Adolescents’ conceptions of learning and education about sex and relationships

Abstract In order for adolescents to learn about sex and relationships, the education must be of significance and meet their needs and interests. The study investigated adolescents’ conceptions of learning and education about sex and relationships. A phenomenographic approach was used. Six focus group interviews were conducted with adolescents ages 18–19 in Sweden. The results showed that stable ground for learning implies select issues of importance, that is, values and prejudices, up-to-date knowledge, and practical skills. These issues should be dispersed throughout the school years in relation to the students’ own maturity. This seemed to enable internalization of different aspects of sex and relationships. Learning about sex and relationships can create meaning for youth and generate progress by fostering autonomy and identity, correcting misconceptions, counteract prejudices, not in isolation rather in society in a defined culture.


Introduction
One of many factors fundamental for people's experience of health and well-being is sexuality (The Public Health Agency in Sweden, 2017). Sexual health should be recognized as an affirmative concept associated with wellbeing and positive qualities and as being more than reproductive health. It is linked to the expression of individual and collective needs, human rights and responsibilities. It should also include the attainment and expression of sexual pleasure (Aggleton & Campbell, 2000). Sexual health covers many different aspects including access to health care and individuals' knowledge in relation to sexuality (The Public Health Agency in Sweden, 2016). A definition of sexual health was developed by WHO: Sexual health is 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 and safe sexual experiences, 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. (World Health Organization (WHO), 2018a) http://www.who.int/ reproductivehealth/topics/sexual_health/sh_definitions/en/index.html In Europe in general, sexual and reproductive health of most adolescents is good, although adolescents are still a risk group for poor reproductive health (Avery & Lazdane, 2008). Adolescents without skills, information, or health services regarding sexual behavior are especially at risk for sexually transmitted infections (STIs) and unwanted pregnancies (Avery & Lazdane, 2008). According to the World Health Organization (WHO) (2016), STIs affect sexual and reproductive health on a worldwide scale. In Sweden in 2017, the incidence of chlamydia infections was 333 cases per 100,000 inhabitants. Of the total number of cases of chlamydia, 22.4% occurred in the age group 15-19 years old. The incidence of gonorrhea in the age group 15-19 years (31 cases per 100,000 inhabitants in 2017), has increased by about 15% each year. (The Public Health Agency in Sweden, 2018). The incidence of teenage abortions in 2017 was 12 abortions per 1,000 women in the age group 15-19 years old, which was a decrease by 50% in the last ten years. The number of births in the age group up to 19 years old was 1,400 (about 2.6% of all births) in 2016 (The National Board of Health and Welfare, 2019). Approaches to prevention of STIs are partly based on counseling and behavioral interventions, which include high quality sex and relationship education, especially education and counseling tailored to the needs of adolescents (World Health Organization (WHO), 2018b).
Sex and relationship education has a long tradition and is mandatory in Swedish schools. Sweden was the first country in the world to introduce mandatory sex and relationship education in 1955 (Wallin et al., 2012). An affirmative view in Swedish society to sexuality was widely accepted in the 1970s, when school education no longer advocates abstinence from sex, but instead encouraged young people to take responsibility for their sexuality (Bolander, 2009). Swedish teachers are expected to give their students essentially a positive view on sexuality and relationships, where sexuality is increasingly seen as something central for young people's self-awareness, for becoming an adult, and forming one's sexual identity (B€ ackman, 2003). An international study (Berne & Huberman, 2000) showed that in countries, such as The Netherlands, Germany, and France, which held an open and flexible view on sex and relationships, the approach to adolescent sexual behavior focused on positive aspects of sexual relationships, communication, and sexual responsibility, along with empathy and corporate responsibility on a societal level. In those countries lower frequencies in health problems related to sexuality, such as unwanted pregnancies and STIs were seen. Adolescents also reported a later sexual debut in those countries (Berne & Huberman, 2000).
In contrast, research suggests that sex and relationship education with an emphasis on danger prevention affects adolescents in ways that could be counterproductive to encouraging disease and pregnancy prevention (Allen, 2007a). Programs focusing on negative consequences of sexual activity fail to meet students' needs for information about pleasure, desire, and the practice of sexual activity and do not afford young people the kind of agency necessary to make empowered decisions about their sexual health (Aggleton & Campbell, 2000;Allen, 2007a;Helmer, Senior, Davison, & Vodic, 2015;Hirst, 2013;Macintyre, Montero Vega, & Sagbakken, 2015). A systematic review of abstinence-plus programs in high-income countries (Underhill, Operario, & Montgomery, 2007) showed that students receiving comprehensive sex or HIV education had a lower risk of pregnancy and STIs than adolescents who received "abstinence-only" or no sex education in the United States and in other high-income countries (Underhill et al., 2007). "Abstinence-plus" programs are comprehensive and promote sexual abstinence, but also encourage condom use and other safer-sex practices (Underhill et al., 2007). "Abstinence only" education is commonly fearbased. This approach is characterized by exaggerating negative consequences of sexual behavior, demonizing sexually active youth and cultivating shame and guilt to discourage sexual activity. This approach has not been shown to change behavior, and with the promotion of abstinence as the only means of prevention, excluding other prevention strategies may result in students ignoring the message (Wilson, Wiley, & Rosen, 2012).
International research from Chile, United Kingdom, New Zealand, and Australia showed that despite policies promoting positive attitudes toward sex, and sexual health and well-being directed toward adolescents, many sex and relationship education programs still focus on negative consequences of sexual activity, that is, prevention of disease and pregnancy (Aggleton & Campbell, 2000;Allen, 2007a;Helmer et al., 2015;Macintyre et al., 2015). According to Allen (2007a), this could be a result of the social construction of sexuality in Western societies as being problematic and dangerous. There is a normative and cultural ideal of adolescents as being nonsexual, which causes a dilemma between acknowledging adolescents' sexual activity and the possible negative consequences of those activities.
In a Swedish survey (Tikkanen, Abelsson, & Forsberg, 2011), one out of five people ages 15-24 judged the quality of sex education as being good or very good. Young people ranked sex education in school in third place, after the Internet and youth clinics, as a source for information about contraception and STIs. This ranking has however deceased over time. A recent review (Pound, Langford, & Campbell, 2016) of young people's views and experiences of their school-based sex and relationship education, including studies from the UK, Ireland, New Zeeland, Canada, Japan, Brazil, and Sweden, showed that schools have taken insufficient account of the specialness of sex and relationship education. Students reported embarrassment and discomfort, exposing the vulnerability of the students. Especially young men were seen as vulnerable and reported disruptive behavior in class as a way to mask their anxiety. Adolescents described sex and relationship education as portraying sexuality as a problem to be managed, promoting appropriate behavior and "legitimate sexuality," as well as being heteronormative and gendered. Another result was that that schools struggle to accept that some adolescents are sexually active. As a result, sex and relationship education was out of touch with many adolescents' lives, failing to discuss issues relevant to sexually active adolescents. The study also showed that adolescents generally regarded their educators as unsuitable for teaching sex and relationship educations, due to lack of training and embarrassment. Teachers were not always trusted to maintain confidentiality and were sometimes perceived as being moralistic and judging students according to different values. Many adolescents in the study approved of sexual health professionals delivering sex and relationship education, as they were perceived as being less judgmental, more informed, and better at delivering sex and relationship education (Pound et al., 2016). UNESCO (2009) states that the primary goal of sex and relationship education is to equip children and adolescents with knowledge, skills, and values necessary for making responsible choices in matters of sexuality and relationships. The learning process in sex and relationship education consists of four components, which are covered by the learning objectives: information; values, attitudes, and social norms; interpersonal and relationship skills; and responsibility (UNESCO, 2009). Learning according to Marton and Booth (1997), can be seen as experiencing the world or aspects of the world in particular ways and through experience gaining knowledge about the world. Learning proceeds from an undifferentiated and poorly integrated understanding of the whole to an increased differentiation and integration of the whole and its parts. The learner may experience in the beginning these undifferentiated and unintegrated wholes as confused and erroneous, but these initial ideas are not so much wrong, but rather only partial, forming an embryo from which new knowledge can grow (Marton & Booth, 1997). Learning about sexuality occurs in subconscious and natural ways (World Health Organization (WHO), & Federal Centre for Health Education BZgA, 2018). There are few studies on adolescents' conceptions of learning about sex and relationships and the greater proportion of studies on adolescents' views on sex and relationship education are quantitative. There is a need for more qualitative research in order to explore adolescents' conceptions of leaning about sex and relationships.
The aim of this study was to investigate adolescents' conceptions of learning and education about sex and relationships and to identify the structures of awareness underlying the students' varying experience of the education.

Methodology
The design of the study was qualitative using a phenomenographic approach. In phenomenographic research the main objective is to describe the qualitatively different ways in which people conceive various phenomena in the world (Marton, 1981). Variations in ways of conceiving something, along with the understanding and awareness of it, come from experiencing the phenomenon as structured, discerning, and relating it to a context. The term conception is seen as reflecting different beliefs about a phenomenon. The ways individuals conceive the phenomenon depend on what aspects or features of the phenomenon are in focal awareness.
The focus in phenomenography is on the collective group, not the individual experience, the aim being to constitute a pool of meanings, which derives from statements related to the group (Marton & Booth, 1997). Different ways of understanding the phenomenon can be understood as part of a larger whole, the "collective sum" of the ways of understanding (Åkerlind, 2005a). The collective sum or categories of description show the qualitatively different ways a phenomenon may appear to people of one kind or another and refer to the collective level (Marton & Booth, 1997). Categories of description describes the most characteristic features of each conception of the phenomenon in study and in a logically related set (Åkerlind, 2012).
Awareness of a phenomenon, according to Åkerlind, McKenzie, and Lupton (2014), is indicated by the potential for variation in that phenomenon. As more aspects of the phenomenon are being discerned, it leads to more inclusive and complex understandings of the phenomenon (Åkerlind, McKenzie, & Lupton, 2014), indicating an increasing breadth of awareness (learning) of different aspects of the phenomenon (Åkerlind, 2008).
The outcome space represents the range of possible ways of conceiving the phenomenon in question and provide an elucidation of relations between the descriptive categories and themes of expanding awareness (Åkerlind, 2012). The logical structuring of the relationships between categories of description and the themes of expanding awareness constitute the structure of the outcome space in a holistic way (Åkerlind, 2005a), and leads to a complexity in the picture of the experience of the phenomenon (Åkerlind, 2005c).
Focus group interviews were used as the method for data collection. Kitzinger (1995) described focus group interviews as a method, which is particularly useful for exploring people's knowledge and conceptions, along with how and why they think that way. Focus groups rely on a group process in which the participants explore and clarify views of understanding, which can be more difficult to achieve in individual interviews (Kitzinger, 1995). The group process allows for the research to go in unexpected directions and to reveal dimensions of understanding. Focus groups as a data collection strategy, through positive group dynamics and interaction (Barbour, 2007), enhances the richness of the data attained (Greenbaum, 2000;McLafferty, 2004).

The context of the study
A new school reform in Sweden came into effect July 1, 2011, including the Education Act (The Swedish National Agency for Education, 2016a). According to the new curriculum and syllabus for the compulsory school, sex and relationship education is an interdisciplinary subject, which is to be integrated into several subjects and written into each course syllabus. The Swedish National Agency for Education states that for sex and relationship education to be successful it should include a variety of pedagogical methods, use dialog, discussions, and allow for reflection, include students' perspectives and capture their thoughts and questions, keep a balance between a health and risk perspective along with adapting the teaching to the student group by progression in the subject matter throughout the school years (The Swedish National Agency for Education, 2011Education, , 2016a. In this study the participants received their sex and relationship education according to the prior curriculum, in which the education was delivered mainly in the 8th grade of upper secondary school.

Participants
The sample consisted of 32 adolescents ages 18-19, both male and female, enrolled in their third year of upper secondary school in three communities. The reasons for the choice of the age group was that it was assumed that they could reflect on their previous sex and relationship education with more insight. At the start of the research project the students were recruited through the youth clinic in a small community. The choice of using the youth clinic for recruitment was because the nurses at the youth clinic had established contacts with a number of adolescents in the community. One of nurses from the youth clinic had participated in sex and relationship education in the schools in the community. Despite sending reminders, only one focus group consisting of three students could be formed (Group 1). Therefore, a new strategy was developed to increase recruitment efforts. The researchers worked together with the principal or the school nurse from the identified schools to choose classes, which could be interested in participating in the research study. Both oral and written information about the research study was given in the different classes by the first author. Six classes were informed of the study. In three of the classes there were enough students willing to participate to be able to form focus groups. Students who wished to take part sent a text message to the researcher. Before the study began the students also signed a written consent form. The study included 32 adolescents divided into six focus groups. All of the participants were ethnically Swedish ( Table 1). The students were given the choice of dividing up into groups of male and female or mixed groups. In all of the classes the students chose to be in mixed groups.

Procedure
Six focus group interviews were conducted with mixed groups of males and females with the exception of one group with only two females. The focus groups varied in size from two to seven participants with a total of six groups. Focus group 2 with two females was from the same small community as focus group 1. The remaining four focus groups were recruited through two high schools in different communities in the county. The students from each high school class may have attended different primary schools. Each focus group interview was about 40-60 minutes in duration. At the beginning of each focus group the following rules were established; what is said in the group discussion stays within the group, show respect for each other's opinions, and speak in turn and do not interrupt each other. A focus group interview guide comprised of four theme questions; tell me about the sex and relationship education you received in the upper secondary school you attended, what was your experience, what should be learned, and why is sex and relationship education important. The first question was answered by each of the students one by one to create an open atmosphere and break the ice. The moderator played both an active part in the interviews but also allowed for discussions between the students. At the end of each interview a summary was made by the interviewer so that the students could correct misunderstandings or make additional statements. The interviews were recorded and transcribed verbatim. The location of the first group interview was in a local youth clinic while the rest of the interviews were conducted in school locations. Participation was voluntary and the students had the right to decline or discontinue whenever they wished. The students did not receive any incentive to participate in the study. The study was approved by the Regional Research Ethical Committee at Uppsala University (dnr 2011/031).

Analysis
The focus-group interview transcripts were analyzed using a phenomenographic approach according to Åkerlind (2005c). The Åkerlind method of analysis (Åkerlind, 2005b) begins with reading the set of transcripts as a whole three times, searching for meaning for the individuals, or variation in meaning across the transcripts and relationships. Notes are not made until the third reading, in which key issues and dimensions are summarized. Both authors independently read the set of transcripts several times to get a feel for the transcripts as a whole and to identify the different conceptions. Similar transcripts or selected quotes were then grouped together by searching for developing categories of description.
The process continued by further readings of the transcripts and then grouping and regrouping the statements by searching for the dimensions of variation in the conceptions of the phenomenon, with focus on similarities within and differences between the developing categories of description. Multiple readings are important in order to discern possible new aspects, which could have been missed in previous readings, and to ensure that the analysis is grounded in the data. The authors then ordered the categories of description into a structure with increasing inclusivity and complexity, moving from the "what" and "how" to finding the meanings of the dimensions of variations.
In the Åkerlind method (2005b), structural relationships are then searched for between the categories of description so they can be systematically grouped into themes of expanding awareness, highlighting the structural relationship between all the categories of description. The authors discussed together after further readings and came to a consensus on the themes of expanding awareness, which were identified and ran throughout each of the categories of description. These were also ordered into the structure in regard to inclusivity and complexity to show an expanding awareness.
The structuring of the categories of description together with the themes of expanding awareness show the hierarchical relationship between them.
The analysis was then performed through comprehensive interconnection, and constitute the formation of the outcome space. According to Åkerlind (2005c), this method of analysis leads to a complexity in the picture of the experience of the phenomena (Åkerlind, 2005c).

Findings/results
The results will be presented in three sections; Categories of Description, Themes of Expanding Awareness, and the Outcome Space. Five different categories of description were identified in the analysis. The Categories of Description are seen in the next section. Each Category of Description reveals a distinctive way of conceiving the phenomenon. In the following section the Themes of Expanding Awareness are presented. Finally, the Outcome Space will be presented in the last section. Quotes are presented to show the variation in the categories of description. Keywords and the names of the categories in this section are written in italics.

Categories of descriptions
The categories of description identified were: What about learning of sex and relationships, To actually learn about sex and relationships, The right time to learn, Trustworthiness of the education provided, and The importance to learn about sex and relationships (see Table 2).

What about learning of sex and relationships
The students conceived that there were concealed meanings and messages being conveyed by their teachers. Sex and relationship education was seen by the students as providing basic factual knowledge with a focus on risks and negative outcomes of sexuality such as sexually transmitted diseases and unwanted pregnancy. It could be conceived by the students that teachers had a hidden agenda to scare and deter from having sex, for example, by providing lessons about STIs in a scary way.
Participant 1, boy, Focus group 6: "I thought that I was a little worried about diseases and things like that, so you know" P 2, girl: "you became really scared" P 3, girl: "of a lot of pictures of STIs, for example extreme cases" P 2 girl: "ya, really extreme cases" P 1, boy: "to scare you" Lessons were also seen as being old fashioned and heteronormative. When omitting homosexual and bi-sexual perspectives the lessons could be experienced as discriminatory toward homo-and bi-sexual youth, the message being that it is not okay to be gay or bisexual.
Sometimes the lessons were not seen as being serious, relevant, or adjusted to reality. The content was seen as not much more than covering STIs and other basic things, while sexuality is something more complex. The content of the course was seen to be mostly factual within the subject of biology and leaving little room for discussions.
The students reflected on what is important to learn and what is missing from sex and relationship education. The students indicated that certain topics are important to address such as anatomy, safer sex, STIs, and their symptoms. Topics which were often seen to be missing included attitudes, prejudices, virginity, and relationships, sexual abuse along with topics about hymen, pregnancy, and abortion. Learning about many different aspects of sex and relationships and gaining knowledge gives a sense of security. Knowledge about the topics they thought were important to learn along with practical skills were considered important in order to create a sense of security. P boy FG4: "What should you do if the condom breaks? We never got to know that. No, it was mostly this is how you put on a condom and so on. Many things you have to, or me at least, learn by your own experience." Students also discussed the need for correcting their own misconceptions and prejudices, and for gaining insights and knowledge. The topic of correcting misconceptions arose several times in relation to the students use of different sources for information and gaps in the content of the sex and relationship education they received. P boy, FG1: "The most important I believe is prejudices and ideals which exist, things you believe can be true from media and such, but which actually aren't or only a very small part is. We did that a little in high school. I felt then that the best part was when we covered everything, like the hymen, that there isn't any difference before and after virginity, things like that and things you assume to be so because you have heard it a lot, but it is good to know that it isn't actually so." To actually learn about sex and relationships Students conceived that the teaching was not adapted to their learning needs, mainly focusing on negative aspects. The students' conception was that they did not get as much out of their sex and relationship education as they had anticipated and had a difficult time recalling what they actually learned. P girl, FG5: "You expected something different than what it was, like now we are going to talk about sex and relationships, but it became help, so scary. When we were there it was all about diseases and things. I don't know that it was about anything special that I wished to learn, like I thought it was going to be about everything." It seemed to the students that teachers did not seem to be aware of what the students wished to learn about, such as to learn what sex and relationships are really like.
Students conceived that they could learn through their own experiences, experimentation, and by a genuine interest. Besides the education, there were other ways of finding out about sex and relationships, such as experimenting on their own, searching the Internet, and talking with friends and parents, films, and television. Thoughts about already knowing everything could be experienced as a hinder to make use of reflections and discussions. "When you think you know everything you throw away the chance to learn more" (boy, FG5). Learning was seen to be facilitated by actively taking part in discussions and using reflections, which helped in gaining new perspectives. To learn about sex and relationships it was good to use reflections and to learn through discussions.
Learning about sex and relationships was seen as something individual yet affected by others, and which each individual experiences differently. The amount learned was dependent on the students in the class. Students stated that it was difficult to learn if the other students in the class did not take the lessons seriously. P 1 girl, FG6: "It was rather good lessons I had, but the class was extremely not serious" P 2 boy: "So I didn't learn very much and that which I learned I already knew" P 1: "Like half of the class wasn't even present at the lesson, so they (other students present) just sat in and caused trouble so it was very difficult to follow and I didn't listen very much to the teacher because he didn't make it interesting to listen to. No, because it should be that you want to listen and to know." When teachers could not gain respect from the students it became impossible for them to teach. Teachers who seemed to have less difficulty in talking about sex were more successful in their teaching and made it more enjoyable for the students to learn. Professionals from the youth clinic or other organizations involved in sexual health, experienced in talking with young people, highly educated, and not embarrassed in talking about sex, were also seen as being able to reach out to the students in a different way than a teacher.

The right time to learn
Lessons could be conceived as to deter early on from having sex by use of scaring tactics. Students experienced that when the lessons were not in sync with their maturity they were worthless and could even be seen as harmful. This was the case both when the lessons were on a too low level as well as when topics came too early. This was seen especially with the use of films where it was considered important to be prepared and for the teacher to follow up by giving explanations and answering questions. If not done adequately this could lead to a distorted view on sexuality and could be experienced as deterring them from having sex.
Students expressed that it takes time to learn about sex and relationships. Students stated that it was common that the sex and relationship education they were provided consisted of only one short lesson, or lessons held only for a short period of time. The lessons did not always seem well planned and often only involved students submitting questions to the teacher. Students acknowledged the need for progression throughout the school years following their psychosocial development. Students experienced that not all of the students were at the same stage of their development at the same time, boys in general seeming to develop later than girls. P girl, FG5: "I remember that there were many boys in the class who weren't really mature enough for the lessons, maybe none of us were, but you noticed it more with them. No, I think they were too young to take it seriously, they saw it more as just something fun." When less mature students were not attentive, showed little respect for the teacher, or did not take the lessons seriously, teaching became difficult for the teachers.
Students considered it beneficial to begin early with learning the facts and then progress toward more discussions following their own development. Students conceived that the sex and relationship education they received was not always in sync with the level of the students' maturity. Apart from taking little time in the curriculum for lessons in sex and relationship education, the lessons were experienced by the students as being introduced too late because many students in the 8th and 9th grades already had experienced sex. Students believed that it would be better to start by learning the basic facts in the 7th grade, then progress with increasing maturity to more relevant topics in the 9th grade.
Students experienced that this was an important time in their lives to learn about sex and relationships. They experienced the need to be prepared in the future for falling in love, having relationships, marriage, and having children. Sex and relationship education in school was seen by the students as being a very important subject to learn.

Trustworthiness in the education provided
Not all teachers were seen by the students to be trustworthy. Students experienced that older teachers sometimes held prejudices and were judgmental about sex, such as: sex is something for the purpose of reproduction and not for pleasure, or were judgmental about early sex. Students believed that some teachers thought that if you talked about sex it would result in students becoming more sexually active.
Uncertainty about judging who to trust was a concern for students. Students experienced that without trust in the teacher, the teacher could not accomplish much. Also because of the teacher-student relationship, students might not want to talk with their teachers about sex. Students experienced that adults other than a teacher, such as a midwife, were more reliable. Midwives were seen as more educated in sexuality and reproduction, as it is their field of expertise. While adults had more experience, they were not always seen as being trustworthy. Not all adults were considered up to date with new knowledge. Yet it was considered better to learn from adults than from friends. Learning from friends could lead to a greater risk for misconceptions. P girl, FG3: "I think it is really bad (hearing from friends) because if it is spread by mouth, it can be like, I heard from a friend that you can become pregnant from swallowing sperm, someone told her, then she tells it to someone else and in the end, you believe it to be true which absolutely isn't true." Students also stated that when evaluating facts students were unsure whether the information/facts were accurate. Students experienced that schools need to stay up to date with debate in society and new phenomena such as the Internet. The Internet was not always seen as a dependable trustworthy source for information. The reason why it was important to evaluate the sources, who to trust, and which fact were accurate, was to prevent or correct misconceptions. For the students to understand sex and relationships the students needed to first decide what to believe and take in. Pornography and what goes on in chat forums and social media, along with the reliability of the Internet and other sources, was something the students experienced a need for discussing in sex and relationship education. Even though some students experienced that they could sometimes learn more from pornography than from classroom education, they were aware at the same time that the image of sex seen in pornography was not the same in reality. In addressing the issue of the use of the Internet and online pornography in sex and relationship education was seen as a way to prevent sexual coercion and sexual abuse.

Importance to learn about sex and relationships
Disclosure of teachers' agenda and deciding what to take in was seen as necessary in order for the students to develop their own norms and values. Students reflected on whether or not the teacher had his/her own agenda, and developed critical thinking about the education they received.
Learning about sex and relationships was connected to becoming independent through gaining life skills, such as learning to handle situations related to sex and relationships, and learning practical skills. Sex and relationship education was seen as an important subject to learn in school and should include factual knowledge, learning more about the social aspects of sex and relationships, along with helping students in feeling more secure in different situations related to sex and relationships. Students experienced that the education they received was not sufficient for learning about a variety of topics, such as: personal boundaries for sex and intimacy, sexual abuse, and how to prepare for sex. Nor was it seen as sufficient for handling different situations, as well as for learning practical skills including condom use.
A result of successful sex and relationship education could be seen as the internalization of the different aspects of sexuality and relationships in the students' psychosocial and sexual development. Students experienced that sex and relationship education could help them in gaining new perspectives along with correcting misconceptions, for example, related to the content of the Internet and pornography, and discussing issues of sexual persuasion and abuse. Another positive effect of sex and relationship education was that learning to talk about sex made it easier to ask for help and advice. This was seen as facilitative to prevent negative outcomes related to sex and for promoting sexual health.
Other positive effects of learning about sex and relationships involved gaining self-efficacy in setting up their own boundaries for sex and relationships, and forming values and norms in relation to relationships. P boy, FG3: "Something I thought was very unclear in high school was about boundaries, where the limits go between saying no and when it is sexual abuse, and when it is rape, that was really unclear. If you don't want to, you should say no and if the other person doesn't respect that, you should talk to someone about that, but they didn't say anything more about that in the lesson." Sex and relationship education were seen as being important because sex and relationships are a part of the students' human nature, lives, and society. According to the students, sex and relationships had to do with love. Students stated that sex and relationship education was a subject in school, which they valued highly. Learning about sex and relationships could also be important when some students could possibly be teaching young people in the future about sex and relationships.

Themes of expanding awareness
Four interrelated themes of expanding awareness were identified. Themes of expanding awareness show the structural relationship between the different dimensions. The themes of expanding awareness, which emerged were Discovering concealed intentions of authority, striving toward an independent self, seeking stable ground for learning, and finding the meaning of sex for youth in society.
Theme 1, Discovering concealed intentions of authority expanded across the categories of description. In category 1 students were attempting to discern whether the teachers conveyed hidden agendas in their lessons. Teachers could have concealed meanings and used fear of negative outcomes to discourage from sexual activity. Omitting homosexual and bi-sexual issues was seen as discriminating and could be interpreted as meaning that it is not acceptable to be gay or bi-sexual. Category 2 showed that there was failure to do what ought to be done. Teaching was not adapted to the students' needs and interests. Teachers were not aware of the interests of the students, and sometimes seemed to have difficulties in teaching due to the sensitivity of the subject. Category 3 revealed poor judgement by the teacher of the students' level of development when lesson planning. Some topics were being presented too early in the compulsory school years, which could be experienced as a scare tactic for deterring from early sex, while other topics came too late. In category 4 the results showed that students experienced uncertainty when judging the trustworthiness of the teachers while discerning teachers' norms and prejudices. Lessons were seen as being heteronormative, out-of-date, and the delivery of the lessons not seeming serious. The trustworthiness of the adult world, friends, and the Internet was questioned. In category 5 the analysis showed that it created insecurity when students are unsure whether or not teachers had their own hidden agenda. Teachers and other sources for information could either help to correct or cause misconceptions and prejudices.
Theme 2, Striving toward an independent self showed that students were striving to develop their own autonomy as an important process in learning about sex and relationships. In category 1 the students' needs were reflected on. The students had to decide which subjects they felt were important to learn and which topics were lacking according to their needs. The literature did not cover all that the students were interested in learning. In category 2 the students were finding ways to learn. Students implied that learning could be achieved by actively contributing to discussions, through their own experiences and experimentation, along with discussing with others such as friends or parents. Through their own initiatives students searched for information elsewhere such as the Internet, films, and other media. There was a genuine interest to learn and to take a position. In category 3 the analysis showed the need for progression throughout the school years following the students' psychosocial development. Sex and relationship education takes time and should be dispersed throughout the school years with a progression in accord with the students' gained experiences and psychosocial development, enabling them to see things in new and different ways. Category 4 revealed that becoming independent in learning involved the need to think for themselves and to judge the trustworthiness of the teacher along with the subject matter being taught. Trustworthy sources were considered to be persons with formal education in sexuality and reproduction, along with persons who had more experience. In category 5 becoming independent was achieved by gaining knowledge. Learning about facts, practical skills, and about their own emotions helped the students to be prepared for handling situations related to sex and relationships. Attaining life skills and knowledge was seen as an important part of learning about sex and relationships.
Theme 3, Seeking stable ground for learning was about what is necessary to facilitate learning. In category 1 the results showed that there were topics the students considered important to learn about but were either insufficiently covered or absent. Learning from experience was seen as a way to learn about norms and prejudices. When the student gained knowledge, it created a stable ground for learning and a sense of security. In category 2 learning was inhibited by attitudes of knowing everything already. There was seen to be a risk for throwing away the opportunity to learn, and to not take an active part in discussions. In category 3 the analysis revealed that lessons need to be in sync with the students' maturity. Students were aware that adolescence is a period of rapid development. They were not the same in the upper teens as when they were younger: they now possessed more experience and knowledge. Therefore, the students realized the need to adapt the lessons according to where they currently were in their psychosocial development. It was seen as age-appropriate to start when younger with basic facts and then progress in the following years to more complex topics and discussions as the students matured. In category 4 there was a sense of insecurity about whether the facts and information are correct, which could result in a risk for misconceptions. Facts could be out of date and some teachers could be judgmental, and hold prejudices and old norms while norms in society are constantly changing. By reflecting on this and critical thinking, students were able to develop their own norms and values. In category 5 internalization of different aspects of sexuality and relationships held meaning for the students in forming their identity as a developmental goal in adolescence. Students experienced that sex and relationship education could help them in gaining new perspectives along with correcting misconceptions.
Theme 4, Finding the meaning of sex for youth in society entailed integrating what they have learned about sex and relationships into their lives. Category 1 showed that the relevance for the students was something that needed to be taken into consideration when delivering the education. This included the importance to correct misconceptions, counteract prejudices, and to gain insights and knowledge. Looking back, students stated that they did not have much use for the sex and relationship education they received in high school. Students also reflected on the unfairness in that the quality of the education they received was dependent on the teachers they had and the school they attended. In category 2 learning about sex and relationships was something that is individual while at the same time being affected by others. In order to learn, it is important that the lessons be taken seriously, which is not always the case due to the level of maturity of some students in the class. Learning was not only affected by other students, but also by teachers. Teachers without difficulties in talking about sex were more successful at teaching and were more beneficial to the students' learning. Other professionals, with a medical background, were seen as a considerable alternative or complement to teachers. In Category 3 adolescence is a time when the development of sexuality is in focus. The results revealed that learning topics at the right time was essential in order to get meaning from what they learned. The quality of sex and relationship education is important for providing students with comprehensive education in order to prepare them for sex and relationships in their lives. In category 4 the analysis showed that students thought critically about the content of the education and were deciding what to believe and take in, and its significance. The students experienced that information came from many different sources and were concerned about the reliability of the information in order to prevent or correct misconceptions. The students could then proceed with internalizing the different aspects of sex and relationships in their psychosocial development. In category 5 sex and relationship education was seen as useful for the promotion of sexual health and to prevent negative events such as sexual coercion and abuse. Students were trying to figure out how to think about sex and relationships and to establish their own norms and values on different aspects of sex and relationships, including thoughts on right or wrong, and on normality. High quality sex and relationship education was seen to be helpful in preventing problems related to sexuality and for promoting sexual health. According to the students it was important to know who to turn to, and have the selfefficacy to do so when in need of advice on matters concerning sexuality and relationships. Sex and relationship education was important for learning about setting up personal boundaries for sex and relationships, and about norms and values in relation to others.

The outcome space
The logical and hierarchal relationship between the categories of description and the themes of expanding awareness constitute the outcome space. In learning about sex and relationships students sensed concealed intentions from the authorities. Teachers failed to do what ought to be done and trustworthiness was questioned. In striving toward an independent self, the students had to decide what was important to learn and how, and to develop their own autonomy in learning in order to gain life skills and knowledge. Stable ground for learning implies select issues of importance, that is, values and prejudices, up-to-date knowledge, and practical skills. These issues should be dispersed throughout the school years in relation to the students' own maturity. This seemed to enable internalization of different aspects of sex and relationships. Learning about sex and relationships can create meaning for youth and generate progress by fostering autonomy and identity, correcting misconceptions, counteract prejudices, not in isolation rather in society in a defined culture.

Discussion
In the theme of expanding awareness Discovering concealed intentions of authority, lessons with a focus on negative aspects of sexuality, such as STIs and unwanted pregnancy, were associated with scare tactics to deter students from engaging in early sexual activities. Students in O'Higgins and Gabhainn (2010) and Macintyre et al.'s (2015) studies also reported teachers use of scare tactics, which were rejected by the students. Sexual pleasure and desire often remain absent from sex and relationship education (Allen, 2007b;Hirst, 2013) despite the recognition of its importance to sexual health, rights, equality, and safeguarding against coercion and harm (Hirst, 2013). This could be a result of the domination of sexual danger discourses in much of sex education (Allen, 2005). The results showed that the students experienced a focus in the education on negative outcomes of sex than on positive aspects, such as sexual health and pleasure. Macintyre et al. (2015) discussed that the separation of risk and pleasure in sex and relationship education could distort the way adolescents understood human relationships and desire. The study showed that topics of pleasure and desire aroused curiosity in both male and female adolescents. According to Allen (2005) and Macintyre et al. (2015) taking into consideration young people's interests and what they see as relevant issues is an important prerequisite to enable learning about sex and to help them gain a sense of empowerment (Allen, 2005;Macintyre et al., 2015). Acknowledging young people as sexual subjects with an interest in pleasure and desire needs to be taken into accord in sex and relationship education. A more balanced curriculum between risks and positive aspects of sexuality, could help adolescents gain a sense of self-worth and empowerment for making wise choices and for negotiating in sexual situations.
In the current study, another aspect of the theme Discovering concealed intentions of authority, was that lessons were being heteronormative. The exclusion of same-sex sexual experiences and relationships was sometimes seen as a message that it is not okay to be a homosexual or bi-sexual young person and discriminatory. This is in line with Allen's (2005) study in which the participants wished for more discussion about same-sex attractions and described schools as being heteronormative spaces. In a report from Australia (Hillier, Mitchell, & Turner, 2005) only 10% of young people stated that same sex experiences were included in sex education and did not find sex education to be useful. The report also showed that schools were beginning to provide relevant sex education information for same sex attracted people. This was not only important for same-sex attracted people, but also for reducing negative attitudes and discrimination in all young people (Hillier et al., 2005). Participants in the study by Allen (2009) considered it important for the educator to challenge heteronormative assumptions and be knowledgeable about sexual diversity (Allen, 2009). Heteronormativity in sex and relationship education, and the absence of the topic of sexual orientation, marginalizes young people with sexual orientations other than heterosexual. Bringing up the topic of sexual orientation can aid in the prevention of negative health outcomes in this group of young people.
In the theme of expanding awareness Striving toward an independent self, gaining factual knowledge, and learning practical skills helped students be prepared to handle different situations related to sex and relationships. Macintyre et al. (2015) discussed the importance of practical skills such as contraceptive use, communication with a partner, and determining personal limits. To use these skills requires good self-esteem and self-efficacy. Although self-esteem and self-efficacy are good inner resources to possess, they do not always prevent risky behavior. This was seen in a study (Unis, Johansson, & S€ allstr€ om, 2015), which showed that adolescents' use of condoms was low despite good self-efficacy in condom use. Critical thinking and practical skills are ways to empower adolescents to make informed decisions regarding their sexuality (Macintyre et al., 2015). Gaining the ability to make informed decisions is instrumental for promoting sexual health and for the prevention of negative outcomes related to sex and relationships.
In the theme Seeking stable grounds for learning, students were uncertain when judging which facts were reliable and which were worth taking in. The Internet was a source for students to find out about sex when their questions were not answered in the classroom. This was also confirmed in a commentary in British Medical Journal (Laws, 2013). Students in the current study realized the importance of sex and relationship education, of addressing the issue of the use of online pornography. In Baker's (2016) study, adolescents judged that online pornography might encourage sexist behaviors or beliefs, or pressure adolescents into doing things they may not want to do. The majority of the adolescents in that study (Baker, 2016) also reported that schools should be teaching about the risks associated with viewing online sexually explicit media (Baker, 2016). A common conception of the students in the current study was that the image of sex seen in pornography is not the same in reality. This was also seen in Baker's (2016) study in which the majority of young people considered pornography as an unrealistic representation of sex (Baker, 2016). Sun, Bridges, Johnson, and Ezzell (2016) found an association in young men between the use of pornography and increased sexual concerns, such as the reliance on pornography, or even prefer it to intimate sexual relations with a partner. The pornographic script may affect young men's expectations about their sexual performance and what they want and expect from a sexual partner (Sun et al., 2016).
The Swedish guidelines (The Swedish National Agency for Education, 2016b) for the integration of sex and relationship education into different subjects could be advantageous for connecting sex and relationships to many different perspectives, not only biology. The guidelines present a plan for which topics to address and how to present them in all different subjects, from 1st grade up to 9th grade. However, there is also the risk that when spread out into many subjects and many different teachers, no one teacher takes on the overall responsibility to ensure the subject is covered in all the subjects and has an overall knowledge of the content in the education. The risk for inequality is then even greater, that sex education could differ dependent on the school, which was also a finding in the current study.
In the theme of expanding awareness Finding the meaning of sex for youth in society, the results of the study showed that it was considered necessary by the students to learn to evaluate sources of information, correct misconceptions, figure out where they stand, and internalize aspects of sex and relationships. Macintyre et al. (2015) discusses the need to promote critical thinking and reflection on broader topics of sexuality with adolescents, including sociocultural and media influences on sexual decision making, sexual orientation, gender, the diversity of sexual practices, peer pressure, discrimination and violence, and emotional and relational aspects of sexuality.
The results showed that learning about sex and relationships students thought was something affected by others, in which the teacher played a very important role. It is important that teachers receive better training in teaching about sexuality and relationships. In Sweden there is very little training in sex and relationship education included in the curriculum for teacher education programs. Young people identified health professionals as trustworthy sources of information and that they were appropriate for teaching them about sexuality and relationships. Health professionals, such as nurses/midwives at the youth clinics and school nurses, should be seen as valuable resources and become more involved in sex and relationship education in order to improve the quality of sex and relationship education.
Effective sex and relationship education targets reproductive health for adolescents in society. It could help to reduce the risk for HIV and other STIs, unintentional pregnancies, coercive or abusive sexual activities, and sexual exploitation (United Nations Educational Scientific and Cultural Organization (UNESCO), 2009). Recently there has been a great focus in Western societies through the #metoo movement on the wide spread of sexual abuse, violence, and harassment, mainly of women. The need to address these issues in sex education has been stressed in public debate. In May 2018, a bill in the Swedish legislation passed requiring mandatory mutual consent for having sex. In a recent Swedish study on sexuality and health among young people ages 16 to 29 (The Public Health Agency in Sweden, 2017), 40% reported having experienced a sexual act against their will, with a higher number (54%) among young women than young men (27%). In this study the results showed that personal boundaries were not discussed clearly in sex and relationship education, and students were unsure how to handle situations related to mutual consent.
The study revealed adolescents' conceptions of learning and education about sex and relationships. Marton and Booth (1997) describe six conceptions of learning divided into two groups. The first included increasing knowledge, memorizing and reproducing, and applying, and the second included understanding, seeing something in a different way and changing as a person. The second group is about learning as seeking meaning (Marton & Booth, 1997). In the results of the current study, accurate knowledge was seen as important and gave a sense of security. The second group could be seen in the theme Finding the meaning of sex for youth in society, in which gaining new insights helped the students in their development create their own norms and values and be prepared for sex and relationships in their future lives.

Methodological consideration
There are ontological and epistemological differences between different qualitative research methods, which require different approaches to validity, and each study should be evaluated by its own merits (Rolfe, 2006). Phenomenographic studies have much in common with other qualitative research, however differences from other qualitative research methods create the need for the use of its own set of practices for establishing trustworthiness (Åkerlind, 2005a). Rolfe (2006) argues that the quality of the research study should be revealed in the report giving the reader the opportunity to appraise the quality of the research. The importance of reflexivity is stressed in which the researcher leaves an audit trail and accounts for the decisions made during the research process.
The total number of participants in the study was quite high (32), which was advantageous in revealing a large range of variations in the experience of the phenomenon, and can be seen as a strength of the study. In phenomenography the focus is on the range of meanings in the sample group, not for each individual in the group and interpreted in the context of the meanings of the whole.
In the data analysis the transcripts were read and reread several times and then analyzed collectively for the qualitatively different global meaning, which constitute the outcome space. Because phenomenographic analysis is a complex and demanding process, the supervision from the second author, a senior researcher with experience of the phenomenographic method, was vital to assure the quality of the analysis. The use of Åkerlind's method, with the additional step of the themes expanding awareness, allowed for more complexity of the outcome space that were identified (Åkerlind, 2005a, 2005c), which was also shown by Forster (2013).
A strength in the study was that the analysis was done independently by both the first and second authors. The results were then compared and discussed until a consensus was reached. The results were then presented for a phenomenographic seminar group at Gothenburg University where the results of the current study were discussed. This led to a further analysis, which was again discussed and agreed on in the following seminar.
The use of focus groups was advantageous for discussions on the subject matter and to go deeper into the students' conceptions of sex and relationship education. Students could trigger each other to discuss a wider range of topics than would have been possible with individual interviews. According to Toner (2009), validity can be maintained even in very small focus groups, in which the process of the group and group development is identical to that of larger focus groups. There is a greater potential in small groups for the facilitator to be perceived more as a member of the group than a facilitator. In these instances, creating more interaction between the facilitator and the group can help rich data emerge, which was the fact in this study.
The students preferred to partake in mixed focus groups with males and females in the same group. This was also seen in a study (Yager, Diedrichs, & Drummond, 2013) of gender preferences of co-participants in focus groups in body image research, in which the majority of both men and women in the study preferred in taking part in a mixed focus group. The reasons reported were that it allowed the participants to hear from both sides or to get both points of view (Yager et al., 2013). These viewpoints were also expressed in the current study. The students could discuss different topics specific to their gender perspective, which may have been advantageous for increasing the number of variations in the interviews.
A limitation to the study could be that two of the focus groups were small. The limitation in smaller groups according to Toner (2009) is that they would have reflected less variation. Morgan (1996) states that smaller groups can be appropriate for emotionally charged topics, which often are characterized by a high level of engagement, because it gives each participant more time to discuss his or her views and it is often easier for the interviewer to manage the discussions than it would be in a larger group (Morgan, 1996). Although two of the focus groups were rather small, lesser variations in the interviews were compensated by richer and deeper reflections on the phenomenon.
Another limitation could be the risk for recall bias. The students that partook in this study were attending their final year of high school and were asked to look back on the sex education they received in primary school. The reason for this was chosen was to capture the students' conceptions of that earlier education after gaining more knowledge and experience, and to explore what had left an impact on them and what had been useful for their sexual and social development. The outcome in this study is meant to represent the range of possible ways of experiencing the phenomenon at this point in time, for the population represented by the sample group collectively, CF Åkerlind 2012.

Conclusion
It is important to gain adolescents' perspectives on learning about sex and relationships in order to improve the education delivered. This in turn, can be beneficial to young people's sexual health and well-being. The findings show that many topics that students regarded as important seemed to be absent in sex and relationship education. Because of this, students felt the need to look elsewhere for information about sex and relationships. This required them to learn to judge the trustworthiness of these sources. The findings showed that young people judged sex and relationship education as being one of the most important subjects in school because it has an impact on their future lives. Sex and relationship education should aim to meet the preferences and needs of adolescents. This could be enhanced by collaboration between teachers who teach sex and relationship education and other health professionals, whom adolescents see as more trustworthy and effective sources for knowledge.