An alternative term to make comprehensive sexuality education more acceptable in childhood

During the intense years of early development, sexual health and rights are widely overlooked (Brilleslijper-Kater & Baartman 2000; Davies & Robinson 2010; Morawska et al. 2015; Robinson & Davies 2016; Stone, Ingham & Gibbins 2013). Studies show that 1–6-year-old children are curious and learn about sexuality early from a vast array of sources, including unreliable ones. Socialisation in sexual issues not only takes place in the family, but also with kindergarten and preschool peers and staff, media and marketing and nearby older minors (Albury & McKee 2017; Collins et al. 2017; Davies & Robinson 2010; Hornor 2004; Josephs 2015; Larsson & Svedin 2002). Despite this, children’s right to receive reliable age-appropriate information, safety skills and positive attitudes regarding their sexuality is poorly implemented.


Introduction
During the intense years of early development, sexual health and rights are widely overlooked (Brilleslijper-Kater & Baartman 2000;Davies & Robinson 2010;Morawska et al. 2015;Robinson & Davies 2016;Stone, Ingham & Gibbins 2013). Studies show that 1-6-year-old children are curious and learn about sexuality early from a vast array of sources, including unreliable ones. Socialisation in sexual issues not only takes place in the family, but also with kindergarten and preschool peers and staff, media and marketing and nearby older minors (Albury & McKee 2017;Collins et al. 2017;Davies & Robinson 2010;Hornor 2004;Josephs 2015;Larsson & Svedin 2002). Despite this, children's right to receive reliable age-appropriate information, safety skills and positive attitudes regarding their sexuality is poorly implemented.
for Children's Position Statement 2017. The European Court of Human Rights ruled in 2017 that children have the right to early SE, even despite parental prohibition (European Court of Human Rights 2018).
In addition, childhood sexual development and common sexual behaviours are minimally researched. Children are treated as primitive forms of adults rather than from their own perspective (LeFrancois 2013). Studies of childhood sexuality show that adult-like sex or reproduction was not the focus of young children's behaviours and questions (Brilleslijper-Kater & Baartman 2000;Cacciatore et al. 2018;Sandnabba et al. 2003;Volbert 2000). In studying and approaching children's sexuality, the child's view should be central and respected (Flanagan 2011(Flanagan , 2014Mckee et al. 2010;UN 1989). Childhood is a period of becoming familiar with one's body and feelings, building necessary socio-emotional skills, self-esteem and body image, learning norms and relationships, and seeking pleasure and safe closeness. The content of SE for young children should respond to this need (Cacciatore, Korteniemi-Poikela & Kaltiala 2019;United Nations Educational, Scientific and Cultural Organization UNESCO, 2009; United Nations Population Fund UNFPA 2014; WHO Regional Office for Europe and BZgA 2010). In our survey study among early childhood education and care (ECEC) professionals and parents of 1-6-year-olds, the most commonly observed sexuality-related verbal expressions among children were comments on the body, and the most commonly observed sexuality-related behaviours were openly displayed emotions such as infatuation for one other (Cacciatore et al. 2020). Hence, young children's SE should provide especially knowledge, skills and positive attitudes about the body and showing emotions.
Many barriers have blocked the implementation of SE for young children, among them erroneous cultural beliefs, myths, fear and ignorance. In our clinical experience, common objections include that children are not fertile and therefore need not know about sexuality, that any information destroys childhood innocence and that SE is conducive to sexual abuse, promiscuity, sex or childbirth at an early age. 'Let them be kids!' and 'Sex and a child do not fit in the same sentence!' are adages, by which adults want to protect their children against too-early information on sex, which is what they fear SE to be. In both parents and professionals, this has caused ambivalence about childhood SE and provoked emotional argumentation, reluctance and an urge to reject the topic (Davies & Robinson 2010;Flanagan 2011;Ketting et al. 2018). This has suppressed sensible discussions around childhood SE (Goldman 2013;Merghati-Khoei, Abolghasemi & Smith 2014).
Misunderstandings about the content of age-matched SE may hinder its implementation. It is of utmost importance that all adults, regardless of background, education and literacy, gain knowledge of what young children's SE should be. Language creates reality. The simplicity of the concepts used is crucial. The first obstacle to understanding childhood SE may be the negative response to the term 'sexuality education'. An individual's ability to understand terminology well enough to make health-promoting decisions is often inadequate. Interventions to improve outcomes associated with health literacy are needed (Geboers et al. 2018). Therefore, alternative terminology for referring to very young children's sexuality and SE, nevertheless covering the relevant contents, may be a helpful solution.
Our aims were (1) to evaluate whether early childhood education professionals and parents of 1-6-year-olds are critical of childhood SE because of connotations of the concept SE with adulthood sexuality and (2) to test whether an alternative term for comprehensive childhood SE, Kehotunnekasvatus [Body-Emotion Education], could reduce resistance to young children's SE.

Method
The stepwise study plan is presented in Figure 1.

Two online studies
To gain an overview of the situation, obstacles and needs regarding childhood SE in Finland, we first conducted two online surveys of ECEC professionals (study A) and parents of 1-6-year-olds (study B) (Figure 1). The surveys explored adults' experiences of, thoughts on and attitudes to sexuality and SE among 1-6-year-old children.

Participant selection for the online studies
• ECEC professionals. In May 2013, via e-mail, we asked (1) the person who organises training days for ECEC professionals, (2) the person who organises the nationwide annual trade fair on ECEC and (3) municipal district managers of ECEC to forward a link to our Questionnaire A to professionals in the field (Cacciatore et al. 2020).
SE, sexuality education. • Parents. In May 2014, we invited parents of 0-6-year-olds to respond to web-based Questionnaire B through the web pages of (1) the Family Federation of Finland, (2) one baby magazine, (3) one family magazine and (4) one tabloid.
For both studies, we set the response time at two weeks. In our covering text, we stated that participation was voluntary, and all data would remain anonymous. We deemed responding to the web-based questionnaire to be informed consent. No responses were excluded because of inappropriate language. The University of Helsinki Ethical Review Board in the Humanities and Social and Behavioural Sciences approved the parents' study. We carried out the studies following the principles of the Declaration of Helsinki.

Questionnaire design for online studies A and B
Our web-based survey on adults' reflections on sexuality and SE among 1-6-year-old children was based on the comprehensive educational model in the In the open-ended questions, the respondents were asked to report their experiences of, thoughts on and attitudes to sexuality and SE among 1-6-year-old children (Appendix 1).
The first data analysed for the present study were the responses to the open-ended questions in the surveys for professionals (A) and parents (B).

Participants and attrition
The professionals' questionnaire (A) was opened 267 times without being completed and filled in 507 times, yielding a response rate of 65%, whereas the questionnaire for parents was opened 1888 times without being completed and filled in 614 times, giving a response rate of 25%. The same person may, however, have opened the questionnaire several times before answering. The distribution of both groups represented the population of Finland across demographic characteristics.

Data analyses
We analysed the open-ended questions in Questionnaires A and B qualitatively, first inductively and then deductively. Inductive and deductive reasoning approaches in the process of qualitative data analysis are described by Elo and Kyngäs (2008:107-115). In the inductive analysis, we conventionally read the material several times to understand the pros and cons of children's SE. Surprisingly, the term 'sexuality education' was one target of criticism: 'We do educate, but we won't call it SE'. 'In my opinion, childhood sexuality is the wrong word and gives the wrong impression'. In the deductive or directed thematic content analysis, we read the material through again, searching for comments that criticised, misunderstood or challenged more the term 'sexuality education' than the education. A presentation of this criticism appears in the 'Results' section.

An alternative term for childhood sexuality education
Secondly, we examined the possibility of replacing the Finnish term for 'sexuality education' for this age group in order to distract attention from adult-like sexuality and better reflect the content of childhood SE. We constructed a new term based on the most common topics of children's verbal expressions and behaviours related to SE themes in day care (Cacciatore et al. 2020). Over 50% of professionals and parents had stated that children in the groups they taught or at home asked daily or weekly questions about different body parts and their functions (such as the navel, ear, 'willy'/genitals, buttocks) and hygiene (such as the appropriate way to clean the buttocks/genitals, teeth and hands). Over 50% of professionals and parents had stated that children talked daily or weekly about liking, infatuation or love for other children or familiar adults (Cacciatore et al. 2020). On the behavioural level, children were most commonly observed to express their emotions easily and to show lots of feelings of infatuation, affection and liking towards each other, for example, by 'kiss chase' games. All these related to the SE topics 'The Body' and 'Emotions' in The Standards (WHO 2010). We, therefore, decided to call young children's SE, Kehotunnekasvatus [body-emotion education], to focus on their major expressions and interests.

Testing the new term
To test the new term's acceptability and usefulness as an alternative to SE in the youngest age groups, we conducted surveys among three different groups of professionals. We formulated a written questionnaire (C) to assess the pros and cons of the new term.

Participants testing the new term
Early childhood education and care professionals: Respondents were professionals in ECEC in southern Finland. They worked daily in kindergartens and/or preschools with 1-6-year-olds and their parents, usually without training or guidance in SE. We distributed Questionnaire C during a training day on aggression management skills. One of the researchers was present, explained the study and collected the completed questionnaires. The response rate was 95% (n = 63).

Public health nurses (nurses): Respondents worked in
Northern Finland and in their daily work met both young children and their parents. The nurses had some training and instruction on counselling about childhood sexuality. We distributed Questionnaire C to these nurses before a training day on childhood SE. Two of the researchers were present, explained the study and collected the completed questionnaires. The response rate was 90% (n = 29).

Sexual health specialists (specialists):
The respondents (n = 17) implemented SE in their work in the same non-governmental organisation, the Family Federation of Finland (Väestöliitto), where two of the researchers worked. The specialists worked as sexuality counsellors, therapists, social workers and healthcare professionals. They promoted SE or counselled mainly adolescents and adults. They often addressed sexuality in their work when people sought help for their problems. Only five of the specialists were counselling or producing material on childhood sexuality. We distributed Questionnaire C by internal mail. After one reminder, the response rate was 100%.
Participation was voluntary, and all data were anonymous. We deemed responding to the anonymous questionnaire to be informed consent. No responses were excluded because of inappropriate language. We conducted the studies following the principles of the Declaration of Helsinki.

Questionnaire C
In Questionnaire C, we introduced the new term as a possible alternative to 'sexuality education' for 1-6-year-olds. The new concept would stress providing age-and developmentappropriate SE following the instructions of The Standards (WHO 2010). We also noted that what was central in this age group was becoming confident about one's own body, learning to control emotions, learning safety skills and acquiring the skills to negotiate about these.
Questionnaire C consisted of seven questions with Likert scale alternatives (

Data analysis
The proportions of those positive and negative to the new concept on each question among the ECEC professionals, nurses and specialists were compared by cross-tabulations with Fisher's exact test statistics. We did statistical analysis using IBM Statistical Package for Social Sciences statistics for Windows version 25 (IBM Corp., Armonk, New York). Statistial significance was set at p < 0.05.
Finally, the comments expressed in the open-ended question will be described.

Ethical consideration
The University of Helsinki Ethical Review Board in the Humanities and Social and Behavioural Sciences approved the parents' study (B). The authors confirm that ethical clearance was not needed/required for the studies A and C.

Criticism of the terms 'childhood sexuality' and 'childhood sexuality education' in Questionnaires A and B
In responses to Questionnaires A and B (Appendix 1), altogether 27 comments about the terms 'childhood sexuality' and 'sexuality education' were identified, and they were all critical: 9 from professionals, 18 from parents (Table 1). Such critical comments were found in response to the following questions: • Adults' attitudes to, thoughts on and experiences of childhood sexuality What forms of expressing themselves and games that you consider sexual have you observed among children? What type of emotional responses does childhood sexuality raise in you? What kind of sexual behaviour do you think is acceptable for a child, and what kind of behaviour requires intervention? Please also justify your answer. We categorised these comments in order of prevalence into five mutually exclusive groups: (1) no 'sexual tone' was observed in children's actions; (2) children's actions are natural, not 'sexual'; (3) the word 'sexuality' has inappropriate connotations with adult-like sexuality; (4) 'SE' is too complicated as a concept for children; and (5) children already receive too much sexuality-related information. Table 1 shows examples of the critical comments.

Acceptance of the new term
The alternative term for childhood SE, Kehotunnekasvatus [body-emotion education], was subsequently introduced to three groups of professionals in Questionnaire C. Acceptance of the new term was excellent, as shown in Table 2. The majority of all respondents considered it appropriate (82%, 97%, 59%, respectively, among ECEC professionals/ nurses/specialists), necessary (70%, 79%, 59%) and usable in their work (86%, 79%, 53%). Only two specialists (12%) and 5% of ECEC professionals, but none of the nurses, reported that they could not use the term at all.
A majority of ECEC professionals (63%) and nurses (71%), but fewer SE specialists (41%), considered the new term easy to use. Likewise, 76% of ECEC professionals and 65% of nurses in the field considered the new term even better than 'sexuality education', whereas of the specialists, 47% considered it better.
Eighty-six per cent of ECEC professionals, 90% of nurses and 71% of specialists considered the new term suitable for professionals' use. The suitability of the new term for use with parents caused more division of opinion: of the nurses, 93% considered it suitable for parents to use; of the ECEC professionals, 73%; but of the specialists, only 47%. However, no one found the new term totally unsuitable for use with parents.
The differences between the groups were statistically significant in concepts of ease, attitude toward use and suitability for use with parents (Table 2).
To the open-ended item in Questionnaire C, we received opinions from 12 specialists and 4 ECEC professionals and 4 nurses.
Of these, some comments highlighted the benefits of the new term: 'Body-emotion education' as a concept may perhaps more clearly reflect or describe the content. I think that using it will make it easier to approach a subject which may otherwise be difficult to address.' (Nurse) 'Body-emotion education' is more neutral and downplays thoughts of sex; it is more positive and may inspire parents to think that this is important for their children … I could, as a parent, use that. 'Ordinary' parents might need some time to learn the term.' (Specialist) Some comments favoured 'SE': 'I think that a new term will confuse parents even more. I would explain these already familiar concepts more thoroughly.' (Specialist)

Discussion
Sexuality education is vital for supporting children and young people in their sexual and general development. It enables them to increase their knowledge of sexual and reproductive health and rights and to develop their decisionmaking, communication and risk-reduction skills, as well as positive and responsible attitudes to sexuality and relationships (WHO 2017). The objective of the present study was to explore criticism expressed towards childhood SE, to present an alternative concept for childhood SE and to test this concept's applicability among professionals working with children and in SE. This we did in order to reduce resistance and to accelerate the implementation of young children's SE in Finland.
Our study suggested that one factor hindering childhood SE was the negative adult-sexuality connotation of the term 'sexuality education'. The term 'sexuality' was considered unsuitable when applied to 1-6-year-olds. To overcome this, we formulated and tested a new childcentred term to replace the term 'sexuality education' for use with young children, however with the same content and meaning as the age-and developmentally appropriate, comprehensive SE recommended in the WHO's Standards for Sexuality Education (2010) for young children. The new term derived directly from observations of what sexualityrelated content emerges in young children's everyday verbal expressions and behaviour, underlined the age-and developmental appropriateness of the education as opposed to teaching adult-centred sexual topics to minors (Cacciatore et al. 2020).
The healthcare and ECEC professionals indicated acceptance of the new term. The majority of all respondents considered it necessary, appropriate, usable in their work and suitable for professionals. Moreover, the majority of ECEC professionals and nurses working daily with parents considered the new term better than SE, easy and suitable for use with parents. The new term was welcomed more positively by professionals in daily contact with parents of young children than by specialists working daily with sexual issues.

Connotations of adulthood -A major obstacle
Our online studies indicated that one factor impeding the implementation of childhood SE in Finland was the adulthood connotation of the term 'sexuality'. Our finding concurs with those of studies in Europe, New Zeland, Australia and the United States of America showing that for many adults the words 'children' and 'sexuality' are incompatible and have risky connotations (Brilleslijper-Kater & Baartman 2000;Flanagan 2014;Hornor 2004;Robinson, Smith & Davies 2017). 'Sexuality' in the standard language is associated with sex and reproduction (Flanagan 2014;Kurtuncu et al. 2015). Our findings are in line with those presented by Leander, Larsen and Munk (2018), who quoted a kindergarten director: 'When children play doctor games, they don't think of it as something sexual. The thoughts of the adults/parents make it something bad'. Adulthood-connected misunderstandings impede the promotion of SE in childhood and even negotiations about it among parents and professionals (Flanagan 2011;Kaeser, DiSalivo & Moglia 2000;Merghati-Khoei et al. 2014). For this reason, the topic is frequently avoided and overridden in everyday life.
Taboos associated with the word 'sexuality' even impede SE for adolescents (Walker & Milton 2006), and using less sex-loaded terms such as 'health education', 'relation education', 'life-skills education' or 'youth education' has often been necessary in order to initiate SE (Ketting et al. 2018). Sexuality education for young children is even more taboo. The time intended for guiding parents to provide appropriate SE was often wasted in explaining the term and calming abrupt responses, emphasised some respondents in our study. Parents were easily alarmed, and fear and erroneous beliefs were common, as also claimed by Robinson et al. (2017).

Professionals' acceptance of the new term
Early childhood education and care professionals and nurses expressed a marked preference for the new term over 'sexuality education'. Possibly they had experiences of obstacles to discussing childhood sexuality with parents and co-workers, who were unprepared and lacked training to understand and to negotiate about childhood sexuality and SE, under several misapprehensions and harbouring prejudices.
Nevertheless, children play sexual games and ask abundant questions in day care (Cacciatore et al. 2020;Larsson & Svedin 2002;Sandnabba et al. 2003), where professionals need to make spontaneous decisions about what are developmentally and culturally correct and health-promoting, age-appropriate answers to infants and with a wide diversity of children (Davies, Glaser & Kossoff 2000;Leander et al. 2018). They need tools and competencies to enhance parents' and coworkers' knowledge and acceptance of the subject and to foster children's rights and healthy development. Using simple language is one means to promote health literacy (Geboers et al. 2018).
The sexual health specialists found the new term easy to use significantly less often and expressed less commonly positive attitudes towards using it. The specialists' work was different from what the other professionals did among families with young children. They met people who were prepared to discuss sexuality-related topics. Many specialists preferred to use the term 'sexuality education' and to make it more known, as Goldman also found to be the case in Australia (2013). The specialists' viewpoint may be biased by a lack of experiences of obstacles in the field.

Child-centred concepts
Words create associations, images and emotions. Because of the sensitive nature of childhood SE, professionals may need words to explain child sexual development and behaviours to parents while avoiding harmful misunderstandings. The difference of childhood sexuality from that of adults becomes more noticeable using age-specific concepts.
Adult words lead to adult-like ideas of children's behaviour (Flanagan 2014). LeFrancois (2013) talked about adultism as adult-centric policies and practices harming children's lives. Adultism results in disadvantage and oppressive social relations. In the case of sexual health, adultism prevents children from receiving the education, information and protection they need and are entitled to (UN 1989). The ECEC professionals' perturbation, confusion and distress regarding the term 'sexuality' contributes to refusal to implement childhood SE (Merghati-Khoei et al. 2014). In a study in the United Kingdom, parents felt that they were interpreting some behaviours and questions from their 3-7-year-old children using adult sexual scripts rather than considering the context from the child's perspective (Stone et al. 2013). Flanagan (2014) noted that parents, teachers and social workers frequently named children's actions from their adult perspectives on sexuality, which led to adult constructions and judgements of childhood sexuality.
One problem impeding the promotion of childhood SE has been the lack of terms free from adulthood connotations. Child-centred frames of sexuality, created with childcentred words, may enable ECEC professionals, parents and policymakers to negotiate and plan childhood SE without serious negative prejudice.
In some languages, words describing childhood sexuality are different from those applied to adults or adolescents. This makes it easier for parents to understand that childhood sexuality is different (Cacciatore et al. 2019). For example, the term 'masturbation' may be offensive to parents unfamiliar with the concept of sexuality in young children (Mallants & Casteels 2008;Nechay et al. 2004). Using words such as 'selfsoothing' have been shown to be more acceptable. In fact, childhood masturbation is mostly aimed at calming (Mallants & Casteels 2008;Sandnabba et al. 2003)  Child-centred words are not euphemisms, but options and synonyms for describing childhood sexuality. Child-specific terms highlight that children have their own kinds of bodies, experiences, intentions, perspectives and needs. Using different words for children's sexuality is not a repressed, evasive or euphemistic representation, but can help adults to see the difference and to overcome their rejections, misunderstandings and objections.

The implementation of the new term in Finland
The Family Federation of Finland has introduced the new term, 'body-emotion education', on its Child and Sexuality webpages, in materials, training sessions and in the media since 2015. At the end of 2019, a Google search yielded over 30 000 hits.
In October 2016, the new National Core Curriculum for Early Childhood Education and Care was delivered, which for the first time was an official and binding document based on the legislation (Finnish National Agency for Education 2018). Each municipality was required to draw up local curricular and qualification requirements based on the national document, to outline how the objectives are to be achieved. In 2017, the Family Federation of Finland encouraged all municipalities to implement SE in their local curricula, at the same time introducing the new term. As a result, at least 21 municipalities out of the 311 in Finland included SE as a part of their mandatory local curricula -18 using the new term alone or together with SE. These municipalities cover 37% of Finnish 0-6-year-olds.
Two Finnish Members of Parliament tabled a written question to the Speaker of Parliament on body-emotion education and the prevention of sexual harassment starting in early childhood education in December 2017.

Limitations and strengths
A limitation of the online studies is that we do not know how widely the links to Questionnaires A and B were distributed. We know how many times the link was opened, but we do not how many individuals received the link without opening it. Individuals uncomfortable with sexuality issues may have avoided the study, resulting in a bias towards respondents willing to communicate about sexuality.
The results in testing the new term are preliminary as the respondent groups were small, and we tested a new Finnish term among Finnish professionals. The new term may not be directly transferable to other languages.
The new term, Kehotunnekasvatus, was built on extensive research among ECEC and parents.

Conclusion
Our study showed that simple, quick and creative methods such as finding new and less adulthood-connected terms can be introduced to overcome resistance towards childhood SE. Healthcare and education professionals welcomed the new term, especially those working daily with parents of young children.
Parents and teachers of young children need support and information to understand the content and importance of comprehensive age-appropriate SE for young children. Nearby adults' ability and capacity to provide SE is crucial for children's safety and well-being. Promoting health literacy uses methods such as reformulating health information to make it better understood.
Policymakers, educational and health authorities, and specialists must make agreements to offer young children accurate SE. New, developmentally appropriate terms can facilitate these negotiations.
More studies are needed to identify the obstacles to childhood SE in different countries. In terminology, idiomatic expressions may be needed for different languages.