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Neuropsychological Research



Nikolina KENIG1,

1Institute of Psychology, Faculty of Philosophy,
Ss Cyril and Methodius University, Skopje, Macedonia
2International Planned Parenthood Federation,
European Network, Brussels, Belgium
Received: 27-March-2019
Revised: 02-May-2019
Accepted: 18-June-2019
Online first: 19-June-2019


The model of comprehensive sexuality education (CSE) is defined as a process of acquiring information and of developing of skills, values and attitudes that should improve the sexual and reproductive health (SRH) and the overall wellbeing of young people. Its main goal is to “enhance the quality of lives of adolescents and contribute to a compassionate and just society” (WHO Regional Office for Europe and BZgA, 2010, p.20). Thus, the right to access age-appropriate sexuality education is considered the basis of equipping young people to have safe, fulfilling relationships and to take responsibility for their own and other people’s sexual health and wellbeing.
Although it is very well documented that learning about sexuality and relationships is of immense importance for young people in order to ensure that they possess necessary skills to address sexual situations properly, make informed choices and avoid unwanted consequences (e.g Burtney, 2000; Haberland, 2015; Holden at al., 2015), many developing countries still face strong opposition against sexuality education in the formal schooling of adolescents and pre-adolescents (Ketting & Ivanova, 2017).
Despite numerous initiatives in the last decade, comprehensive sexuality education is not yet introduced in the state curricula for primary and secondary schools in the Republic of Macedonia. Some components like anatomy and the prevention of sexually transmitted infections are covered in the biology curriculum, and, starting from 2009, several other relevant topics (like sexual consent, relationships and gender equality) were presented within the subject named “Life skills.” Topics on SRH are not completely absent; however, the findings from a desk review of curricula and textbooks have pointed out that these contents are often insufficient and sometimes misleading (Trajanovski et al., 2010). Other research on access to SRH information in primary and secondary schools in the country (Vasilevska, 2014) found that only in a few schools has there been a discussion on how to use condoms (12%) and oral contraception (3%). In summary, the curricula that are in use do not provide adequate information to equip teenagers on how to practice safe sex and protect their sexual health, and do not help them to understand sexuality in a rights-based context.
The most recent study on the health of school-aged children in the country (Kjostarova-Unkovska & Georgievska-Nanevska, 2017) shows that the sexual debut of teenagers in the country happens relatively early. There is a significant gender disparity among boys and girls (33% of boys and only 3% of girls) in the age range of 15-17 who report having made their sexual debut, which could be considered a sign of an existing double sexual standard in the country. The same study provided information about a high rate of homophobic bullying in Macedonian schools.
CSE curricula have not yet introduced as a mandatory component of formal education, despite advocacy for this implementation by NGOs. The process has been blocked mainly for reasons of conservative ideology (Ketting & Ivanova, 2017), because the content and values of CSE often contradict dominant community standards, especially those regarding gender norms and roles and sexual diversity.
Facing institutional limitations and political constrains on one hand, and indications of a deterioration of young people’s access to the SRH rights on the other, the NGO HERA decided to develop its own curriculum for non-formal CSE. The expert team that developed the new CSE programme followed the WHO and BZgA Standards for Sexuality Education (BZgA, 2010), the IPPF Framework for Comprehensive Sexuality Education (IPPF, 2009) and some existing teaching materials (Population Council, 2009). HERA also created a manual for peer educators on CSE to complement this new curriculum. It includes materials to support the delivery of workshops targeting young people above the age of 13. It covers7 CSE components: Gender, Sexual and Reproductive Health, Sexual citizenship, Relationships, Protection from Violence, Diversity and Pleasure.
The progamme is implemented in schools who volunteer to run it, by young accredited peer educators who go through extensive theoretical and practical training before they start implementing the non-formal education. It is carried out over a period of 2-3 weeks with groups comprising of 20-25 students. An evaluation system that includes administering pre- and post-test questionnaires, attitude scales, focus group discussions with students and interviews with responsible school staff has been applied in all participating schools.
Recognising the complex relationships between gender and adolescent sexuality, many scholars in the sphere of sexuality education (Muhanguzi and Ninsiima, 2011; Paiva and Silva, 2015; Rogow et al., 2013; Tolman et al., 2003) have extensively described the intricacies of creating an integrated gendered model of adolescent sexual health. A recent comprehensive review of evaluations of the efficacy of different sexuality education programs strongly suggests that effective sexuality education curricula must address gender, and specifically gender power asymmetry (Haberland, 2015). At the same time, it is documented that maintaining gender equality as a dominant value of sexuality education with young people from communities where heteronormative notions of gender and sexuality prevail is a very demanding and cumbersome endeavor (e.g. Ngabaza et al., 2016; Rogow et al., 2013).
The primary objective of this research is to assess the effectiveness of the implemented programme model, through the progress that participating students have made in improving their knowledge and changing their attitudes regarding all covered components. This objective will be addressed by comparing pre- and post-test results of programme participants on relevant progress indicators (Study 1). The second goal is to identify the ways in which the programme could be improved on the basis of the reflections and experiences of programme participants (Study 2).


Participants: Study 1 was conducted with 154 participants (113 female and 41 male) who attend schools where Macedonian is the language of instruction, aged thirteen to fourteen (n=67) or seventeen to eighteen (n=87). They all voluntarily participated in CSE workshops that were implemented either as an extracurricular activity at their schools or in youth centres. Participants were divided into two groups – those that had been present at all sessions or had missed only one –full attendance– (n=115) and those that had at least two absences – partial attendance (n=39).
Study 2 was based on collecting qualitative data through four focus group interviews conducted with 24 selected programme participants who provided insights into their perceptions of the CSE training. They were chosen from those who voluntarily expressed willingness to take part in the discussion. After being divided into two groups based on the regularity of attendance at the CSE sessions, participants were chosen randomly. Each focus group comprised of six adolescents of the same sex and age group (13-14 or 17-18). Half of the participants within the groups were boys or girls who attended all CSE sessions, while the rest had missed more than one session.
Instruments: In order to measure the effectiveness of the CSE training, we obtained pre-test and post-test measures on participants’ knowledge and attitudes relevant for all CSE components. These were measured using custom-designed instruments: a test for examining knowledge on CSE components; and an attitude scale for assessing their views on relevant issues that stem from these components.
The multiple choice assessment tests were administered in two parallel forms, one before and one after the CSE training. They consisted of 18 questions covering the seven included components, with split-half reliability r = 0.84 for the first and r = 0.82 for the second version.
The attitude scale was devised for assessing acceptance of values underlying the seven CSE components. It comprised 28 statements (12 of them reversed) on a 5-point Lickert scale designating different degrees of acceptance. Exemplary statements for some of the components are as follows: 1. Men should not allow themselves to be weak or to cry (gender); 2. An HIV positive person should never work as a healthcare worker, a teacher, or as a waiter (reproductive health); 3. It is not acceptable if homosexuals get the same rights as heterosexuals, because their sexual orientation is distorted and sick (diversity).
Higher scores indicate a higher endorsement of the programme’s underlying values. Each component was represented by four statements organised in seven subscales. The internal consistency of the sub-scales ranges from Cronbach alpha ranged from 0.56 to0.78 whereas for the whole scale, it was considerably high for the respective group of participants (Cronbach alpha = 0.90).
The focus group interviews were conducted using a semi-structured approach. The questions covered several main facets: how did students like the overall program; which were the topics that they found being most/least useful and what they felt about the specifics of each of these dimensions, especially those covering or intertwining with sexual orientation and gender identity.
Procedure Pre-test quantitative data was gathered prior to starting the CSE programme, whereas the post-test data was collected immediately after its ending. The average time distance between the two measurements was 10 weeks. Due to organisational inconveniences, the focus group discussions were not conducted immediately after the CSE programme was completed, but three months later. The two gender-matched facilitators were persons included in designing or organising the programme implementation. By communicating their informed consent, all participants understood that their data would be anonymous and strictly protected.
Data analysis The quantitative analysis was performed by using t-test for repeated measures in comparing the pre-test and post-test means of the included variables, as well as two-way ANOVA for testing the relationships between post-test knowledge, participants’ sex and regularity of attendance of the programme.
In analysing the data gathered through focus groups, we employed the strategy of identifying the main themes and patterns within the participants’ accounts. After transcribing audio recordings from the focus groups, the thematic analysis of the content began with familiarisation with the data through several re-readings and continued with developing initial codes, followed by initial identification of the themes and patterns and naming the final themes after several revisions (Braun & Clarke, 2006). The reliability of the categories was ensured by comparing the similarity of developed codes of three researchers who identified them independently from each other.


Study 1. Findings from the analysis of the quantitative data have shown that progress was made regarding all included components that define CSE, from the perspective of improving both knowledge and attitudes. For the whole group of participants, the total score on the attitude scale increased from Mpre= 107.18 (SDpre=18.51) to Mpost=117.50 (SDpost=15.47), while the test score rose from Mpre= 11.64 (SDpre=3.40) to Mpost=13.94 (SDpost=2.70). Both differences are significant (tatt(153)=10.56, p<0.01 and ttest(153)=10.90, p<0.01), with very large effect sizes (Cohen’s d=0.85 and 0.88).
The quantitative analysis in this particular study has been focused on examining whether there are different effects of the programme for the participating boys and girls. The presentation of age-differences has been omitted due to space limitations. The differences in pre- and post-measures on the attitudes regarding each of the CSE components as well as on CSE-related knowledge segregated by gender are shown in Table 1.

Table 1

Differences in post-test and pre-test measures on attitudes and knowledge for girls and boys (t-test for repeated measures)

The results presented in Table 1 show that the implemented model was not equally effective for boys as it was for the girls. In all components, with exception of only one (sexual and reproductive health), the shift was more effective for the boys than for the girls, which could be partly attributed to their different pre-test measures.

In the further analysis we explored the links between the post–test results, regularity of attendance of CSE sessions and participants’ reported sexual activity. Due to limited space, attention here will be given only to results that suggest significant interactions between the main factors. These results are presented in Table 2. The two-way ANOVA analysis of post-test results for the acquired knowledge revealed interaction between sex and regularity of attendance (Fsex*att(1.152)=6.72. p<0.05) accompanied by the main effect of sex (Fsex (1.152)=9.10. p<0.01). The same pattern emerged for two attitude components: citizenship (Fsex(1.150)=21.14. p<0.01; Fsex*att= (1.150)=7.0. p<0.01) and sexual diversity (Fsex(1.150)=26.0. p<0.01; Fsex*att(1.150) =3.92. p<0.05).

Table 2

Interaction effect of participants’ sex and regularity of attendance of CSE on three post-test measures

The post-hoc statistical analysis for differences in attitudes among the subgroups defined by sex and regularity of attendance revealed that the group of boys who attended the sessions regularly had significantly lower (p<0.01) average than the other three subgroups that do not differ among themselves. In other words, while the other subgroups attained similar post-test average, boys who were exposed to all (or all but one) CSE sessions performed less successfully on the questions intended to measure CSE related knowledge. Regarding the attitude on sexual rights (citizenship component) and sexual diversity, post-hoc analysis discloses significant differences among all groups (p’s<0.01) and again, the group of boys with regular attendance has the lowest post-test average.
In order to discover the reasons for this unexpected effect of the program for the group of boys, we conducted Study 2 that explores the accounts of programme participants of their expectations, experiences and personal views on the content and methods in which the CSE was delivered.

Study 2. While the main focus in this qualitative study was exploring the impact of the CSE programme on male adolescents and understanding their self-defined sexuality education needs, the views of their female peers were also taken into consideration because they are useful for contextualising data. In order to preserve anonymity in reporting the findings, participants were identified by a number (according to the order in which they started talking) and gender (G=girl, B=boy).
Generally, both girls and boys agreed that their participation in CSE was an interesting experience especially because they had a chance to hear each other’s’ opinions and views on topics that are rarely discussed in a structured manner. While girls generally agreed that all of the content was useful for them, boys tended to acknowledge that they found sexually transmitted infections as being the most useful component, the others being “more or less familiar to them, from before.”
A strong underlying theme emerging from the boys’ responses was the heteronormative framing of their masculine identities.
Interestingly, their female counterparts recognised this need and coped with it in the class dynamics as something expected and almost unavoidable:
G1: Boys in our class think that they are stronger (than the girls) and they tease the others, especially the weaker ones in order show it and to technically protect themselves from teasing. If they are not violent, they think they are not man enough.
G2: In class, when they do that, when they attack verbally someone, we (girls) have no voice, because they will start to fight… Although I think honestly that there are girls who are stronger than them.
All participating girls agreed that they felt strong pressure not to oppose the strong voices of the loudest male peers in class who used the tactic of ridiculing the idea that gender norms and roles are relative and changeable. According to the girls’ accounts, gender (and sexuality) norms were often “policed” by a few individuals who were considered opinion-makers, and when some individuals did not fit into the mainstream, they faced intensive mockery, public jeering and emasculation. Some girls strongly highlighted their awareness that complying with traditional gender regime is far more stringently enforced for the boys than for the girls.
G2: “Most of the guys were afraid to say their opinion … because they could have been ridiculed afterwards.”
G4: “They then invent stories about you that are not true… and even if they were true…they are laughing and mocking about it, they will say after that he’s gay … even if that guy is not and he would feel bad and ashamed.”
G5: “And if they do not do that, if they are not violent, they think they are not masculine enough…”
G2: “You know, it is technically a way of protection, prevention, they (boys) kind of protect themselves with that harassing – if they do not harass the others, someone will harass them…”
Boys, on the other hand, especially the younger ones, were not as prepared to reflect on what was going on as girls were. They were rather reluctant to articulate their opinions and experiences and instead responded to questioning in a very specific way. When confronted with critical questions (on gender norms, sexual orientations etc.) they “answered” with laughter and an account that their laughter is very hard to explain because it was their “private joke”. It appears as if they were building some kind of homosocial (Sedgwick, 1985) solidarity, brotherhood around the opposition to challenging the heteronormativity.
B3: “Ok, equality is equality –I do not need someone who will bother me with that – that information will not change anything in my life…”
B7: “There was too much about the homosexuals…too much and it was a waste of time…I am not saying that we should exclude that but it was too much.”
B1: “Girls in our class – they do not know anything, they are like bots, they just nod but do not listen at all.”
The examination of participants’ focus group accounts suggested that boys, especially younger ones, tended to expect more practical guidance that would provide them with skills that would enable them to further comply with the societal binary expectations of gender identity. This theme is aligned with their need to be viewed as ‘real men’. Their explanation of this need was within the frame that “they already know more or less the other things that were presented”, but would like to know how to protect themselves from negative consequences of having sex:
B2: “We knew the other things but we have learned new things for the diseases. That is what we need more, to learn how to protect ourselves [giggling].”
B3: “It is good that we learned how to put on a condom; the girl will not do that for me for sure.”
B1: “I would like to know more about protection, here we learned about crabs and how not to exchange underwear with others [sarcastic laughter].”
B2: “The other topics are not for us [males]…you can’t expect for instance to be raped by a girl [laughter].”
The adolescents from the older age group appeared to have a more accepting attitude regarding gender equality and sexual diversity. However, their responses indicated low emotional engagement. Their reactions suggested that they are trying not to go too deep into the topics that challenge the heteronormative definitions of manhood. As an illustration, one participant said:
B10: “There have always been opposing sides, we cannot all be on the same side and agree, there will always be those who think that one has the advantage and others are weaker.”
It seems that both girls and boys experienced anxiety when the notion of gender roles as fixed and natural was challenged. This was especially visible among younger boys who used excessive mockery when discussing the possibility of men taking some of the traditional female roles and much more when discussing male homosexuality.
Some of them were convinced that ‘boys were discriminated against’ because the majority of the examples illustrating gender-based violence put men or boys in the position of perpetrator. Girls on the other hand felt less uncomfortable, yet still tried to distinguish themselves from ‘feminists’ who “unjustly blame men for inequalities that do not exist (in our country).”
G3: “We tried to discuss the topic [of sexual diversity], we started to talk, but it was like that, very shortly… it became insulting … Boys for example, the strongest ones, would start to talk and will emphasise certain things and will turn towards weaker boys by directly pointing to them and others will laugh anyway … and we did not finish that discussion, because every time it ends up with jokes or an insult to someone weaker…”
G5:”They say weaker males behave feminine and that they are homosexuals and tease them for that…”
G8: “Not like feminists who say that they are feminist but hate men, especially white men, as if all white men are bad. In Macedonia we think we are equal, men and women.”
One of the boys exposed the way in which the male peer group imposes the norm of masculinity defined as contra-identification with male homosexuals:
B3: “If you are not against gays, you are gay, as simple as that.”

Limitations The findings of this study must be seen in light of certain limitations. First of all, the number of participants is quite limited along with the very restricted scope of schools where the programme has been implemented. Additionally, dictated by the objective circumstances, the sizes of gender groups differ considerably, especially in the case of male students who did not attend the sessions regularly. Thus, the finding on the interaction effect has to be taken into account with caution. Further, focus group facilitators were connected to the programme because they were part of the programme’s implementing group, which might have potentially inhibited the respondents in sharing their negative experiences or attitudes. Although focus group participants seemed to have very vivid memories of the CSE sessions, another latent source of imprecision might be the extended period between the actual programme and the focus group participation.


The main finding of Study 1 is that the non-formal CSE programme had an effect both on boys and girls. The effect among boys is even more salient. The main reason for this is that the boys had a low starting position: they were not informed about and had negative or neutral attitudes toward the issues covered with the programme. Though there was a significant impact, the boys did not succeed to reach the pre – test position of the girls. Another reason to engage with Study 2 and to further explore participants’ expectations and personal views was the discrepancy in the post results between male students who attend all or most of the session and those who only attended some.
The Study 2 focus group discussions indicate that the issue of sexual orientation and gender identity provokes negative feelings, resistance, and above all, a tendency to ridicule or even discriminate especially among boys from primary schools.
The evident overreaction among the boys when sexual orientation and gender identity is mentioned can be interpreted as avoiding a change of mindset that might endanger their perception of masculinity. Bringing up the issues of other possible masculinities, for example one that is not heteronormative, is usually met with exaggerated laughter and a search for an object to be ridiculed, usually the gays or the girls. They identify homosexuality with effeminacy, which is crucial for their anxiety about gender inversion, and consequently immediately triggers the performance of homophobia. The same pattern follows any mention of gender equality and the possibility of transforming gender roles, especially overturning hegemonic masculinity:
“Boys may feel uncertain about their identities as young men. They may feel antagonistic towards a feminist that insists that men can only name themselves as figures of power who are somehow responsible for the subordination and oppression of women. Since this is not the way young men experience themselves, they can feel uneasy and confused.” (Seidler, 2006, p. xi)
This might be one of the reasons why the boys who were adherent to the programme performed less successfully on the questions intended to measure CSE-related knowledge. Another explanation could be that those who only partially attended the programme provided more socially agreeable responses because they were not exposed to the notion that gender equality is mainstreamed across all CSE components.
The formative age of the boys should be taken in consideration not only because they had never had previous access to sexuality education, but also because they had been exposed to educational curricula stereotyping gender and state campaigns promoting patriarchal values throughout their lives to date. This is a likely explanation of their defensiveness. In the words of Connell (2005, p.224): “to resist the integration of personality around the subordination of women or the dichotomy of masculinity/femininity is to court disintegration, a gender vertigo.”
The boys are asking for clear information on practical issues. As the girls pointed out, they came to learn about sex. So, they want tips and tricks on how to perform their constructed heteronormativity. In doing so, they want to be sure how to stay safe from STIs and unintended pregnancy. It might be hypothesized that this need is associated with what they have learned from society and an educational system that, over the past decade, has intentionally promoted retrogressive values to revive the “natural” patriarchal role of men by intentionally strengthening “socially constructed division between the sexes as natural, self-evident.“ (Bourdieu, 2001, p.9).
It is indicative that those few participants in the focus group who accepting of sexual diversities and wanted to discuss the issues were silenced. The girls also reported in the follow–up discussions that the issues related to sexual orientation and gender identity were taboo. A worrying fact is that the young boys conveyed homophobic and discriminatory statements during focus group discussion. Their ease with expressing homophobia could be a signal of tolerated discrimination against young people with different sexual orientations, gender identities and expressions in school.
The younger boys, in comparison with the older high-school boys, had their first opportunity to talk about these issues in the classroom, albeit in a semi-formal way. Consistently with findings in other similar settings (Ngabaza et al., 2016; Rogow et al., 2013), this suggests that CSE (especially when outside of the formal system) can achieve its objectives only if there is a supportive learning environment in place. In order to achieve this goal, the whole school curricula should embrace and mainstream gender equality across all subjects. In addition, these findings could be considered an indication that CSE should start earlier in education process with age appropriated approaches.
A positive indication of this research is that young boys are willing to be engaged in protecting their sexual and reproductive health, though with the somewhat problematic motive of confirming their hegemonic masculinity. Nevertheless, this can be seen as an entry point for revising the school curricula and improving CSE curricula specifically.


The Macedonian model of CSE for adolescents needs to be further improved by tailoring it to current societal norms. It must be made more accessible for boys, who will find little encouragement from wider society to accept a discourse designed to emancipate them from rigid heteronormativity. A way forward lies in:

    • ensuring that the gender equality is mainstreamed across the curricula in primary schools.
    • making formal and age-appropriate comprehensive sexuality education available in the primary schools from early age.

While further research should be conducted on ways of engaging boys in gender equality in conservative societies, their interest in protecting their sexual and reproductive health should be seen as an entry point.


The authors express their gratitude to Catherine Bailey Gluckman for her valuable comments and suggestions and to Jovana Ananievska for her technical support and participation in organising and carrying out the focus group interviews.

Conflict of interests:
The authors declare no conflict of interests.


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How to cite this article: Kenig, N., Kostovski, D. Gender Differences in the Effects of Comprehensive Sexuality Education. Journal for ReAttach Therapy and Developmental Diversities. 2019 Sep 08; 2(1):40-50.

Copyright ©2019 Kenig, N., Kostovski, D. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0)

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