How Comprehensive Sexuality Education is Implemented and Perceived in Malaysia: A Systematic Review

The implementation of comprehensive sexual education in Malaysia is fraught with challenges despite existing policies mandating its inclusion. Consequently, Malaysian youth lack adequate knowledge, attitudes, and practices related to sexual health. This systematic study endeavors to explore how comprehensive SE is implemented in Malaysia as perceived by parents, school teachers, and university students and to recommend potential solutions to enhance the effective delivery of comprehensive sexual education in Malaysia. The PRISMA Statement is used in the review process. A total of four articles that meet the inclusion and exclusion criteria were collected from four databases. One study examined the parents’ perception of SE. One study focused on Islamic teachers’ attit udes toward SE and two studies discussed the perceptions and attitudes toward SE among university students. Enhancing sexual education in Malaysia requires a comprehensive approach including the misconception on the impact of sex education, curriculum revision, the readiness of the trained teachers or trainers, lack of family and parental involvement as well as lack of multidisciplinary collaboration. Experts from various stakeholders are encouraged to collaborate effectively in harmonizing the subject in ensuring that it can be recognized as comprehensive sexual education and subsequently improve the sexual health of its citizens.


Introduction
Sexuality education (SE) is a curriculum-based process in which students are taught and learn about the cognitive, emotional, physical, and social components of sexuality. Its fundamental goal is to give knowledge, skills, attitudes, and values to children and young people that will enable them to achieve their health, well-being, and dignity (Sato et al., 2023). Furthermore, SE seeks to assist persons in developing respectful social and sexual interactions, considering the impact of their choices on their own and others' well-being, and understanding and protecting their rights throughout their life (International Technical Guidance on Sexuality Education, 2018). There are two basic approaches to SE, notably abstinence-only sexuality education (AOSE) and comprehensive sexuality education (CSE). The latter aims to provide teenagers with the knowledge, skills, attitudes, and values needed to make informed decisions and enjoy their sexuality physically, emotionally, individually, and in partnerships (IPPF, 2010;Ganji et al., 2017). Although CSE recognizes abstinence as the best and first option for preventing pregnancy and sexually transmitted diseases, it also provides teenagers with contraceptive techniques to help them make decisions. AOSE, on the other hand, believes that abstinence is the greatest method to avoid becoming pregnant or suffering sexually transmitted infections (Pittman and Gahungu, 2023). The provision of high-quality sex education (SE) to youth is a multifaceted issue influenced by various complex factors. The gender and social sexualization of children are significantly shaped by the attitudes and support of parents, teachers, and other stakeholders. These individuals play a crucial role in ensuring the successful implementation of SE programs (Bastien et al., 2011;Zhuravleva and Helmer, 2023). Among them, teachers are considered the most suitable individuals to teach SE in schools due to their comprehensive availability and accessibility (Nilan and Nearchou, 2023). However, the effectiveness of SE programs is contingent on the knowledge and attitudes of teachers, as highlighted by recent research (Warraitch et al., 2021). A lack of sufficient knowledge among teachers regarding SE can result in inappropriate attitudes toward sexuality and hinder the successful implementation of SE programs. Therefore, it is crucial to ensure that teachers possess adequate knowledge and training in SE to facilitate the delivery of high-quality SE to youth (Zhuravleva and Helmer, 2023). According to data from the Royal Malaysian Police, juvenile cases increased by 31 in 2019, resulting in a total of 743 cases. However, there was a significant decrease in 2020 and 2021, with a total of 438 and 355 cases, respectively. This can be attributed to the implementation of the government's movement control order to combat the COVID-19 pandemic (Malaysian Youth Data Bank System, 2023). According to the New Straits Times, the Minister of Education, Dato Seri Mahdzir Khalid, indicated in June 2016 that the government was taking steps to develop a proper sex education syllabus for pre-schoolers. However, United Nations (UN) treaty monitoring bodies have recommended that sexual and reproductive health education should be made a mandatory component of learning. Additionally, the Committee on the Elimination of Discrimination against Women (CEDAW) has called on Member States to provide compulsory sexual education systematically throughout all educational institutions. In Malaysia, the topic of sex education (SE) has been a contentious issue. However, due to various societal concerns, the necessity for SE has garnered various perspectives from scholars, parents, and higher education students. Children are especially vulnerable due to their age and immaturity, making them prone to peer and media pressures (UNESCO, 2018). In Malaysia, introducing SE poses issues because the culture feels that sexual matters should be learned naturally after marriage. In Malaysia, young people's morality is an issue since exposure to sexuality may lead to sexual experimentation. As a result, it is critical to study the surrounding concerns with sex education. Tabatabaie (2015) claims that there is a growing connection between "immaturity" and "sexuality" in the lives of contemporary young people, making childhood/adolescent sexuality and sex education a hard topic for many Muslims. As a result, there is a need to identify childhood/adolescent sexuality and agency as crucial issues of (re)examination, particularly in Islamic studies and with the SE needs of young Muslims. The implementation of comprehensive sexual education in Malaysia is fraught with challenges despite existing policies mandating its inclusion. These challenges include the absence of standardized curricula, insufficient teacher training, and cultural and religious sensitivities. Consequently, Malaysian youth lack adequate knowledge, attitudes, and practices related to sexual health, resulting in high rates of unplanned pregnancies and sexually transmitted infections. Therefore, this systematic study endeavors to explore how comprehensive SE is implemented in Malaysia as perceived from diverse perspectives and to recommend potential solutions to enhance the effective delivery of comprehensive sexual education in Malaysia.

Materials and Methods
Review Methodology -PRISMA The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement guided the review. To conduct an SLR that was both well-organized and transparent, the authors used the following procedures to locate and synthesize all relevant papers. Mohamed et al (2018) suggested three systematic methods for identifying, screening, and determining eligibility that was used to locate the relevant publications. Online databases such as ScienceDirect, Springer Link, National Central for Biotechnology Information (NCBI), and Google Scholar were used to collect published articles for the study. During the process of searching, the keywords: 'sexual education', 'sexuality education', and 'sexuality and health education' were combined with terms such as 'parents', 'teachers', 'students', 'opinions', 'views' and 'perceptions'. 1403 relevant documents were retrieved using the selected databases. The articles were then screened, and they were either included or excluded from the study based on four common inclusion criteria: a) document timeline, b) document type, c) language, and d) subject area. Therefore, this review restricted the screening process to papers published between 2010 and 2022. This timeframe was selected since enough research was published to comprehensively analyze. Based on the document type, the selected paper is an article written in English got reviewed to minimize mix-ups. In addition, only papers emphasizing the perceptions of sex education' implementation in school settings were included in the selection. The screening process is demonstrated in (Figure 1). The rest of the papers were identified independently by the authors. 93 articles were removed since they did not focus on the perceptions of parents, teachers, and students towards the implementation of school-based sex education in the Malaysian context in a review of the literature and were not scientifically grounded. 21 were assessed for eligibility ( Figure 1). As a result, there was a total of four articles approved for review which are related and appropriate. The goal of this study is to learn more about the implementation of sexual education in schools as well as the opinions of the parties concerned.

Results
This review examines the opinions of parents, teachers, and higher education students on the implementation of CSE for school students in Malaysia. Four articles were reviewed, providing insights from these three different groups. The results of this investigation are summarized in Records identified from ScienceDirect, Springer Link, National Central for Biotechnology Information (NCBI) & Google Scholar (n = 1403) the keywords: 'sexual education', 'sexuality education', and 'sexuality and health education' were paired with terms such as 'parents', 'teachers', 'students', 'opinions', 'views' and 'perceptions.

Screening
Included Table 1 respectively. According to Sham et al (2020), all eight parents/participants agreed that they never received adequate sex education when they were young and only learned a little bit from science and religious classes. Seven out of the eight participants believed that mothers are the best persons to educate children about sex since they are closer and more comfortable with them. However, two of the participants mentioned that busy parents have limited time to sit together with their children, resulting in children having more freedom. Moreover, all parents agreed that schools play a crucial role in delivering sex education. According to Ihwani et al (2016), all respondents stated that sexual health education features in Islamic education could protect Muslim students from any sexual misconduct provided the topic is taught thoroughly. All respondents acknowledged that components of sex education have been taught in Islamic education classes. Aside from that, all respondents consider male/female relationships and adultery to be parts of sex education. Even though the topic was agreed upon by all respondents, four respondents saw dress code as not being one of the sex education parts. Six respondents stated that sex education topics are covered under the theme of cleanliness. According to a survey on students' attitudes conducted by Talib et al (2012), half (49.3 %) of 152 respondents felt that introducing sexual education is one of the best strategies to minimize social problems. This is further reinforced by the acceptance rate for the notion that this module will help reduce social sickness, which stands at 47.4% of respondents. The response pattern to the suggested appropriate age to introduce sexual education shows a descending rate of agreement, with 74.3 % of respondents agreeing to introduce it to upper secondary school students, 48.7 % agreeing to expose this module to lower secondary school students, and 18.4 % agreeing to begin sexual education as early as primary school. Meanwhile, as revealed by (Shah et al., 2021), all respondents exhibited a good attitude toward sex education by expressing their views on the early age of beginning to acquire sexual education in school, increasing the scope and execution. Furthermore, all respondents agreed that sex education should be taught in schools throughout Malaysia for students to understand responsibility, interpersonal attitudes, and skills, to answer their inquiring minds about sex, and to avoid sex misconceptions that keep them from engaging in pornography.

Perceptions Toward Implementation of Comprehensive Sexual Education in School Parents
According to a study by Sham et al (2020), participants reported misunderstandings about sex education due to the lack of exposure to the subject during their upbringing. Parents shared that they never received adequate sex education themselves, only learning a limited amount from science and religious classes in school. One respondent stated, "Back then there was no sexuality education taught in our school. We learned a little bit from a science teacher and a religious person, but there was no specific sex education subject. I think sex education should become an official subject so that we can learn more detail." Parents acknowledged the importance of sex education for their children and recognized the need to equip themselves with proper knowledge before discussing the subject with their children. They also emphasized the importance of teachers who are not embarrassed to talk about sex education, as this can impact students' comprehension of the content and may lead to insufficient information being passed down to them. Additionally, Ihwani et al (2016) noted that parents agree that schools should provide comprehensive sexual education to educate students on the elements of sex, and Islamic Education teachers are seen as individuals who are more responsible for delivering effective knowledge of sex education than parents.

School Teacher
Undoubtedly, the teacher's knowledge and qualifications are of paramount importance as they are responsible for educating the upcoming generation. According to Ihwani et al (2016), respondents agreed that comprehensive sexual health education in Islamic education might prevent Muslim students from engaging in sexual misbehavior. This includes teaching various components of sexual health education across multiple subjects to promote a healthy lifestyle, guard against sexually transmitted infections, prevent premarital pregnancy and prostitution, and foster good and healthy habits. The majority of respondents also believed that Islamic education teachers should not be the only ones responsible for teaching sex education components, but other subject teachers should also understand their responsibility and provide accurate information to students. Nonetheless, respondents in the study suggested that teachers should undergo specialized training to effectively teach sexual health education components and enhance their understanding of Islamic sex education concepts. Furthermore, some urged that the issues addressed in sex education parts in Islamic education be reviewed and improved. Islamic education teachers must overcome any sentiments of embarrassment or awkwardness during the teaching and learning process to produce comprehensive sexual health education.

Higher Educational Student
School students' perspectives are critical in molding their growth and attitudes regarding sexual education. According to Talib et al (2012), 49.3% of 152 respondents felt that providing sexual education is an effective strategy to minimize social problems. Respondents also had differing opinions on the appropriate age to introduce sexual education, with 74.3 % agreeing to introduce it to upper secondary school students, 48.7 % agreeing to expose this module to lower secondary school students, and only 18.4 % agreeing to begin sexual education as early as primary school. Similarly, Shah et al (2021) discovered that all respondents believed that sex education should be taught in Malaysian schools to foster responsibility, interpersonal attitudes, and abilities, and to address sex myths that may lead to pornographic consumption. Respondents proposed that sex education begins in primary school (about 9-12 years old) and that the government hold seminars such as "HIV awareness" in schools. Furthermore, respondents stated that sex education should not be restricted to Biology classes but should be integrated into Social Studies and Islamic programs as well.

Discussions
This review aims to examine the perceptions of parents, educators, and higher education students regarding the integration of SE into Malaysian classrooms. Eisenberg et al (2008); Eisenberg et al (2012); Sham et al (2020); Yeo and Lee (2023) stress the importance of parents as key stakeholders in health and education policy affecting children, hence their views and opinions towards SE need to be taken into account to secure their support. The results of this review demonstrate that all parents acknowledged their limited exposure to sex education during their upbringing, and most participants had little knowledge about SE. Despite this, most parents recognized the benefits of SE for their children's development, indicating a growing awareness of the subject. This finding supports the view of Akande and Akande (2007) that parents are influential in shaping their children's sexual development and socialization. However, many parents feel uncomfortable discussing sexuality openly with their children as they lack knowledge about human sexuality or are unsure about how to explain what they do know (Lukolo and Van Dyk, 2014). Furthermore, this review explores the perspectives of teachers regarding the incorporation of sex education in Malaysian schools. Most of the participants expressed that teachers who are not Islamic education teachers should be responsible for teaching sex education components. The relaxed approach towards sexual health education in Malaysian schools is attributed to teachers' attitudes. To enhance teachers' understanding of Islamic sex education, several respondents suggested the need for specialized training for teachers to teach sexual health education components. According to a study by Elizabeth et al (2018), teaching sex education to children is often associated with introducing them to early sexual intercourse and the risk of pregnancy. All participants agreed that Islamic education teachers should overcome their discomfort and hesitancy in the teaching and learning process to establish a comprehensive sexual health education curriculum (Ter Avest, 2021). Effective communication between teachers and students is vital for an efficient educational process, as pointed out by (Ihwani et al., 2016). In addition, the opinions of students were also considered in this review. Almost half of the respondents believed that implementing sexual education could be an effective means of addressing social problems. The appropriate age for introducing sexual education varied among the respondents, with the majority agreeing that it should be introduced to upper secondary school students, followed by lower secondary school students, and finally, in primary school. The optimal age for implementing sex education depends on several factors such as an individual's physical, emotional, and intellectual development, as well as their level of understanding (Boonstra, 2015;Ketting et al., 2021;). Furthermore, all of the respondents agreed that sex education should be taught in Malaysian schools to foster responsible behavior, interpersonal skills, and attitudes, and to address misconceptions about sex that may lead to engagement in pornography. Research has shown that effective sex education should start before an individual reaches puberty and before they have established patterns of behavior (Mueller et al., 2008;Astle et al., 2021). Malaysia is planning a range of strategies to increase sexual education among its students. Sexuality education is currently compartmentalized and divided into health-based, academicbased, or religious-based components, making it difficult for the public, particularly children and young people, to recognize its existence. The most difficult task is bringing specialists from many fields (such as educators, health professionals, religious experts, and social activists) together to produce a subject of comprehensive sex education that is culturally, religiously, and socially acceptable. While many experts prepare content for sex education within their respective disciplines, what is most lacking is a champion to streamline and harmonize the syllabus so that it conforms to Malaysia's multiracial society's culture and religion while also aligning with the international (Western) understanding of human rights. Because Muslims account for almost two-thirds of Malaysians, comprehensive sex education must satisfy and conform to majority standards while not marginalizing minority requests. Religious experts must incorporate in Islamic Education that the core teaching of Islam is congruent with current notions of human rights (particularly women's rights); Islam emphasizes an individual's right to life, freedom, respect, justice, privacy, and good life (JB, 2013). Sexuality education should be developed and provided to Malaysian youth without regard for gender. It is vital to stress the need of respecting all genders, whether they be men, women, or others. The Islamic perspective on sexuality demands boys and young men to learn to control their libidinal drives, and girls and young women to wear hijabs or maintain their aurat (private parts). The key to effective comprehensive sex education is a collaborative approach from diverse stakeholders, not only religious experts. As a result, future developments should consider the perspectives of all specialists within government sectors or non-governmental organizations (NGOs). More importantly, the perspectives of children and youth, as well as parents and the public, should be considered in the development of comprehensive sex education in this country. The primary educators for comprehensive sexual education are parents and families. Their involvement in this country is drastically lacking. The way forward is to improve parental and family involvement in providing sex education. There are currently no activities in the school-based sex education curriculum that require parents to participate in learning and debate. Assignments (such as questions or triggers) that require students to get thoughts or input regarding sexuality from their parents could be used to improve. This method has the potential to indirectly foster good parent-child interactions and communication while also increasing school-parent connectedness. According to studies, adolescents who reported feeling devoted to their parents and relatives were more likely to postpone initiating sexual intercourse than other teenagers (Resnick, 1997;Smallbone and Dadds, 2000;Potard et al., 2017). Personal and delicate sexuality themes could be easily discussed and expounded on through parent-child discussion. Concerns expressed by educators about delivering sex education should also be addressed. Comprehensive sexuality education is unlikely to be properly delivered if trainers lack a defined goal and the appropriate skills and methodologies. Other countries' experts have also described difficulties in delivering sex education, such as disagreements about the subject's content, duration, and timetable, difficulty teaching subspecialty areas (such as psychologically informed skills), insufficient teacher training and development, unavailable or underutilized material, staff shortages, and resources to implement and support the new curriculum (JB, 2013). Because of these concerns, non-implementation is to be expected. Perhaps the best way to go with the acceptance of sex education is to first train educators in sexuality knowledge, excellent communication skills, and specific solutions to sexuality-related concerns before teaching the subject to students.

Conclusion
The topic of sex education (SE) has been a contentious issue. However, due to various societal concerns, the necessity for SE has garnered various perspectives from teachers, parents, and higher education students. All parents agreed that schools play a crucial role in delivering sex education. Islamic education teachers generally had positive attitudes toward sex education and felt that the curriculum for sex education should be in line with Islamic teachings and values. The university students agreed that sexuality education should be taught in secondary schools. They also identified several topics that they believed should be covered in sex education, including reproductive health, safe sex practices, and gender identity to foster responsibility, interpersonal attitudes, and abilities, and to address sex myths that may lead to pornographic consumption. Overall, improving sexual education in Malaysia necessitates a multifaceted approach that addresses misconceptions about the impact of sex education, curriculum revision, the readiness of trained teachers or trainers, a lack of family and parental involvement, and a lack of multidisciplinary collaboration. In enhancing sexuality education in Malaysia, all experts from various stakeholders are encouraged to collaborate effectively in harmonizing the subject in ensuring that it can be recognized as comprehensive sexual education and subsequently improve the sexual health of its citizens.

Conflict of Interest
None declared.