intervention) of their four-year training programme.
Data were collected using an adapted version of the 2013 National Survey of Australian
Secondary Students and Sexual Health self-administered survey questionnaire (Mitchell
et al. 2014) after receiving relevant permission. University education in Bhutan is con-
ducted in the English language and no translation was required. However, the question-
naire was piloted for understanding, and expert advice was sought to refine and
accommodate to the Bhutanese setting.
The questionnaire contained six categories of questions focusing on growth and
development, sexual behaviour, understanding pregnancy and parenthood, STIs and
HIV, body image and healthy living, and behavioural issues. Section I of the questionnaire
collects socio-demographic information such as age, sex, parents’ educational level,
current relationship status and location. Section II included questions pertaining to
knowledge, while Sections III and IV ask questions related to attitude and practices,
respectively. Respondents completed the same questionnaire at baseline and post-
intervention data collection.
Ethics approval was received from the Centre for Educational Research and
Development at Paro College of Education of the Royal University of Bhutan, and
permission to conduct the survey was obtained from the respective college heads. All
students commencing teacher training in both colleges in 2015 participated, were briefed
about the objectives of the study and were requested to sign a consent form prior to
completing the survey.
Data from both the baseline (n = 380) and post-intervention (n = 350) surveys were
entered, screened and analysed using SPSS v22. The post-intervention data were col-
lected after almost four years, and there were 30 missing respondents for various reasons.

Findings
Demographic characteristics
Demographic information (baseline, n = 380 and post-intervention, n = 350) is provided in
Table 1.

Sexuality education
Findings show that more than 84% of the respondents had received formal instruction on
sexuality education during their schooling. However, further analysis showed that more
than 60% of the trainee teachers wanted more information about sexuality as indicated by
both the baseline and post-intervention data. Teachers (71.5%) topped the list of sources of
trainee teachers’ information on sex and sexual health, followed by health workers (70%)
and friends (69.5%). Parents and siblings (below 30%) ranked lowest in terms of the source
of information on sex and sexual health. Findings also indicate that women appeared to
632 U. TSHOMO ET AL.

Table 1. Demographic characteristics.

Baseline Post Total
Characteristic Category n % n % n %*
Gender Male 191 50.3 140 39.9 331 45.2
Female 189 49.7 210 59.8 400 54.6
Age Below 19 74 98.7 0 0.0 74 10.1
20–24 0 0.0 152 65.3 152 20.8
25 and above 0 0.0 81 34.7 81 11
College PCE 214 56.3 162 46.3 377 51.5
SCE 166 43.7 188 53.7 354 48.4
Marital Status Have a boyfriend/girlfriend 183 49.7 149 42.5 332 45.4
Are married 18 4.9 48 13.7 66 9.0
Are married and have a child 1 0.3 16 4.6 17 2.3
Have boyfriend/girlfriend and a child 1 0.3 4 1.1 5 .7
Are single 165 44.8 130 37.0 296 40.4
Are divorced 0 0.0 4 1.1 4 .5
You are raised by a family that is Nuclear (father, mother and siblings) 256 71.7 247 71.0 504 68.9
Extended (parents, grandparents, uncle, aunty) 45 12.6 40 11.5 85 11.6
Single (only mother) 25 7.0 30 8.6 55 7.5
Single (only father) 14 3.9 5 1.4 19 2.5
Father and stepmother 15 4.2 11 3.2 26 3.6
Mother and stepfather 2 0.6 11 3.2 13 1.8
Others 0 0.0 4 1.1 4 .5
Academic year residence Home 96 29.2 59 16.9 155 21.2
Dorm 204 62.0 175 50.0 379 51.8
Relative’s house 13 4.0 25 7.1 39 5.3
Rented apartment 16 4.9 86 24.6 102 13.9
Others 0 0.0 5 1.4 5 .7
*The percentages for each characteristic do not add up to 100% due to missing values

talk slightly more about puberty, love, HIV/AIDS and STIs, and pregnancy prevention with
their parents and other adults in the family compared to their male counterparts.

Levels of knowledge about sex and sexual health

There was an overall decrease in the percentage of respondents who said ‘nothing’ with
regard to various aspects of sex and sexual health (such as how much do you know about
growing up and changes in your body, sexual feelings and emotions, gender and
sexuality, etc.) from baseline to post-intervention, and a general increase in the percen-
tage of respondents who said ‘yes a lot’ indicating that there is a general increase in their
level of knowledge on sex and sexual health (see Table 2).
However, findings also suggest that even following intervention, there were trainees
who said they did not know anything, ‘yes a little’ about sex and sexual health, and no
more than 67% said ‘yes a lot’ on any individual item. Quite surprisingly, even after the
intervention, ‘knowledge of sexual abuse and harassment laws’ scored the lowest (27.4%).
Findings suggest that at post-intervention there remain trainee teachers who appear
to have confusion or lack knowledge on important aspects of sex and sexual health (see
Table 3). For instance, there were still some trainee teachers (3.1%) who viewed it as not
against the law to have sex with a boy or girl under the age of 16. Furthermore, 4% of the
respondents claimed that they did not know if it was against the law or not to have sex
with a boy or girl under 16 years. Likewise, 8.6% thought that condoms can be used more
than once and 18.3% indicated that they did not know if condoms could be used more
than once or not. Quite surprisingly, the percentage of trainee teachers who said ‘do not
 SEX EDUCATION 633

Table 2. Level of knowledge on sex and sexual health.

How much do you know about . . . ? Nothing (%) Yes a little (%) Yes a lot (%)
Growing up and changes in your body (i.e. puberty) Baseline 4.0 32.4 63.6
Post 1.1 31.4 67.4
Sexual feelings and emotions Baseline 8.6 66.3 25.1
Post 7.8 58.9 33.3
Gender and sexuality Baseline 5.4 59.1 35.5
Post 5.2 50.4 44.4
Responsibility and rights in relationships Baseline 6.4 44.8 48.8
Post 5.7 47.9 46.4
HIV/AID and STIs prevention Baseline 3.5 45.5 51.6
Post 2.0 40.7 57.3
Contraception (birth control) Baseline 3.5 45.5 51.1
Post 2.0 40.7 57.3
How to use a condom Baseline 24.0 45.9 30.1
Post 15.8 41.5 42.7
Pregnancy Baseline 8.3 52.8 38.9
Post 4.9 43.4 51.7
Alcohol and sex Baseline 13.8 52.5 33.7
Post 10.1 47.1 42.8
Drugs and sex Baseline 19.8 53.5 26.7
Post 15.8 47.4 36.8
Abortion Baseline 26.3 54.8 18.8
Post 18.0 50.1 31.9
Sexual abuse and harassment laws in Bhutan Baseline 11.7 67.0 21.3
Post 11.1 61.4 27.4

know’ with regard to many aspects of sex and sexual health increased (some even up to
53.6%) despite the intervention (see Table 3).

Attitudes towards providing information

According to the findings of this study, giving young people information about how to
obtain and use condoms and other contraception seems to have an impact on when the
trainee teachers will have sex, as one third (33.4%) of the participants who responded to
the baseline survey felt that such information would encourage them to have sexual
intercourse earlier. However, the post-intervention findings showed that this belief had
slightly decreased, as only 27.4% of respondents held the view that providing young
people with information about condoms and other contraception would encourage early
sex. Interestingly, findings showed that slightly more than half of the respondents in both
baseline and post-intervention data did not know whether giving young people informa-
tion about how to obtain and use condoms and other contraception would impact on
when they would have sex.

Attitudes towards sex and sexual health

Inspection of the mean differences (see Table 4) between baseline and post-intervention
suggests that the attitudes of the trainee teachers towards sex and sexual health had
generally improved.
634 U. TSHOMO ET AL.

Table 3. Knowledge about sex and sexual health.

True False Do not
Statement (%) (%) know (%)
It is against the law to have sex with a boy or girl who is under 16 Baseline 87.0 7.9 5.0
Post 92.9 3.1 4.0
Masturbation causes physical and mental harm Baseline 16.3 38.5 45.2
Post 19.1 27.4 53.6
Condoms can be used more than once Baseline 9.3 74.8 15.9
Post 8.6 73.1 18.3
All infections caught from having sex can be cured with medical treatment Baseline 12.2 56.4 31.4
Post 7.6 62.8 29.7
Even if contraception is used correctly, there is still a chance that a girl can Baseline 56.0 23.6 20.4
become pregnant. Post 65.6 12.6 21.8
You cannot buy condoms if you are under 16 Baseline 13.5 43.4 43.1
Post 9.1 42.9 48.0
It is possible to get pregnant if sperm gets near the opening of the vagina, even Baseline 16.9 31.5 51.6
though the penis does not enter the vagina. Post 21.4 25.1 53.5
Adolescents experience frequent and sometimes extreme changes in mood Baseline 65.3 2.7 32.1
Post 66.0 4.3 29.7
Once boys attain puberty, they can make a girl pregnant through unprotected Baseline 67.9 10.9 21.2
intercourse Post 68.2 10.0 21.8
A girl will stop growing after she has intercourse for the first time Baseline 9.8 36.6 53.6
Post 6.9 43.8 49.3
Sexual desire is biological need Baseline 73.9 9.3 16.8
Post 78.9 7.1 14.0
You can get pregnant having sex for the first time Baseline 30.9 31.2 37.9
Post 45.1 23.4 31.4
A girl can get pregnant if she has sex standing up Baseline 26.1 21.3 52.6
Post 33.4 15.0 51.6
A girl cannot get pregnant during her menstruation Baseline 53.7 21.4 24.9
Post 47.4 21.6 31.0
I know how to get free and confidential emergency contraception Baseline 30.3 9.5 60.3
Post 37.8 9.7 52.4
You can get infected with STIs during oral sex Baseline 24.7 33.3 42.0
Post 28.1 26.4 45.6
Someone with STI might not know about it Baseline 37.5 16.8 45.7
Post 34.3 15.0 50.7
For a boy, nocturnal emissions (wet dreams) means he is experiencing a normal Baseline 53.8 7.0 39.2
part of growing up Post 57.7 2.6 39.7

Sexual behaviour/practice
The sexual behaviour/practice of the trainee teachers can be considered under two sub-
themes – sexual intercourse and sexual experience.

Sexual intercourse
Almost three-quarters of the respondents (71%) reported having experienced sexual
intercourse (92.1% of the men and 57.6% of the women). ‘I loved the other person’
topped the list of reasons for having sex followed by ‘I wanted to try’ and ‘I was curious’.
For those who had not experienced sexual intercourse, the most popular response for not
having sexual intercourse was ‘I think it is too risky, you might get pregnant’ followed by ‘I
did not want to’ and ‘I think it is too risky, you might get [an] STI’. The mean age for the
first sexual experience was 19.4 years (male = 18.4 and female = 20.9).
 SEX EDUCATION 635

Table 4. Baseline and post-intervention comparison of attitudes towards sex and sexual health.
Baseline Post
Mean dif-
Item n M SD n M SD ference
1. During menstrual cycle girls are too weak to participate in sports or 376 3.63 1.24 349 4.00 1.15 +0.37
exercise
2. When women have periods people around feel sleepy 379 3.37 1.21 349 3.33 1.14 +0.04
3. Women having period should not visit holy places 377 3.47 1.31 349 2.95 1.35 +0.52
4. It is man’s role to initiate sex 375 2.77 1.03 351 2.62 0.98 +0.15
5. Boys should have more partners 375 1.85 1.05 344 1.68 0.97 +0.17
6. Girls desire sex as much as boys 372 3.27 1.20 345 3.37 1.09 +0.10
7. In a family, men should have more say over important decisions 378 2.49 1.30 350 2.17 1.21 +0.32
than women
8. It is more important for boys than girls to do well in school 377 2.24 1.29 347 1.92 1.09 +0.32
9. It is natural for a person to be sexually attracted to person of same 376 2.84 1.21 350 3.06 1.13 +0.22
sex
10. Sexual relations with someone of the same sex are wrong 376 3.12 1.24 346 2.62 1.07 +0.50
11. I believe there is nothing wrong with unmarried youth having 380 3.61 1.35 351 3.75 1.20 +0.14
sexual intercourse if they love each other and use protection against
pregnancy and STIs
12. It is acceptable for a girl or boy to get married below the age of 16 377 2.15 1.30 350 2.16 1.21 +0.01
years if their parents or other family members agree
13. A woman cannot refuse to have sex with her husband 378 2.90 1.35 345 2.66 1.28 +0.24
14. I am confident that I could insist on condom use every time I have 376 3.62 1.12 351 3.44 1.07 +0.18
sex
15. Girls should be more responsible than boys for contraception and 378 3.53 1.38 349 3.15 1.39 +0.38
protection
16. It is important to have sex once you are in a relationship 378 2.41 1.24 351 2.44 1.19 +0.03
17. Boys can also be sexually abused 379 3.63 1.07 349 3.97 0.91 +0.34
18. In a sexual act, it is necessary both partners agree 378 4.01 1.26 350 4.55 0.74 +0.54
19. Men have more rights than women when it comes to sex 376 2.39 1.18 350 2.01 1.04 +0.38
20. The way women dress can provoke sexual advances 377 3.58 1.15 348 3.61 1.15 +0.03
21. Sexuality is an acceptable topic for everyday conversation 378 3.51 1.10 349 3.62 1.05 +0.11
22. Women should not masturbate 377 2.90 1.12 349 2.56 0.94 −0.34
23. Sexual feelings, desires and fantasies are natural 376 4.30 0.88 349 4.20 0.85 −0.10
24. A person’s sexual behaviour is his/her own business and nobody 377 3.81 1.14 349 4.02 0.97 +0.21
should make value judgements about it
25. Men with multiple sex partners are gentleman 377 2.10 1.25 347 1.81 1.07 +0.29
26. Women with multiple sex partners are prostitutes 377 3.56 1.25 344 2.97 1.39 +0.59
27. Premarital sex is morally wrong for girls 373 3.43 1.07 343 3.14 1.04 +0.29
28. It is acceptable for someone to send sexually explicit materials 373 2.53 1.26 347 2.20 1.14 +0.33
through social media
29. It is acceptable to hear someone speak sexually explicit 374 2.95 1.27 346 2.73 1.15 +0.22
conversation to you
30. Avoiding pregnancy is primarily a woman’s responsibility 376 3.56 1.21 348 3.07 1.31 +0.49
31. Fathers are equally responsible for the unwanted pregnancy 375 4.19 0.91 348 4.27 1.06 +0.08
32.A relationship doesn’t have to include sex 370 3.99 1.05 349 3.71 1.22 +0.28
33. Young people are more likely to have unprotected sex under the 379 4.0 0.96 347 4.12 0.96 +0.12
influence of alcohol and drugs
34. It is sinful to masturbate 377 3.01 1.11 349 2.73 1.02 +0.28
35. Religious beliefs influence one’s sexual behaviour 377 3.15 0.95 345 3.13 0.97 +0.02
36. Skinny girls are more attractive than fatter ones 379 3.31 1.13 346 2.97 1.14 +0.34
37. Happiness depends on physical appearance 377 2.77 1.27 341 2.68 1.13 +0.09
38. Once a man gets sexually excited, he cannot control himself-he has 379 3.18 1.11 348 3.13 1.06 +0.05
to have sex
39. Boys abused by women are lucky 379 2.68 1.08 347 2.44 1.03 +0.24
40. Only people having many sexual partners have STDs 377 2.71 1.28 348 2.80 1.21 +0.09
41. People who have HIV should be isolated from the society 373 1.92 1.32 348 1.76 1.11 +0.2

Sexual experience
Findings indicate a slight improvement in trainee teachers’ overall sexual experience
when compared to the pre-intervention period. Students’ frequency of condoms and
636 U. TSHOMO ET AL.

Table 5. Sexual experience.

Baseline Post
Have you done or experienced any of the following M SD M SD Mean difference
Used condoms 1.51 .85 1.92 .87 +.41
Had sex with more than one partner 1.31 .64 1.37 .62 −.06
Was forced to have sex 1.13 .37 1.18 .43 −.05
Involved in a gang fight 1.19 .53 1.11 .43 +.08
Talked openly about sex with a boy/girl friend 1.88 .91 2.13 .88 +.25
I go for check-up for HIV/STIs 1.26 .63 1.39 .66 +.13
Used other contraception 1.20 .53 1.47 .64 +.27
Tested for pregnancy 1.15 .45 1.29 .52 +.14
Intoxicated with alcohol/drugs 1.28 .58 1.30 .54 −.02
Undergone an abortion 1.05 .25 1.04 .26 +.01
Diet to maintain my figure 1.30 .59 1.27 .50 +.03
Got hit by your partner 1.32 .74 1.14 .49 +.18
Wash my genital parts 3.01 1.08 3.20 .98 +.19
Use erotic materials/web pages for sexual pleasure 1.36 .64 1.33 .65 +.03
Have sex even when you or your partner does not want to 1.23 .59 1.26 .49 −.03
I can turn down a sexual advance 1.65 .92 1.64 .87 +.01
I can deal with anger without hurting others or damaging things 1.92 .90 2.21 1.01 +.29
I visit hospital when I have discomfort around my genitals 1.70 .92 1.73 .85 +.03
Have you ever felt discriminated about your body 1.41 .67 1.37 .62 +.32
I take marijuana 1.22 .57 1.12 .39 +.1
I smoke 1.39 .72 1.36 .68 +.03
I have more sexual partners than my friends 1.15 .46 1.15 .46 0

other forms of contraception use, check-ups for HIV/STIs, not dieting to maintain their
figure, and washing their genital organs slightly increased. However, the findings also
reveal that there are still many trainee teachers who have sex with more than one partner,
force someone to have sex, and get intoxicated with alcohol and other drugs before
having sex (see Table 5).

Discussion and implications

The objective of this study was to explore and examine the impact of a comprehensive
sexuality education programme on trainee teachers in two teacher training colleges, but
the findings raise issues broader than the CSE curriculum itself and its delivery. While
there was some improvement in trainee teachers’ level of awareness of sex and sexual
health at the end of the four-year training programme, there are areas requiring attention.
It is encouraging to note that teachers topped the list of trainee teachers’ sources of
information on sex and sexual health followed by the health workers and friends. Parents
and siblings were at the bottom of the list. Such findings have implications if family
members are to play a more active role in educating their children about sex and sexual
health. There is evidence from other countries to show that appropriate forms of parental
monitoring and less parental permissiveness may help delay sexual initiation, and encou-
rage less risky sexual behaviour, fewer sexual partners and unplanned pregnancies, and
increased condom use among young people (Guha 2013; Li et al. 2000; Miller et al. 1999;
Romer et al. 1994; Wang et al. 2007). Given Bhutanese culture, in which children have
great respect for their parents, parents have the potential to make an impact on the lives
of their children alongside teachers.
 SEX EDUCATION 637

While there was some improvement in terms of trainee teachers’ knowledge about sex
and sexual health, the findings largely corroborate those of previous studies suggesting
that adequate and appropriate knowledge about sex and sexual health has not reached
the majority of Bhutanese young people (Dorji 2015; Sherab et al. 2017, 2019). For
instance, among this educated sample of young Bhutanese, only about one quarter of
the respondents agreed that they know a lot about sexual abuse and harassment laws.
Less than 50% of respondents said they knew a lot about growing up and body changes,
sexual feelings and emotions, gender and sexuality, responsibility and rights in relation-
ships, HIV and STIs prevention, contraception, how to use a condom, pregnancy, termina-
tion of pregnancy, and influence of alcohol and other drugs on sexual behaviour. Some
trainee teachers held the perception that condoms can be used more than once, they
think that a girl will stop growing after she has intercourse for the first time, and they think
that masturbation can cause physical and mental harm.
The general improvement observed in the attitudes of trainee teachers towards sex
and sexual health was a positive development. However, overall the intervention pro-
grammes did not make a huge impact. This has implications for the stakeholders. It is
concerning that after the comprehensive sexuality education programme still about one
quarter of the trainee teachers held the belief that providing information about condom
use and other contraception would encourage early sex rather than delaying it.
Findings revealed that there was some improvement evident in condom use and other
forms of contraception among more than 70% of the trainee teachers who were sexually
active. However, there is a need to continue promoting practices such as using condoms
for safer sex, going for regular check-ups, not forcing someone to have sex, and avoiding
sex when under the influence of alcohol and other drugs.

Conclusion and recommendations

Based on the findings of this study, some recommendations can be made. First, the
existing CSE module would benefit from further review, with active trainee teacher/
consumer participation in the revisions and in preparing new content. Any review
would benefit from forming and/or strengthening partnerships with key diverse stake-
holders (Fenaughty 2019). The review should include evidence-informed information to
ensure: ‘balance’ in content and presentation; the removal of ‘moralistic’ content; discus-
sion on pleasure and positive sexuality; inclusion of diverse sexualities; increased partici-
patory learning; content on the impact of stigma and discrimination; and the impacts of
sex and sexuality-based bullying (Ezer et al. 2019a, 2019b). As Ezer et al. (2019a) conclude:
In order to better young people’s sexual health knowledge, it is necessary to provide sexuality
education that is nuanced to the differing needs of young men, women and LGBT persons;
that serves as a basis for clarifying and reinforcing knowledge acquired elsewhere; and which
is age appropriate. (611)

Second, for greater impact, it may be valuable to ensure multi-modal delivery such as via
face-to-face in groups, the integration of digital technology, the use of games, and the use
of social media. For instance, the computer-based The World Starts with Me
(Vanwesenbeek et al. 2016) Comprehensive Sexuality Education delivered in resource-
poor settings package might provide a model for some pre-service CSE delivery in
638 U. TSHOMO ET AL.

colleges, as well as for continuing education. This could be especially useful in settings
with geographical and infrastructure issues, such as Bhutan.
Multi-component approaches, bringing together actions to improve individual
empowerment, strengthen the health system and create a more Sexual and
Reproductive Health and Rights supportive environment, have been regarded as crucial
for some time. These approaches are more effective and sustainable than single-
component interventions (Vanwesenbeek et al. 2019).
Third, while a few youth-friendly health services exist in Bhutan, there remains a need for
better forms of sexual and reproductive health service provision for young people. These
might include the provision of accessible, appropriate and confidential youth-friendly clinics
(on and off campus) offering a comprehensive menu of services and activities such as rapid
screening and testing for STIs and pregnancy, nutrition and other health problems including
mental health issues. Services might also include access to mentors; peer-to-peer delivery;
school/college counsellors and nurses; and interactive online resources; as well as free male
and female condoms and lube (WHO 2018b). The Happiness and Well-being Centres being
implemented across the Royal University of Bhutan campuses, with a digital platform and
apps in addition to counselling services could be an ideal on-campus home (Namgay 2019).
Via such means, vital knowledge about sexuality and available services would be available
for all college students, not only trainee teachers.
Fourth, given evidence from other contexts, it is crucial that Bhutanese parents be
encouraged to play a more active role in providing sex and sexuality information to their
children. This effort should complement the effort made by the schools and health
workers. Case study research into successful parental practices could be carried out in
the future to add to the existing literature.
Fifth, earlier research has shown that media influence sexual behaviour (Dutt and
Manjula 2017; Rizal and Dem 2018). Today, online sources and social media are emerging
as an alternative source of sex education offering the ‘benefits’ of anonymity, speed of
information delivery and 24-hour a day availability, especially in contexts where cultural
norms can constrain more formal curricula and pedagogical approaches (Thianthai 2018).
While it was beyond the scope of this study to explore the influence of social and other
media on trainee teachers, the influence of the media on developing attitudes and
practices cannot be ignored (European Expert Group on Sexuality Education 2016).
Sixth, studies concerning the sex and sexuality of young people are often conducted
from within a positivistic tradition and there is a lack of interpretivist accounts. Mixed-
methods evaluations may better bring to light the impact of the broader cultural context
(e.g. the dominant ‘messages beyond the classroom’) and the attitudes and values that
require addressing among pre-service trainees (Browes 2015). Emerging evaluation meth-
odologies for the evaluation of CSE in schools could also be modified for teacher educa-
tion and training. For instance, Keogh et al.’s (2019) index to measure the quality of CSE
implementation in low- and middle-income countries identifies seven key components of
a successful programme: range of topics, values imparted, teaching methods, teacher
training, resources available, monitoring and evaluation, and the school environment.
 SEX EDUCATION 639

Limitations
All studies have their limitations. In this study, there were 30 dropouts in the post-
intervention survey, implying that loss to follow-up was greater than 5%. This sets limits
on the validity of any differences observed. As the study was carried out in the only two
teacher training colleges of the Royal University of Bhutan (PCE and SCE), the findings
cannot be generalised to the students elsewhere in the university. However, the partici-
pants in the study comprised all commencing teacher training students at Bhutan’s only
two teacher training colleges in 2015, and thus can be regarded as reasonably represen-
tative of recent teacher trainees in the country.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by the UNFPA Bhutan [N/A].

ORCID
Kezang Sherab http://orcid.org/0000-0003-2002-6868

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