Gender implications in sex education, knowledge, and vulnerability to sexually transmitted infections of healthcare students

The challenges posed by the implementation of sex education within a social context, by teachers or parents, are impasses that compromise adolescents’ and young adults’ sexual health, resulting in sexual risk behaviors. This study evaluated the forms of sex education, knowledge about sexually transmitted infections, and the vulnerability of university students within the Brazilian Legal Amazon. A total of 149 healthcare students provided their sociodemographic data and how they obtain information about safe sex practices. The data collected were evaluated using the Sexually Transmitted Disease Knowledge Questionnaire (STD-KQ) questionnaire. Bivariate analyses and Pearson correlation were performed. The sources of sex education were primarily accessed by students approaching course completion and female students nearing graduation, through teachers, specialized books, media, and friends. In general, men were found to have a higher degree of knowledge about STIs, while women reported feeling less protected sexually. Time spent at the university and the knowledge men possess were not found to reduce risky behavior. This cross-sectional study confirms that interventions to combat misinformation in the face of risky sexual behaviors and their consequences should be prioritized and should consider the gender of individuals and all the differences in the perceptions and actions of both male and female healthcare students.


Introduction
Sexually Transmitted Infections (STIs) are considerable impasses in health systems and are among the most pressing issues in the world today. The number of cases of gonorrhea, syphilis, and chlamydia have increased substantially since the 1970s (Williamson & Chen, 2020). The challenges posed by STIs in terms of morbidity and resistance to therapy, among other things, adds to the difficulty of controlling them through appropriate treatment and lack of provision of health services for diagnosis, which ultimately hinders the introduction of suitable methods of protection to the community, vaccination in primary care and stimuli to educational policies (Unemo et al., 2017;Mohammed et al., 2018). Irregular use of condoms, multiple sexual partnerships, sexual intercourse under the influence of alcohol or drugs, and early sexual activity constitute risk behaviors that increase the likelihood of infection and unintended pregnancy (Amare et al., 2019;Spindola et al 2019). Such behaviors are prevalent among adolescents and young adults in university, especially in relation to inconsistent use of condoms (Pimentel et al, 2016;Sales et al, 2016;Palacios-Delgado & Ortego-Garcia, 2018;Kassie et al, 2019). The reasons identified for such conduct include social acceptance, difficulty negotiating the use of a condom with one's respective partner, association of using condoms with infidelity, and the perceived loss of pleasure due its use (Mthembu et al., 2019). Although many understand the associated risks are aware of safe sex practices, in practice, they do not apply this knowledge due to the belief of self-control (Xu et al., 2019).
The school environment is a space for mutual, collective, and interdisciplinary exchange between teachers and students. The socialization role of school facilitates change through challenging and reflecting on students' daily practices, which helps reinforce the health-disease process and normality-pathology. Freirean pedagogy is an effective means of support for carrying out health education activities on sexuality and STI prevention, enabling subjects to properly recognize and reflect on their actions in relation to sexual behavior risk (Beserra et a.l, 2011;Gava & Vilela, 2016). This transformative educational role in reducing vulnerability was observed by Lindskog and Durevall (2020) who reported the positive impact of educational reform in reducing human immunodeficiency virus (HIV) infections among young adults during their first sexual intercourse Development, v. 10, n. 9, e56710918354, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i9.18354 or early pregnancy. Students who received formal education on how to refuse sex were less vulnerable to sexual assault upon entering university (Santanelli et al., 2018). In addition, family participation in sex education policies could help protect young people from potential risks once they start becoming sexually active (Grossman et al., 2014).
On the other hand, the shortcomings of formal education in relation to reproductive and sexual health limit students' knowledge about sexuality and vulnerability, resulting in the inconsistent use of condoms during sexual intercourse (Silva et al, 2002) which compromises the safety of the individual and his/her respective sexual partner. Taboos, beliefs, and myths could hinder a pedagogy of liberation and autonomy when the subject of sexuality is, often considered by the school community as non-school, non-political, and non-ideological content, creating a highly conservative learning environment (Zanatta et al., 2016).
The difficulties in the implementation and practice of sex education as a cross-sectional subject across academic year levels emphasizes the need for the University to act as a training institution for future professionals who are committed to the humanization and socialization of knowledge. The omission or marginalization of the discussion of human sexuality meets the need for students who belong to an age group that is susceptible to risky sexual behaviors to become more educated and selfaware. In this context, medical and nursing students have realized that knowledge about sexuality in the university environment is necessary to explore the different stages of an individual's life and to identify the potential consequences of diseases (Figueiroa et al., 2017;Komlenac et al., 2019) to be able to properly carry out self-care (Petry et al., 2019). On the other hand, the lack of attention to this subject in academic education could compromise professional actions, resulting in the asexualization of care, impersonality of relationships, lack of dialogue, or rising constraints (Sehnem et al., 2014).
In Brazil, university students' risky sexual behavior and knowledge about STIs have been reported by several groups (Fonte et al., 2018;Nascimento et al., 2018;Spindola et al., 2020), since they can still get STIs despite having increased access to information about sexual health (Teixeira et al, 2019). Therefore, the analysis of the approach to sex education prior to entry into the academic environment and during university education and its association with knowledge about STIs must be highlighted because it provides an opportunity to determine which measures of health education are necessary to avoid possible sexual health risks and promotes the implementation of this subject in the various undergraduate year levels as an act of humanization of health issues. Based on these aforementioned aspects, this study sought to evaluate students' knowledge about STIs while considering their sexual education throughout their academic life and overlooking their vulnerability.

Research design
This is a descriptive, cross-sectional, and quantitative study that examines the knowledge of undergraduate healthcare students during their first and last year about STIs. Data were collected from November 2019 to March 2020 through a selfcompleted and anonymous survey, which was used to obtain the variables of interest. The ballot machine technique was used to ensure the confidentiality of the responses in order to improve the reliability of answers to socially controversial questions.
Participants were informed that they could skip questions they did not feel comfortable answering. Further details regarding participants, procedures, measurements, and statistical analyses are presented below:

Participants
For convenience, university students from the Federal University of Tocantins (UFT), Palmas, Brazil were chosen as the research subjects. A booth was set up in the areas next to the Nursing, Medicine, and Nutrition buildings to recruit students.

Procedures
The research methodology was approved by the Research Ethics Committee of the UFT (CAAE: 22138619.2.0000.5519). The participants voluntarily signed an informed consent form after being informed about the study objectives. No compensation was offered for their participation.

Measurements
Participants were asked about their age, gender, sexual orientation, family income, and whether they were junior or senior students. The age of the participants was categorized into three groups: adolescents (18-19 years), young adults (20-24 years), and adults (> 24 years).
The "Questionnaire on Knowledge of Sexually Transmitted Diseases -(STD-KQ)" was used to evaluate the participants' understanding of Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), Hepatitis B, Human Papillomavirus (HPV), Genital Herpes, Chlamydia, and gonorrhea (Jaworski & Carey, 2007). The questionnaire was adapted according to the particularities of each population evaluated (Saad et al, 2012;Pourmazi & Sharami, 2017). This study used the STD-KQ recently validated in Brazil by Teixeira and collaborators (Teixeira et al., 2015;Teixeira et al., 2019). The questionnaire consists of 23 questions, which are answerable by "true," "false," or "I don't know." Students' sources of information about safe sex included the following: parents, other family members, media (e.g., television, radio, newspapers), sexual partner, colleague/friend, the Internet, teachers, health professionals, religious community (e.g., pastor, shepherd, religious group), and specialized books. To assess the students' vulnerability, unprotected sex during their last sexual encounter was considered as risky sexual behavior.

Statistical analysis
Data were analyzed using descriptive statistics in SPSS Statistics 25 (IBM Corp., Armonk, NY, USA). Categorical variables were expressed as relative and absolute frequencies. Chi-square and Fisher's Exact were performed to explore the association between sex and sociodemographic variables. The same tests were used to verify the association between risky sexual behavior, sex education, and other variables. The respondents' level of knowledge was according to the method proposed by Weaver (Weaver, 2015) who classified the number of correct answers as low (0-9), moderate (10-18), and high (>18). The correlation between protected sex and the year level, STD-KQ, and sex education of the students were examined using Pearson's correlation coefficient. In all the analyses, p was considered statistical when < 0.05.
The predominant age group was 20-24 years (50.3%), highlighting the 18-19 year age group for female students (p=0.004). In terms of sexual orientation, majority reported being heterosexual. Out of the 149 participants, 92 (61.7%) reported an income above 3 minimum wages. Among the participants whose family has an income of up to 3 minimum wages, there were 2.8 times more female participants (p=0.003) compared to males. In the analysis, 98 (65.8%) participants were in the first year, and 51 (34.2%) were seniors (Table 1). However, the association with year level indicated that beginners were more likely to answer "I do not know" (p<0.01). The subsequent objective was to evaluate students' knowledge about STIs through the STD-KQ questionnaire (Table   3). Accordingly, in terms of the level of knowledge, there was a predominance of moderate (53%) and high scores (43%). Men who were nearing graduation obtained higher scores, while juniors obtained moderate scores (p<0.05). The same phenomenon was observed for women. However, the female juniors generally got low scores (p<0.05) ( Table 3). In order to investigate vulnerability in relation to risky sexual behavior, participants were asked about their use of condoms during their last sexual encounter. Initially, those who reported not having an active sex life were disregarded. In effect, 119 participants were included in the analysis and 65 (54.6%) reported using protection during sexual intercourse and 54 (45.4%) did not use condoms. 63.6% of the students who were nearing graduation and 34.7% of those who were at the beginning of their academic life engaged in unprotected sex (p= 0.002). Majority of men from the earlier year levels used condoms (p<0.01) (CI 95%: 1.42 -4.45). For women, there was no association between year level and using protection (Table   3).
Based on the analysis of the association between year level and sex education and the degree of knowledge about STIs, considering the sex of the students, a correlation was established to determine whether such variables could be related to the practice of safe sex. For male students, Spearman's correlation showed that there was a negative correlation between the year level, number of questions answered in the STD-KQ, and practice of safe sex. No significant correlation was found among female participants (

Discussion
In this study, access to sex education related to the practice of safe sex was mainly evident in the school environment through teachers and specialized books, as well as media and interpersonal relationships. Sources of information and sexual counseling vary between men and women. No differences in access to sex education were observed among men. Although adolescents and young women have better access to sexual health information through their parents, primarily their mothers, whom they can dialogue with about sexuality and sexual experiences (Measor, 2015), this study found that men were more included in the transmission of knowledge within their respective families. The study's results match with that of Isaksen and collaborators (Isaksen et al., 2020) who found that less than half of the girls had spoken with their parents about romantic and/or sexual issues, but that proximity through family connection was a key factor for obtaining information. Parents play a key role in deciding when their children begin engaging in sexual intercourse, impeding early sexual activity (França & Frio, 2018). When sex education also comes from partners, parents, friends, and religious leaders, there is a greater chance of changes in one's perceptions and behaviors (Pinyaphong et a.l, 2018).
The students themselves wonder about lack of communication in the family regarding sexuality (Ew et al., 2017).
Oftentimes, the difficulty in the approach, embarrassment about the subject, lack of interest in seeking further information, or lack of knowledge are factors that hinder parental intervention (Barbosa et al., 2008;Ramos et al., 2020). Although other information resources are available (e.g., school, media, and friends), the safest space where teenagers can expose their doubts, anguish, and ideas about this subject is still the family environment, which helps individuals form their own values and beliefs (Savegnago & Arpini, 2016).
For Brant and Martins (Brant & Martins, 2020), unmediated media access, which is part of daily life, could make young people vulnerable to STIs, since one of its effects is to promote early sex. Consequently, young people need to be careful about the appropriacy and safety of the content they are exposed to (Brant & Martins, 2020).
Although the school is a conducive environment and a primary tool for the development of sex education (Tanton et al., 2015) because it is where students spend most of their time and because it is a place of information and training (Genz et al., 2017), young people consequently have few opportunities to discuss sex and end up receiving a superficial sex education, which consists of distorted information permeated by taboos and prejudice, and is insufficient for risk prevention (Ew et al., 2017). In the Brazilian territory, such initiatives are often temporary and implemented by professionals who do not belong to the school board (Furlanetto et al., 2018).
The present study found that healthcare students had sufficient knowledge about STIs. The average number of correct answers was higher compared to the first Brazilian study that validated the instrument (Teixeira et al, 2019). Unlike other studies (Fonte et al., 2018;Teixeira et al., 2019;Pereira & Carmo, 2014), women ended up answering more questions than the men did. This could be attributed not only to the greater presence of women from the earlier year levels (75.9%), but also by other variables beyond the scope of the study, including economic condition and age. These variables were directly proportional to the participants' degree of knowledge. In fact, although access to the university corresponds to access to knowledge in relation to the general population, the variables of poverty and unsafe living conditions could also have a greater impact on the vulnerability of these students.
In this study, it is worth highlighting the lack of knowledge about the signs, symptoms, and treatment for chlamydia, hepatitis B, HIV, and their correlation with HPV. In the academic context, the lack of attention given to sex education in the training of health professionals may compromise their care, dialogue, and self-confidence in their future service. The means of addressing this subject must go beyond t being a mere biological and scientific vision, and allow the subjects to discover their attitudes through an interactive bias, which could help them maintain their sexual health.
Knowledge about risky sexual behaviors does not always result in the actual adoption of safe practices (Xu et al., 2019;Fonte et al., 2018;Tobin-West et al., 2014). This study's findings are similar to those of Folasayo et al. (Folasayo et al., 2017) who found the inadequate use of protection among most sexually active healthcare students who had moderate knowledge about STIs.
In this context, women had a 1.5 chance of engaging in risky sexual behavior in relation to men. Particularly among seniors, the number of respondents who indicated that they did not use condoms was relatively high. One explanation for this phenomenon is the persisting gender asymmetry in sexual relations wherein men still exert greater power in ultimately deciding whether or not to use a condom that impacts the sexual health of their partners. This patriarchal system still perpetuated in Brazilian society limits women's sexual freedom (Chacham et al., 2016;Tavares et al., 2020). Even though women are aware of STIs and have direct access to information about sexual health, behavior aimed at adopting adequate protection measures has not been properly taught (Olivi et al., 2008).
Gender stereotypes, which have existed in Brazilian society for centuries, contribute to the reinforcement of attitudes based on patterns and convictions about what it is to be male, and the role played by the sexes. Consequently, convinced of their invulnerability and perceiving STIs as a sign of weakness, men take less care of themselves and put themselves at risk, despite possessing sufficient knowledge. With respect to the effects of this stereotype on the role of women, women are judged more when it comes to the topic of sex, and are often criticized for owning a condom or when their partners do not use protection, resulting in female vulnerability (Nascimento et al., 2018;Santos et al., 2016). This cultural aspect of Brazil's monogamous and conservative society marginalizes individuals who carry condoms, judging them as infidels and/or being promiscuous. In light of this, men and women must be educated on how to recognize and be more respectful of their partners' desire to have a safe sexual relationship.
Interventions to combat misinformation in the face of risky sexual behaviors and their respective consequences should be prioritized in view of significant differences in the perceptions and actions of men and women. Although access to university is a means of acquiring knowledge, it must consider the social vulnerability of the young population. Finally, parental involvement in the school environment could promote the robust implementation of sex education in a longitudinal manner. In this context, such actions focused on the process of educating based on guiding documents and specific legislation beyond the technical-scientific aspect must respect the phases and cultural environment of each individual in order to minimize existing gaps.
The main limitation of this study is related to the sample size of the population. It should be noted that the study sought to recruit a larger number of participants. However, the original questionnaire design was originally carried out prior to the COVID-19 pandemic. Therefore, due to mandatory physical and social distancing, online application was not possible because it would allow the participants to access information, and this would affect their responses. In a way, the evidence of vulnerability despite having knowledge about STIs was evidenced in this study.

Conclusion
This study identified the vulnerability of healthcare university students in relation to sex, despite their acquisition of sexual education and knowledge about STIs. Women had more possibilities on sex education and were less likely to be sexually protected. Men had a higher level of knowledge about STIs and risky sexual behavior. The time integrated into the university environment favors the acquisition of knowledge, but not protective measures. School-led health promotion policies and interventions that promote sexual health have to encourage sexual assertiveness and reduce risky sexual practices within the young population that is very vulnerable to sexually transmitted infections.