“Why do people do sex?” an analysis of middle school students’ anonymous questions about sexual health

ABSTRACT Sexual health education should meet the needs of all students. One strategy educators can use to ensure instruction meets students’ needs is to encourage the submission of anonymous questions, allowing students to gain information without fear of instructor or peer reactions. We investigated anonymous questions submitted by middle school (7th-grade, ages 12-13) students during a sexual health education curriculum in Ohio, USA. Questions (n=893) were organised into 12 categories: reproductive anatomy (n=186), LGBTQ+ topics (n=130), sexual behaviour (n=120), class-related questions (n=99), pregnancy (n=78), slang (n=52), STIs (n=44), protection/birth control (n=33), relationships (n=19), consent (n=14), health services (n=9), abstinence (n=1), and unrelated questions/comments (n=108). After categorising questions, we conducted thematic analysis with the three largest categories (reproductive anatomy, LGBTQ+ topics, sexual behaviour). Results revealed students wanted to know about the normality of the processes and functions of their bodies. Students also expressed concern and had internalised social norms about LGBTQ+ topics. Student questions about sexual behaviour suggested they wanted to learn more about the purposes and processes of sex, e.g., how people have intercourse. Findings underscore the need for inclusive, comprehensive and medically accurate sexual health education for early adolescents. We discuss implications for student health/well-being, educator development, and school staff.

overall have been made to categorise anonymous questions based on health education standards or tools provided by reputable health promoting organisations such as the US Centers for Disease Control and Prevention (CDC).There is a need to understand the types of anonymous questions students may have and the topics they entail.Additionally, there also is a need to understand student anonymous questions in relation to the instructional tools teachers typically utilise.This is especially important given current public debates about the various sexual health education topics taught within schools (e.g.LGBTQ+ [lesbian, gay, bisexual, transgender, queer/questioning, and others] subject matter, contraceptives; Young 2022), and the age at which students should receive sexual health education.
This article presents novel research entailing an analysis of middle school students' anonymous questions during a comprehensive, sexual health education unit.Student anonymous questions were identified and analysed in relation to the Centers for Disease Control and Prevention's (2019a).Healthy Behaviour Outcomes found in the Health Education Curriculum Analysis Tool (HECAT).This article focuses on the gap in the literature in understanding young adolescents' questions about sexual health topics within human sexuality education, and does so within the framework of health education standards and teaching tools.Understanding anonymous questions within a framework of health education standards and tools can help identify gaps in content coverage, with the goal of meeting national health education standards.

Anonymous questions
Good quality health education programmes should address the needs of all students.One strategy teachers have used to address student needs during sexuality health education is allowing students to ask anonymous questions.The function of anonymous questions is for students to have the opportunity to ask questions specifically and tangentially related to curricula.Teachers can encourage students to ask anonymous questions via a variety of strategies.For example, teachers can place a box in the classroom where students can submit questions they have written on paper.In recent years, technology-based strategies for soliciting anonymous questions have also been used.Examples include using anonymous forms in a teacher learning management system or anonymous emails sent to online question portals (e.g.Allsop et al. 2023;Buzi, Smith, and Barrera 2015).
One of the earliest reviews of school-based sexuality curricula found that 22 of 23 reviewed curricula utilised an anonymous questions box (Ogletree et al. 1995).Expert health teachers, sexuality education experts, and researchers have recommended having a permanent anonymous questions box so teachers can regularly connect with students by answering their questions and promoting discussion to combat stigma and discomfort with topics related to sexuality (e.g.Radhika et al. 2019).Implementing anonymous questions within curricula has been employed internationally.For example, researchers in Mexico (2022) utilised anonymous questions within a sexual health education intervention to learn more about young people's concerns and questions pertaining to dating relationships and sexual health (Rodriguez et al. 2022).
The opportunity to ask anonymous questions may be particularly worthwhile during early adolescence, for several reasons.First, early adolescence is the period during which changes associated with puberty begin to occur (Wigfield, Byrnes, and Eccles 2006).While such changes may not be visibly evident to students' peers, the use of anonymous questions provides individuals with opportunities to pose questions pertaining to their own experiences they might not be comfortable asking in the presence of peers.Second, during early adolescence, students' comfort in discussing personal issues with parents or caregivers often declines (Gutman and Eccles 2007); the ability to anonymously ask questions of teachers, who may be viewed as trusted adults (Meltzer, Muir, and Craig 2016), provides students an opportunity to seek answers to questions that might remain unanswered, or be answered by untrustworthy sources without this opportunity.
There are several benefits to using anonymous questions.First, this strategy can easily be employed with large or small groups of students.Prior studies on anonymous questions have ranged from studies conducted in one classroom or setting, to large-scale studies, such as over 24 classrooms at one time (Francisca, Goldfarb, and Constantine 2014).All students have equal opportunity to submit questions when anonymous questions are used, and students often experience less anxiety in submitting questions anonymously rather than asking questions directly in front of their classmates and teachers.The protection and privacy afforded to individuals when teachers utilise anonymous questions may be particularly important to help prevent bullying or marginalisation of students who are not considered part of the majority, such as gender or sexuality minority youth, as many already experience greater bullying in schools when compared to their peers (Espelage, Merrin, and Hatchel 2016).Additionally, adolescents have reported that the use of anonymous questions during sex education helps to increase comfort in the learning environment (Brown, Sorenson, and Hildebrand 2012).
A second benefit of using anonymous questions is that content of the questions may be utilised to inform subsequent teaching.Performing one of the earliest analyses on anonymous questions within sexual health education, Davis and Harris (1983) analysed 288 questions and found that the top three categories were reproduction, sexuality and contraception (generating 51, 48 and 43 questions each respectively).These subjects are generally recommended for inclusion in sexual health education courses (Centers for Disease Control and Prevention 2019a, 2019b, 2020).The use of anonymous questions provides teachers with invaluable information about topics that students want to learn about, and about the types of questions that students have during instruction (Sally et al. 2013).Using anonymous questions may enable teachers to better plan future activities, such as large group question and answer sessions surrounding one or two specific topics, as Gordon suggested in one of the first published works discussing sex education in schools (Gordon 1974).A third benefit of anonymous questions is that analysis of the anonymous questions can aid in helping teachers to understand how well their students are comprehending the topics being taught.Misconceptions in students' anonymous questions may indicate underlying lack of knowledge regarding human sexuality, anatomy, STIs and pregnancy prevention, or any other topic discussed within human sexuality education (Wynn, Angel, and Trussell 2009).Generally, analyses of anonymous questions has led researchers to emphasise the need that still exists for greater comprehensive sexual health education for young people (Pariera and McCormack 2017).
Research on anonymous questions submitted during sexual health education courses has primarily focused on high schoolers, college students and adults (e.g.Buzi, Smith, and Barrera 2015;Pariera and McCormack 2017;Valois and Waring 1991).However, some studies have focused on younger individuals or combinations of younger and older teenagers.For example, Davis and Harris (1983) analysed anonymous questions from 288 students ages 11-18.Rodriguez et al. (2022) analysed questions specific to dating and relationships from 112 Mexican middle schoolers, and Linda, Lee, and Erkut (2012) also analysed 859 anonymous questions from 795 sixth graders who participated in an evaluation of a sex education curriculum.Previous categorisations of the themes found in student anonymous questions have been guided by how the anonymous questions relate to common categories within sex education (e.g.pregnancy prevention, STI prevention, etc.), constructing themes as analysis occurs (e.g.Linda, Lee, and Erkut 2012).Little to no research has focused categorising anonymous questions based in national health education standards (where they exist) or reputable tools provided by reputable organisations, such as the US CDC.

Sexual health education tools
In the USA, there are no nationally mandated K-12 sexual health education standards.This is due to law which prohibits federal government officials from imposing any type of direction or control (i.e.standards) over curriculum instruction programmes, administration/personnel of educational institutions, and school systems (USDOE [U.S.Department of Education] n.d.).Thus, curricular decisions are left to individual states and local agencies, resulting in state standards varying considerably.However, many states use established frameworks and tools created by government organisations, such as the US CDC, to develop local and statewide K-12 health education standards (Centers for Disease Control and Prevention 2019b).The CDC promotes quality sexual health education standards based in scientific research and best practices which provide developmentally appropriate and culturally relevant skills for students (Centers for Disease Control and Prevention 2020).It should be noted that non-government entities in the USA also promote sexual health education educational standards and tools (e.g.SHAPE America, (n.d.)).However, all standards and tools are not necessarily easily accessible to those involved in health education throughout the country, whereas CDC tools are.CDC tools that exist for aiding in development and implementation of effective sexual health education include Developing a Sexual Health Education Scope and Sequence (Centers for Disease Control and Prevention 2016) and the Health Education Curriculum Analysis Tool (Centers for Disease Control 2019a).The HECAT is designed to specifically help educators in schools, state education agencies, curriculum developers, and faculty and students in teacher preparation programmes to identify, assess, revise and develop health education curricula best suited to ensure quality health education specific to the needs and practices of individuals within their communities (Centers for Disease Control and Prevention 2020).
In promoting healthy behaviours as part of the general sexual health education framework, K-12 school-based sexual health education should be based on medically accurate, developmentally appropriate, culturally inclusive, and research-based information, and should promote knowledge, skills, and prevention-focused behavioural outcomes (Breuner et al. 2016;Centers for Disease Control and Prevention 2016, 2019a, 2020).Examples of prevention-focused behavioural outcomes include practising and promoting abstinence, or properly using a condom when engaging in various sexual activities.The HECAT identifies healthy behaviour outcomes as end-result behavioural outcomes of students participating in various aspects of health curricula, including topics such as physical activity, food and nutrition, violence prevention, and sexual health (Centers for Disease Control and Prevention 2019a).The HECAT recommends ten health behaviour outcomes for sexual health curricula.They are presented in Figure 1 (Centers for Disease Control and Prevention 2019a).Prevention-focused behavioural outcomes of practising abstinence or properly using condoms when engaging in sexual activity coincide respectively with health behaviour outcome 5 (Be sexually abstinent) and health behaviour outcomes 6 (Engage in behaviours that prevent or reduce sexually transmitted disease (STIs), including HIV) and 7 (Engage in behaviours that prevent or reduce unintended pregnancy).

The present study
Given the benefits that may arise from utilising anonymous questions during a sexual health education unit or course, and noting the need to examine the types of anonymous questions generated by younger adolescents (i.e.middle school students), the purpose of this study was to examine the topics and types of questions young adolescents have while receiving a comprehensive, inclusive, and medically accurate sexual health education curriculum.The novel use of the HECAT health behaviour outcomes allowed us to organise findings by topic.Such organisation has the potential to inform curriculum in a rigorous, high-quality manner, in accordance with national health education tools.Our analyses centre on student perspectives and add to the literature available for those preparing to teach sexual health education courses.The following research questions guided this study: (1) What are the most common topics found in 7 th -grade students' anonymous questions asked during sexual health education?(2) What types of anonymous questions do 7 th -grade students have during sexual health education?
A pre-K-12 sexual health curriculum should enable students to: HBO 1 Recognise developmental changes experienced by self and others during childhood and adolescence.HBO 2 Establish and maintain healthy relationships HBO 3 Treat all people with dignity and respect with regard to their gender identity and sexual orientation.HBO 4 Give and receive consent in all situations.HBO 5 Be sexually abstinent.HBO 6 Engage in behaviours that prevent or reduce sexually transmitted infections (STIs), including HIV.HBO 7 Engage in behaviours that prevent or reduce unintended pregnancy.HBO 8 Support others to avoid or reduce sexual risk behaviours.HBO 9 Avoid pressuring others to engage in sexual behaviours.HBO 10 Use appropriate health services to promote sexual and reproductive health.

Participants
This study was approved by the institutional review boards belonging to the hospital/ university partners conducting this research.Participants were 7 th -grade students from 18 urban middle schools in Ohio.Public enrolment data indicated 2,668 students attended 7 th grade in the schools in the year this study took place (ODE [Ohio Department of Education] 2022).Students attending 7 th grade in the USA are typically between the ages of 12-13.Due to the anonymity of the questions, the number of students that submitted anonymous questions is unknown, as is demographic information.However, as part of programme evaluation, students were invited to respond to surveys, reporting their demographic information (Table 1).Thus, the information provided offers a demographic overview of students who had the opportunity to ask anonymous questions, although it should be noted that students who submitted anonymous questions may not have responded to surveys, and vice versa.Because participants cannot be fully described, the setting of the study is described, enhancing the transferability of findings.
The region where this study was conducted has above average rates of teenage pregnancy, infant and maternal mortality, and cases of sexually transmitted infection.Racial disparities in rates of teenage pregnancy, infant and maternal mortality, and STIs also exist, with Black and Latinx individuals disproportionately affected (ODH Ohio Department of Health n.d.).Because of these health disparities, students in the district where this study took place were provided with sexual health education during grades seven and eight using the Get Real curriculum (Planned Parenthood 2014).This decision was made by stakeholders which included the school district, the city government, a local university, and the local children's hospital.Get Real instruction was offered as an opt-out programme, meaning that students participated unless their parent/guardian submitted an electronic form indicating they did not want their child to receive Get Real.
Get Real is a 27-lesson sexual health education curriculum divided into nine lessons delivered in each of grades six to eight, and aligns with standards represented in the HECAT, including provision of comprehensive, inclusive, and medically accurate information.Get Real emphasises informed decision-making and engages parents/guardians in the sexuality education process (Planned Parenthood 2014).Get Real is also intentional in its aim to create an inclusive environment through language use and topics taught, teaches about sexuality openly and honestly (i.e.without fear, shame or stigma), and emphasises sexuality education as a right and lifelong process (Planned Parenthood 2014).In grade 7, students received 9 lessons, typically occurring over the course of two school weeks.Each lesson was taught in a class period lasting 45-50 minutes.

Instrumentation
During each Get Real lesson, held virtually due to the COVID-19 pandemic in autumn 2020, students were provided with a link to an anonymous Google Form asking, 'What is your question?Write it below!' Students were allowed to submit as many questions as they wished and were not limited to one question per session.They were also informed their questions would be answered in the next lesson.

Procedure
Students submitted anonymous questions at the end of each lesson using Google Forms.
Instructors synthesised and answered those questions at the beginning of the next class.All questions were compiled into a single Excel document organised by date, lesson, school, instructor, and class period by the second author.The lead author used the health behaviour outcomes from the sexual health curriculum module in the HECAT (Centers for Disease Control and Prevention 2019a) to guide question topic identification.Three topics not included in the health behaviour outcomes were added, pertaining to sexual behaviour, sexual slang terms, and class-related questions (e.g. the lesson).These additional topics were identified and added based on patterns found in the questions, namely topics and word usage, not easily connected to any of the health behaviour outcomes.Two health behaviour outcomes (8 and 9; see Figure 1) were unrelated to student questions and therefore were not utilised.After categorisation of the anonymous questions, we identified the three categories with the greatest number of questions, and we subsequently used those questions for analysis.

Data analysis
Data were analysed using thematic analysis (Braun and Clarke 2006).A combination of deductive and inductive analyses took place, allowing for the organisation of a large amount of data using a well-known health framework while still allowing meaning to be derived inductively from student questions.We identified topics semantically, based on the explicit meaning of the questions that students asked within a category; we then interpreted the topics for deeper understanding of the meaning or significance of these identified patterns in the data (Braun and Clarke 2006).First, the first [YA] and second [AB] authors read the responses multiple times.The first author categorised the questions, after which the second author reviewed the categorisations to determine agreement; for example, in some cases a question might have reasonably fit in multiple categories.When this was the case, the first and second author discussed the topic it best aligned with, relying not only on mutual interpretation of the question, but other indicators such as the topic of the lesson in which the question was asked.Once we reached agreement on categorisation, the second author assigned codes, and then the first author reviewed those codes.The two coders discussed any disagreements.Consensus was reached on all categorisations and codes.Based on the coding procedure, topics were advanced and discussed between authors one and two.
The trustworthiness of findings presented here is supported by several factors (Lincoln and Guba 1985).Credibility is supported by the researchers having prolonged engagement with the data (Nowell et al. 2017), as they compiled each question systematically according to school, instructor, lesson, class period, and date; organised questions by topic, and analysed all responses.Authors one and two were both involved in the data analysis process and discussed all decisions, which adds to the credibility of findings (Nowell et al. 2017).We also documented decisions made about categorisation and coding of anonymous questions, particularly those which the authors discussed in order to reach agreement, adding to dependability.Finally, we provided a detailed description of the setting in which this research took place in order to support transferability.Establishing credibility, dependability, and transferability contribute to the confirmability of findings presented herein, lending to the overall trustworthiness of the research (Lincoln and Guba 1985;Nowell et al. 2017).

Results
Student questions aligned with 12 categories, including reproductive anatomy, sexual behaviour, LGBTQ+ topics, pregnancy, STIs, protection/birth control, slang, relationships, consent, abstinence, health services, and class-related questions.See Figure 2 for examples and frequencies for each category.Thematic analysis of the three categories with the greatest number of questions revealed that adolescents had questions about reproductive anatomy and functions, sexual orientations and gender identities, and the purposes and processes of sexual behaviour.Across categories, many questions also expressed concerns about normality pertaining to human sexuality.Descriptive statistics are provided, followed by presentation of topics and sub-topics from the three largest categories identified in the data. 1 Keeping in line with traditions of semantic thematic analysis (Braun and Clarke 2006), we present the patterns found in the data in the results section, and we interpret the meaning of these patterns in the discussion section.

Descriptive statistics
Students across the 18 schools submitted 893 questions (averaging 49.6 questions per school, range = 1-189).The average number of questions per lesson was 99.2.Patterns suggested students asked the most questions during lessons 1-4 (Figure 3).Question frequency patterns within the three major categories were similarly distributed, apart from questions about sexual behaviours, for which frequencies were more evenly dispersed across lessons.

Reproductive anatomy and functions
Students asked 186 questions about human reproductive anatomy.Four topics in the category of reproductive anatomy were identified: biologically female anatomy (n = 91), biologically male anatomy (n = 47), anatomy and arousal (n = 23), and other questions about the body's reproductive organs (n = 48).

Biologically female anatomy
Of the 91 questions about female anatomy, 60 were about periods (menstruation), making this the largest subtopic.Students most often asked about period care products, especially tampons (e.g.'How do you insert a tampon for the first time?').Students had many questions about thefrequency of periods and their 'normality', such as, 'So it's normal to miss your period?' Finally, students expressed curiosities about periods, including, 'Why does everyone always think that periods are so embarrassing?' and 'Why are girls a little moody on their periods?'Other questions about female anatomy pertained to specific reproductive organs, such as asking about location and function of various body parts.

Biologically male anatomy
Questions about male anatomy were most often about the penis (n = 25) and testes (n = 17).Questions about the penis were commonly about penis size/growth, such as, 'When does the penis stop growing?' and 'How big is a penis supposed to be?' Questions about testes tended to pertain to sperm and semen, such as asking if sperm/semen can ever 'run out', and clarifying what sperm and semen are.

Anatomy and arousal
Questions about anatomy and arousal included those specific to orgasms and those more generally about arousal (e.g.'Why does a girl's vagina get wet?').While there were some questions not specifying sex, ten questions were specific to male arousal (e.g.'How long can a man be hard?') and six were specific to female arousal (e.g.'Where the heck is a clitoris?').Students most often used variations of the word 'cum' (as a verb) to refer to orgasming and/or ejaculating.

Other
Finally, the 48 questions about the body included the subtopics of hygiene (n = 13), discharge (n = 10), those not easily categorised (n = 18), and a small number about puberty and hormones (n = 7).Questions about hygiene only pertained to infections, usually the definition and causes of yeast infections, or cleanliness (e.g.'How do I wash my private area?').Questions about discharge included why discharge occurs and whether it is normal.Finally, questions not easily categorised included several questions about body hair and questions that were only tangentially related to reproductive anatomy (e.g.'Do kidney stones affect the genitals?').

Gender identity
Students asked 51 questions about gender identity, which also included subtopic-questions about transgender individuals (n = 22), normality and social support specific to gender identity (n = 9; see separate topic), and terminology (n = 9).Examples of questions about gender identity broadly included, 'Can a person have more than 2 genders?' and 'If a girl said that their gender is a male could they use the boy's bathroom?' Students had 22 questions about transgender individuals, which included questions about transitioning (e.g.'Will you talk about what if someone is trans (ftm like me) and they wanna be a boy how will that work?') and questions about periods/reproductive capacities of transgender individuals.Nine questions asked about terminology (e.g.'What's genderfluid?').

Sexual orientation
Students asked 77 questions about sexual orientation, making it the largest topic within the LGBTQ+ category.Subtopics included normality and social acceptance/support specific to sexual orientation (n = 35; see separate topic), coming out (n = 10), and terminology (n = 6).General questions about sexual orientation included questions such as, 'Do lesbians have sex?' or 'What would happen if two men have sexual intercourse instead of one man and one woman?'.Coming out was a subtopic of sexual orientation and included ten questions, all of which were about social support (e.g.'How do you come out to your family?').Students had six questions about terminology (e.g.'What is bisexuality?')

Normality and social acceptance/support
Forty-two questions pertained to perceptions of normality and social acceptance/ support related to gender identity or sexual orientation.Normality questions (n = 25) included questions like, 'Is it okay to explore my gender identity while still being young?' and 'Is it ok if I'm not fully sure of my sexuality?'Questions about social support (n = 17) included 'What if my guardian thinks that being bisexual isn't a thing?like what do I do' and 'How do I control my anger when somebody makes fun of your sexual orientation?'

Confusion
Finally, 17 questions were about confusion over sexual orientation (n = 15) and/or gender identity (n = 5).Questions included, 'How do I know what my sexual orientation is?' and 'How do you find your gender and sexuality?'While confusion could have reasonably been a subtopic for both the sexual orientation and gender identity question topics, the authors chose to separate it due to the salience of identity exploration and development during adolescence.

Sexual behaviours: norms, purposes and processes of sex
Students asked 120 questions about sexual behaviours, which had five topics: norms about sex (n = 43), the purposes and processes of sex (n = 40), age and sexual experiences (n = 31), masturbation (n = 23), and terminology (n = 11).

Norms about sex
Forty-three questions about sex referenced norms or sought socially comparative information (e.g.'What's the right age to have sex?Some people say when you're ready, but my parents probably will say when I'm like 18-older').Frequently, questions expressing norms were related to age or masturbation.For instance, students wanted to know the 'best' age to have sex or whether having sex at a young age was permissible, good, bad, normal, etc., and they asked 25 questions related to both norms and age.Students had similar normative questions about masturbation, with a total of 12 about both norms and masturbation.

The purposes and processes of sex
Students asked 40 questions related to the purposes or the processes of sex.Purpose questions (n = 9) were about why people have sexual intercourse (e.g.'Why do people do sex?').Process questions pertained to the mechanism of having sex, and students asked questions like, 'Where do we inject the penis?' or 'How do you give oral sex?' Another subtopic focused on sensations associated with sex (n = 11); students mostly asked about pain, pleasure, or feelings (i.e.physical/psychological sensations) associated with sex (e.g.'What does having intercourse feel like?' or 'Why is sex so addicting?').

Age and sexual experiences
Students asked 31 questions about age, most of which were related to normative information about the 'best' age to have sex (discussed above).Questions about age but not about norms did not have any discernible subtopics.

Masturbation
Students asked 23 questions about masturbation, mostly focused on normative information, such as, 'Is it normal for people our age to pleasure ourselves?'.Questions about masturbation but not about norms tended to focus on terminology clarification (e.g.'What is masturbation?'),but otherwise did not have any discernible subtopics.

Terminology
Eleven questions about sexual behaviours asked for terminology clarifications, mostly about types of sexual intercourse (i.e.oral, anal and vaginal).Students did not ask more terminology questions at the beginning of the programme as opposed to the end or during any particular lesson.

Discussion
We categorised and analysed anonymous questions from students who received a comprehensive, medically accurate, and inclusive sexual health education programme.By allowing students to ask questions anonymously, we can better understand students' perspectives on the information they seek from sexual health education.These findings have implications for students and teachers, as well as the development and adjustment of health education standards and school district policies/practices.

Increased depth and honest education for student well-being
Research has indicated adolescents benefit from education about the positive aspects of human sexuality, namely positivity towards sex, pleasure, and discussion of anatomy and physiology (Helbekkmo et al. 2021).Our results support previous findings, indicating that young adolescents want to learn more about their own bodies and sex (e.g.Corcoran et al. 2020).Adolescents deserve to discuss sexuality with trusted adults (e.g.parents/guardians, health teachers, etc.), including physiological responses and reasons for engaging in sexual activity.While adolescents want educators to address community and personal values related to sexuality when discussing sexual health (Canan and Jozkowski 2016), they also need and want science-based, medically accurate sexual health education (Breuner et al. 2016;Corcoran et al. 2020).
In this study, anonymous questions about reproductive anatomy focused on normality, function and processes.Answers to these questions may have implications for prompting individuals to seek medical attention based on their knowledge of 'normal' bodily functions.For instance, knowing what constitutes normal versus abnormal discharge may be important for prompting individuals to seek medical attention for various health concerns (e.g.STIs, yeast infections).Therefore, sexual health education emphasising typical and expected anatomy development/processes may better suit student needs.
Importantly, the number of questions about menstruation suggested that menstruation education may benefit from greater engagement and strengthening.Students expressed concerns about discussing period care and frequency, specifically.This topic may be particularly salient for young adolescents reaching menarche (i.e.average age = 12.25; Biro et al. 2018).Questions about period normality may also be important for prompting individuals to seek medical attention; medical concerns related to period frequency can range from pregnancy to malnutrition.Menstruation education is crucial for both reproductive health and overall wellness.
Anonymous questions about LGBTQ+ topics indicated students have concerns about normality and social support/acceptance based on gender identity and sexual orientation.Questions suggested some students may have internalised negative social norms about gender identity and sexual orientation.Others have not.This underscores the need for comprehensive sexual health education curricula that are inclusive of all gender identities and sexual orientations (Hobaica and Kwon 2017).Many questions indicated students wanted more information about LGBTQ+ topics; this stands in stark contrast with recent advancement of legislation in some parts of the USA that aims to limit/restrict inclusion of LGBTQ+ topics in school settings (Garg and Volerman 2020).Providing inclusive sex education can help students feel safe and understand decisions they make about intercourse, which may be especially important for LGBTQ+ community members who are more likely to be at risk (Snapp et al. 2015).
Finally, questions about sexual behaviours revealed that students had questions about sex and social processes (e.g. the socially acceptable age to have sex, the social acceptability of masturbation, and wondering why people have sex/how to have sex with someone).Questions suggest that by the time students receive sexual health education in middle school, they already have beliefs about sexual behaviour, including what is and is not acceptable.Research has identified the importance of beginning comprehensive sexuality education early, taught in a way that is sequential and allows for students' prior knowledge to be built upon.Beginning sexual education earlier may help interrupt the emergence of problematic social norms around sexuality (Goldfarb and Lieberman 2021).
Given that younger adolescents may begin to experience physical and cognitive changes associated with puberty, we suggest increased comprehensive sexual health education well before high school, tailored to student needs.While there is a lack of tailored sexual health education (Eisenberg et al. 2010), student anonymous questions may be utilised to inform teachers about specific needs of students in their classrooms.For example, if teachers receive many questions regarding menstruation, particularly after already having been taught about menstruation, they may wish to review/repeat a lesson, with greater in-depth conversation and activities.Teachers may also compile summaries of anonymous questions and inform parents/guardians about common topics, promoting conversation about sexual health at home.Involving parents/guardians in sex education is beneficial for students and has been associated with increased competence and sexual health skills (S. A. Brown, Turner, and Christensen 2021).

Increased education for teachers
In addition to tailored instruction for students, increased training for sexual health educators is needed.Unfortunately, professional development for health education remains limited (Sondag, Johnson, and Mary 2022).Instruction in teaching methodologies tailored to sexual health education, specifically, during pre-service teacher education programmes, may prove beneficial.When adolescents feel their teachers value the sexual health content being taught, students may experience increased self-efficacy related to sexual health skills (e.g.saying no to sex, asking a partner to use a condom; Allsop and Anderman 2022).Although teachers report valuing content related to sexuality education (Timmerman 2009), many may still be uncomfortable teaching the subject, particularly if they have limited training or are not certified health educators.Thus, opportunities for additional training to increase teacher expertise and comfort with content are warranted.The results of this study may be useful in guiding pre-service teacher training, so that educator preparation programmes provide more effective training.Moreover, the findings provide insights into topics middle school students want to know more about, which may be useful for middle school health educators.

District practices
School districts can offer greater support to health educators.Increased support and professional development opportunities for human sexuality educators improve teachers' self-efficacy in delivering sexual health education, and lead to greater knowledge and comfort with the subject, particularly in relation to sexual orientation and gender identity (Szucs et al. 2020).
Increased professional development opportunities for those teaching sexual health education should be offered school the districts.Administrators should regularly and collaboratively review district-wide sexual health education curricula with health teachers.Curricula should generally be free from opinion or local cultural constraints, ensuring students receive medically accurate, comprehensive sexual health education.Additionally, district support staff with expertise on human sexuality can be available to answer teacher questions or concerns.Prior research has indicated that observational opportunities and personalised coaching by district staff for teachers are helpful for educators teaching about human sexuality (Szucs et al. 2020).Furthermore, school districts may consider offering parent-student education opportunities focused on communication about sexual health, specifically related to anatomy, LGBTQ+ topics and sexual behaviours.

Limitations and future research
There are some limitations to this study to note.We analysed a large sample of anonymous questions; however, because of the anonymity of the questions submitted, it is impossible to know how many students submitted those questions or whose perspectives were or were not included (e.g.students with disabilities or other minoritised populations).Additionally, not all students may have submitted anonymous questions during Get Real instruction, so the extent to which the questions are representative of the student body is unknown.Second, though the anonymous question categorisation is informative, the types of anonymous questions submitted cannot be generalised to all students in sexual health education courses; various cultural and regional influences may impact the questions students have during a sexual health education unit.Third, though the health behaviour outcomes were utilised as a basis for categorisation of questions, it is possible others would interpret the same health behaviour outcomes and anonymous questions differently.However, given the authors' expertise in sexual health education, we believe the categorisation and interpretation to be trustworthy.
Future research within sexual health education and adolescents' questions may wish to focus with greater depth on questions related to anatomy, LGBTQ+ topics, sexual behaviours (especially social/cultural norms surrounding sex), and knowledge and comfort level of teachers answering student questions.Additionally, the approaches of teaching human anatomy and human sexuality may beneficial when practiced within multiple classes and fields, such as health class and science courses (i.e.biology).Researchers may wish to prioritise teachers' education, knowledge, practice and comfort in teaching about human anatomy and sexuality in a variety of settings, including classroom and extracurricular programmes.Furthermore, researchers may wish to find ways to collect student demographic information while keeping question submission anonymous, thus allowing for greater in-depth study of student anonymous questions during sexual health education in relation to specific contexts.

Conclusions
Given the myriad of topics involved in human sexuality education, it is imperative to understand the types of questions young adolescents have related to sexual health.Results of this study suggested that middle school students asked more questions about reproductive anatomy, especially processes, functions, and 'normality', than other topics.Some students also expressed internalised negative social norms about gender identity and sexuality, underscoring the need for comprehensive and inclusive sexual health education.Student anonymous questions also focused on sexual behaviour and norms, suggesting the need for more open and honest communication from adults to adolescents about the purposes and processes of engaging in sexual behaviour.Analyses of student questions can help educators better understand and address adolescent health concerns, carrying implications for the promotion of adolescent health and well-being.

Endnote
1.At times, one question submission may have contained multiple topics.Thus topic totals may not equal question totals within a category.

Figure 1 .
Figure 1.Sexual health curriculum health behaviour outcomes from HECAT.Source: (CDC Centers for Disease Control and Prevention 2019a)

Figure 2 .
Figure 2. Question categories and examples.

Figure 3 .
Figure 3. Question frequency per lesson.Occasionally multiple lessons were taught in the same session or questions were recorded after content delivery ended.Thus, lesson of origin is undetermined for 106 questions.
Information is approximate.Students taking surveys may differ from those who submitted questions.