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Teachers’ conflicts in implementing comprehensive sexuality education: a qualitative systematic review and meta-synthesis



Comprehensive sexuality education (CSE) enables children and young people to learn about the cognitive, emotional, physical, and social characteristics of sexuality. Teachers experience conflicts in teaching CSE due to different cultural and religious backgrounds. This qualitative systematic review aimed to describe the conflicts experienced by teachers in the implementation of CSE in schools. Furthermore, this study aimed to identify the causes of conflict among teachers in implementing CSE.


This article focused on teachers’ conflicts in implementing CSE from 2010 to 2022. Online bibliographic databases, such as PubMed, Web of Science, and ERIC, were used to search for relevant articles. The following search term was used: Teacher, Comprehensive Sexuality Education, and Conflict.


A total of 11 studies were included in the review. All 11 studies were conducted in countries with a predominantly Christian population. The majority of the studies were conducted in Africa. The study respondents included teachers, school principals, and school coordinators. The studies identified that CSE implementation is related to multiple conflicts, depending on the context of the country. Five themes on the causes of conflict emerged from the thematic meta-synthesis: (1) Hesitancy in talking about sex education among teachers due to the cultural and religious context; (2) non-integration of traditional sex education into comprehensive sexuality education, (3) fostering effective facilitation of CSE among teachers, (4) determining the appropriate age to start sex education, and (5) roles of stakeholders outside the school.


This qualitative systematic review and thematic meta-synthesis highlighted several conflicts among teachers in CSE implementation. Despite the teachers having a perception that sex education should be provided, traditional sex education has not yet transformed to CSE. The study findings also emphasize the need to identify the teacher’s role in CSE implementation. The thematic meta-synthesis also strongly reflected the context of Christianity in Europe and Africa; thus, further research on the religious context in other regions is needed.


School health education may lead to better health outcomes with intervention methods in the school setting. The Health Promoting School concept was recommended by the World Health Organization (WHO) and other United Nations (UN) partners to enhance health and the ability to acquire knowledge, skills, attitudes, and values among children and adolescents at school [1]. Efforts in health promotion are associated not only with increasing knowledge of healthy attitudes and behavior but also with a slight reduction in active sexual behavior and mental health issues among adolescents [2]. In particular, for adolescents, educators should provide life skills education, including education on sexual reproductive health and rights, in cooperation with parents and the community [3].

The United Nations Educational, Scientific and Cultural Organization (UNESCO) advocated for comprehensive sexuality education (CSE) in 2009 to help young people make responsible choices in relation to appropriate sexual behavior by acquiring the right scientific knowledge and skills according to their age and culture [4]. CSE is essential to enhance adolescent health because of increased sexual and reproductive health issues globally. However, there were some challenging issues with the implementation of the CSE due to religious and cultural backgrounds in the society and community, because school health policy on sexual education was not recommended in some countries [5]. According to the CSE status report in 2021, 85% of 155 countries surveyed have policies or laws relating to sex education [6]. Furthermore, most of the countries indicated that they have some curriculum based on the policies or laws in each country. However, this report evaluated that curricula were not enough to deliver sex education effectively. Teachers were also provided with training, but many still did not feel confident to deliver sex education to students [6]. Teaching sex education is strongly influenced by social norms and experiences from personal views, leaving teachers often feeling uncomfortable or defensive about it [7]. Moreover, some of the barriers to the implementation of CSE were impacted by culture and religion, and it was associated with the school context and community [8]. Therefore, to promote the implementation of CSE as part of school health policies, it is necessary to consider the cultural and religious background of each country.

Cultural and religious factors influence the implementation of CSE. Teachers’ confidence in CSE implementation is shaken by the cultural and religious backgrounds of their communities and by fears of negative effects, such as encouraging students to engage in unhealthy sexual behavior. Sexual topics are related to the traditional culture and local situation [9]; thus, consideration of these factors is crucial for the promotion of CSE. Moreover, it is considered that the guidance of sexuality education is strongly related not only to educational institutions but also to policies and traditional values of society [10]. Unfortunately, previous studies relevant to CSE were mostly conducted in the context of predominantly Christian regions [9, 10] and there is a paucity of studies focusing on the context of other religions. According to the systematic review of CSE in low-and-middle-income countries in 2022, the findings of this review indicated that multiple factors such as social, economic, cultural, and political influenced the implementation of CSE and integration into the educational systems [11]. Furthermore, quantitative studies conducted previously have not yet identified the common cultural and religious factors affecting school-based sexuality education implementation.

In psychology, conflict is defined as the arousal of two or more strong motives that cannot be solved together [12]. Conflict can be defined as an expression of hostility, negative attitudes, antagonism, aggression, rivalry, or misunderstanding. Moreover, it is associated with situations that involve contradictory or irreconcilable interests between two opposing groups. In psychology, the theory of conflict was advocated by Kurt Lewin in 1935 [13]. This qualitative systematic review focused on the conflicts experienced by teachers in the implementation of CSE in the school setting.

This qualitative systematic review aimed to explore teachers’ experiences of conflict in the implementation of CSE in schools and to identify the causes of conflict to overcome the challenges. The following review question was considered: What conflicts are experienced by teachers in the implementation of CSE in the school setting? Moreover, the systematic review aimed to answer the following questions:

  1. 1.

    Causes of conflict: What types of conflict occurred in implementing CSE among teachers?

  2. 2.

    Overcoming conflict: According to the causes of conflict (primary outcome), how do teachers overcome the conflicts in implementing CSE?


This systematic review adopted a meta-synthesis approach and adhered to the ENTREQ and PRISMA guidelines [14,15,16,17]. The review protocol was registered with PROSPERO (registration number: CRD42022353313). The qualitative systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol [17]. The included studies were evaluated using the Joanna Briggs Institute Critical Appraisal Checklist [18, 19].

Search strategy

The study focused on conflict among teachers in the implementation of CSE from 2010 to 2022. The search was limited to the period of 2010–2022, because CSE was promoted in 2009. The search strategy was constructed as follows: Search #1 Target population; Search #2 comprehensive sexuality education; Search #3 Implementation; and Search #4 Setting (Table 1). The basic formula utilized was as follows: (teacher*) AND (“comprehensive sex education” OR “comprehensive sexual education” OR “comprehensive sexuality education” OR “sex education” OR “sexual education” OR “sexuality education”) AND (“conflict*” OR “challenge*” OR “factor*” OR “experience*” OR “perception*” OR “attitude*”) AND (“school*” OR “primary school*” OR “secondary school*” OR “junior high school*” OR “senior high school*” OR “high school*”).

Table 1 Keywords and the combinations used in the search strategy

Eligibility (inclusion and exclusion) criteria

The title and abstract of the results generated from the searched database were screened using the following inclusion criteria:

  1. 1.

    Publication period: studies published in a peer-reviewed journal and written in English from 1 January 2010 to 1 August 2022.

  2. 2.

    Participants: teachers at primary schools, secondary schools, and senior schools.

  3. 3.

    Study objective: to review the relevance of teachers’ conflict in implementing CSE.

  4. 4.

    Study design: all qualitative study designs, including mixed methods studies.

  5. 5.

    Location and language: focused on all countries and written in English.

Inclusion criteria were considered to identify the justification of the qualitative systematic review from five perspectives (Table 2). Teachers who did not work at primary or secondary schools were excluded from the study.

Table 2 Summary of the inclusion criteria

Information sources

Online bibliographic database search was conducted. PubMed, Web of Science, and ERIC were used to search for relevant articles. The search formula was adapted to each database style. No geographic limit was applied to the search.

Study selection

First, duplicates were removed, and articles published outside 2010 to 2022 were excluded. Then, two researchers (FS and SK) independently screened the selected articles, first by title and abstract. Next, full-text articles were screened based on the inclusion criteria of the review protocol. Eligibility was negotiated by consensus among co-researchers at each stage of the screening process.

Quality appraisal

All titles and abstracts that were identified through the literature search were included in the primary review process. The quality of the included studies was independently assessed by two researchers with master’s degrees (FS and SK), according to the JBI Critical Appraisal Checklist for Qualitative Research [19]. The JBI Critical Appraisal Checklist contained ten questions addressing the possibility of bias in research design, conduct, or analysis. The studies were appraised using the checklist and were categorized into three. First, the studies which fulfilled the inclusion criteria that have a low level risk of bias were identified as A level. Second, the studies which partially fulfilled the inclusion criteria with a moderate risk of bias were identified as B level. Finally, the studies which did not satisfy the inclusion criteria and had a high risk of bias were categorized as C level. Articles that reached A or B levels were included in the meta-synthesis. The results from the selected studies were analyzed through a thematic analysis to synthesize all of the relevant studies that included a qualitative systematic review. Meaning units/supporting quotations were then extracted from the results of the included studies and analyzed to conduct thematic meta-synthesis.

Data synthesis

The thematic-meta synthesis was conducted in three stages, as described by Thomas and Harden in 2008 [19]: (i) line-by-line coding; (ii) developing descriptive themes; and (iii) generating analytic themes.

  1. i)


    In the first stage of inductive coding, relevant qualitative data were extracted from the results of each study that included meaning units/supporting quotations.

  2. ii)

    Descriptive theme

    In the second stage of the inductive thematic analysis, descriptive themes were created to systematize the codes.

  3. iii)

    Analytic themes

    In the third stage of deductive thematic analysis, the descriptive themes were synthesized into analytic themes according to Lewin’s theory of conflict [13].

Procedure of the meta-synthesis

The data extraction and meta-synthesis were conducted in three stages: (i) coding; (ii) development of descriptive themes; and (iii) creation of analytic themes.

  1. i)


    The principal investigator (FS) independently conducted the coding process under the supervision of two researchers (RT and JK). All extracted codes from the selected studies were compiled in an analysis sheet. The principal investigator (FS) and two researchers (RT and JK) reviewed the extracted codes to ensure that these were based on the data from the selected studies.

  2. ii)

    Development of descriptive themes

    First, the principal investigator (FS) developed the descriptive themes based on the extracted codes under the supervision of two researchers (RT and JK). Next, the principal investigator (FS) and two researchers (RT and JK) ensured that the extracted descriptive themes were based on the codes that were recorded in the analysis sheet.

  3. iii)

    Creation of analytic themes

    First, the principal investigator (FS) created the analytical themes and sub-themes based on the developed descriptive themes under the supervision of two researchers (RT and JK). Second, the principal investigator (FS) and two researchers (RT and JK) ensured and elaborated the analytical themes that were based on the analysis sheet and were created to synthesize all findings from the studies. Finally, the principal investigator (FS) and five researchers (CE, DPS, RT, HK, and JK) discussed the findings and resolved disagreements through consensus to finalize the validity of the extracted codes, descriptive themes, and analytical themes.


Screening process

A total of 854 studies were identified during the screening process from the three databases: PubMed (n = 166), Web of Science (n = 335), and ERIC (n = 353). After removing the duplicates, 732 studies remained. Six hundred thirty-two citations were excluded after the title and abstract screening, leading to the retention of 100 potentially relevant articles. Finally, 11 studies were included in the meta-synthesis. The search outcomes are summarized in the PRISMA flowchart of the review in Fig. 1 [17].

Fig. 1
figure 1

PRISMA flow chart of the review (PRISMA)

Characteristics of the included studies

The characteristics of the included studies are summarized and presented in Table 3. The majority of the studies included in the review took place in Africa. Of the 11 studies, nine were qualitative and two were mixed methods studies. Regarding the participants’ characteristics, 11 studies targeted teachers and included school principals and school coordinators. Participants included teachers who teach sexuality education in the school setting. Most of the studies focused on the context of Christianity, having been conducted in predominantly Christian regions and involving Christian participants.

Table 3 Characteristics of the studies included in the systematic review

Study selection quality appraisal

The methodological quality of the review was assessed according to the Joanna Brigs Institute Critical Appraisal Checklist for Qualitative Research [18, 19]. The results of the study quality appraisal are shown in Table 4. All included studies described the philosophical perspective. The background and potential influence of the researcher were not addressed in most of the studies.

Table 4 Quality appraisal of the included studies (Joanna Briggs Institute Critical Appraisal Checklist)

Thematic meta-synthesis

The studies included in the meta-synthesis identified multiple conflicts CSE implementation depending on the country’s context. The studies focusing on conflicts among teachers in implementing CSE were conducted in seven countries, namely: Ethiopia, Ghana, Kenya, South Africa, Uganda, Zambia, and Spain. Five themes were generated from the thematic meta-synthesis (Table 5): (1) Hesitancy in talking about sex education among teachers due to the cultural and religious context; (2) Non-integration of traditional sex education into comprehensive sexuality education; (3) Fostering effective facilitation of CSE among teachers; (4) Determining the appropriate age to start sex education; and (5) Roles of stakeholders outside the school.

Table 5 Analytical and descriptive themes

Theme 1: Hesitancy in talking about sex education among teachers due to the cultural and religious context

Some of the teachers were hesitant to talk to students at school about sexual and reproductive health (SRH). This is because SRH is still a sensitive topic, and it might be necessary to show what the right way is as an option for students. It seems difficult to facilitate interest in CSE among teachers [20, 21]. The teacher is afraid that sex education will promote ‘sexual awakening’ among children and may encourage student sexual behavior. Moreover, some of the parents have not yet acknowledged talking about sexuality at school, because they felt that sex education fosters ‘sexual awakening’ among children [25]. The teacher also expressed concerns on losing their moral authority as a professional educator in front of students, which results in a loss of control over students. Furthermore, the relationship between students and educators is not easy to develop since teachers are perceived as disciplinarians [24, 29].

Many teachers mentioned that providing information on contraceptive methods depends on teachers’ perceptions and experiences. Teaching sex education and demonstrating contraceptive methods in school remain taboo due to being culturally inappropriate [22, 30]. Sexuality education is still inhibited due to both cultural and religious backgrounds, and these multiple pressures might impact the educator [22]. The main message of sex education is abstinence, and the teacher hopes to share the belief of the benefits of abstinence education with students [22, 28, 30]. Conflict occurs when teachers have to teach contraceptive methods to students as a teacher at school, while they must teach abstinence to children as a parent at home [28].

Theme 2: Non-integration of traditional sex education into comprehensive sexuality education

The challenge of implementation in school is that majority of the official subjects on traditional sex education have not been integrated into the official curriculum [21]. In addition, some teachers are afraid that students tended to easily learn about sex recently; thus, there is a gap between teachers and students [22]. Furthermore, the parents complained to the school principal, because a teacher provided a sexual topic (as a CSE curriculum) to students at school [30]. Regarding consideration of minorities, three main points were identified: intellectually disabled learners; HIV-positive adolescents; and homosexuals [23, 25, 27].

Theme 3: Fostering effective facilitation of CSE among teachers

Teachers reported positive motivation toward fostering the effective facilitation of CSE in the school setting. One of the teachers taught comprehensive content, such as communication, assertiveness, and decision-making skills. Therefore, both old and new types of integrated sex education could enhance the effective facilitation of sex education in schools [21, 23, 26, 30]. In addition, the contents of traditional sex education should be included in CSE. Abstinence, which is discussed in traditional sex education, can help avoid teen pregnancies and STIs, including HIV and should, therefore, be included in CSE [26, 30].

Theme 4: Determining the appropriate age to start sex education

Some teachers recommended providing sex education at the beginning of early adolescence, since almost all adolescents start to talk about sexuality during this period [22, 29]. Moreover, there is a challenge to the lack of educational material aimed at this developmental period. Teaching CSE to this cohort is challenging, since the current framework has not yet identified its moderation throughout lectures on home economics or religious education. In addition, students can easily access information on sexuality; thus, the need to update the current guidebook was also identified [23, 30].

Theme 5: Roles of stakeholders outside the school

Parties outside the school were involved in the implementation of the CSE. Teachers recommended involving parents in counseling for students [24]. Through this involvement, parents will start talking about sex education with their children and enhance behaviors for promoting CSE [24]. The teacher’s role is to involve parents to form students’ behavior and have a role to support students as community members. The teachers hoped for students to complete their school education without unwanted pregnancy [22]. It is also reported that the health sector is responsible for some of the health education on CSE [23, 30]. It is common for health center personnel to directly conduct health education on certain health issues in schools on behalf of teachers.

In-service training by UN agencies positively impacted teachers and also influenced teachers to change their own behavior [20, 21]. The training program by the United Nations International Children’s Emergency Fund (UNICEF) was targeted at teachers, head-teachers, and students in the school community and was enhanced [21]. It was indicated that school-based CSE programs are essential to strengthen CSE. This is because the Presidential Initiative on AIDS Strategy to Youth (PIASCY) school club in Uganda had a positive impact on students [23].


This qualitative systematic review aimed to describe the conflicts experienced by teachers in the implementation of CSE in schools. Furthermore, the study aimed to identify the causes of conflict among teachers in the implementation of CSE.

This study identified the following findings regarding the implementation of CSE in the school setting. First, it was indicated that a transition from traditional sex education to comprehensive sexuality education (CSE) is needed. Second, it should be clear that an appropriate stage and consideration of sexual minorities for implementing CSE. Third, the teacher’s role in implementing sex education has not been identified; thus, the roles of teachers and other institutions should be clarified. Five themes on the causes of the conflict emerged from the thematic meta-synthesis: 1) Hesitancy in talking about sex education among teachers due to the cultural and religious context; 2) Non-integration of traditional sex education into comprehensive sexuality education; 3) Fostering effective facilitation of CSE among teachers; 4) Determining the appropriate age to start sex education; and 5) Roles of stakeholders outside the school.

As shown in Table 6, the five themes described the characteristics of conflicts based on the synthesized studies’ findings. The first theme, “Prohibitions on sexuality education”, enumerated the reasons why sexuality education is still prohibited. Notably, sub-theme 1–5 showed the association between sexuality education and religious backgrounds. The theme “Commonality of the conflicts” indicated common challenges identified by most of the included studies. The third theme, “Diversity of the conflicts”, showed the diversity of the conflicts throughout this systematic review and qualitative meta-synthesis. Finally, the “Suggestions for future promotion of school-based sexuality education”, describes recommendations which should be overcome to promote school-based sexuality education.

Table 6 Overview of the analysis of conflicts

The transition from traditional sex education to CSE is crucial to foster effective CSE at school. The integration of traditional sex education and CSE can influence effective facilitation among teachers [21, 23, 26, 30]. This is because CSE implementation still depends on teachers’ experience and perception due to the lack of an official curriculum or guideline. Policies related to the abstinence approach have still prohibited the demonstration of contraceptive methods in sex education [10]. It was reported that the provision of information about contraception influenced immoral and health-compromising sexual behaviors among students due to an abstinence message [31]. Thus, as an influence of the abstinence approach, there is a need to emphasize the provision of not only the physical aspect of sex education but also the promotion of moral education and appropriate relationships among students. It was reported that if teachers understand only the biological or physical components of sex education, such as the differences between male and female bodies, the mechanism of pregnancy, and the prevention of STDs, teachers might be afraid that CSE would have a negative effect of encouraging students to engage in promiscuous sexual behavior. Conversely, if teachers understand the children’s human rights component of comprehensive sexuality education, they will be able to understand that it promotes independent understanding of sexuality among children, rather than the perceived negative effects [32, 33].

In terms of the dissemination of CSE, this study reveals the need to consider sexual minorities among adolescents in society, as well as the appropriate age to start CSE, because the appropriate age has not been specified and some of the teachers felt conflicted about the period of starting sex education still being delayed. The relevant literature includes substantial evidence to support that sex education is most effective when it begins early, before young people start engaging in sexual activity [32]. On the other hand, it was reported that LGBTQ students still faced a hostile environment in school, because they felt that they routinely heard anti-LGBTQ language and experienced victimization and discrimination [9, 34]. Hence, to solve these challenges, CSE should be provided at an appropriate stage, with consideration of sexual diversity and sexual minorities in schools.

Although multiple subjects should be covered by educators, one study that was selected in this review noted that the teacher’s role in implementing CSE has not been officially identified [21]. Since underlying factors included the incompatibility of CSE with the traditional culture and religious norms in each country, teachers were regarded as having a parental role at schools, with an obligation to teach students to recognize responsibility or morals [30]. A study conducted in six Southern African Countries showed that CSE was commonly provided by life orientation teachers or class teachers in schools [35]. Moreover, this study reported that learners (students) preferred to be taught CSE by family members, such as parents or grandparents, and it indicated the importance of the family role in the implementation of CSE. Especially, in low- and middle-income countries, the provision of health services is mostly covered by the private sector and there are international non-government organizations that specialize in sexual and reproductive health (SRH) policy [36]. Therefore, CSE should not only be taught by teachers in schools, but should also involve parents, the private sector, and health workers in the community.

Complaints by parents to school principals due to the provision of sexual topics to students in schools was reported in rural Zambia [30]. Considering this case, enhancing the leadership and connections of the school principals with parents in the community should also be explored. According to a previous study, it was considered that support by school principals set a foundation for cultural change and working for a robust school environment, and training for principals might foster leadership and family engagement in the community [37]. Moreover, the strengthening of partnership-building as one of the core educational provisions between parents and educators would support students in accessing necessary information [38]. Roberts revealed that the role of principals as a spokesperson, negotiator, and coordinator within the school environment is crucial in implementing comprehensive school health [39]. Therefore, school principal leadership might be recognized as a crucial role in linkage with parents in the community, which is needed to change the school culture and perceptions toward CSE.

The results of the thematic meta-analysis also emphasized the need for further research in other regions, since the findings were synthesized based on findings from Africa and Spain. The CSE status report in 2021 recommended three points for CSE implementation in countries worldwide: 1) Clear mandates and budgets to ensure implementation of policies and programs that support the availability of good quality comprehensive sexuality education for all learners; 2) Invest in quality curriculum reform and teacher training; and 3) Strengthen monitoring of the implementation of CSE [6]. These recommendations address the causes of the conflict among teachers which were identified in the thematic meta-synthesis. Furthermore, the findings of the meta-synthesis indicated a necessity for further research to explore the implementation of school-based sexuality education.

The studies included in the meta-synthesis mostly reflected the experience of African countries and thus may have missed the context in other regions. For example, the Asia–Pacific region, which is home to more than half of the 1.8 billion young people of 10–24 years of age [40], still has diverse socio-economic and cultural factors that can negatively influence access to sexual and reproductive health and rights services and the provision of CSE [41].

The findings of this thematic meta-synthesis also strongly reflected the Christian context. Religions have different norms and beliefs; thus, there is a need to explore the experience in countries with other religions, including Islam. A systematic review that focused on Muslim women in 2020 indicated that Islamic norms still tended to prohibit sexual and reproductive health education and access to relevant information [42]. Alomair et al. recommended that an intervention for Muslim people may contribute to overcoming barriers to reproductive health education and services to improve knowledge [42]. Hence, further research on implementing CSE in Asian regions and other religious contexts could be enhanced.

The present study was associated with two limitations. The first is that it only included English-language papers. Since the search focused on keywords and databases that reflect peer-reviewed sex education and sexual health literature, some of the research published outside of this literature may not have been fully represented. Therefore, the search strategy limited the ability to evaluate all of the existing literature. The second limitation is that the systematic approach was not exhaustive and may not have yielded the full range of evidence and findings, and it was assumed that some relevant papers were not included due to the search strategy or selection database. Thus, the approach should be enhanced by searching a broad selection of databases and screening reference lists of all included papers to conduct a gray literature review, or by conducting a hand search.


This qualitative systematic review and thematic meta-synthesis highlighted several conflicts among teachers in the implementation of CSE. Despite the teachers providing sex education, the education they provide has not yet transformed from traditional sex education to CSE. The study findings also emphasize the need to identify the role of teachers in CSE implementation as family members at schools. Furthermore, it has indicated the need to clarify how collaboration with parents, the private sector, and health workers in the community can be done. This thematic meta-synthesis also strongly reflected the context of Christianity in Europe and Africa; thus, further research on the religious context in other regions is needed.

Availability of data and materials

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Comprehensive sexuality education


Enhancing Transparency in Reporting the Synthesis of Qualitative Research


Preferred Reporting Items for Systematic Reviews and Meta-Analyses


Sexual and reproductive health


United Nations Education, Scientific and Cultural Organization


World Health Organization


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The authors would like to thank all of the collaborators from the University of the Philippines Manila and the University of Mataram for their cooperation in conducting the study and developing the manuscript. This study would not have been possible without the support of the supervisors from the University of the Ryukyus in improving all of the research processes and assisting in the data analysis and development of the manuscript.


This study was supported by the Project toward the EDU-Port Japan Project as a “2022 Research Project” under the Ministry of Education, Culture, Sports, Science and Technology, Japan and Grant for National Center for Global Health and Medicine (22A06).

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FS, RT, and JK conceived and designed the study. FS, CE, DPS, HK, HS, RT, and JK contributed to the systematic review protocol. FS and SK searched the databases, and FS, SK, RT, and JK extracted data and performed the study selection. FS, RT, and JK interpreted the results and performed the data analysis. FS, CE, DPS, HK, HS, RT, CW, and JK developed, edited, and revised the manuscript. All authors read and approved the final manuscript for publication.

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Correspondence to Jun Kobayashi.

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Shibuya, F., Estrada, C.A., Sari, D.P. et al. Teachers’ conflicts in implementing comprehensive sexuality education: a qualitative systematic review and meta-synthesis. Trop Med Health 51, 18 (2023).

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