limitations of Ontario sexual health curriculum design of a serious game

Introduction

Health Canada reports that “ positive sexual health outcomes and reducing negative sexual health outcomes are available to all Canadians regardless of their age, race, ethnicity, gender identity, sexual orientation, socioeconomic background, physical/ cognitive abilities, religious background or other such characteristics” (Canadian Guidelines for Sexual Health Education, 2008, p.2). School-based education is considered the main means of educating teens to fulfill this goal in Canada (McKay, 2004). However, in the last 20 years, the sex education curriculum in Ontario has experienced a large number of criticisms and the topic is still very controversial ( Garcia, 2015). The controversy is due to various limitations, unsupported teachers and gaps in students’ knowledge and their needs ( Boyce, Doherty, Fortin, & MacKinnon, 2003; Kumar et al., 2013), teens’ inaccurate or absence of knowledge about Sexually Transmitted Infections (STIs) ( Frappier, Kaufman, Baltzer, Elliot, Lane, Pinzon, & McDuff, 2008) teachers inability to have interesting classes using different teaching strategies and sources due to lack of training (Cohen, Byers, & Sears, 2012), not addressing different sexual orientations, new sex technologies and pleasant aspects of sex (Basian, 2015).

Against all the attempts, the shift to a Conservative government in March, 2018, led to the rejection of the updated curriculum documents, and schools were instructed to use the 1998 curriculum documents. Therefore, in this paper, all the discussions about sex education curriculum are based on the 1998 curriculum documents. I will discuss some of the fundamental limitations of the 1998 sex education curriculum, including: limitations in teachers’ preparedness to teach the sex education curriculum, gaps between the students’ expectations and what they receive at school, and limitations of the abstinence-based curriculum in Ontario. Afterwards, I will move on to discuss the potential of serious games and how they can target the aforementioned limitations in the sex education of Ontario.

Current Situation in Sexual Health in Ontario

In this part I will talk about where we are standing in terms of STI rates, curriculum system, and teachers and students’ perspectives. As schools are expected to prepare teenagers to be self-regulating in their sexual behaviours ( Valk, 2001) and the goal is to equip them to behave responsibly and understand the difference between safe and unsafe sexual practices ( Weaver, Smith, & Kippax, 2005) a look at the current situation in Ontario regarding STIs and unintended pregnancy rates can show where we are now and how efficiently our teenagers are trained to deal with the sexual aspects of their lives. Kirby, Laris, and Rolleri (2006) also acknowledged that curriculum-based sex education can be positively effective on sexual behaviour of the students. Teen pregnancy, STIs, age of first intercourse and condom use are among the most significant issues for youth in Ontario and Canada (McKay, 2004). The information collected between 2007 and 2013 show that the teen abortion rate in Ontario declined from 13.0 per 1,000 to 7.8, a decline of 40.0% (Sex Information and Education Council of Canada, unpublished data). Regarding STIs in Ontario, gonorrhea has increased from 3,966 per 100,000 in 2010 to 5,932 in 2015 (Choudhri, Miller, Sandhu, Leon, & Aho, 2018) and chlamydia has also increased from 33,478 to 39,024 per 100,000 (Choudhri, Miller, Sandhu, Leon, & Aho, 2018). In terms of Syphilis, the rates of reported cases of infectious syphilis increased by 95.1% between 2005 and 2014, from 3.4 to 6.6 per 100,000, of which 858 cases being in Ontario (Report on Sexually Transmitted Infections in Canada: 2013-2014).

Although different factors account for these trends, the role of education cannot be ignored in the increase or decrease of these rates. This idea can be confirmed when we consider students’ feedback saying they need to know more about STIs at their schools (Basian, 2015). For example, many students in Ontario said that the information they received about STIs was too little and too late ( Causarano, Pole, Flicker, & the Toronto Teen Survey Team, 2010). Considering the effectiveness of education for the prevention of STIs and unintended pregnancy, education should start before most of them are sexually active. If it is delayed until later ages, there is the chance that the group at potentially highest risk (i.e., youth who are most likely to drop out of school or to have poor school attendance as they get older) miss education (Herold, Fisher, Smith, & Yarber, 1990). All that being said, I move on to discuss the limitations that might be the reasons for inefficiencies in the sex education of Ontario, Canada.

Obstinance-based Curriculum

I will begin with describing three general sexual health curricula. Obstinance-only “requires that abstinence be taught as the only option outside of marriage; discussion of contraception is either prohibited or its ineffectiveness in preventing pregnancy and STIs or HIV is highlighted” (Landry, Kaeser, & Richards, 1999 p.177). Abstinence-plus policies “promote abstinence as the preferred option for adolescents; this policy allows contraception to be discussed as effective in protecting against unintended pregnancy and STD or HIV” (Landry et al., 1999, p.177). Several studies approved the inefficiency of abstinence-only programs (Kohler, Manhart & Lafferty, 2008). Stanger-Hall and Hall (2011) revealed a positive correlation between abstinence-only education and teenage pregnancy and birth rates.

Curriculum in Ontario is in the abstinence-based or abstinence-plus category since abstinence is not regarded as the only way to stay healthy and it is trying to equip the students with some self-regulatory information and strategies to remain healthy. It cannot be considered a comprehensive curriculum since discourse of pleasure, decision-making and negotiation skills, effects of drugs and alcohol in decision etc., are not covered. In grades five through eight of the curriculum documents, general topics like puberty changes, menstruation, major parts of the reproductive system, effective communication with the opposite sex, STIs and ways to prevent them, understanding ‘abstinence’ as a healthy sexuality, and finding sources of support regarding sexual health are covered (Smylie, Maticka‐Tyndale, & Boyd, 2008). Although this list suggests very productive results but they are not accompanied by comprehensive instruction in sexuality and pleasure, group discussions, and interactive activities to develop negotiation and decision-making skills. Curriculum doesn’t provide more than factual information but the teachers are expected to develop the students’ knowledge, attitude and skills (Cohen et al., 2012).

Smylie et al., (2008) ran a multidimensional sexual health comprehensive programme for 420 students in six schools in Ontario and compared the result with a control group, which received the usual abstinence-plus curriculum of Ontario. They found that their program positively affected the students’ sexual health knowledge about birth control and STIs (with the exception of gonorrhoea), their attitudes towards equal roles in sex and acceptance of a partners’ rejection of sexual activity. They also found that the use of representatives of community organisations to deliver at least some of the sexual health curriculum and collaborative partnerships can have positive effects on the quality of sexual health education in secondary schools. Furthermore, interactive and multimedia programmes supported by games, videos and discussions can be more interesting and engaging for the students than the traditional lecture-style delivery of sexual health curriculum happening now in most of the schools of Ontario (Smylie et al., 2008). In another study in Finland, the researchers found that the students who received better quality sex education had greater sexual knowledge (Kontula, 2010).

Non-specialist Teachers

There is a positive relationship between the effectiveness of a sexual health education curriculum and the preparation of the teachers who provide it (McKay and Barrett, 1999). In Canada, trained teachers to deliver sexual health education are given very low priority (SIECCAN 2004) and non-specialised teachers or teachers with no training in sexual health issues are increasingly required to teach sexual health topics ( McKay and Barrett 1999; Ninomiya 2010; Cohen, Byers, & Sears, 2012).

Westwood and Mullan (2007) in a study in England found that teachers who do not have sufficient knowledge or when they do not feel ready to teach sex education, in many cases, prefer not to teach. In their study, one-third of teachers did not like teaching sex and relationships lessons. Cohen et al., (2004) examined 336 elementary and secondary school teachers in New Brunswick, Canada. About 65% of the teachers reported having had no training for teaching sexual health. They also found that teachers were least comfortable teaching about topics such as masturbation, and sexual pleasure and orgasm.

Cohen et al., (2012) explored the factors affecting Canadian teachers' willingness to teach sexual health education. The factors they assessed were associated with skills, beliefs, demographic, personal characteristics, professional qualifications and attitudes towards sexual health education. They found that “ teachers’ perceptions of their knowledge about sexual health topics was the most important contributor to their willingness to provide sexual health education … That is, to fully realise the goals of a sexual health curriculum, teachers need specific training in how to teach sexual health topics” Cohen et al., 2012, p. 311). They found that the three topics that middle and elementary teachers were least willing to teach were sexual pleasure and orgasm, masturbation, and sexual behaviour.

Some possible reasons for lack of training.

Ninomiya (2010) informed by Cohen et al. (2004) studied the experiences of teachers providing sexual health education in junior high schools in Newfoundland and Labrador. None of the 31 respondents in their study reported having had pre-service training it is mainly because Memorial University, where many teachers in Newfoundland and Labrador complete their Bachelor of Education degree, does not offer any courses for prospective teachers to prepare them for teaching sexual health education.

McKay and Barrett (1999) studied Bachelor of Education (B.Ed.) programs at Canadian university faculties of education. They surveyed 66 respondents from 84 programs and found that 15.5% of the programs provided compulsory training in sexual health training and 26% had optional courses and just one third of the students took one of the optional courses. The results suggest a lack of theoretical and practical training of sexual health education for potential teachers (McKay and Barrett, 1999).

Funding, as another reason, is directed at reducing STIs and preventing pregnancy in which sexual pleasure education has no place (Oliver et al., 2009). Also, many teachers thought that “teaching pleasure in the classroom was fraught with ethical issues and would provoke considerable backlash from parents” (Oliver et al., 2009 p.145). They also considered the curriculum as a source of limitation since it does not address sexual pleasure (Oliver et al., 2009).

Students’ Perspectives

Although there are some references that looked at STI rates to evaluate the students’ knowledge (Givaudan, Van de Vijver, Poortinga, Leenen, & Pick, 2007; Meaney, Rye, Wood & Solovieva, 2009) and reported positive growth in this matter, students’ satisfaction with their educational experiences, as one evaluative measure of school-based sexual health education should not be ignored (Meaney et al., 2009; Fisher & Fisher, 2000; Mueller, Gavin, & Kulkami, 2008). “Satisfaction measures how well the product (education) has met the expectations and needs of its consumers (students)” (Meaney et al., 2009, p. 108). “ measures of student satisfaction may indicate whether sexual health education programs are achieving their goals” (Meaney et al., 2009, p. 109).

Byers, Sears, Voyer, Thurlow, Cohen & Weaver (2003) surveyed 1663 high school students grades 9-12 in New Brunswick and reported that 92% were in favour of sexual health education at school, most of them thought they should have received the sexual knowledge and training earlier in middle school. The vast majority of the students asked for the controversial topics like masturbation, pornography, and orgasm to be covered in their middle school program. Only13% of them rated the quality as very good or excellent and regarding the satisfaction with teaching methods the students thought that teachers did not cover the topics that made them uncomfortable.

Meaney et al., (2009) studied perceptions of, and satisfaction with, school-based sexual health education among 161 university students recently graduated from high schools (Catholic and public) in Ontario. Regarding the topics covered, participants gave high or relatively high ratings to most of the 20 sexual health topics they were asked to assess based on importance to learn about them in high school with no difference in gender or between Public and Catholic high schools.

In terms of the timing of the exposure, participants reported that the topics they learnt about in grades 6-8 were taught at the right time but for six of the 10 topics they covered in grades 9-12 they preferred grade level was lower, at grades 6-8. These six topics are "birth control methods and safer sex practices", "sexual coercion and sexual assault", "sexual decision making", "sexuality in the media", "sexually transmitted infections", and "teenage pregnancy/parenting". The topic "attraction, love, and intimacy" had equal number of preferences for grades 6-8 and 9-12. The students in both types of schools were generally satisfied with their teachers and their satisfaction with the sex education they received was slightly above mid-point. The limitation of this study is that all of the participants had finished high school so that had the chance to cover all the topics.

Fine and McClelland (2006) argued that discourse of pleasure can result in better and more agentic decision making and can get the students more interested in sexual education. However, the discourse of pleasure is still missing in the curriculum of Canada (Begoray, Wharf-Higgins, & MacDonald, 2009). In Ontario, many students feel that sexual education predominantly emphasizes negative consequences of sexual activity (Oliver, van der Meulen, Larkin, Flicker, & the Toronto Teen Survey Research Team, 2013 ). Findings from the Toronto Teens Survey show that the students are not satisfied with the fact that the curriculum is generally not sex-positive in nature, too narrowly focused on risks, not presented and implemented early enough in their lives and discourages discussions (Oliver et al., 2009).

To summarize the limitations of the current curriculum in Ontario as supported by the extant literature, the curricula doesn’t comprehensively prepare students and doesn’t address their needs, is mainly risk and biology centered, different sexual orientations are not imbedded, and most importantly teachers are not trained to discuss such issues and answer the students’ questions. Video games are believed to have the power to make a change (Baranowski, Buday, Thompson, & Baranowski, 2008).

Potential of Video Games

Numbers and Statistics

Since 1970’s video games have made huge progress in terms of graphics and simulating reality. As the graphic quality grows the number of people spending time playing them also increases. Statistics shows that 13-year-old students in the united states spent 6.3 hours a week playing video games during 2013 (“Value of the video game,” 2018). The numbers are clearly showing the importance of this industry in 21st century and its necessity for a very special attention on this strong entertaining tool. Education specialists have looked at video games from different perspectives. Many have looked at the negative consequences of playing video games (e.g. Anderson & Bushman, 2001; Greitemeyer & Osswald, 2010; DeCamp, & Ferguson, 2017) and a large number of references show findings in favour of video games (Gee, 2007; Griffiths, 2002; Shaffer, 2006). I will briefly review some of the findings about the positive outcomes of video games.

Educational Video Games for Health Improvement

Spatial ability and other important skills like hand-eye coordination are proved to be enhanced by video games. Demarest (2000) case study on a 7-year-old child with autism showed that video games could help him improve his serious deficiencies in language and understanding, and social and emotional difficulties. Kappes (1985) could show a reduction in impulsivity in incarcerated juveniles (ages 15 to 18 years) by providing either biofeedback or experience with a videogame. The game ‘Packy and Marlon’ could enhance self-care and medical skills in children and adolescents with diabetes (Brown, Lieberman, Germeny, Fan, Wilson & Pasta, 1997).

Educational Video Games for Sexual Education

Video games have already entered into the sexual health education area. Thomas, Cahill, and Santilli (1997) designed a game to enforce adolescents’ perceived self-efficacy in HIV/AIDS prevention programs. The participants’ perceived ability in successful negotiation in real context and their factual information about safe sex was significantly improved. Downs, Murray, Bruine de Bruin, Penrose, Palmgren and Fischhoff (2004) used and interactive video game and compared the result with a control group that received knowledge about STIs using high-quality informational interventions. Self-reports revealed that those assigned to the interactive video were significantly more likely to be abstinent in the first 3 months following initial exposure to the intervention, and experienced fewer condom failures in the following 3 months, compared to controls. Downs, Ashcraft, Murray, Berlan, de Bruin, Eichner, ... and Salaway (2018) also reported similar results when used video interventions to increase self-efficacy for condom use. All these studies show the high potential of video games in health care and sexual health education. In the next part, I will discuss how a serious game can attractively create a comprehensive learning program to help teachers to address discourse of pleasure in the right time and for everyone in Ontario.

A serious game for Ontario

Serious Games refers to applications developed using computer game technologies that serve purposes other than pure entertainment (Arnab, et al., 2013). Lack of training is one of the reasons that the teachers may not feel ready and comfortable in answering the students’ questions (Cohen et al., 2012). The students also complain that their curriculum is mainly lecture-based and not attractive and skill-based, which is also rooted in non-trained teachers and rigid curriculum. Video games provide extensive player involvement so they can be great tools for an engaging, multimodal, experiential, and communicative forms of learning. Technically, they have the potential to embed different real-life scenarios, videos, texts, questions, etc. (Baranowski, 2008). Dewey (1916) considered that “education is not an affair of telling and being told, but an active, constructive process”.

Features that Can Help

There are several features that if added into a serious game can enhance the students’ intrinsic motivation to play and enjoy the learning process. Story and fantasy have proved to have a high potential in attracting the players (Baranowski, Buday, Thompson, & Baranowski, 2008). Melodrama issues like struggles between good and evil (pleasure or risk in the context of sex education) appeals more to players’ emotions than cognition and can be great tools for behavioral intervention in a serious game (Baranowski et al., 2008). Role-playing as another feature of video games, combines the emotion of storytelling with the power of character immersion (Baranowski et al., 2008). The feeling of having power and control over your character adds more interactivity in the game (Salen & Zimmerman, 2005). Fantasy has proven to enhance active engagement among the youth (Parker and Lepper, 1992) and is primary source of intrinsic motivation (Klinger, 1969). Parker and Lepper (1992) found that embedding educational information in fantasy contexts can be significantly more powerful in learning and knowledge transfer than non-fantasy contexts. These functions, if added to a sexual health serious game, can provide a channel for delivering health behavior change experiences and messages in an engaging and entertaining format and can compensate the lecture-based classes and rigid curriculum of Ontario.

Context for Negotiation and Discussion

Online role-playing games have the potential to connect players (Childress, & Braswell, 2006). The players can text their peers, exchange goods or negotiate over a deal. Students are believed to rely on peers or the Internet rather than other well-grounded sources of information (Grace, 2018) which can lead to inaccurate information about STIs, methods of contraception, and their efficiencies, etc. A sex expert can play in the role of a peer and answer their questions. Teachers should not be given passive roles but should be able to prompt discussions into the game. The teacher can highlight themes from the game scenarios like negotiation skills and encourage students to participate in interactive discussions leading to reflection (Whitton, 2010). They can also practice negotiation during the game and see the results of a proper negotiation. The game can be an online platform in which trained teachers, sexual health experts, parents, etc. can get involved and contribute to the students’ sexual knowledge and skills.

Discourse of Pleasure for Attraction

Another problem mentioned by the students in Ontario is that they do not receive any information about the pleasant aspect of sex and teachers also feel uncomfortable or not knowledgeable enough to cover these topics. Discourse of pleasure can be a great tool to make a balance between attraction and deep learning in a game. Designing a serious game to support the deep learning can be challenging. Graesser, Chipman, Leeming and Biedenbach (2009) argued that a serious game with deep learning foundations may not be very exciting for the players and on the other hand an exciting serious game may not be able to offer anything more than shallow form of meaning. An example of a shallow learning in a sexual serious game is “defender” in which the players play in the role of condoms shooting to kill STIs or pregnancy-causing sperms (Brown, Bayley, & Newby, 2013). Although this game is in the category of educational video game and the players get very engaged, it doesn’t encourage deep learning because the players are not analyzing the process of the game and are not deeply involved.

A Scenario for Experiential Learning

A possible scenario for an interesting sexual serious game that can support deep learning at the same time could be managing pleasure and avoiding viruses or unintended pregnancy when making decisions in the game. Graesser et al., (2009) argued that “tradeoffs of processes in a complex system and a way to resolve conflicts” can lead to deep learning in a serious game because “these activities require reasoning and are taxing on cognitive resources” (Graesser et al., 2009 p. 84). Teaching doesn’t have to happen very directly; the students can see the consequences of their decisions during the game. This is in line with the experiential model of learning proposed by Kolb (1984). In His model he said “in experiential model of learning, individuals are encouraged to reflect on their actions and consequences, so as to foster understanding and re-application of this understanding in future actions” (as cited in Arnab et al., 2013, p.17). A game based on this model can improve the decision-making aspect of sexual knowledge in the students. On the other hand, games offer the players safe environments for exploring and experiencing developmental issues without immediate real-life consequences (Subramanyam, Greenfield, & Tynes, 2004).

Feed Them in Time and Remove the Filters

The students could be given different alternatives when they want to keep the pleasure part up and avoid losing the game because of contracting different STIs. Another problem found in the literature and expressed by the students in Ontario is that the sex education they received was too little, too late (Causarano, Pole, Flicker, & the Toronto Teen Survey Team, 2010). An attractive serious game can provide the players the knowledge and skills they need in the right time and as much as they need. Having avatars instead of real pictures and names can allow the players to ask their very private questions without the fear of being judged by others or any other affective filters like embarrassment. The teachers who may avoid answering some questions because of not feeling comfortable talking about them can take advantage of the avatars as well.

Open Learning Context for Everyone

The game will be open to be played by people with different sexual orientations, disabilities, and from different cultural backgrounds. Students who discontinue taking sexual health education in Grade 10 and onwards can still have access to a reliable source of knowledge about sex given that many important topics get covered after grade 10 in Ontario (Basian, 2015). Immigrants who have never had sexual health education in their original country can also enjoy from the benefits of such game in Canada. Inconsistency in the topics covered and time spent on instruction in different schools in Ontario as another problem can be targeted by a sexual serious game. This serious game can be a small step in moving the Ontario sexual health curriculum from abstinence-based to a comprehensive program.

References

Klinger, E. (1969). Development of imaginative behavior: Implications of play for a theory of fantasy. Psychological Bulletin, 72(4), 277.

Salen, K., & Zimmerman, E. (2005). Game design and meaningful play. Handbook of computer game studies, 59, 79.

Anderson, C. A., & Bushman, B. J. (2001). Effects of violent video games on aggressive behavior, aggressive cognition, aggressive affect, physiological arousal, and prosocial behavior: A meta-analytic review of the scientific literature. Psychological science, 12(5), 353-359.

Arnab, S., Brown, K., Clarke, S., Dunwell, I., Lim, T., Suttie, N., ... & De Freitas, S. (2013). The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Computers & Education, 69, 15-30.

Baranowski, T., Buday, R., Thompson, D. I., & Baranowski, J. (2008). Playing for real: video games and stories for health-related behavior change. American journal of preventive medicine, 34(1), 74-82.

Basian, C. (2015). Best practices and obstacles teaching sexual health education at the high school level (Unpublished master’s thesis). University of Toronto, Toronto, Canada.

Boyce, W. F., Warren, W. K., & King, A. J. (2000). The effectiveness of a school-based HIV education program: a longitudinal comparative evaluation [Skills for Health Relationships program]. The Canadian Journal of Program Evaluation, 15(2), 93.

Boyce, W., M. Doherty, C. Fortin, and D. McKinnon. 2003. Canadian youth, sexual health and HIV/AIDS study: Factors influencing knowledge, attitudes and behaviors. Toronto, ON: Council of Ministers of Education, Canada.

Brown, K. E., Bayley, J., & Newby, K. (2013). Serious game for relationships and sex education: application of an intervention mapping approach to development. In Serious games for healthcare: Applications and implications (pp. 135-166). IGI Global.

Brown, S. J., Lieberman, D. A., Germeny, B. A., Fan, Y. C., Wilson, D. M., & Pasta, D. J. (1997). Educational video game for juvenile diabetes: Results of a controlled trial. Medical Informatics 22, 77-89.

Byers, E. S., Sears, H. A., Voyer, S. D., Thurlow, J. L., Cohen, J. N., & Weaver, A. D. (2003). An adolescent perspective on sexual health education at school and at home: I. High school students. The Canadian Journal of Human Sexuality, 12(1), 1-18.

Canada, P. (2019). Report on Sexually Transmitted Infections in Canada: 2013-2014 - Canada.ca. Canada.ca. Retrieved 9 March 2019, from https://www.canada.ca/en/public-health/services/publications/diseases-conditions/report-sexually-transmitted-infections-canada-2013-14.html

Childress, M. D., & Braswell, R. (2006). Using massively multiplayer online role‐playing games for online learning. Distance Education, 27(2), 187-196.

Choudhri, Y., Miller, J., Sandhu, J., Leon, A., & Aho, J. (2018). Chlamydia in Canada, 2010-2015. Canada Communicable Disease Report, 44,49–54. doi:10.14745/ ccdr.v44i02a03

Choudhri, Y., Miller, J., Sandhu, J., Leon, A., & Aho, J. (2018). Gonorrhea in Canada, 2010-2015. Canada Communicable Disease Report, 44,49–54. doi:10.14745/ ccdr.v44i02a03

Cohen, J. N., Byers, E. S., & Sears, H. A. (2012). Factors affecting Canadian teachers' willingness to teach sexual health education. Sex Education, 12(3), 299-316.

Cohen, J.N., Sears, H.A., Byers, E.S., & Weaver, A.D. (2004). Sexual health education: Attitudes, knowledge, and comfort of teachers in New Brunswick schools. Canadian Journal of Human Sexuality, ¡3, 1-1

DeCamp, W., & Ferguson, C. J. (2017). The impact of degree of exposure to violent video games, family background, and other factors on youth violence. Journal of youth and adolescence, 46(2), 388-400.

Demarest. K. (2000). Video games – What are they good for? Located at: http://www.lessontutor.com/kd3.html

Dewey, J. (1916). Democracy and education. An introduction to the philosophy of education (1966 ed.). New York: Free Press

Downs, J. S., Ashcraft, A. M., Murray, P. J., Berlan, E. D., de Bruin, W. B., Eichner, J., ... & Salaway, J. (2018). Video intervention to increase perceived self-efficacy for condom use in a randomized controlled trial of female adolescents. Journal of pediatric and adolescent gynecology, 31(3), 291-298.

Downs, J. S., Murray, P. J., Bruine de Bruin, W., Penrose, J., Palmgren, C., & Fischhoff, B. (2004). Interactive video behavioral intervention to reduce adolescent females’ STD risk: a randomized controlled trial. Social Science & Medicine, 59(8), 1561–1572. https://doi.org/10.1016/j.socscimed.2004.01.032

Fine, M., & McClelland, S. (2006). Sexuality education and desire: Still missing after all these years. Harvard educational review, 76(3), 297-338.

Fisher, J. D., & Fisher, W. A. (2000). Theoretical approaches to individual-level change in HIV risk behavior. In Handbook of HIV prevention (pp. 3-55). Springer, Boston, MA.

Frappier, J-Y., Kaufman, M., Baltzer, F., Elliot, A., Lane, M., Pinzon, J., & McDuff, P. (2008). Sex and sexual health: A survey of Canadian youth and mothers. Pediatric and Child Health, 13 (1), 25-30.

Garcia, C. K. (2015). Sexual health education in Quebec schools: A critique and call for change. The Canadian Journal of Human Sexuality, 24(3), 197–204.

Gee, J. P. (2007). Good video games and good learning: Collected essays on video games, learning and literacy. New York: Lang.

Givaudan, M., Van de Vijver, F. J., Poortinga, Y. H., Leenen, I., & Pick, S. (2007). Effects of a School‐Based Life Skills and HIV‐Prevention Program for Adolescents in Mexican High Schools 1. Journal of Applied Social Psychology, 37(6), 1141-1162.

Grace, A. P. (2018). Alberta Bounded: Comprehensive Sexual Health Education, Parentism, and Gaps in Provincial Legislation and Educational Policy. Canadian Journal of Education/Revue canadienne de l'éducation, 41(2), 472-497.

Graesser, A., Chipman, P., Leeming, F., & Biedenbach, S. (2009). Deep Learning and Emotion in Serious Games. In Ritterfeld, U., Cody, M., & Vorderer, P. (Eds.). Serious games: Mechanisms and effects (83-102). Routledge.

Greitemeyer, T., & Osswald, S. (2010). Effects of prosocial video games on prosocial behavior. Journal of personality and social psychology, 98(2), 211.

Griffiths, M. D. (2002). The educational benefits of videogames. Education and health, 20(3), 47-51.

Health Canada. (2019). Canadian guidelines for sexual health education. Retrieved 10 March 2019, from https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/publicat/cgshe-ldnemss/pdf/guidelines-eng.pdf

Herold, E. S., Fisher, W. A., Smith, E. A., & Yarber, W. A. (1990). Sex education and the prevention of STD/AIDS and pregnancy among youths. Canadian journal of public health= Revue canadienne de sante publique, 81(2), 141-145.

Higgins, J. W., Begoray, D., & MacDonald, M. (2009). A social ecological conceptual framework for understanding adolescent health literacy in the health education classroom. American journal of community psychology, 44(3-4), 350.

Kappes, B. M., & Thompson, D. L. (1985). Biofeedback vs. video games: Effects on impulsivity, locus of control and self-concept with incarcerated individuals. Journal of Clinical Psychology, 41, 698-706.

Kirby, D., Laris, B. A., & Rolleri, L. (2006). Sex and HIV education programs for youth: their impact and important characteristics.

Kohler, P. K., Manhart, L. E., & Lafferty, W. E. (2008). Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy. Journal of adolescent Health, 42(4), 344-351.

Kontula, O. 2010. The evolution of sex education and students’ sexual knowledge in Finland in the 2000s. Sex Education 10, no. 4: 373–86.

Kumar, M. M., Rodrick, L., Langford, C., Seabrook, J., Speechley, K. N., & Lynch, T. (2013). Sexual knowledge of Canadian adolescents after completion of high school sexual education requirements. Paediatric Child Health, 18(2), 74–80.

Landry, D. J., Kaeser, L. & Richards, C. L. (1999) Abstinence promotion and the provision of information about contraception in public school district sexuality education policies, Family Planning Perspectives, 31, 280–286.

Malone, T.W. (1981). Toward a theory of intrinsically motivated instruction. Cognitive Science, 4, 333-369

McKay, A. (2004). Sexual health education in the schools: questions and answers. The Canadian Journal of Human Sexuality, 13(3-4), 129-142.

McKay, A., & Barrett, M. (1999). Pre-service sexual health education training of elementary, secondary, and physical health education teachers in Canadian faculties of education. The Canadian Journal of Human Sexuality, 8(2), 91-91.

Meaney, G. J., Rye, B. J., Wood, E., & Solovieva, E. (2009). Satisfaction with school-based sexual health education in a sample of university students recently graduated from Ontario high schools. The Canadian Journal of Human Sexuality, 18(3), 107-126.

Mueller, T. E., Gavin, L. E., & Kulkarni, A. (2008). The association between sex education and youth’s engagement in sexual intercourse, age at first intercourse, and birth control use at first sex. Journal of adolescent health, 42(1), 89-96.

Ninomiya, M. M. (2010). Sexual health education in Newfoundland and Labrador schools: Junior high school teachers' experiences, coverage of topics, comfort levels and views about professional practice. The Canadian Journal of Human Sexuality, 19(1-2), 15-27.

Oliver, V., van der Meulen, E., Larkin, J., Flicker, S., & Toronto Teen Survey Research Team. (2013). If you teach them, they will come: Providers’ reactions to incorporating pleasure into youth sexual education. Canadian Journal of Public Health, 104(2), e142-e147.

Ontario Ministry of Education. (2013b). What do you need to graduate? Retrieved from www.edu.gov.on.ca/extra/eng/ppm/graduate.html

Parker, L. E., & Lepper, M. R. (1992). Effects of fantasy contexts on children's learning and motivation: Making learning more fun. Journal of personality and social psychology, 62(4), 625.

Public Health Agency of Canada. Canadian guidelines for sexual health education. Ottawa: Public Health Agency of Canada; 2008, p. 2.

Russell, A. (2018). Doug Ford reverting Ontario back to 1998 sex-ed curriculum is ‘dangerous’ for kids, experts say. Global News. Retrieved 9 March 2019, from https://globalnews.ca/news/4327836/doug-ford-1998-sex-ed-curriculum-dangerous/

Sex Information and Education Council of Canada. (unpublished data). Teen abortion rates were generated using Canadian Institute for Health Information therapeutic abortion data (number of abortions) for Ontario age 19 and under, 2007 and 2013 (http://www. cihi.ca/) and Statistics Canada population estimates for females age 15 to 19 for 2007 and 2013 (Statistics Canada CANSIM Table 051-0001: http://www5.statcan.gc.ca/cansim/ pick-choisir?lang=eng&p2=33&id=0510001)

Shaffer, D. W. (2006). How computer games help children learn. Macmillan.

Smylie, L., Maticka‐Tyndale, E., & Boyd, D. (2008). Evaluation of a school‐based sex education programme delivered to Grade Nine students in Canada. Sex Education, 8(1), 25-46.

Subrahmanyam, K. & Greenfield, P. (1994). Effect of video game practice on spatial skills in boys and girls. Journal of Applied Developmental Psychology, 15, 13-32.

Subramanyam, K., Greenfi eld, P. M., & Tynes, B. (2004). Constructing sexuality and identity in an online teen chat room. Applied Developmental Psychology, 25, 651–666.

Thomas, R., Cahill, J., & Santilli, L. (1997). Using an interactive computer game to increase skill and self-efficacy regarding safer sex negotiation: Field test results. Health Education and Behavior, 24, 71-86.

Value of the video game market in the U.S. 2020 | Statistic. (2018). Statista. Retrieved 23 May 2018, from https://www.statista.com/statistics/246892/value-of-the-video-game-market-in-the us/

Vivancos, R., Abubakar, I., Phillips-Howard, P., & Hunter, P. R. (2013). School-based sex education is associated with reduced risky sexual behaviour and sexually transmitted infections in young adults. Public Health, 127(1), 53-57.

Weaver, H., Smith, G., & Kippax, S. (2005). School‐based sex education policies and indicators of sexual health among young people: a comparison of the Netherlands, France, Australia and the United States. Sex Education, 5(2), 171-188.

Westwood, J., & Mullan, B. (2007). Knowledge and attitudes of secondary school teachers regarding sexual health education in England. Sex education, 7(2), 143-159.

Whitton, N. (2010). Learning with digital games: A practical guide to engaging students in higher education. NewYork: Routledge.