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This is the cultural context that numbers of Kenyan women and girls are fighting against. Even if they do not want to undergo the cut, many will in order to uphold tradition, please their families and secure good marriages. In Marsabit, other girls said that they wanted to be circumcised to appeal to their prospective partners. One 18-year-old girl’s well-to-do Catholic parents did not want her to undergo FGC; but she was dating a handsome Rendille man, two years older, who had told her that he would never marry an uncut woman. So, the girl insisted that her parents allow the practice, threatening suicide if they did not agree.
We recruited a cohort of AGYW aged 16-20 in Thika, Kenya between 2014 and 2016. Thika is located on hour from Nairobi and residents live in a suburban setting. A community advisory group composed of individuals with positions of influence within the community (including school principals, peer counselors, health care workers, district chiefs/administrators, religious leaders, women's groups) assisted with community engagement by introducing the study staff as health care workers conducting a research study with the aim of teaching young girls about reproductive health and preventing HSV-2. For those interested in the study, girls aged 16-17 were accompanied by their guardians to hear a health presentation, and if they desired participation, subsequently screened for the study. Those aged ≥18 years came independently for screening. We initially sought AGYW who reported no prior history of sexual intercourse. The protocol was subsequently amended to include those who reported only a single sex partner. Sex was defined as vaginal penetrative intercourse. The eligibility criteria were not divulged to potential study participants or to individuals outside of the study; parents/guardians did not learn whether their child met eligibility criteria. Potential participants needed to be willing to undergo external genital examinations and remain in follow-up for 3 years. Guardians who consented to study screening and participation for girls <18 years were informed that, after enrollment, all interactions between participants and study staff would remain confidential.
Study approval was obtained from the Kenya Medical Research Institute Scientific Ethics Review Unit, and the University of Washington Institutional Review Board. For participants under age 18, written informed assent was obtained, and written informed consent obtained from a parent/guardian. Assent was obtained separately and privately from parents/guardians, to allow participants to ask questions and to decide whether they wanted to participate free of parental influence. For participants age 18 or older, written informed consent was obtained. Participants received free, confidential medical services including contraception, HIV testing and condoms, and psychological counseling services. Participants also received transportation reimbursement for each study visit attended.
Among the 78 participants who reported one lifetime sexual partner, the median age at first sexual intercourse was 18.7 years, and the median age of the sexual partner was 22 (IQR 21-24) (
This research was funded by R01 HD091996-01 (AR) from NICHD, by P01 AI 030731 (AW), and by the Center for AIDS Research (CFAR) of the University of Washington/Fred Hutchinson Cancer Research Center AI027757. The funders had no role in study design, data collection, and analysis, or preparation of the manuscript. Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Washington funded by UL1 TR002319, KL2 TR002317, and TL1 TR002318 from NCATS/NIH.
The measure we developed addresses only the range of topics taught, not other essential components that may determine the comprehensiveness of a sexuality education program, such as integration of youth and community engagement into curriculum development, use of participatory teaching methods, safety of the learning environment, and links to SRH services and other initiatives that address adolescent sexual and reproductive health (ASRH) issues.
Nearly all key informants agreed that sexuality education offered in secondary schools was not comprehensive. The curriculum is focused on biology and excludes topics related to SRHR, and the approach was described as purely academic with little attention to improving students’ practical skills. There were differences in opinion among respondents regarding what content should be covered in a “comprehensive” program. Several noted that sexuality education must include information on contraceptives and pregnancy prevention, and take a holistic approach to education to provide adolescents with the requisite skills to transition to adulthood. Others insisted that topics such as abortion, contraceptives and sexual orientation should be excluded from sexuality education initiatives targeting adolescents. Respondents who held a more restrictive viewpoint cited religious and cultural inhibitions about discussing sexual matters with students, and some stakeholders opposed inclusion of topics related to contraceptives because such information was deemed to encourage teenage sex. The evidence base, however, shows that making the link between improved access to contraceptives and increased sexual activity among adolescents is an incorrect belief.
Another notable challenge identified by key informants is the centralization of education in Kenya. The majority noted that in theory, centralization ensures national investments in teacher training and curriculum development, wider coverage of programs and continuity of content delivered in schools across the country. However, it was also noted that a decentralized approach to school-based sexuality education would allow for programs to be adapted to different contexts, would reduce bureaucratic delays and barriers, and would encourage counties to prioritize the needs of adolescents and young people. Key informants elaborated on several of these issues:
The vast majority of students in our study were first exposed to topics related to sexuality education in primary school (96%), while 4% were first exposed in junior high school. The majority of students (65%) began sexuality education in Standard 6 (on average, students in this standard are 12 years old), and 85% of students had received teaching on sexuality education by the time they completed that year. One-fourth (26%) of the students in our sample (mostly aged 15–17) had already had sex—42% of males and 15% of females (see
Comprehensive sexuality education programs seek to teach adolescents to exercise their sexual and reproductive rights safely and responsibly by recognizing that sexual activity at their age is normative. Most students surveyed, however, reported a fear-based and prescriptive tone in the messages they received. Three-fourths reported that their teachers very strongly emphasized that they should not have sex before marriage and that having sex is dangerous for young people. Fewer than half of all students reported that the message to avoid having sex, but to use condoms if they do, was very strongly conveyed. For all of these messages, there were significant student reporting differences among the counties, and for the first two messages, differences were also observed between students attending public versus private schools.
