Background: Sexual health education and training is a matter of great importance, however it remains, most of the times, a controversial issue across cultures and countries. Risky health behavior, with the lack of insight, may be an obstacle in providing adolescents with greater opportunity for a healthy sexual and reproductive life. Purpose: To examine Greek-Cypriot adolescents’ knowledge, attitudes and beliefs about sexuality, sexual and reproductive health and explore the influence of the dynamic interplay of transnational and local socio-cultural norms and values. Sample and Method: A Pancyprian survey of 697, third grade public general secondary schools students has been conducted. An anonymous and self-completed questionnaire was used to assess beliefs on sexual and reproductive health. For the analysis of data was used the statistical package SPSS 15 and the methods chi-squared test, pearson r and descriptive statistics. Results: Almost 50% (N=346) of the participants reported that contraception is a sin. The factors that affect adolescents’ emergent sexuality are church power (29%), family (79%), knowledge on sexuality issues (81%) and media power (43%). For the majority of the participants (97%) religion plays a central role in their daily life. Also, 30% (n=102) of males and 27% (n=97) of females stated that the church should be involved in sexuality education. Further, 42% (n=143) of the men believed that is acceptable for a woman to have premarital relations, as opposed to 31% (n=113) of women who believed that is acceptable for a woman to have premarital relations. Conclusion: The results reveal the influence of socio-cultural factors, such as church and family in participants’ understanding sexuality. The use of a descriptive model will help in understanding the local socio-cultural parameters that influence the general understanding of sexuality.
sexuality, model, Cyprus, adolescents, culture, religion
Each year, worldwide, at least 5 million girls aged 15-19 undergo unsafe abortions and it is estimated that worldwide, one in twenty adolescents every year contract a Sexually Transmitted Infection (STI) including HIV/AIDS . On the other hand in recent years non occupational exposure to HIV/AIDS increases steadily .
Many sexually related practices are deeply embedded in various cultures. Sexual decisions are filtered through at least three culturally determined factors: the meaning of sexuality and sexual life, the process of male-female negotiations and youths’ perceptions of danger . In all societies there is a meaning of particular sexual behavior. What messages each society transfers to its people and how people interpret them are mainly products of culture. This implies the parameters that have a strong relation with culture, such as religion, that plays a crucial role in adolescents’ sexual behaviour [4,5]. There is evidence that cultural stereotypes and religious beliefs influence the timing and the reason for the initiation of sexual activity .
The International Planned Parenthood Federation (IPPF)/Youth Manifesto  stated that young people must a) have access to information and education on sexuality and best possible sexual and reproductive health services, b) be able to be active citizens in their society and c) be able to have pleasure and confidence in relationships and all aspects of sexuality, meaning to give people more choices than those imposed by society’s gender roles, choices that themselves decide and feel happy about.
Cyprus is included among the low-prevalence countries for HIV/AIDS, with an estimated prevalence rate of 0.1% and a total of 400-500 infected people among the adult population. Every year, there are on average 24 (0.003%) new HIV/AIDS reported cases [8,9]. Cyprus has much lower rates on HIV/AIDS cases compared to other European countries: in Greece 0.08% of the total population are living with HIV/AIDS, in United Kingdom 0.09% of the total population and in Cyprus
0.03% of the total population10. The cases of syphilis were doubled from last year, from 3% to 7%, from which almost half of them were people of 20-30 years old; also 22% of all reported STI’s cases were genital herpes . Further,  (0.007%) medical abortions were carried out in the year of 2000, 90% of which were between the ages of 15-44 . These figures are likely to be an underestimate as are based only on reported cases which come through the public. There is no official data for private clinics or hospitals.
The Greek-Orthodox church has enormous power on the Cypriot society’s norms and values. Sexual issues are considered as taboos by the church. Premarital sex was the main reason that in 1999 the Cyprus church abandoned the engagement ceremony. Church representatives felt responsible of encouraging the tradition of young people living together after their engagement. Based on research conducted in other countries it is more socially acceptable for young adolescent males to desire sex, while young females are encouraged to stay virgins as long as possible . Having an illegitimate child is severely frowned upon by the Cypriot society that marginalizes both the women and the children involved . The woman is considered to bring dishonor to her family. In order to preserve the family honor, the family will do its utmost to conceal the pregnancy and will put enormous psychological pressure on the woman to abort the fetus . However, the church also holds the view that abortion is a sin even in rape. The Cypriot law permits an abortion under certain circumstances, usually medical reasons. Further, sexual feeling and activities express all the contradictions of power relations, such as gender, class and race . Men and women in more traditional cultures emphasize gender role differences .
This paper explores the factors that explain perceived sexuality in Cypriot adolescents, through a schematic representation. It aims to challenge the relevant stakeholders, as to develop a comprehensive sexuality education for young people and promote sexual and reproductive health.
Access and approval of the study
The Ministry of Education and Culture gave permission for this study to be undertaken after reviewing its aims and the data collection tool. It must be noted that the questionnaire was thoroughly examined and no questions were allowed about the status of sexual activity or intention to engage in sexual activity.
Sample and Method
Participants who met the following inclusion criteria were selected to participate in the study: 1) willingness to participate, 2) 13-15 years of age, 3) ability to speak and read Greek, and 4) being a third grade student in public general secondary school in Cyprus. Potential participants were recruited on the basis of their availability. The principal of each selected school was informed by the researcher about the purpose of the study and asked to give his/her permission to involve the pupil, acting as in loco parentis. Those who agreed to participate were asked to complete the questionnaire. Twenty-seven schools were randomly selected after they had been first stratified by urban/rural areas. Then 27 classes were randomly selected from these schools and all pupils in each selected class participated in the study. Thus, 697 questionnaires were distributed and completed (334 males and 363 females).
In order to explore the influence of the dynamic interplay of transnational and local socio-cultural norms and values to the adolescents’ sexuality and sexual and reproductive health an anonymous questionnaire was used based on previous studies [17,18]. The questionnaire was administered in the Greek language. The first part of the questionnaire included questions to elicit information on the demographic characteristics of the participants and the second part on adolescents’ knowledge, resources/needs and attitudes and beliefs regarding sexual and reproductive health. The face validity of the questionnaire was explicitly assessed through feedback from a panel of experts, who reviewed the questionnaire and confirmed it with minor wording changes. Expert validity is a form of content validity, which is demonstrated by asking experts to review the content of the instrument. The minimum number of experts required is five . The expert panel consisted of two representatives HIV/AIDS and epidemiologists experts from the Ministry of Health, one Cyprus Family Planning Nurse, one academic (Health Education) and two youth expert researchers. Initially, the experts were asked to respond independently to a questionnaire that was developed for the assessment of the questionnaire. They were asked to rate the clarity, the concreteness, the centrality, and the importance of each item using a three-point rating scale (1 = “not clear”, 2 = “clear”, and 3 = “very clear”). The items were considered adequate if there was >85% agreement. The feedback offered tips and suggestions to improve the questionnaire.
The questionnaire was tested in a pilot study sample in order to explore the degree of understanding of the questions from the participants. Minor changes in the wording were suggested by the pilot study. The particular school was excluded from the study.
All of the items were coded and scored, and the completed questionnaires were included in the data analysis set. SPSS-15 (SPSS, Chicago, IL, USA) was used to analyze the data. Values <0.05 were considered to be statistically significant, unless otherwise stated. The chi-square test was used to explore the existence of a statistically significant relationship between the categorical variables.
The majority of the participants (90%) was living with both parents and was Christian Orthodox (97%). They had at least one parent who had graduated from college or had a higher level of education. Moreover, 53% of the youth lived in the urban areas.
For the majority of the participants (97%) religion plays a central role in their daily life (Table 1). Chi-squared test was statistically significant (p<0.001) and showed that 42% (n=143) of the men believed that is acceptable for a woman to have premarital relations, as opposed to 31% (n=113) of women who believed that is acceptable for a woman to have premarital relations (Table 2).The individuals were asked to answer where they usually find resources for sexuality matters. Chi squared test revealed that females are more likely to ask their parents, as opposed to males who prefer to ask friends than parents (Table 3).
Nineteen percent (19%, n=65) of the males and 15% (n=55) of the females agreed that ‘contraception is a sin’, whereas 30% (n=102) of males and 27% (n=97) of females stated that the church should be involved in sexuality education. Data suggest that participants were likely to respond in the same way to the statements ‘contraception is a sin’ and ‘the church should be involved in sexuality matters’ (p<0.001). One third of the participant reported that church is very or somehow important in their lives. As seen in Table 4 the relation of participants’ belief ‘contraception is a sin’ and church importance in their lives.
Regarding knowledge, research revealed that 82% of the participants were more knowledgeable in matters related to alcohol and narcotics and 41% in matters related to conception and contraception The Mann-Whitney test revealed that males reported to be more knowledgeable (12±2.9) than the females (10±2,6) on HIV/AIDS, STI’s (p=0.04).
An important percentage (43%) of the participants reported that mass media influences their beliefs and generally their behaviour.
Based on participants’ answers Figure 1 is a schematic representation of the results regarding sexual and reproductive health of adolescents in Cyprus.
One of the aims of this study was to develop a descriptive model in order to explain emergent sexuality of Greek-Cypriot adolescents. Statistical analysis revealed that adolescents’ sexuality is influenced from 4 parameters: church power, politics, family and knowledge on sexuality and resources.
Αccording to the results of the present study, participants, reported that they perceived contraception as a sin and that the church should be involved in sexuality matters. Furthermore, οne third of the participant reported that church is very or somehow important in their lives. A possible explanation for this finding is that even in nowadays, church plays a significant role in everyday life of the young. This is also shown in other studies in Cyprus, underlining the influence and power of the Greek Orthodox Church and youth attitudes and beliefs .
Ethnohistory of Cyprus depicted the powerful role of the Greek Orthodox Church. Even in contemporary years the presence of church within everyday life is not ignorable. It is notable that in Cyprus church partially owns a television station. Moreover, several church representatives are in key positions in different societal organizations/associations such as for drug users. Church presence and involvement is valued and welcomed, however sometimes a step backward may be needed by the church as to understand contemporary young people’s needs .
Several times society and politicians do not exactly adopt church’s positions. A characteristic example is the decriminalization of homosexuality in 1998 . Such actions may have been taken due to the process of European harmonization and not because most politicians really believed in them.
Politicians need to understand the political aspect of Greek-Cypriot sexuality. Acknowledging the diversity of people and understanding people’s needs are essential for the formation of any policy or law. Their most critical role though is to act for people’s welfare within the context of everyday Greek-Cypriot life. Church preaches the principles of Orthodoxy and anyone is free to adopt them. However, forgiveness, support and understanding are essential components of Christianity and anyone that at some point of his/her life may have behaved outside those principles can always be forgiven.
Greek-Cypriot young students value family very much. Most young people want their parents to talk to them about sexuality matters, meaning that they trust them and that they value their advice . Communication within the family regarding sensitive issues is better to be established since childhood and not to wait until the crucial stage of adolescence to be developed and explored. It could be argued, that strong family bonds and open communication sometimes can delay first sexual intercourse as well as reduce high-risk behavior.
Regarding knowledge, research revealed that 82% of the participants were more knowledgeable in matters related to alcohol and narcotics and 41% in matters related to conception and contraception, a finding that confirms those of Veresies and Pavlakis . Since the publication of their study much work has been done in Cyprus on drug use and misuse but less on sexual health matters.
Regarding the individuals reports about the resources for sexuality matters, the results showed that females are more likely to ask their parents, as opposed to males who prefer to ask friends than parents. This is also a characteristic of the Cypriot culture as well as the formation of gender roles in Cyprus .
Τhe results of the present study also showed that an important percentage of the participants reported that mass media influences their beliefs and generally their behavior. This finding in conjunction with the rapid development of mass media in Cyprus at during the past decade, shows that mass media play an increasingly vital role in the attitude and beliefs of the young. During the past few years several discussions were presented by some media regarding sexuality matters mainly education. This was due to the fact that discussions about sexuality education were taken place at political level. Despite this, limited programs tried to have a scientific analysis on sexuality issues and much less have presented local research evidence. It is the authors’ criticism that there is a different understanding of sexuality education, sexual and reproductive health and adolescents’ needs and expectations among interested and involved parties such as politicians, parents, students. The role of the media is essential and dynamic [23,24].
Media can educate, provide alternative opinions or positions scientifically based and may influence political decisions. Media power should be used though and not misused for the benefit of the public and not for personal ambitions of any reporter, quest or channel.
All these factors -church, politics, media, family- as they interact themselves and with the other factors have a direct influence on gender roles within Greek-Cypriot society. Therefore, the government, the different related ministries (e.g. Ministry of Health, Ministry of Education and Culture) can collaborate in promoting adolescent sexual health. The school may provide knowledge and/or skills, but the role of supporting services is at the same time essential..Non-governmental organizations can also contribute the development of such services [14,19]. The involvement of young people in decision-making is also an asset in successfully promoting sexual and reproductive health [7,18]
Health professionals may contribute in promoting sexual health. Although they are knowledgeable in health matters, many times the dimension of sexuality is undermined within the human life cycle .
Almost half of the men believed that is acceptable for a woman to have premarital relations, as opposed to 31% of women who believed that is acceptable for a woman to have premarital relations. In general, premarital sexual intercourse is acceptable for men, but not for women (Table 2). This may be explained since Cyprus is a small country, personal reputation is important. Most of the times people pay attention on the female sexual behavior whilst male sexual behaviors are more acceptable and pass unnoticed.
According to the findings of the current study participants reported the need for further education in sexual and reproductive health. Sexuality education has been included since 1992 as a unit of the school health education program. It can be argued, that for several reasons such as the sensitivity of the topic, the relative closeness about it within Cypriot society, the limited resources, this has not been effective. However, there is no research evidence to support this. In recent years there has been an on-going debate for the introduction and exploration of sexuality education in schools as part of health education program, whether this will benefit Cypriot adolescents, and how this can best be implemented and accepted within the Cypriot culture. Despite that a pilot program was implemented in some high schools, up until now the government has not adopted a comprehensive sexuality program in schools. Detorakis supported the view that sexuality programmes must be studied scientifically and very thoroughly . Otherwise, it will not only cost time and of human resources but money too, in spite of the good intention of an educational programme.
Further, in Cyprus there is a weak support system for sexuality education. For example, services for youth’s health are almost non-existent. Thus, even if young students acquire some knowledge from school when they actually need help, do not have many choices as far as services/centers is concerned.
All of these issues discussed above have a powerful impact on the individual; his/her self-image, self-identity and consequently his/her sexuality. The attitudes and beliefs of the participants about sexuality reflect traditional collectivist values. Although there are some changes nowadays, still strong taboos influence young people’s beliefs. The basic concepts of this model can be used to develop a national policy and/or strategy related to sexual and reproductive health, including education in Cyprus. This may be applied to some other countries with similar socio-cultural background.
The contribution of the descriptive model is that it offers an understanding of Greek-Cypriots adolescents’ sexuality based on the impact of local and transnational socio-political norms and values on sexuality and sexual and reproductive health. This can be used as a guide by those interested in sexuality such as health educators, health professionals and school teachers.
It is an immediate need to support and guide adolescents to learn about themselves; and understand and become comfortable not only with one’s own sexuality, but with other people’s attitudes and beliefs related to sexuality and sexual behavior. Relevant authorities and organizations need to understand these needs, but more important is to take action for it.