• TABLE OF CONTENTS
HIDE
 Front Cover
 Title Page
 Introduction
 Modern Mongolia
 The government responds to changing...
 Beyond the classroom: Using popular...
 Monitoring and evaluation
 Ongoing challenges
 Lessons learned
 References
 Resumen en Espanol
 Resume en Francais
 About the authors
 Back Cover














Group Title: Quality/Calidad
Title: Universal sexuality education in Mongolia
CITATION THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00088798/00001
 Material Information
Title: Universal sexuality education in Mongolia educating today to protect tomorrow
Series Title: Quality = Calidad
Physical Description: 34 p. : ill. ;
Language: English
Creator: Population Council
Publisher: Population Council
Place of Publication: New York N.Y. USA
Publication Date: c2002
 Subjects
Subject: Sex instruction -- Mongolia   ( lcsh )
Hygiene, Sexual -- Mongolia   ( lcsh )
Sex Education -- Mongolia   ( mesh )
Adolescent -- Mongolia   ( mesh )
School Health Services -- Mongolia   ( mesh )
Genre: international intergovernmental publication   ( marcgt )
bibliography   ( marcgt )
non-fiction   ( marcgt )
Spatial Coverage: Mongolia
 Notes
Bibliography: Includes bibliographical references (p. 31).
 Record Information
Bibliographic ID: UF00088798
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 50504416
lccn - 2008270238
issn - 1097-8194 ;

Table of Contents
    Front Cover
        Front Cover
    Title Page
        Title Page 1
        Title Page 2
    Introduction
        Page 1
        Page 2
        Page 3
        Page 4
    Modern Mongolia
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
    The government responds to changing needs of adolescents
        Page 10
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
    Beyond the classroom: Using popular media
        Page 24
        Page 25
        Page 26
    Monitoring and evaluation
        Page 27
    Ongoing challenges
        Page 28
        Page 29
    Lessons learned
        Page 30
    References
        Page 31
    Resumen en Espanol
        Page 32
    Resume en Francais
        Page 33
    About the authors
        Page 34
    Back Cover
        Page 35
Full Text

















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Universal Sexuality
Education in Mongolia:
Educating Today to
Protect Tomorrow


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Quality/Calidad/Qualit6, a publication of
the Population Council, highlights exam-
ples of clinical and educational programs
that bring a strong commitment, as well
as innovative and thoughtful approaches,
to the issue of high-quality care in sexual
and reproductive health. The series is
based on the philosophy that people have
a fundamental right to respectful treat-
ment, information, choice, and follow-up
from reproductive health-care providers.
Q/C/Q documents projects that are mak-
ing important strides in one or more of the
following ways: broadening the choice of
methods and technologies available; pro-
viding the information clients need to make
informed choices; enabling clients to be-
come more effective guardians of their sex-
ual and reproductive health; making inno-
vative efforts to increase the management
capacity and broaden the skills of service
providers at all levels; combining health
care, family planning, and related serv-
ices in an innovative ways; and reaching
underserved and disadvantaged groups.


Projects are selected for documenta-
tion by an advisory group made up of
individuals who have a broad range of
experience with promoting quality of care
in sexual and reproductive health. None
of the projects documented is being
offered as a model for replication. Rather,
each is presented as an unusually cre-
ative example of values, objectives, and
implementation. These are learning expe-
riences that demonstrate the self-critical
attitude required to anticipate clients'
needs and find affordable means to meet
them. This reflective posture is exempli-
fied by a willingness to respond to
changes in clients' needs as well as to the
broader social and economic transforma-
tions affecting societies. Documenting
the critical choices these programs have
made should help to reinforce, in practi-
cal terms, the belief that an individual's
satisfaction with sexual and reproductive
health services is strongly related to the
achievement of broader health and pop-
ulation goals.


d Population Council
The Population Council is an international, nonprofit, nongovernmental institution that seeks to im-
prove the well-being and reproductive health of current and future generations around the world and
to help achieve a humane, equitable, and sustainable balance between people and resources. The
Council conducts biomedical, social science, and public health research and helps build research
capacities in developing countries. Established in 1952, the Council is governed by an international
board of trustees. Its New York headquarters supports a global network of regional and country offices.
Population Council, One Dag Hammarskjold Plaza, New York, New York 10017 USA
tel: (212) 339-0500, fax: (212) 755-6052, e-mail:qcq@popcouncil.org, http://www.popcouncil.org.

Publication of this issue of Quality/Calidad/Qualite is made possible by support provided by the
Ford Foundation, and by the Gender, Family, and Development Program of the Population Council.
Statements made and views expressed in this publication are solely the responsibility of the authors
and not of any organization providing support for Q/C/Q. Any part of this document may be repro-
duced without permission of the authors so long as it is not sold for profit.
Cover photograph courtesy of UNDP/Mongolia.
Number Twelve 2002 ISSN: 1097-8194
Copyright 2002 The Population Council, Inc.






Introduction

What Are We Learning about
Sexuality Education?

by Delia Barcelona and Laura Laski


There are now more than a billion young
people between the ages of ten and 19
in the world (UNFPA 1999b). In their
transition to adulthood, these young
people face a range of challenges, the
particularities of which are shaped fun-
damentally by their economic circum-
stances, gender, and culture. Along with
services, life-skills training, and liveli-
hood links, there is a universal need for
sexuality and reproductive health edu-
cation. How can the adults responsible
for designing policies to protect adoles-
cents' health and well-being best carry
out this daunting charge?
The agreements made at the 1994
International Conference on Population
and Development in Cairo and the 1995
UN Conference on Women in Beijing
provide guidance. For example, the Cairo
Programme of Action states that "Coun-
tries, with the support of the international
community, should protect and promote
the rights of adolescents to reproductive
health education" and that "full attention
should be given to the promotion of mutu-
ally respectful and equitable gender rela-
tions and particularly to meeting the
educational and service needs of ado-
lescents to enable them to deal in a pos-
itive and responsible way with their sex-
uality" (United Nations 1995).
Indeed, more countries are adopting
reproductive health initiatives for adoles-
cents, including both formal and infor-
mal sexuality education (UNFPA 1999b).
Lending momentum to this trend is a
growing body of literature documenting
that sexuality education can contribute
toward better health outcomes, includ-
ing HIV prevention (Grunseit 1997; Kirby
2001). Additionally, most parents want
their children to learn about the funda-


mental of sexuality, reproduction, and
decisionmaking (MSCI 2000; KFF 2001;
Esiet 2002). Finally, the reality of the HIV
pandemic has given courage to some
leaders in settings where they fear resis-
tance to sexuality education programs
and condom promotion.
Discussion is wide-ranging, however,
about the most appropriate content,
scope, and form of such programs. Al-
though these will vary by setting, some
findings are emerging from the literature.
The first is that abstinence-only ap-
proaches have not proved to be effec-
tive. No evidence has been found that
such programs delay sexual intercourse
(Kirby 2001; AFY 2002). Furthermore,
by teaching adolescents to associate
sexuality with fear and guilt, abstinence-
only curricula prepare them poorly for
satisfying sexual lives as adults.
The second lesson is that, although
specific circumstances vary by setting, a
defining factor governing a teenager's
autonomy, sexual health, and reproduc-
tive outcomes is gender. Because we are
so accustomed to considering "adoles-
cents" as a group distinct from adults,
we often fail to see the defining differ-
ences between girls' versus boys' expe-
riences and needs.
For girls, cultural, economic, and le-
gal structures that foster submissiveness,
limit schooling, constrain access to live-
lihoods, and encourage early marriage
are among the influences on their abili-
ty to navigate their own sexual lives. For
example, girls are frequently coerced into
having unwanted sex in exchange for
material favors or the hope of love, as an
exercise in domination, or because they
are forced into early marriages where
they are sexually available to their hus-


Number 12, 2002 1








bands. Even in high-risk situations, girls
are often unable to negotiate condom
use; consequently, females account for
67 percent of new HIV infections among
15-24-year-olds in developing countries
(LNICEF 2002). In addition, 40 percent
of the 4.4 million girls who undergo
abortion each year must do so in unsafe
conditions (UNFPA 1999a).
Although girls are typically subject to
the most grievous outcomes, boys suffer
as well from current social arrangements.
As a result of traditional masculine so-
cialization, many boys suffer from inter-
nalized pressures to demonstrate their
manhood in accordance with culturally
accepted norms that may foster risk-tak-
ing and violence. Often, boys grow up
profoundly confused by seeing their
fathers hit their mothers, or by not hav-
ing fathers around at all. Furthermore,
the stigma attached to deviating from
traditional (and heterosexual) male roles
is often severe. The harmful effects of
such pressures to boys' physical and
mental well-being have been extensive-
ly documented (Barker 2002). Every day,
boys are growing into men without the
basic information or the opportunities
to reflect that would enable them to be-
come the kind of men they want to be-
come, the fathers they would like to be.
Indeed, comparative studies on fac-
tors associated with early sex are a stark
reminder that boys and girls occupy
very different worlds. For example, a
Mongolian study (MHSW and UNFPA
1996) cited in the following pages found
that teenage boys tend to have inter-
course for reasons of curiosity and plea-
sure, whereas girls say they do so for
love. A US study found that among boys,
high self-esteem in middle school is a
predictor of early intercourse; converse-
ly, high self-esteem among girls is a pre-
dictor for delayed sexual debut (Spen-
cer et al. 2002). US-based research on
the impact of athletic participation is
similarly contradictory: Boys who par-
ticipate in athletics are more likely to


have early sex, whereas female athletes
are less likely to do so (WSF 1998).
How is the approach to sexuality edu-
cation evolving in response to our grow-
ing understanding about the underlying
cultural factors that shape sexual behav-
ior? Many sex educators have shifted
from a strictly didactic approach to one
emphasizing clarification of values, goal-
setting, and communication skills. This
modified approach often still lacks a
gender analysis, however. By focusing
on the generic adolescent or the ado-
lescent "couple," such curricula, for the
most part, have buried the critical issues.
They have failed to take adequate
account of boys' and girls' often distinct
-and frequently competing-rationales,
constraints, experiences, interests, ex-
pectations, feelings, and meaning in
regard to sexuality and relationships.
Unfortunately, even when sexuality
curricula have considered gender, typi-
cally the topic of gender is simply
tacked on, often at the end of the cur-
riculum. This happens for a variety of
understandable reasons, including lim-
ited time for adding a topic and skepti-
cism about the prospects of changing
entrenched gender roles. A rapidly grow-
ing body of evidence, however, suggests
that education programs can effect real
change in the area of gender norms.
Examples are available from around the
world of small programs that are suc-
cessfully enabling adolescent boys and
girls to reflect on-and transcend-tra-
ditional gender roles as a way to im-
prove the quality of their lives and repro-
ductive health (CEDPA 2001; Barker
2002; Haberland and Measham 2002).
What might a sexuality and family-life
curriculum that truly placed gender and
power at its heart-that considered the
meaning of "family life" in a fresh way-
look like? Such approaches generally
do not exist in school-based programs.
Good curricula will, of course, provide
students with basic information and help
them to develop communication skills


2 Quality/Calidad/Quait6








and self-respect. However, one more
stretch is needed: Education can and
should help young people become more
cognizant of their social context and help
them to analyze it critically. The architec-
ture of such an approach, then, would be
based on social studies. Both boys and
girls would increase their knowledge and
reflect upon such questions as the follow-
ing (depending on local circumstances):
What are the chances for school
completion, income generation, and
HIV transmission for girls versus
boys in the country?
Why do particular social or econo-
mic practices exist in the country,
for example, the dowry system, early
age at marriage for girls, female
genital cutting, patterns of trading
sex for money to pay school fees,
and the habit of ignoring pervasive
sexual violence?
Who benefits from the current
social structures? Who loses?
Is there a better way to live?
Such a social studies framework could
complement and give a meaningful foun-
dation to subsequent technical sessions
on puberty, contraception, prevention of
sexually transmitted infections (STIs),
sexual consent, self-esteem, and values,
placing these "health" top-
ics in a larger context of s
development, equality, and n
human rights. Such an ap-
proach might lead, finally,
not only to increased op-
portunities and postpone-
ment of marriage, but also
to a delay in intercourse,
more effective condom use,
and reduced rates of disease
and unwanted pregnancy.
In the meantime, it is -
important to give attention
to country examples that
are moving in a promising Because we
direction with intellectual we often fail


and political courage, driven by the
willingness to overcome opposition in
the name of the safety, well-being, and
indeed, the survival of tomorrow's gen-
eration. In this issue of Quality/Cali-
dad/Qualitc, Caitlin Gerdts reports on
PO Zorgaa-the government of Mongol-
ia's sexuality-education program, sup-
ported by UNFPA.
Like many postsocialist countries,
Mongolia has an atypically high rate of
female education, together with relative-
ly low fertility. Nonetheless, it is facing
many of the same challenges as the rest
of the world in safeguarding the sexual
and reproductive health of the next gen-
eration: rising STI rates, earlier ages of
sexual debut, sexual violence, and a
barrage of confusing and exploitative
images and messages about sexuality in
the media. The courageous example of
the Mongolian government can encour-
age other countries that are considering
how to implement this critical aspect of
the Cairo and Beijing documents.
While PO Zorgaa is not without its
challenges and limitations, it is extraor-
dinary in several key respects:
SThe government made an explicit pol-
icy decision to support sexuality edu-
cation for every Mongolian school-
child every year, starting in third grade;
," . s. *lll


are so accustomed to considering "adolescents" as a group distinct from adults,
to see the defining differences between girls' versus boys' experiences and needs.


Number 12, 2002 3









Rather than depend solely on out-
side experts to design the curricu-
lum, the government invested in
training a team of local experts who
then developed and tested their
own curriculum;
The curriculum pays significant
attention to the issue of gender.
Mongolian parents have been much
more supportive of the program than
many officials had feared might be the
case. Of course, in some countries, con-
servative movements will oppose sexual-
ity and family-life education vociferous-
ly when it deviates from the abstinence-
only approaches mentioned above.
Without the courage of public health
leaders, many young people in such
settings will grow into adults who are
not fully capable of having healthy sex-
ual lives; others will not live to adult-
hood. We, too, need to ask ourselves:
Who benefits from this? Who loses? Is
there a better way to live?

References
Advocates for Youth. 2002. "Abstinence-only-
until marriage programs." catesforyouth.org/abstinenceonly.htm>. Ac-
cessed 5/19//02.
Barker, Gary. 2002. "Engaging adolescent boys
and young men in promoting sexual and re-
productive health: Lessons, research, and pro-
grammatic challenges," in background docu-
ment prepared by the Population Council for
the UNFPA Workshop on Adolescent and
Youth Sexual and Reproductive Health: Chart-
ing Directions for a Second Generation of
Programming. New York: Population Council.
Center for Development and Population Activi-
ties (CEDPA). 2001. "Adolescent girls in India
choose a better future: An impact assess-
ment." pdf/blp_report.pdf>. Accessed 5/24/02.
Esiet, Adenike. 2002. "Building support for
adolescent health education and services in
Nigeria: Reflections from the experience of
Action Health Incorporated," paper pre-
sented at the UNFPA, WHO, and The
World Bank panel on Adolescents at the
Crossroads: Learning about Health and
Rights. New York, 8 May.


Grunseit, Anne. 1997. "Impact of HIV and
sexual health education on the sexual
behaviour of young people: A review
update." UNAIDS. publications/documents/children/schools/
grunskme.pdf>. Accessed 5/22/02.
Haberland, Nicole and Diana Measham, eds.
2002. Responding to Cairo: Case Studies of
Changing Practice in Reproductive Health
and Family Planning. New York: Population
Council.
Henry J. Kaiser Family Foundation (KFF). 2001.
"The AIDS epidemic at 20 years: The view
from America. A national survey of Amer-
icans on HIV/AIDS." tent/2001/3183>. Accessed 5/22/02.
Kirby, Douglas. 2001 Emerging Answers:
Research Findings on Programs to Reduce
Teen Pregnancy. Washington, DC: National
Campaign to Prevent Teen Pregnancy.
Margaret Sanger Center International (MSCI).
2000. "Results of focus group discussions
on adolescents' knowledge, practice, relat-
ed to sexuality, attitudes, and their service
needs." Unpublished program document.
Ulan Bator: MSCI.
Mongolian Ministry of Health and Social Wel-
fare (MHSW) and UNFPA. 1996. Adoles-
cent Reproductive Health Survey. Ulan
Bator: MHSW.
Spencer, Jennifer M. et al. 2002. "Self-esteem
as a predictor of initiation of coitus in early
adolescents." Pediatrics 109(4): 581-584.
United Nations. 1995. "Programme of Action of
the International Conference on Population
and Development, Cairo, Egypt, 5-13 Sep-
tember 1994," in Report of the International
Conference on Population and Develop-
ment, UNDoc.A/CONF.171.13/Rev.1. Para-
graphs 7.3, 7.46. New York: United Nations.
UNFPA. 1999a. Annual Report. unfpa.org/about/report/report99/report99e
ng.pdf>. Accessed 5/24/02.
UNFPA. 1999b. The State of the World Popula-
tion 1999. Chapter 3: "Reproductive Health
and Reproductive Rights." unfpa.org/swp/1999/chapter3d.htm>. Ac-
cessed 5/14/02.
UNICEF. 2002. "Girls and HIV/AIDS." www.unicef.org/programme/lifeskills/prior-
ities/girls_hiv.html>. Accessed 5/14/02.
Women's Sports Foundation (WSF). 1998. "The
Women's Sports Foundation Report: Sport
and Teen Pregnancy." East Meadow NY: WSF.


4 e Quality/Calidad/QualitW








Universal Sexuality Education

in Mongolia: Educating Today

to Protect Tomorrow

by Caitlin Gerdts




Modern Mongolia


Mongolia is a vast expanse of steppe,
desert, and mountains landlocked be-
tween Russia and China where temper-
atures during the long winter hover as
low as -30"C. Close to 2.4 million peo-
ple call this country home, with a third
of the population living in the capital
and only major city, Ulan Bator.'
Despite, or perhaps because of, cen-
turies of foreign occupation, Mongols-
of whom 82 percent are ethnic Khalkh
(NSO and UNFPA 2001)-have a strong
sense of identity and take pride in their
country and in maintaining their tradi-
tional culture. For example, even today,
Mongols generally use only one name;
when bureaucratic or formal occasions
require more precise identification, they
add their father's or mother's first initial
or name as a sort of identifier. Tradition-
al music and dress are still common in
the city as well as the countryside.
The country was ruled by the Chinese
for most of the eighteenth, nineteenth,
and early twentieth centuries. In 1917,
during the Russian Revolution, Mongo-
lia became a battleground for conflicts
among the Chinese, White Russians,
and Bolsheviks. The Mongols eventual-
ly threw in their lot with the Bolsheviks,
establishing the People's Government of
Mongolia, nominally headed by a tradi-
tional Buddhist leader. In the late 1920s,
however, communists replaced the reli-
gious leader, and Mongolia became a


satellite state of the USSR, falling almost
completely under Soviet political con-
trol. For most of the past century, the
government was socialist.
Socialist rule produced a planned
economy, proscriptions against religion,
investments in basic services such as
health care and education, and the


.4


- jl


CC -
-EL.;


Although urban areas attract a constant flow of migrants, close to half
the population still earns its livelihood by farming and herding. The
nomadic herders take down and rebuild their circular dwellings, or ger,
as they move their livestock across the grassy steppe.

promotion of gender equity in many
spheres. Collectivization of farming
eased the need for child labor, and the
Mongolian government not only pro-
vided universal education but also
required all families to send their chil-
dren to school through the eighth grade.


SAt 1.5 people per square kilometer, Mongolia's population density is among the lowest in the world.


Number 12, 2002 5


'^01 lamsS









As a result, the literacy rate soared from
about 4 percent in the early part of the
century to a remarkable 98 percent in
2000 (Sabloff 2001; NSO and UNFPA
2001). The state further encouraged fam-
ilies to send their children (girls as well
as boys) for higher education. The gov-
ernment promoted women's ability to
drive, handle farm equipment, and man-
age other nontraditional tasks.
Despite the benefits women enjoyed
in education, they were not accorded
full social equality. For example, even
as women filled the ranks of the profes-


Government investments in universal education for both girls and boys,
even in remote rural regions, have resulted in a 98 percent literacy rate.
Family law also requires a minimum age of 18 for marriage.


sionals, the top positions in most fields
continued to be held by men. Women
also performed most domestic chores in
addition to working outside the home.
Reproductive choices were influenced
by the government's strong pronatalist
policy. Beginning in 1957, formal finan-
cial and social awards were established
for childbearing. Women who bore five
children were awarded the Second
Degree Order of Glorious Motherhood;
those who produced eight were granted
the First Degree Order. Women with
four or more children qualified for early
retirement with a pension (Patel and


Amarsanaa 2000). At the same time,
women had no access to contraception,
and (in contrast with many socialist
societies) abortion was illegal. Partly
because safe abortion was unavailable,
maternal mortality remained high de-
spite the government's deep investment
in antenatal and general health care.
Together with this system of incentives
and constraints, however, socioecono-
mic security also contributed to rising
fertility rates, as Mongolians enjoyed con-
fidence about their children's prospects.
Mongolia's political climate began to
change in the mid-1980s, as glasnosttook
shape in the Soviet Union. In 1989, the
First Mongolian prodemocratic demon-
Sstrations began in Ulan Bator. As the
Soviet Union collapsed, Mongolia was
increasingly left to its own devices, and
the new Mongolian National Democratic
Union led the demand for change. What
is now known as the Peaceful Revolu-
tion unfolded with bewildering speed.
By 1990, Mongolia was a self-governing
state for the first time in nearly 300 years.
Shortly thereafter, the constitution was
amended to expand democratic rights
(see "Democracy and the Rights of Wom-
en" on the next page). At the same time,
the economy began to shift to a free
market structure, as small farms, herds,
and housing units were privatized.


Mongolia Today
The socialist era has left an uneven
legacy. After 70 years without religious
practice, the Mongolian people have re-
mained largely secular. Nonetheless, the
government has restored some aspects
of Tibetan Buddhism, and nearly 1,000
lamas (Buddhist priests) practice in 150
newly reopened and restored monaster-
ies. Moreover, the privatization of the
economy has extended to the larger
entities, such as the large-scale herds,
farms, and industries (for example, min-
ing companies).


6 Quality/Calidad/Qua&itc6


A4b










Democracy and the Rights of Women
Mongolia's constitution, drafted just over a decade ago, guarantees the rights to free
speech, religion, and assembly, as well as multiparty elections. It also prohibits dis-
crimination on the basis of sex and guarantees that "men and women shall enjoy
equal rights in political, economic, social, cultural fields, and in marriage" (Consti-
tution of Mongolia, cited in Sabloff 2001). Indeed, the punishment for obstructing a
woman from exercising these rights is a fine of up to 100,000 tg (about US$90) or
three years' imprisonment (Patel and Amarsanaa 2000). The constitution further
states that "Marriage shall be based on the equality and mutual consent of the spous-
es who have reached the age determined by law," currently set at age 18.


The dismantling of the collective farm
has had an impact on education and
gender roles. Once again, families need
their sons to help with herding. A strong
cultural pride is attached to boys' ability
to survive and take care of themselves
through their physical labor, so that now
many boys leave school by early ado-
lescence. On the other hand, girls are
seen as relatively expendable from an
economy and daily life organized
around herding; they are considered as
more in need of an education than boys
in order to become productive and self-
sufficient. Moreover, girls tend to per-
form better academically, and therefore,
they advance to the university level in
greater numbers than boys. As a result,
since 1990 Mongolia has had an unusu-
al gender disparity in terms of educa-
tion. Whereas primary-school class-
rooms have an almost equal number of
girls and boys, among 15-19-year-olds,
girls comprise 57 percent of the student
body. This discrepancy increases with
years of schooling, so that young wom-
en make up 60 percent of college grad-
uates each year (NSO and UNFPA 2001;
Lhagvasuren 2002). As a result, in many
marriages, the woman is the more edu-
cated partner (NSO and UNFPA 2002).
Not surprisingly, urban women still
fill the ranks of the professional classes:
Four out of five doctors and more than
three of five lawyers are female. The ten-
dency remains for top positions to be


occupied by men, however. Although 93
percent of primary-school teachers and
70 percent of secondary-school teachers
are female, only 23 percent of school
principals are women. (Ministry of Health
and Social Welfare [MHSW] and UNICEF
2000). Furthermore, 91 percent of the
members of parliament (Lhagvasuren
2002) are male.
Universal health care has been sus-
tained, with a shift toward preventive
care. This shift, along with the expanded
space for political and cultural debate,
has influenced sexual and reproductive
health policy. On one hand, the govern-
ment has maintained childbearing incen-


Because a strong cultural pride is attached to boys' ability to survive and
take care of themselves through their physical labor, many boys now
leave school by early adolescence. As a result, girls predominate in sec-
ondary school and university.


Number 12, 2002 7









tives, that is, large families still receive
social welfare benefits. Concomitantly,
the state has recognized the individual's
right to make decisions about childbear-
ing. In the last decade, as a public health
measure, the government began wide
provision of contraceptive information
and services. In 1998, 44 percent of all
women aged 15-49 were using a contra-
ceptive, and 33 percent were using a mod-
ern method (NSO and UNFPA 1999).
First-trimester abortion was legalized
in 1989. Purevsuren, a prominent obste-
trician-gynecologist, explained the
straightforward rationale for legalizing
the procedure:

There was a high rate of nonmed-
ical (untrained) people performing
abortions using all kinds of meth-
ods. There was a lot of sepsis and
trauma-and it i1as costing a lot of
money to treat. A group of doctors
asked that it be legalized, and so it
was.

Although women in remote rural areas
still have difficulty obtaining an abortion
and contraceptive services (particularly
in winter, when travel is a great obsta-
cle), the days when typical family size
was in the double digits are long gone.
Today, the typical Mongolian family has
three children.


Changes in Sexual
Experience, Marriage
Patterns, and the
Reproductive Health of
Adolescents
The new Mongolia, having opened its
borders in 1990, understandably con-
fronts modern dilemmas. On one hand,
increased freedom of movement has
allowed for travel to and from foreign
countries, and Mongolians now have far
greater opportunities for business, tour-
ism, and study. Of course, the borders


After opening its borders in 1990, Mongolian society was
flooded with popular media from other countries. As young
Mongolians encountered new representations of romance
and sexuality, social norms began changing.


were opened not only to individuals but
also to the vehicles of culture, including
the suddenly ubiquitous popular media
of foreign countries, particularly Europe
and the United States. Before 1990, the
only films available were Russian or Mon-
golian movies in which scenes of a sex-
ual nature had been cut; even a film kiss
was considered risqu6. Now tastes in
popular music and fashion have begun to
mimic the films and television shows (for
example, MTV) from the West. Further-
more, as press constraints were relaxed,
many tabloid newspapers began to pub-
lish erotic photos on the front pages.
Media representations of romance
and sexuality have contributed to chang-
ing social norms. Whereas public dis-
plays of affection did not exist before
1990, now, although kissing in public
remains taboo, couples commonly walk
hand in hand. Young people's views
concerning sexual intercourse appear
to be changing as well. Oyun, a 35-
year-old female physician, comments
on this culture shift:

11 hen I was a teen, a boy u would meet
his girlfriend after school and carry her
backpack, take her to a movie, help
with some household things. (Sexu-
all, J the most exciting thing to hear
was that someone kissed someone.


8 Quality/Calidad/Qualit/









It changed rapidly with the transfor-
mation of the system. I can't really
point to the time when it happened,
but in 1994 or '95, I realized that
having a girlfriend or boyfriend
meant to have sex, at least for col-
lege and some high-school stu-
dents. I believe the influence of free
mass media played a huge role in
this transition.

A girl is no longer expected to be a
virgin at marriage; indeed, the age of
sexual initiation appears to be decreas-
ing. In 1995, an adolescent reproductive
health survey found that 26 percent of
teenagers aged 17-18 had had sex; by
1999, this figure had risen to 35 percent
(MHSW and UNFPA 1996; Reilley et al.
1999). Sex-disaggregated data from the
1995 survey show a marked gender
gap: 36.3 percent of boys aged 17-18
reported having had intercourse, com-
pared with 18.8 percent of girls. When
asked their reasons for first having sex,
the most frequent response among girls
(44 percent) was "to show love," while
56 percent of boys offered "curiosity
and pleasure" as motives.
Along with earlier onset of sexual
activity, both men and women are mar-
rying later. Between 1989 and 2000, the
mean age at first marriage for women
increased from 21.1 to 23.7 years; the
mean age for men rose from 23.3 to
25.7 years (NSO and UNFPA 2001).
Data on marriage and on premarital be-
havior, however, are difficult to inter-
pret; younger couples commonly live in
informal unions (called "sitting togeth-
er"), referring to each other as "hus-
band" and "wife," but not registering
their marriage with the state until after
the arrival of a first birth. This attitude
toward legalized union was expressed
by one young man who proudly an-
nounced that his wife was going to have
a baby. Asked if he was going to marry
her formally, he responded, "We'll do it


sometime. It isn't important to us."
Regardless of whether they eventually
settle into formal or informal unions,
most girls remain with their families
throughout adolescence; in 2000, only
6 percent of females aged 15-19 were
married or cohabiting (NSO and
UNFPA 2001).
Despite the rising rates of contracep-
tion among adult women, adolescents
are generally at high risk of both un-
wanted pregnancy and sexually trans-
mitted infection. A survey of teenagers
between the ages of 11 and 18 who have
had intercourse found that only 36 per-
cent used any form of contraception the
first time they had sex (Irvin forthcom-
ing). Indeed, since 1990, Mongolia has
witnessed a significant rise in the rate of
STIs and unwanted pregnancies among
teenage girls, whose contribution to the
total number of abortions more than dou-
bled between 1996 and 2001 (National
Center for Health Development [NCHD]
and UNFPA 2001). Between 48 and 52
percent of sexually transmitted infections


As is true in many settings, the primary reasons for first having intercourse
differ by gender: Girls most frequently want "to show their love," whereas
the majority of boys say "curiosity and pleasure" are their main motives.


Number 12, 2002 9








now occur among young people younger
than 25 (Purevdawa et al. 1997; MHSW
1998). Although adolescents comprise
about 25 percent of the population (NSO
2001), clinical services, for the most part,
are either unavailable or unappealing to
teens. Moreover, the adolescent survey
cited above (Irvin forthcoming) docu-
ments that adolescents' main source of
information about reproductive health
and sexuality is friends, with television and
newspapers being secondary sources.


The Government
Responds to Changing
Needs of Adolescents
In 1997, the Ministry of Health and the
Ministry of Enlightenment (recently re-
named the Ministry of Science, Techno-
logy, Education and Culture-or MOS-
TEC) established a joint initiative to pro-
mote the country's new commitment to
a preventive approach to public health


Ministry officials asked themselves
what adolescents needed to know
if they were going to reduce their
risk of unwanted pregnancy, STIs,
and physical abuse. As one official
recalled, "We didn't have a clue."


care. A key part of the initiative was to
design a primary- and secondary-school
health-education program that would
address the most pressing public health
concerns facing young Mongolians. In
partnership with the World Health Or-
ganization, the Mongolian government
identified ten thematic areas to include
in a comprehensive health-education


curriculum; one of these areas was re-
productive health.2
Initially, the Ministry of Health encoun-
tered some resistance from the Ministry
of Enlightenment about the inclusion of
reproductive health and, in particular, the
idea of sexuality education. For centuries,
Mongolians had avoided public (and
much private) discussion of these issues.
The hesitation was based in part on a
concern that such education would re-
sult in promiscuity. Extensive dialogue,
joint participation in international meet-
ings, and a review of the literature on
this topic led, however, to a consensus
that the culture was already in transition,
and that effective education could re-
duce rates of unwanted and unsafe sex.
Nergui, Senior Officer in the MOSTEC
Division for Policy Coordination of Pri-
mary and Secondary Education, explained
why reproductive health was included:
"Because of changes in politics and life
of the society, the risk of STIs, unwant-
ed pregnancies, et cetera is greatly in-
creased. Reproductive health education
is one way of addressing these issues."
Jointly, the Ministries established work-
ing groups to develop the specific con-
tent and curricula for each theme. The
goal of the reproductive health curricu-
lum was to enable adolescents to reduce
sexual risk-taking behavior, with the ulti-
mate objectives of reducing rates of ado-
lescent pregnancy, sexually transmitted
disease, physical abuse, and abortion.
Although the Mongolian Foundation for
an Open Society provided initial support
and technical assistance, by and large,
these groups worked on their own with
little sense of precisely what they should
produce.
The Reproductive Health Working
Group was charged with developing a
basic reproductive health-education cur-
riculum that would be available to pri-


SThe other topics were: infectious disease prevention; mental health; nutrition; smoking, alcohol and other
substance abuse; hygiene and sanitation; physical exercise; healthy lifestyle; oral health, and first aid.


10 Quality/Calidad/Qualite








mary- and secondary-school teachers.
Unfortunately, the members worked
from outdated information about teen-
age sexuality and limited information
about how social norms such as gender
dynamics shape sexual decisionmaking.
Furthermore, no one in the group had
expertise in education. As Oyun, the
physician in charge of the health-educa-
tion program for the Ministry of Health,
explains, "We asked ourselves, 'What
did our teenagers need to know?' We
didn't have a clue." Nevertheless, the
Reproductive Health Working Group,
along with the other thematic working
groups, published and distributed its draft
curriculum to educators nationwide.

The Birth of PO Zorgaa
(Project Zero Six)
To support the implementation of the
curriculum and related work in adoles-
cent reproductive health, the government
sought to collaborate with the United
Nations Population Fund (UNFPA). The
resulting Mongolian Adolescent Repro-
ductive Health Project, nicknamed PO
Zorgaa,' originally had four components:
formal education (implementing
the curriculum as a pilot program
in selected schools and then mak-
ing it available nationwide);
informal education (working with
nongovernmental organizations to
reach young people not in school);
information and communications
(print and electronic media);
clinical services
In May 1998, two professionals were
hired to lead PO Zorgaa. Altanchimeg
(known as Agi), a physician who also
holds a public health degree, became
the national project coordinator; Oyun-


tungalag, a journalist, was hired as the
first information, education, and com-
munication (IEC) officer. The following
month, as part of a partnership estab-
lished by UNFPA with the Margaret
Sanger Center International (MSCI), An-


The PO Zorgaa team faced the task of enabling teachers in every pri-
mary and secondary school in the country to provide gender-sensitive
sexuality education.

drea Irvin joined the team in Ulan Bator
to serve as resident technical advisor.
A baseline survey and a series of
focus-group discussions among adoles-
cents helped the team identify the basic
knowledge and attitudes of Mongolian
adolescents (see the discussion of mon-
itoring and evaluation below). In addi-
tion, focus-group discussions with par-
ents and consultations with teachers
indicated that both groups wanted
young people to have the basic infor-
mation for protecting their sexual and
reproductive health, but that neither
group felt adequately prepared to teach
this material themselves.
With this information, PO Zorgaa began
its work. Four years later, the school sex-
uality-education program and a news-
paper for teenagers have been the most
innovative and successful elements of
the project. This issue of Q/C/Q focuses


3The project's name in Mongolian (Usvur Uyiin Nukhun Urjikhuin Eruul Mend Tusul) was long, so it quick-
ly came to be called by the nickname PO Zorgaa, which refers to UNFPA Project number 06. (Zorgaa is
Mongolian for six).


Number 12, 2002 11








on what has been achieved and learned
from these two activities, particularly
from the government's explicit effort to
provide gender-sensitive sexuality edu-
cation to every student in the country
from primary through secondary school.

Universal Sexuality
Education
As Agi, Oyuntungalag, and Andrea re-
viewed the reproductive health curricu-
lum, they developed some serious con-
cerns. First, teachers were reporting that
the material was too technical and that
they lacked guidance about how to pre-
sent the information. In addition, much
of the information in both the reproduc-
tive health and mental health curricula
drew on out-of-date materials inherited
from the Soviet Union. (For example, the
mental health curriculum asserted that
childhood masturbation is caused by
parasites and that treating the parasites
is, therefore, the best way to "cure" small
children of masturbation.) Although the
government had initially viewed sexual-
ity as a marginal element of the repro-


ductive health curriculum, the new PO
Zorgaa team felt it should be placed at
the heart of any effort to improve ado-
lescent reproductive health outcomes.
One important early achievement was
that they and the officials in the govern-
ment ministries were able to achieve
consensus on this matter.
Although the necessity of revising the
curriculum was clear, the project staff
and their government colleagues real-
ized that there were no sexuality-edu-
cation experts in Mongolia. They agreed
on the importance of international tech-
nical assistance, but were committed to
building local expertise and enabling
the development of culturally appropri-
ate materials. The first decision was that
Andrea should train an initial corps of
"master trainers," who would become
Mongolia's experts on sexual and repro-
ductive health education. These experts
would be charged with revising the cur-
riculum, they would learn how to train
schoolteachers to teach it, field-test and
refine the curriculum, and finally, con-
duct training sessions for the teachers.


11*


I ,--311P. -


One of the first objectives of the master training was to foster greater ease with the topic of sexuality by helping people to become
comfortable with using sexual language.


12 a Quality/Calidad/Qualit6


~p~' ;.~.t
. ;,.
f








The team set about selecting 20 indi-
viduals for the master training team. An
ad in the newspaper requesting people
to apply who were committed to edu-
cation and the promotion of reproduc-
tive health issues for adolescents drew a
considerable response. The majority of
applicants for the master training were
medical doctors. A huge surplus of doc-
tors exists in Mongolia, and many are
keen to work in nonclinical programs
that draw upon their expertise.
The staff also worked with MOSTEC
to select four pilot aimags, or provinces,
including the capital city and a western
aimag with a significant Kazakh popu-
lation. Staff traveled to each aimag and
met with government ofil. i.il to select
pilot schools in the area. Then they met
with the school principals to secure
their support and commitment for send-
ing two teachers to the training and pro-
viding salaries and time for them to
teach the curriculum upon their return.

The Master Training
Course
Along with knowledge of teenage sexu-
ality, the master trainers needed the
skills to pass on their information and
abilities to schoolteachers in an effec-
tive manner. Although elements of the
master training course were interwoven,
an approximate breakdown of course
content included:
* 3.5 weeks on sexuality and gender;
* 2.5 weeks on teacher-training skills;
* one week on counseling;
* Practicum 1: 10 hours of practice teach-
ing to secondary-school students
Practicum II: Two to three weeks of
supervised training of schoolteachers
In October of 1999, Andrea taught
the first session of the course, beginning
with an overview of sexuality. Jenny
Hendy, a volunteer from Volunteer Serv-


ices Overseas, conducted the teacher-
training sessions, and an American social
worker facilitated the counseling work-
shop. The principal aspects of this pro-
cess are described below.

Sexuality Training
The government's initial approach to sex-
uality education had a technical, clini-
cal health focus. The new team em-
braced a more comprehensive approach.


Participants were asked to list
what aspects of their lives they
would like the opposite sex to
experience. The male participants
came up with three items; the
women immediately generated a
list three or four times longer.


Accordingly, the training emphasized
psychosocial issues, such as defining
sexuality and sexual pleasure; commu-
nication and decisionmaking in relation-
ships; gender roles; sexual orientation;
sexual behaviors, including masturba-
tion; and sexual violence. A secondary
but still important aspect of the training
focused on technical information includ-
ing anatomy and physiology; fertility
awareness; contraception and abortion;
childbirth; sexually transmitted infec-
tions; and the sexual response cycle.
Encouraging personal reflection was
an essential part of the training. For ex-
ample, in an exercise about gender roles
and socialization, the participants were
asked to list what aspects of their lives
they would like the opposite sex to ex-
perience. The male participants came up
with three items: shaving, military service,
and the male perspective on relation-
ships. In contrast, the women immedi-
ately generated a list three or four times
longer, including cooking, child care,


Number12,2002 13








ironing, shopping, cleaning, and caring
for parents. In the ensuing discussion,
the women agreed that most men help
with household chores, but the men
understood the women's frustration that
even employed women carry a signifi-
cantly heavier domestic burden.
Several of the master trainers recall
their initial exposure to the course and
the process by which they learned to con-
ceptualize sexuality more broadly than
they had before they took the course and
to assess how each topic related to them
personally and to Mongolian culture:
It was very different from what I ex-
pected. I had understood before that
sexuality is more about sex, only
about sex, preventing pregnancy or
STIs. During the training I began to
understand that sexuality is about the
whole of human life.
-Bold, Lecturer in Public Health at the
National Medical University of Mongolia

After training I understood (more)...
my attitudes toward sexuality have
changed a lot. For example, homo-
sexuality was always very strange to
me. I thought it was very wrong, and
not a normal thing. Now I can talk free-
ly with other people about these topics.
-Oyuntsetseg, Supervising Teacher at
the School for Education Development

Training in Counseling and in
Participatory Methods
The master training course emphasized
the learners' personal engagement to pro-
mote real change. In addition, two mod-
ules focused explicitly on interactive ap-
proaches, and the trainers used interactive
methods throughout the sexuality mod-
ule. These included modules on coun-
seling and on interactive teaching skills.
A major reason for including training
in counseling was that both adolescents
and adults were likely to turn to the
newly trained and open-minded master


trainers with questions and problems.
The week-long counseling training in-
cluded topics such as mental health;
counseling versus advice; the role of the
unconscious in decisionmaking; setting
goals and boundaries in counseling;
interviewing skills; assessing individual
risk; depression and substance abuse;
adolescent development; and the spe-
cial counseling needs of adolescents.
(This last item included a consideration
of the emotional needs of gay adoles-
cents; the trainer invited a gay American
man to speak about his experience of
growing up and to answer questions
from the group, most of whom had
never met someone whom they knew
was gay.) As Oyun commented,

I still remember that feeling of sur-
prise: that counseling wasn't about
giving advice, but about being a good
listener, about guiding someone to
understand their problem and to see
by themselves why it is happening
and how they feel about it. We had
our own circle of four or five trainees
who would stay late after the sessions
and discuss and role-play the issues
from the day. This course was a very
powerful experience for me.

The unit on teaching followed a stan-
dard "training of trainers" approach,
with a focus on sexuality education.
Overall, the participants were delighted
by the interactive methods they were
learning. As Bayar, who replaced Oyun-
tungalag (but assumed the role of train-
ing officer) explained,

I taught at the medical school for six
or seven years, but I used traditional
teacher-centered methods. Now we
focus on more student-centered meth-
ods. Its very important for everyone to
be comfortable and to create a nice
atmosphere.


14 Quality/Calidad/Qualit/W








Practicum
Gaining practical experience in teach-
ing was a central element of the master
training. Participants went in pairs to
schools and universities in Ulan Bator to
teach sample lessons. For a total of ten
hours, one taught while the other ob-
served, then they reversed roles. The
sessions concluded with a peer-critique
process. After the formal part of the
master training was completed, the sec-
ond part of their practicum began,
involving two to three weeks of prac-
tice-teaching to teachers from sec-
ondary schools. Andrea and Jenny
helped the master trainers prepare,
observed their teaching, and offered
extensive feedback.
By spring of 2000, eight of the origi-
nal 20 participants had completed the
didactic training and field practicum, ob-
served a teacher-training session, passed
an exam, and earned a master trainer
certificate. (Eight more had earned a
sexuality-educator certificate for com-
pleting the course but not the practi-
cum.) Mongolia had a team of master
trainers in sexuality education.


Curriculum Development
and Testing
While the master trainers were com-
pleting their course and practicum, they
began a parallel effort to revise the draft
school curriculum for reproductive
health. The PO Zorgaa staff organized a
two-week workshop for this process.
Bayar described the task they faced:

The main aim was to change adoles-
cents' attitudes so they would prac-
tice safer behavior. But we also had
to increase their knowledge and
skills, for example, their understand-
ing of anatomy and physiology and of
STIs, and their decisionmaking, com-
munication, and sex-refusal skills.


The team believed that adolescents
needed to begin learning relevant infor-
mation and skills while still very young
in order to protect their sexual and
reproductive well-being. The master
trainers, therefore, had to assess which
topics should be covered with students


As in all countries, language
reflects culture; for example, in
Mongolian the word for
"communication" and the word
for "relationship" are the same.


of each age group, define the appropri-
ate learning objectives at each grade
level, and develop the lesson plans for
Mongolia's coeducational schools. They
also sought to design a curriculum that
would be appropriate or adaptable to
the disparate urban and rural lifestyles
in Mongolia.
Another task was to identify and use
appropriate terminology in Mongolian.
This task was complicated because the
trainers often worked from English writ-
ten materials and had to translate them
into a language in which there was little
public discourse (or shared terminolo-
gy) about sexuality. Furthermore, as in
all countries, language reflects culture;
so, for example, in Mongolian the word
for "communication" and the word for
"relationship" are the same. To ensure
they were adopting the best language,
Andrea, Agi, and Bayar discussed vari-
ous concepts and words at length.
A more formidable challenge was
limited classroom time. Sexuality was
still just one of the ten topics being cov-
ered in the government's new health-
education program. Based on the initial
expectation that the reproductive health
curriculum would focus narrowly on


Number 12, 2002 15








technical topics, the Ministry of Edu-
cation initially allocated only 22 hours
to be spread across eight years-an
average of 2.75 hours per year. Andrea
explains how they were able to expand
that allocation by 50 percent.

Because so many hours in the original
mental health curriculum u ere used
to address sexuality and life-skills is-
sues t e spoke t ith the mental health
working group and asked it % e could
revise their lessons together. joining
their 11 hours to ours. which the\
agreed to do. Additional: the work-
ing group for infectious diseases was
allotted three hours to address sexual-
I. transmitted infections and HIV
AIDS, so ne asked that group it we
could include those lessons in our
revised curriculum, to which they also
agreed. This gave us a total or 36
hours to work t ith

Thirty-six classroom hours over eight
years-a total number of hours roughly
equal in duration to a 45-minute class
meeting twice a week for a single semes-
ter-is still low by the standards of most
experts.4 This amount of time is certain-
ly not enough for making the kind of
impact the project was designed to have.
But the trainers hope it can begin to in-
fluence adolescents' knowledge base and
attitudes and establish a precedent from
which to grow. (See sections below on
Encountering Realpolitik and on On-
going Challenges for further discussion.)

Deciding What Adolescents
Need to Know
The staff had conducted focus-group dis-
cussions among young people to learn
what issues were of greatest interest and
concern to them. They did not, however,


depend on the students for input regard-
ing specific content. Asking adolescents
about their concerns was seen as more
useful than asking them to identify what
they would like to learn about a topic
about which they have little understanding.
The master trainers also relied on
their own learning experience. Having
just completed an extensive course in
sexuality and reproductive health, they
reviewed notes from their training to
help them decide which topics were
most relevant and which exercises were
most effective. They paid renewed atten-
tion to how their own experiences and
attitudes colored their views about what
information was important. The group
divided into teams of three to four peo-
ple, with each team taking responsibili-
ty for drafting lesson plans for a certain
number of topics. After heated discus-
sions, the team came to consensus; the
most challenging decisions focused on
which topic was most appropriate at
each grade level and on the design of
lessons for exploring values.
The group recognized that although
students needed basic factual informa-
tion, the most challenging topics were
not the technical ones, but rather, the
social and psychological factors that
affect sexual decisionmaking, for exam-
ple, gender dynamics, body image, and
the desire for love.

An Emphasis on Gender
Among the topics that proved most chal-
lenging were those related to gender
roles, a thorny topic for the group. Be-
cause Mongolian women are generally
more educated than men and often have
higher earning power, a sense exists that
some problems are related to gender.
The curriculum-development team grad-


4 For example, the FLASH (Family Life And Sexual Health) curriculum for grades 5-12 contains 83 lessons;
the Advocates for Youth "When I'm Grown: Life Planning Education" K-6 curriculum includes 201 activ-
ities. According to Andrea Irvin, many health educators argue that an hour a week is a rule of thumb for
effective health education.


16 e Quality/Calidad/QualiWt








ually recognized that the experiences of
females are different from those of males
and that this difference matters funda-
mentally in issues of sexuality and
reproduction. Several of the master train-
ers alluded to this concern:
Especially in the countryside, there are
strict gender roles. And still, in society,
among decisionmakers, very few are
women.
Bold, a male trainer
(Domestic violence) is fairly common,
but it's not always clear if people know
what is or is not domestic violence.
Bayar
The curriculum the team agreed upon
contains two lessons that focus directly
on gender issues, that is, that seek to
provide learners with a greater sense of
how gender functions at individual,
interpersonal, and societal levels. Many
of the lessons on other topics are seen
through the "lens" of gender. Thus, to
teach the curriculum, schoolteachers
must be trained to analyze how gender
dynamics affect a wide range of other
issues, such as sexual decisionmaking,
sexual pleasure, and the risk of vio-
lence. The team began to appreciate
that they were dealing with a constella-
tion of intersecting social and technical
topics, and that gender issues were
often at the heart of that intersection. As
Bayarmaa, a female gynecologist and
specialist in adolescent medicine on the
team, pointed out:

The most important things (to teach
about are) contraceptive use and get-
ting sexual pleasure. Many people
think contraceptive use and unwanted
pregnancy depend entirely on the
woman, that they are not men's re-
sponsibility. We need to change that.
Women need to learn how to get
pleasure from sex. They have to know
that the clitoris is their most sensitive
organ for sexual pleasure.


There was some discussion among the
trainers that boys and girls might best
learn about some issues in sex-segregated
groups. The teachers told them that hold-
ing segregated classes would not be
practical, however. The team agreed
that, given the level of depth into which
teachers can go in the current number
of hours available, both boys and girls
benefit from receiving all of the infor-
mation offered.

Selecting Topics for the
Curriculum and for Each
Grade Level
As a guide, the team followed the basic
structure of their own master training and
the curriculum guidelines developed by
the Sexuality Information and Education
Council of the United States (SIECUS),
which groups topics under six themes:
society and culture, relationships, per-
sonal skills, human development, sexu-
al behavior, and sexual health. Most of
the 37 topics selected fall under the
social rubric of self and others-helping
young people consider basic issues of
adolescence, gender roles, and deci-
sionmaking. The technical topics such
as anatomy, physiology, and contracep-
tion, which comprise much of traditional
sexuality education elsewhere, account


The curriculum calls for third graders to
their bodies, and emotions.


Number 12, 2002 17


learn about gender roles,








for a minority of the topics in the Mon-
golian curriculum (see Table 1).
After the list of topics was devised,
the master trainers sought to agree on
what information would be appropriate
for each grade level. Although classroom
hours were limited, the team planned to
introduce some sexuality education in
grade three (students aged 9-10) and to
maintain continuity and reinforcement
through grade ten (the final year of sec-
ondary school). To establish a basic struc-
ture and to gather further content for this
eight-year program, the team relied on
references that came primarily from West-
ern models.s Although the team adapted
these prototypes to build their curricu-
lum, they also drew on their experience
as Mongolian parents, clinicians, teach-
ers, and, of course, former adolescents.

Paying Attention to Details:
Multiple Revisions and
Collaboration with Schools
The most time-consuming phase of
launching the sexuality-education pro-
gram was the extensive editing and revi-
sion of the curriculum. The team revised
the draft curriculum numerous times,
based on field-test results and on feed-
back from government officials. To en-
courage teachers to replace the old cur-
riculum with the new one, PO Zorgaa
staff and trainers also invested time and
resources to make the new curriculum
attractive and user-friendly, aspects of
the product that had been field-tested.
The project also made efforts to fos-
ter successful implementation at the local
level. As a centralized project with no
field staff, the PO Zorgaa work plan had
not allowed for significant community-
level input at the conceptual stages. The
project staff worked closely, however,
with school leaders to enhance imple-


Table 1
Topics Originally
Selected for the
Curriculum

General Adolescent and
Psychosocial Topics
Gender roles
Self-esteem
Personal values
Defining human sexuality
Messages about sexuality
Expressing emotions
Friendship
Love
Sexual identity
Marriage; life commitments
Family or domestic violence
Planning for the future
Sexual relationships, sexual behavior
(including pleasure)
Masturbation
Decisionmaking about sex
Abstinence
Communication and consent
Risk assessment
Safer sex and alcohol
Styles of communication
Peer pressure
Refusal skills
Child and sexual abuse
Sexual violence (rape, date rape)
Sexual harassment
Stress
Diversity

Technical Topics
Anatomy and physiology
Puberty
Menstruation
Breast and testicular self-examination
Conception and pregnancy
Prenatal care
Contraceptive methods
Abortion
STIs/HIV/AIDS
Safer sex and condom use
Human sexual response


5 These included SIECUS' Developing Guidelines for Comprehensive Sexuality Education; the Seattle,
Washington FLASH (Family Life And Sexual Health) Curriculum for grades 5-12, and the Center for
Family Life and Education.


18 e Quality /Calidad/Qualite








mentation. They met with school admin-
istrators to negotiate the schools' com-
mitment and participation and to iden-
tify criteria for teacher selection, and
they developed a pamphlet for schools
to give parents that defines sexuality
education and describes the govern-
ment's program.

Encountering Realpolitik:
Decisions about Time
and Content
In many settings, conservative segments
of society launch campaigns against sex-
uality-education programs. Although this
was not an overriding concern in Mon-
golia, Ministry officials felt responsible
for considering potential risks and pit-
falls that could trigger a backlash against
the curriculum. The Ministries gave ini-
tial approval to the curriculum in June
of 1999, but the PO Zorgaa staff and
master training team faced two con-
straints on the scope of their work.
The most serious limitation was the
classroom time allotted for teaching the
curriculum, even with the increase to 36
hours. The range of topics simply did not
fit into 36 hours. Although the master
trainers, along with many teachers and
students, wanted more time for the class-
es, they felt that building the program
was most important and that a gradual
expansion would reduce the likelihood
of causing a negative reaction. Still, Bayar
would like to see the number of hours
doubled at least. Agi agrees, adding:

At present, there are too few hours for
us to reach our objectives for sexual-
ity education in secondary schools.
We need to advocate with the gov-
ernment, and when they revise the
standard hours in 2003, we must use
this opportunity.

The second constraint concerns con-
tent. With officials from the Ministries of
Health and Education, the project team


worried that some of the topics might be
considered too controversial (or, in some
cases, not essential) for inclusion in the
required curriculum. Predicting whether
a vocal minority will protest a sexuality-
education program is never easy, but be-
cause community-level consultation dur-
ing the establishment of PO Zorgaa was
limited, its leaders were especially cau-
tious. Guided, therefore, by a sense that
maximizing the likelihood of the project's
acceptance among the nation's school-
teachers and parents was advisable, the
team designated eight potentially sensi-
tive topics as elective elements of the cur-
riculum. (Table 2 shows topics that re-
mained in the mandatory core curricu-
lum.) The reclassified topics were: sexual


Because of concerns that some
topics might be controversial, the
team designated eight potentially
sensitive topics as elective
elements of the curriculum.


harassment; child sexual abuse; decision-
making about sex; abortion; masturba-
tion; family or domestic violence; human
sexual response; and responsible sexual
relationships. As Agi explained, "Because
it was our first experience, we thought it
was better to be cautious. If we caused a
big negative reaction, it could kill the
whole program." Withdrawing these
eight topics from the standard curriculum
also resolved the problem of how to fit
the required curriculum into 36 hours.
In some ways, the reclassification of
certain topics as electives was a major
setback in the development of a com-
prehensive sexuality-education program.
The training team and their colleagues
in the government held extended dis-
cussions about whether to reclassify any
of the topics and about which ones were
most appropriate to designate as elec-


Number 12, 2002 19










Table 2
Topics by Grade Level in the Final Curriculum


Grade
3


Teachers who choose to teach the elective topics allocate time beyond the 36 hours already allot-
ted The materials for the elective topics are not speotic to particular grade levels.


tives. Although the team recognized that
categorizing some topics as optional
made the curriculum less comprehen-
sive, the program was understood to be
taking an enormous first step. Sexuality
and reproductive health issues had not
been discussed publicly anywhere in
modern Mongolia, and the government
was still adjusting to the idea of educat-
ing students about sexuality. Moreover,
many controversial topics remained in
the standard curriculum, and the elec-
tive topics have not been censored. The
materials for the optional lessons are in-
cluded in the published curriculum, and
the master trainers still teach the elective-
lesson topics in their teacher-training
courses. Indeed, the master trainers ex-


plain to the teachers why these topics
are classified as elective and explore why
these issues they raise are sensitive ones.
As one of the master trainers, Bold, com-
ments, "My favorite part is to teach diffi-
cult topics like sexual orientation. Teach-
ing about attitudes is very different for
Mongolians. We talk about knowledge
and skills, but attitudes are hard."
The final decision about whether the
elective topics will be offered rests with
each teacher (or in some cases, with the
school's principal), and generally de-
pends on his or her own comfort level
and the comfort level of the students.6
Bayar believes that many teachers will
choose to teach at least some of the
elective topics. He says, "Mongolians


6 The presentation of these units is accompanied with the following explanation from the Ministries of
Health and Education: "Besides the official lessons, we have developed the following topics for elective
hours and for answering questions that may be raised from students."


20 Quality/Calidad/Qualiti


Age
9-10
10-1 1

11-12
12-13

13-14

14-15

15-16



16-17


Topics
Gender roles: anatomy and physiology
Feelings; pubery changes (physical and emotional):
menstruation: wet dreams
Friendships; peer pressure and deisionmaking; self-esteem
Society and messages about sexuality: communication basics:
assertive communication: \alues
Diversity; love: commurucation and consent;
managing stress; rape: date rape
Anaromy and physiology 11: conception and pregnancy:
abstinence; condoms, contraception: breast/testicular sell-exams
Communication about safer sex and condom use:
refusal skills: sexual identity and orientation:
sexual relationships and behavior; risk assessment;
saler sex and alcohol
Marriage, commitments, and rearing children;
goal setting: prenatal care and childbirth:
sexuality through life cycle: STIs and HIV/AIDS








are very open people. If they don't know
about something, they are willing to
learn. So when we teach information on
new and controversial topics, they start
to think about it rather than just argue."
Another master trainer, Bayarmaa,
shares Bayar's optimism. She explains
that the team is taking the long view:
"Mongolia has a tradition of not talking
about these issues, like abortion and mas-
turbation. We are trying to change that."
Bayar and Bayarmaa may be right.
The Mongolian government can hardly
be accused of putting its head in the
sand or promoting a narrow abstinence-
only approach. Even an official at the
Ministry who was originally unsure
about including sexuality in the health-
education program has since become a
strong supporter of PO Zorgaa and is
holding it up as a model for how the
government can develop and implement
curricula for the other health-education
topics in a systematic and thoughtful way.

Training for Teaching
Young People
In the summer of 1999, four master train-
ers conducted the first teacher-training
for 25 teachers from the 12 pilot schools.
Most Mongolian schools now have des-
ignated health educators, and most of the
training participants are from this group.-
The structure of the two-week teach-
ers' training resembles the training that
the master trainers received; it includes
a dual focus on the sexuality-education
curriculum and on participatory teach-
ing. It is less intensive because school-
teachers are not expected to become
national experts on adolescent sexuality
or train teachers themselves. The lessons
have been modified and developed us-


ing examples from traditional and mod-
ern Mongolian culture. Like the master
trainers, the schoolteachers are enthusi-
astic about the participatory learning
climate, which is radically different from
the didactic lecture style that is typical
in Mongolian schools.
At the same time that the master
trainers began to work with teachers,
the plan to distribute the curriculum to
the pilot schools only was altered.
Implementation of the national health-
education plan was under way, and
many teachers were already using the
original and inadequate reproductive
health curriculum. The Ministry of Edu-
cation argued that, given the enormous
investment in developing the new cur-
riculum and the quality of the materials
prepared for it, all schools should re-
ceive it-even before their teachers had
been trained to use it. Therefore, even
as the project staff conducted a formal
assessment of the curriculum among
trained teachers in the pilot schools,
they simultaneously provided the print-
ed curriculum to every secondary school
in the country as a resource. As Andrea
commented, "You plan carefully for
things to be one way, but then reality is
always more complex."
To ensure that every Mongolian stu-
dent learns about reproductive health
and sexuality from a well-trained teacher,
the master trainers are working to develop
a corps of specialized health-education
teachers who have learned to teach this
curriculum specifically. Therefore, once
the first group of schoolteachers began
teaching the curriculum, the training ex-
panded to include teachers from schools
not in the pilot aimag, as well as some
health professionals. The government's
goal is to provide each of the 683 secon-


In addition to the designated health-education teachers, some third- and fourth-grade teachers attend the
training, because for those grades, the grade teacher provides health instruction. Where possible, PO
Zorgaa training stresses criteria for selecting teachers: an interest in teaching about sexuality, an open-
minded and nonjudgmental style, an approachable manner, good communication skills, and involvement
with young people beyond school.


Number 12,2002 21








dary schools in Mongolia with at least
one qualified sexuality educator on staff.
As of early 2002, the master trainers have
trained about 300 secondary-school


mm.


To institutionalize sexuality education in teacher training, all students
training at the Pedagogical University to become primary-school teach-
ers are required to take a 60-hour course on reproductive health and
sexuality education.


teachers; however, at least an equal num-
ber of teachers are using the curriculum
without the benefit of training. Nergui
estimates that close to 60 percent of
schools are now offering the curriculum.
Another important achievement has
been the project's collaboration with the
Ministry of Education to institutionalize
sexuality education in teacher-training
programs. The Pedagogical University in
Ulan Bator now requires all students
training to become primary-school teach-
ers to take a 60-hour course on reproduc-
tive health and sexuality education. The
university also has begun to offer a course
on these topics for biology teachers. The
PO Zorgaa staff hope that the university
will eventually offer health education-
including coursework in sexuality educa-
tion-as a specialization within the stan-
dard curriculum for teachers in training.

Reaching Young People
Typically, the sexuality-education cur-
riculum is offered within classrooms,


but some teachers continue offering the
course after the school year is finished.
One morning in late June, Narantog-
tokh, one of the original pilot teachers,
conducted a session on gender roles at
Nairamdal summer camp for a group of
about 60 12-year-olds.
The group included young people
from across Mongolia, but the majority
lived in and around the capital. Most of
their schools had already begun to imple-
ment the curriculum, so for this session,
Narantogtokh adapted two popular
lessons generally taught in the younger
grades. The first was a group exercise on
gender roles. Narantogtokh facilitated a
forced-choice exercise, designed to in-
spire reflection on aspects of gender that
the students may have taken for granted.
After asking a few nonthreatening warm-
up questions, she read the students a
series of statements related to gender,
including, for example:
If a boy invites a girl on a date, he
must pay for everything.
Mothers should take more care of
their babies than fathers.
Girls need education more than
boys do.
After each statement, the students
considered whether they agreed or dis-
agreed, and demonstrated their choice
by walking to the side of the room des-
ignated "agree" or the other designated
"disagree." Those who could not decide
were allowed to stand in the middle.
The students then argued in defense of
their choices before moving on to the
next statement.
The last statement to be put forth
sparked the most debate: "Girls should
not say 'I love you' first." All but three
girls moved to the "agree" side of the
room. For ten minutes the three female
dissenters held fast to their belief that
girls should be as free as boys to express
their feelings, despite opposing argu-
ments defending Mongolian tradition


22 Quality/Calidad/Qua&it6









whereby boys are always the first to
declare love. They asked, "Why does it
have to be like that?" and "What if the
girl feels like saying it first?" By the end
of this discussion, the two sides had
evened out: While some girls stayed on
the "agree" side, a number of boys had
crossed the line to the other side.
At the end of the exercise, Narantog-
tokh asked the students about the nature
of stereotypes in general. The students
were quick to volunteer their opinions,
commenting, "stereotypes are assuming
things about people" and "a lot of times
stereotypes are wrong." Drawing on the
debate about who may say "I love you"
first, Narantogtokh helped the students
examine the ways in which we accept
unquestioningly as "tradition" and, in so
doing, perpetuate stereotyping.
The second lesson concerned com-
munication, specifically how one distin-
guishes among expressing oneself pas-
sively, assertively, and aggressively. The
lesson began with a demonstration of
ways to ask for a pencil, then extrapo-
lated to communication within intimate
relationships.
After these group exercises, Naran-
togtokh distributed an issue of the PO
Zorgaa newspaper UerkheLove that con-
centrates on gender issues. At first, the
students' embarrassment was palpable;
the room filled with blushing cheeks
and occasional laughter. Within five min-
utes, however, the group was nearly
silent-every student with a newspaper
in hand or peering over the shoulder of
a friend, deeply engaged in UerkheLove.

Response from the Teachers
In-depth feedback was provided by the
teachers in the pilot schools, who re-
turned to Ulan Bator a year after their
training to discuss the curriculum. Dash-
tsermaa, a chemistry teacher in Tuv aimag
45 minutes outside the capital, recalled
teaching her fourth-grade students the
lesson about menstruation. Mongolian


girls do not discuss menstruation open-
ly, and most adult women say that when
they were young, it was an uncomfort-
able topic to bring up even with older
women in the family. Dashtsermaa com-
mented, "The girls were asking about
things they really needed to know, and I
realized just how important it is for them."
The teachers who received the train-
ing along with the curriculum have pro-
vided much positive feedback. Their pri-
mary concern remains that they have too
few hours allocated to sexuality educa-
tion, as well as too few materials with
which to teach it.

Response from the Students
The students, too, are notably positive
about the program. The following com-
ments are typical of those offered:
Before, we couldn't get information;
we couldn't talk to our parents or
other adults. The only way to get
information is from classes or from
the media, and the media doesn't
give us correct or understandable
messages about sexuality.
Delgerdalai, a teenage girl from
Tuv aimag


The curriculum engages students in lively interactive exercises, but the
learning objectives are serious. As one student remarked, "After the dis-
cussions, I think the boys started to think about the realities of gender
roles in a family and in relationships."


Number 12, 2002 23









We confront these issues every day.
We have to deal with issues of love,
relationships sexuality, and we
need to know this information. For
example, following the gender-issues
lesson, I think boys and girls have
begun to respect each other more, to
understand our differences more."
Batdelger, a teenage boy from
Arkhangai aimag

Although the students stated that
there is relative gender equity in Mon-
golia, when asked what they felt were
the most compelling or important issues
about which they were learning, the
topics they emphasized had clear gen-
der dimensions: sexual violence, un-
wanted pregnancy, STIs, and communi-
cation and decisionmaking in relation-
ships (determining what love really is,
communicating true feelings to each
other, deciding whether to have sex,
discussing contraception).
Ariuntsetseg, a 17-year-old girl from
Tuv aimag, commented:


UerkheLove has become one of Mongolia's most widely read publica-
tions, circulating to one-fifth the country's adolescent population.


In one lesson, bo\ s \iere saving that a
man s role is to organize the tamilv
and to plan atit ities, and the wom-
an's role was lust housewlork. Ile
started to argue u ith them, sa\ ing,
'Hot% can you be a planner for a
lamil\ when iou can't eten be a
good student?" After the discussion, I
think the boys started to think about
the realities of gender roles in a tam-
il\ and in relationships

The students shared one specific
complaint about the curriculum. Nearly
all of them expressed a desire for more
class time, resources, and information.
As Erkemtuya, a 17-year-old girl from
Ulan Bator, said, "I think that it's so sad
that there are so few health-education
lessons. It's more important than any-
thing else we learn in school. ."


Beyond the Classroom:
Using Popular Media
Understanding that the classroom is only
one avenue for transmitting messages
about sexuality, and, given the need to
reach out-of-school young people, the
project also has an information, educa-
tion, and communication component,
making use of the popular media (both
electronic and print) to reach adoles-
cents and complement the school-
based education. One aspect of the IEC
component-a newspaper for teen-
agers-has been spectacularly successful.

UerkheLove
In 1998, the project developed a news-
paper for adolescents. To help engage its
audience, the staff established a board
of teenagers by asking students at sever-
al pilot schools to volunteer (see box on
next page). The role of the board was to
work with the IEC officer in choosing
topics for articles, responding to drafts
submitted for publication, and contribut-


24 e Quality/Calidad/QualitW










The Teen Board
Although PO Zorgaa initially took all the volunteers they could find to form a teen board
for UerkheLove, now many more teens want to join the board than there are spaces
available. Staff seek to ensure that the board is made of individuals-male and female-
who have writing skills or are interested in journalism and who seek an opportunity to
work in teams and to grow personally from their involvement. Eight members of the
teen board sat down one Friday afternoon to explain their excitement about their work:
In high school, reproductive health education is so limited. This newspaper focuses on ado-
lescents, and almost all other newspapers focus only on adults. As a teen board member, I
can form close relationships with other adolescents, and I can understand the issues myself
and share with others. Ariuntuya, 19-year-old girl
We will all be parents one day, so we need to know this information for our children too.
Teenagers can learn communication skills and how to love and respect each other. (This)
program is really needed for our future. Erkhemtuya, 17-year-old girl
These teenagers debated which sexual and reproductive health issues are the most
difficult for adolescents in Mongolia. The girls were the most vocal, and their comments
echoed those of the young people at the summer camp, emphasizing STIs, sexual deci-
sionmaking, unwanted pregnancy, and sexual violence.
Although they recognize the problems that they are facing, these eight young peo-
ple and their fellow board members are proud and optimistic. They believe that through
the newspaper they have created a forum that is, for the first time in Mongolian histo-
ry, providing adolescents across the country with correct information about critically
important issues. As Ariuntuya states:
When we write the newspaper, we try to explain things in a way that teenagers will under-
stand it. It's for them, not for adults. When we meet with teenagers in the countryside, they
just shine and shout at each other, because they are getting the information for the first time
from our newspaper. They can't get it anywhere else. In my experience, people who have
problems get information from the newspaper, and now they can start to fix them.
Her friend Erkhemtuya is equally proud: "We have many readers, and lots of stu-
dents read the paper and send questions. Our readers are increasing day by day." She
adds that classroom sexuality education benefits from the popularity of the newspaper,
stating, "My class really liked the reproductive health lessons, partly because they're
related to our newspaper."


ing directly to the "Teen Voice" page. The
newspaper was called UerkheLove, which
translates loosely as "intimate love."
UerkheLove is published four times a
year, each issue focusing on a single
theme. Past issues have addressed such
themes as gender roles, communication,
body image, mental health, setting goals
for the future, adolescent pregnancy, sub-
stance use, and violence. The eight-page
publication is organized so that the first
three pages carry substantive articles and
editorials concerning the central theme;


the following two pages contain inter-
views and articles on popular culture;
page six carries a question-and-answer
column, "Dear Hulan"; page seven
offers "Teen Voices" (opinions, poems,
and so forth); and page eight provides
announcements, resources, and infor-
mation for parents. For example, the
September 2001 issue was called "What
can you do to avoid violence?" (see
page 26).
With each issue of UerkheLove, the
teen board has assumed a more integral


Number 12, 2002 25









UerkheLove Special Issue: What Can You
Do to Avoid Violence?
Substantive articles included:
* "Your body is yours"
* 'Let's talk about sexual violence (hai is it? Types ol sexual violence, the right to
privacy; consequences ol violence; eight rules for avoiding violence, how to help your
friend; when a boy is affected by violence: trust your child and answer questions.)
Teen editorials included.
* "Is it their fault" Some thoughts on homeless children"
* "Report from an HIV,'IDS conference I attended"
* Book revie%- The novel Gite Ale One Kis andi I Will Go
"Dear Hulan" questions included:
* "I li\e in a remote area and have been repeatedly raped by my uncle, my period is
missing. and I ha\e discharge from my vagina. What shall I do?"
* "When 1 kissed her she liked it, but suddenly she ended the relationship. Is it true
that when girls say no, they really want it? Do they have satisfaction when they're raped?"
Additional resources included:
* "Do you know about it? A rest on violence issues"
* "Talking about education and knowledge- Quotes Irom the poet Ts. Khulan. the pop-
ular singer B. Sarantuya, and the composer B. Dolgion.


role in the paper's development. Current-
ly, adolescents are writing parts of the
question-and-answer page. After decid-
ing which questions they can answer,
members of the board consider the top-
ic, find the answers, and respond in a way
that provides accurate information and
is accessible to their peers. The articles
are checked for accuracy and quality.
UerkheLove is distributed free, pri-
marily through schools and by youth-
oriented nongovernmental organizations.
A small number of copies are also dis-
tributed through health providers, the
teen board, and directly from the pro-
ject and the UNFPA field offices. The
newspaper is reaching an enthusiastic
audience. In Andrea's words:

It took off like a house on fire. The
kids loved it... the adolescent board
made sure it was something that kids
really wanted and t\ ere interested in.
and they did a lot in terms of devel-
oping contributions themselves. For


the first issue we printed 5,000
copies, and then 10,000, then
15,000, then 20,000. People kept
saying, "Its not enough!" For the last
five editions of UerkheLo\e. we hate
printed 100,000 copies-one for
every five adolescents in Mongolia.

Members of Parliament and provincial
governors have asked the project to pro-
vide them with copies of every issue so
they can distribute it to their constituen-
cies, and one parliamentarian praised
the publication explicitly in an official
speech. Although a few adults have ques-
tioned the appropriateness of the news-
paper for children, in general, adults in
the community have been pleased with
it and request copies for their children.
As one prominent member of the com-
munity explained, "I usually put it in
the bathroom. I have two teenage sons,
but because I can't talk to them openly,
I give them the newspaper ... so they
will have correct information."


26 Quality/Calidad/Qualiti








According to Erkhemtuya, a board
member, the teachers also appreciate the
availability of a resource that comple-
ments their classroom lessons. She re-
calls that some of her teachers say, "you
should read this newspaper very care-
fully. It is very important for your future."


Monitoring and
Evaluation
Even under the best circumstances, doc-
umenting the impact of an education
program on the target population's sex-
ual and reproductive health is difficult.
If positive outcomes occur, how many
of them can be attributed to the pro-
gram rather than other social factors? If
no impact is measurable, is that the
result of allocating too few hours to an
otherwise well-designed and important
curriculum? In the case of Mongolia, re-
sources are not currently available for
the kind of complex assessment that the
government could use to determine the
long-term return on its investment in
sexuality education.
Nonetheless, the project has imple-
mented a number of measures in the ef-
fort to gauge the outcomes of its efforts.
Before classroom education began, the
project staff, in collaboration with the
National University Population Teaching
and Research Center, designed a base-
line survey documenting students' know-
ledge, attitudes, and behavior, as well as
their characterizations of their relation-
ships with their parents and the sources
of their information about sexuality.
More than 1,400 students completed
this survey. Moreover, project staff con-
ducted 17 focus-group discussions to
gather more qualitative, in-depth data
on the affective aspects of these issues,
including discussions with parents
about their desire for school-based sex-
uality education. Analyzing the data
and completing the report of this base-


line study has been a major undertak-
ing, but preliminary analysis revealed a
pattern not unlike that in many coun-
tries, including:
high acceptance of premarital sex
among both boys and girls, but
greater acceptance of sexual expe-
rience for boys than for girls;
higher levels of information about
contraceptives (including condoms)
among girls;
greater discomfort in obtaining con-
doms and negotiating their use
among girls;
friends and media as primary
sources of information about sexu-
ality; and
strong support among both students
and parents for sexuality education
at school.
The original plan was to repeat the
baseline survey in the pilot areas within
two years of initiating classroom sexual-
ity education. Project staff feel that
repeating it so soon would be prema-
ture, because the curriculum is under-
going revision and the material is still
new to the teachers. Without those
results, UNFPA is relying primarily on
site visits and staff consultations to gath-
er information and assess the future
direction of its support for adolescent
reproductive health.
For its part, the government is proud
of PO Zorgaa and hopeful about its fu-
ture. According to Nergui of the Mini-
stry of Health, "(For) the next UNFPA
country program (2002-06), we have
discussed strategies to strengthen and
sustain this project. I hope this project
will continue and become a sustainable
part of the curriculum." Linda Demers,
the UNFPA Representative who has
worked closely with the government
and the PO Zorgaa staff, is similarly
optimistic:


Number 12, 2002 27









UNFPA considers the P-06 project as
one of our success stories in Mon-
golia. This project is bringing net%
approaches to sexuality education.
and stimulating strategic changes in
the way sexuality education is dealt
with; and truly building national
capacity. A critical element in the
success of this project has been the
continuous partnership and dialogue
between the government, the UNFPA
Field Office, the project stafh and
other partners, combined nsith a con-
tinuous critical reassessment of the
project. We net er took any thing for
granted, and wie alitua s tried to refine
our approach. P-06 has put in place a
solid foundation to build on; in its
new hve-.ear program. UNFPA will
fund the expansion of the successful
pilots and continue support to se\u-
ality education and IEC-taking into
account the lessons learned from P-
06 and filling in the gaps. JThe UN
Foundation supports UNFP- for a
complementary project including cli-
nical services and education efforts
for parents and out-of-school youth.
for example.)



Ongoing Challenges
The Mongolian Adolescent Reproduc-
tive Health Project-PO Zorgaa-has
created a foundation for enabling the
next generation of Mongolians to pro-
mote their own sexual health. From a
policy perspective, PO Zorgaa is already
a significant success story: The project
is enjoying far greater parental support
than anyone had anticipated, and it has
been successfully integrated into teacher-
training programs. Despite the enor-
mous credit the Mongolian government
merits for these achievements, UNFPA,
government officials, project staff, and
the master trainers are acutely aware
that the project must face a number of
challenges if it is to achieve its potential.


Increasing Classroom
Hours for Sexuality
Education
The staff and the master trainers are
aware that five or six hours a year of
sexuality education will have little or
no impact on behavior. Even with the
input of UerkheLove and the devotion
of trained teachers who spend a signifi-
cant portion of their total health-educa-
tion time teaching about sexuality and
reproductive health, the government
will need to expand the number of
allotted hours to provide what may be
considered "comprehensive sexuality
education." The Ministry of Education
plans to revise the allocation of hours
in 2003, and project staff are planning
an advocacy campaign to increase
hours. They are hoping that the lessons
learned about the pedagogic require-
ments for sexuality education, along
with the project's track record, will
facilitate an expanded time allotment.
Clearly, such an increase is essential if
the program is to achieve its promise
and justify the investment in its careful
development.


PO Zorgaa has developed two local texts to comple-
ment the curriculum. This one, aimed at primary-
school children, is titled "Sexuality Education."


28 Quality/Calidad/Qualit/








Revising the Curriculum
The curriculum distributed nationally
contained some minor errors and poor
examples, which have been corrected.
When more experience has been gleaned
and if the government expands the num-
ber of hours for reproductive and sexu-
al health education, a second edition of
the curriculum will be produced and
distributed nationally. As more hours
become available to teachers and broad
community support for the project is
documented, the elective topics-some
of which are a critical part of sexuality
education-may be reconsidered for
the core curriculum.

Developing More and
Better Resources for
Adolescents
There is still a dearth of written materi-
als currently available to young people.
To address this need, the project has
developed two local reference texts,
one for primary school and one for sec-
ondary school, to complement what stu-
dents are learning from their teachers.
In addition, the project has translated
two English-language books.8

Developing Resources for
Parents
Although the project staff did not work
closely with the community in building
political support for sexuality education,
early discussions held with parents indi-
cated support for implementing a cur-
riculum in the schools. Staff have, nev-
ertheless, been struck by how uniform-
ly positive parents' response has been.
In more than three years, only one par-
ent has called to complain (about the
newspaper), and negative feedback
from schools has been rare. PO Zorgaa


staff understand that they are dealing
with sensitive issues and that deeper
investment in the community of parents
can make a valuable contribution. Staff
see a particular need to support parents'
own knowledge base, both for parents'
own well-being and in order to foster
communication with their children and
support for their children's education.
To this end, in collaboration with
UNESCO and MOSTEC, the staff have
developed a book that aims to help par-
ents communicate with their adolescent
children about issues related to sexuali-
ty. The book contains both didactic infor-
mation and related exercises and will


Staff have been struck by how
uniformly positive parents'
response has been. In more than
three years, only one parent has
called to complain.


be used as part of a MOSTEC distance-
education program that also includes
radio programs and classroom sessions.
In the distance-education program, par-
ents read the book and complete the
exercises on their own, listen to the radio
broadcasts, and meet thereafter with
tutors and other parents in classroom
settings. PO Zorgaa staff believe that
community support of sexuality educa-
tion for adolescents will be enhanced
as parents are given a chance to partic-
ipate in learning and in teaching their
children.


Developing Clinical
Services for Adolescents
Other than a few clinics in Ulan Bator,
few places exist where teenagers feel


It's Perfectly Normal is by Robie Harris, published by Candlewick Press (1996). How Sex Works is by
Elizabeth Fenwick and Richard Walker, published by Dorling Kindersley (1996).


Number 12, 2002 29








comfortable about seeking reproductive
health-care services. Although the exist-
ing clinics technically are open to ado-
lescents, most teenagers report that they
are concerned about their privacy, be-
cause local populations are small and
"people talk." Adolescents seeking serv-


The Mongolian government has
begun to implement a universal
project in the schools that will
eventually reach every child
every single year in grades three
through ten.


ices report that doctors have been rude
to them. PO Zorgaa staff are cooperating
with a sister project, also funded by
UNFPA, to open eight confidential, ado-
lescent-friendly pilot clinics this year.
Each clinic will have a teen board.

Reaching Out-of-school
Youth and the Broader
Community
The initial project plan called for the
Margaret Sanger Center International
and UNFPA to expand the capacity of
nongovernmental organizations (NGOs).
The NGOs were to work with different
communities to extend the reach of the
curriculum. PO Zorgaa conducted a
three-week training course for NGO
staff and volunteers in 1999, and the
project distributes materials such as
UerkheLove to the NGOs. Because of
financial constraints, however, this ele-
ment of the project has not yet been
developed, and the curriculum is not
yet reaching the large number of out-of-
school adolescent boys, for example.
Improving upon early efforts to produce
radio and television programs will also
help the program expand its reach.


Lessons Learned
The Mongolian government, responsible
for fostering the well-being of a diverse
population ranging from nomadic herd-
ers to sophisticated urbanites, has taken
a clear look at the present and coura-
geously affirmed its commitment to the
future. To this end, it developed a cadre
of national trainers in the fields of sexu-
ality and reproductive health. These
trainers have designed an up-to-date,
culturally appropriate curriculum that
places issues such as gender roles and
self-esteem at the core. They have begun
to implement a universal project in the
schools that will eventually reach every
child every single year in grades three
through ten. They have established a
place for the most controversial topics,
and have won over skeptical officials.
Mongolia is beginning to receive the
attention its deserves for the first stages
of its reproductive health and sexuality-
education program. A considerable
effort must be made if the program is to
achieve its goal: providing the young
with the information and skills they will
need to negotiate their way through a
changing culture and to protect their
sexual health. Nonetheless, valuable
lessons can be derived from this pro-
gram for leaders in other countries seek-
ing to implement a thoughtful and
effective sexuality-education program:
Even in settings where gender in-
equity is relatively moderate, issues
such as unwanted sex and gender
roles are among adolescents'-
especially girls'-most pressing
concerns.
In settings with relatively high ado-
lescent literacy rates, written mate-
rials remain a relatively inexpensive
and effective means for providing
teenagers with informative and
thought-provoking material.
Authentic local expertise is key to a
program's being culturally relevant


30 Quality/Calidad/Qualit6










and appropriate; building local ex-
pertise also allows for a sense of
ownership and will enable a coun-
try to meet its own needs for train-
ing and institutionalization. Although
development of local expertise may
demand high initial investments of
funding and energy, the process of
training local experts, developing a
curriculum, and beginning to pre-
pare sexuality educators to teach it
can take less than two years.
Parental opposition in some settings
may be virtually nonexistent; given
a chance, many parents express
gratitude for this sort of education.
With proper training, many teach-
ers will choose to teach even those
topics that may be considered sen-
sitive and are that not required.



References

Irvin, Andrea. Forthcoming. "Reproductive
Health and Sexuality Knowledge, Attitudes,
and Practices of Secondary School Students
in Mongolia: A Baseline Survey." Ulan
Bator: Ministry of Health and Social Wel-
fare, UNFPA, and GTZ.
Lhagvasuren, Nomin. 8 Feb 2002. "Mongolia's
Universities: A Woman's World." Eurasia-
N et. < h irr .,. .. _1.ii .- r jii, ,.r /depart-
ments/culture/articles/pp020302.shtml>.
Mongolian Ministry of Health and Social Wel-
fare (MHSW). 1998 Statistical Report of
MHSW. Ulan Bator: MHSW.
Mongolian Ministry of Health and Social Wel-
fare (MHSW) and UNFPA. 1996. Adole-
scent Reproductive Health Survey. Ulan
Bator: MHSW.
Mongolian Ministry of Health and Social
Welfare and UNICEF. 2000. "Mongolian
Adolescents Needs Assessment Survey
Report." Ulan Bator: UNICEF.
National Center for Health Development of
Mongolia (NCHD) and UNFPA. 2001.
"Unwanted Pregnancies and Abortions in
Mongolia." Ulan Bator: NCHD.
National Statistical Office of Mongolia (NSO).
2001. Mongolian Statistical Yearbook 2000.
Ulan Bator: NSO.


Young people in Mongolia need information, skills, and a critical analy-
sis to negotiate their way through a changing culture and to protect their
sexual health.


National Statistical Office of Mongolia (NSO)
and UNFPA. 1999. National Report:
Reproductive Health Survey, 1998. Ulan
Bator: NSO.
- 2001. 2000 Population and Housing
Census: The Main Results. Ulan Bator: NSO.
- 2002. "Gender in Mongolia: Analysis
Based on the 2000 Census." Ulan Bator: NSO.
Patel, Arthi and D. Amarsanaa. 2000. Repro-
ductive Health, Gender, and Rights in Mon-
golia. Ulan Bator: Mongolian Ministry of
Health and Social Welfare and UNFPA.
Purevdawa, E. et al. 1997. "Rise in sexually
transmitted diseases during democratization
and economic crisis in Mongolia." Interna-
tional journal of STDs and AIDS 8(6): 398-
401.
Reilley B., J. Narantuya, and N. Oyungerel.
1999. "HIV/AIDS/STD Prevention Among
Young Persons 15-25: Survey Results." Ulan
Bator: Medecins Sans Frontieres and Health
Management Information and Education
Center of Mongolia.
Sabloff, Paula. 2001. Modern Mongolia: Re-
claiming Genghis Khan. Philadelphia: Uni-
versity of Pennsylvania Museum of Archae-
ology and Anthropology Exhibit. Also avail-
able at: Mongolia>.


Number 12,2002 31







Resumen en Espahol
El interns que tantos pauses muestran hoy
por los programs integrados de educa-
ci6n sexual tiene varias causes: la exten-
si6n del SIDA entire adolescents (y en
particular entire mujeres j6venes); una
mayor consciencia sobre la dinAmica
social en la definici6n del comportamien-
to sexual; y la documentada ineficacia de
los programs que se basan s6lo en la
abstinencia para prevenir embarazos no
deseados y relaciones sexuales sin pro-
tecci6n. Este nlmero de Q/C/Q informa
sobre un pais que se comprometi6 a
entregar a todos sus estudiantes un cur-
riculum de educaci6n sexual sensible a la
problematica del g6nero y basado en la
escuela, durante ocho afros consecutivos.
A partir de su denominada Revoluci6n
Pacifica del 1990, Mongolia ha vivido pro-
fundos cambios culturales, entire los que
se destaca una mayor precocidad sexual
entire los adolescents y un aumento en
los indices de ITS y embarazos no desead-
os. El gobierno, con el apoyo del FNUAP
elabor6 un program national, conocido
como PO Zorgaa, que ayuda a los adoles-
centes a promover su propia salud sexual
y reproductive.
Inicialmente se temia que la educaci6n
sexual podrfa conducir a la promiscuidad,
pero al poco tiempo las autoridades
quedaron convencidas de que el comporta-
miento sexual estaba cambiando por cuen-
ta propia, y que la educaci6n podria ayu-
dar a que los j6venes tomaran decisions
mas responsables. Las encuentas con gru-
pos de padres indicaron ademds que la
gran mayoria de 6stos querfan que sus
hijos aprendieran sobre sexualidad, pero
que los padres no estaban dispuestos a
encargarse del tema.
Un asesor t6cnico del proyecto orga-
niz6 un curso de 9 semanas de duraci6n
con el fin de crear un Equipo Superior de
Capacitaci6n que elaborarfa el curricu-
lum y luego capacitaria a maestros que lo
ensefiarian en las escuelas. La capacita-
ci6n detall6 la manera en que las dinAmi-
cas sociales-y particularmente el genero-
determinan la toma de decisions sexu-
ales, el placer sexual, el riesgo de la vio-
lencia, y la capacidad de negociar el uso
de condones. Por lo dicho, el curriculum
enfatiza problemdticas sicosociales mas


que temas t6cnicos. Los Capacitadores
Superiores ya han preparado a mas de la
mitad de los maestros de la naci6n.
El proyecto ha enfrentado various desa-
ffos. El sistema formal de educaci6n ded-
ica apenas 36 horas para la enseiianza
sobre sexualidad a lo largo de 8 afos. Esta
claro que para tener un verdadero impact
se necesitan muchas horas mis; el person-
al del proyecto propone como minimo
unas 72. Otro problema surgi6 porque tanto
las autoridades del gobierno como los miem-
bros del personal del proyecto temian que
algunos de los temas pudieran ser contro-
versiales. Por lo dicho, 8 de los temas
fueran designados como optativos, aunque
siguen siendo parte de la capacitaci6n de
maestros y del curriculum impreso.
La reacci6n de los estudiantes ha sido
muy positive. Cuando se les pregunta cuAles
temas son los mas importantes, los estudi-
antes sefialan aquellos que tienen claras
dimensions de g6nero: la violencia sexu-
al, los embarazos no deseados, las ITS y la
toma de decisions dentro de la relaci6n.
Adems del program escolar, el PO
Zorgaa public una revista trimestral para
adolescents e imprime un ejemplar por
cada 5 adolescents en el pais. PrActica-
mente la totalidad de los padres y de los
politicos han apoyado la revista y el pro-
grama de educaci6n sobre sexualidad.
Con el prop6sito de documentary el im-
pacto, el proyecto ha programado una
segunda encuesta de base sobre conoci-
mientos, actitudes y comportamiento. El
gobierno tambi6n est~ tratando de com-
plementar el program en las escuelas
con otras actividades.
La experiencia de Mongolia demuestra
que: 1) temas como el sexo no deseado y
los roles de genero preocupan much a
los adolescentes-y especialmente a las
mujeres; 2) el material impreso es un
medio de comunicaci6n econ6mico y
efectivo; y 3) existen muchos contextos
donde los padres no se oponen a la edu-
caci6n sexual, y hasta pueden estar agra-
decidos por la misma.
Como lo dijo una joven mongola,
"Nosotras enfrentamos estos temas todos
los dias... Tenemos que manejar proble-
mas de amor, relaciones... sexualidad, y
necesitamos conocer esta informaci6n."


32 o Quality/Calidad/Qua&6







Resume en Franlais
Avec la propagation du VIH parmi les ado-
lescents (surtout les filles), la conscience
croissante du r6le de la dynamique social
dans la prise de decision en matiere sex-
uelle et I'inefficacit6 documented de I'ab-
stinence comme seule methode de preven-
tion des rapports sexuels non voulus ou
sans pr6servatif, un plus grand nombre de
pays cherchent a mettre en ceuvre des pro-
grammes d'6ducation a la sexuality com-
plets. Ce numero de Q/C/Q offre I'exem-
pie d'un pays qui s'est engage sur le plan
national A fournir a tous les 6leves, pen-
dant huit annies cons6cutives, un pro-
gramme scolaire d'6ducation a la sexual-
ite tenant compete de chaque sexe.
Depuis sa revolution pacifique de 1990,
la Mongolie a connu des changements cul-
turels spectaculaires, parmi lesquels I'ac-
tivit6 sexuelle precoce chez les adolescents,
entrainant une augmentation des taux d'IST
et de grossesses non voulues. En reponse a
cette situation, le gouvernement (avec I'ap-
pui du FNUAP) a elabor6 un programme
national-appele "PO Zorgaa"-pour per-
mettre aux adolescents de promouvoir
leur propre sante sexuelle et reproductive.
Au d6but, on redoutait quelque peu que
I'education a la sexuality n'entraine la pro-
miscuite. Toutefois, les responsables in-
quiets ont vite 6te convaincus du fait que la
culture changeait d6ja et que ]'education
permettrait aux jeunes de prendre des d6ci-
sions plus refl6chies. Par ailleurs, des dis-
cussions de group avec les parents ont
clairement montre qu'une majority 6cras-
ante des parents voulaient que leurs en-
fants soient informs sur la sexuality, mais
qu'ils n'etaient pas prets a dispenser eux-
memes cet enseignement.
Un conseiller technique du project a or-
ganise un course de neuf semaines afin de
cr6er une equipe de formateurs principaux
qui 61aboreraient le programme, puis for-
meraient les enseignants a son utilisation.
La formation a permis de documenter com-
ment la dynamique sociale-surtout la dif-
ference entire les sexes-influence fonda-
mentalement la prise de decision en ma-
tiere sexuelle, le plaisir sexuel, le risque de
violence et I'habilet6 a negocier I'emploi
du pr6servatif. Ainsi, le programme suiv-
ant insisted plus sur les questions psycho-
sociales que sur les sujets techniques. Les
formateurs principaux ont deja form la


moiti6 des enseignants du pays a I'utilisa-
tion du programme.
Le project a 6t6 confront a plusieurs defis.
Le programme actuel d'education A la sex-
ualite ne comprend que 36 heures s'6ta-
lant sur huit ans. II est evident qu'il faudrait
augmenter consid6rablement ce nombre
pour obtenir un veritable impact; le per-
sonnel du project preconise que le nombre
d'heures soit au moins double. Ensuite, les
representants du gouvernement et le per-
sonnel du project se preoccupaient de ce
que certain sujets pourraient &tre consid-
eres comme delicats. Ainsi, huit sujets ont
6te designs comme facultatifs, bien qu'ils
soient toujours inclus dans la formation des
enseignants et dans le programme public.
La reaction des 61eves a et& tres posi-
tive. Lorsqu'on les interroge sur les sujets
les plus important, ils soulignent ceux
portant clairement sur les specificit6s de
chaque sexe, tels que la violence sexuelle,
les grossesses non voulues, les IST et la
prise de decision dans les relations.
En plus du programme scolaire, "PO
Zorgaa" public un journal trimestriel pour
adolescents et imprime d6sormais un ex-
emplaire pour cinq adolescents en Mon-
golie. Les reactions des politicians et des
parents au journal ainsi qu'a I'enseigne-
ment de la sexuality en classes ont et6
entierement positives.
Pour documenter cet impact, le person-
nel du project refera I'enquete de base sur
les connaissances, les attitudes et les com-
portements. Le gouvernement travaille
egalement afin de complete le pro-
gramme scolaire avec d'autres activities.
Parmi les lemons tirees de I'experience de
la Mongolie, on peut retenir les points suiv-
ants: 1) les questions telles que les rapports
sexuels non voulus et les r6les sexuels sont
parmi les inquietudes les plus pressantes des
adolescents, surtout des filles; 2) les docu-
ments sont un media efficace et peu cou-
teux; et 3) I'opposition des parents pourrait
etre pratiquement inexistante dans certain
milieux-en effet, lorsque I'occasion leur
est donnee, de nombreux parents expri-
ment de la gratitude pour cette education.
Comme I'a dit un jeune Mongol, "Nous
sommes quotidiennement confronts a ces
sujets... Nous devons nous occuper de ques-
tions telles que I'amour, les relations... la
sexuality, et il nous faut connaitre cette
information."


Number 12,2002 33








About the Authors
Delia Barcelona and Laura Laski are
Senior Technical Officers, Technical
Support Division, UNFPA.
Caitlin Gerdts was formerly an intern
with Margaret Sanger Center Internation-
al in Ulan Bator and in New York City.

Editor: Debbie Rogow
Research and
Production Assistance: Anna Stumpf
Designer: Mike Vosika


Advisory Group


Errol Alexis
Gary Barker
Judith Bruce
Susana Galdos
Francoise Girard
Nicole Haberland
Judith F. Helzner
Katherine Kurz
Ann Leonard
Ann McCauley
Liz McGrory


Suellen Miller
Isaiah Ndong
Nancy Newton
Saumya Ramarao
Julie Reich
Ann Starrs
Cynthia Steele
Gilberte Vansintejan
Beverly Winikoff
Margot Zimmerman


Acknowledgments
The author wishes to acknowledge Agi, Bayar, Bold, and Andrea Irvin of the Adolescent
Reproductive Health Project (PO Zorgaa) for extensive help in gathering information for
this article and for review of and contributions to the manuscript. Thanks also to Oyun (on
leave from the Ministry of Health) and to Linda Demers of UNFPA/Mongolia, both of
whom reviewed the text and made helpful suggestions. Finally, the New York staff at
Margaret Sanger Center International offered valued collegial support, and both MSCI and
Stanford University generously provided institutional support for different aspects of the
development of this article.



We invite your comments and ideas for projects that might be included in future edi-
tions of Quality/Calidad/Qualitd. If you would like to be included on our mailing list,
please send an e-mail to: qcq@popcouncil.org. Most past editions are available on-
line at: www.popcouncil.org/publications. The following are also available in print;
single or multiple copies may be ordered by e-mail:


Celebrating Mother and Child on the
Fortieth Day: The Sfax Tunisia Postpartum
Program (English only), no. 1, 1989.
Man/Hombre/Homme: Meeting Male Re-
productive Health Care Needs in Latin
America (English, Spanish), no. 2, 1990.
Gente joven/Young People: A Dialogue
on Sexuality with Adolescents in Mexico
(English, Spanish), no. 5, 1993.
The Coletivo: A Feminist Sexuality and
Health Collective in Brazil (English, Por-
tuguese), no. 6, 1995.
Doing More with Less: The Marie Stopes
Clinics of Sierra Leone (English only), no.
7, 1995.


Introducing Sexuality within Family Plan-
ning: Three Positive Experiences from
Latin America and the Caribbean
(English, Spanish), no. 8, 1997.
Using COPE to Improve Quality of Care:
The Experience of the Family Planning
Association of Kenya (English, Spanish),
no. 9, 1998.
Alone You Are Nobody, Together We
Float: The Manuela Ramos Movement
(English, Spanish), no. 10, 2000.
From Patna to Paris: Providing Safe and
Humane Abortion (English only), no. 11,
2001.


34 e Quality/Calidad/Qua&it6
















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