The Understanding of Difference between Sex and Gender among Secondary Level Students in Nepal

The International Conference on Population and Development (ICPD) which Nepal is a signatory of, identifies sexuality education as a human right. Right to comprehensive sexuality education is also protected by many other international human right treaties. Sexuality education, which is crucial among adolescents, is a vast subject and awareness of the difference between sex and gender is the initial and the most important part of sexuality education. Learning about the differences in gender and sexual identities and respecting those differences can put children in much safer place, less vulnerable of physical and mental exploitations and also make children aware of right against gender based violence, sexual abuse, exploitation and harmful prac-tices. The study particularly focuses on finding out if the senior most students of school are aware about the basic part of sexuality education, i.e. the difference between sex and gender. The data and information required for the study was collected through survey questionnaire and on desk text books' content review. The survey required for this study was done from January till February of 2020. The major findings of the study reveal that the students of secondary level have heard teachers and seniors talk about sex and gender often but have not actually understood those words and the education curriculum also seem insufficient and ineffective in dealing with topics of sex and gender. The finding of this study shows that approximately 19% of the total respondents had some level of understanding of the difference between sex and gender. Through this study one can get an idea on how ineffective and insufficient the curriculum and content are when it comes to sexuality education because the senior most students of schools are unaware about the basic topic which falls under sexuality education, i.e. understanding the difference between sex and gender.


Introduction
Sexuality education is a human right and learning about the differences between sex and gender is the basic part of sexuality education. Good quality sexuality education is grounded in internationally accepted human rights, in particular the right to access appropriate health-related information. This right has been confirmed by the United Nations Committee on the Rights of the Child "Adolescents have the right to access adequate information essential for their health and development and for their ability to participate meaningfully in society. It is the obligation of States parties to ensure that all adolescent girls and boys, both in and out of school, are provided with, and not denied, accurate and appropriate information on how to protect their health and development and practise healthy behaviours. This should include information on the use and abuse, of tobacco, alcohol and other substances, safe and respectful social and sexual behaviours, diet and physical activity." (CRC/GC/2003/4, para 26), the Committee on the Elimination of Discrimination against Women (General recommendation No. 28 on the core obligations of States parties under article 2 of the Convention on the Elimination of All Forms of Discrimination against Women), the Committee on Economic, Social and Cultural Rights ("The Committee interprets the right to health, as defined in article 12.1, as an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health, such as […] access to health-related education and information, including on sexual and reproductive health").
(Committee on Economic,Social and Cultural Rights,General Comment No. 14,para. 11), and also in the United Nations Convention on the Rights of Persons with Disabilities (Article 25-Health, United Nations Convention on the Rights of Persons with Disabilities) 1 .
There is no doubt about the fact that sexuality education is a human right.
Awareness of the difference between sex and gender is the initial and the most important part of sexuality education but the reality in Nepal is that, both teachers and students feel ashamed and are hesitant to talk about issues related to sexuality. Teaching sexual health is often very poor, which is directly associated with teacher's embarrassment, lack of knowledge and poor teaching techniques.
In addition, teachers are also confused as existing courses are insufficient to address young people's need (Pokharel, Kulczycki, & Shakya, 2006).
In one of the online available contents of Social Studies subject of grade 9 of Nepal, under the chapter, "We and Our Community", gender identity has been 1 https://www.euro.who.int/data/assets/pdf_file/0008/379043/Sexuality_education_Policy_brief_No_ 1.pdf Accessed on 13 Feb, 2021.

The Difference between Sex and Gender
Human beings are both biological and social beings. People are born with some traits and as they grow up they acquire some traits. The traits they are born with tend to remain mostly permanent and these traits are mostly physical. The traits they learn as they grow up are not as permanent as the physical traits they are born with. People learn these traits through socialization. Sex is a biological trait and gender is a social trait.
According to Stoller, Sex is a biological ascription whereas gender is the result of psychological factors (Stoller, 1968). Okaley says that sex is a biological term and gender is a cultural term. People are born with a particular biological sex, but gender is a social and cultural construction, and it develops in the individual through social processes. Gender is learned. The individual develops their gender and their gendered identity through social and personal interactions (Okaley, 1972). Similarly Unger and Crawford discuss that sex is taken as a biological property (e.g., maleness and femaleness). Gender is taken as a cultural-societal property (e.g., masculinity/femininity) (Unger and Crawford, 1993 The World Health Organization (WHO) refers gender to the socially constructed characteristics of women and men, such as norms, roles, and relationships of and between groups of women and men. It varies from society to society and can be changed. Gender refers to the roles, behaviours, activities, attributes and opportunities that any society considers appropriate for girls and boys, and women and men. Gender interacts with, but is different from, the binary categories of biological sex 5 . To summarize, sex and gender are two different types of identities having different characteristics. One is biologically constructed and Open Journal of Social Sciences other is socially and culturally constructed.

Some Important Definitions Related to Gender and Sexual Identities
The UN Free and Equal, United Nation's Global Campaign against Homophobia and Transphobia has defined important words which describe gender and sexual identities. According to the UN Free and Equal, " LGBT stands for "lesbian, gay, bisexual and transgender"; "LGBTI" for "lesbian, gay, bisexual, transgender and intersex". While these terms have increasing resonance, different cultures use different terms to describe people who have same-sex relationships or who exhibit non-binary gender identities (such as hijra, meti, lala, skesana, motsoalle, mithli, kuchu, kawein, travesty, muxé, fa'afafine, fakaleiti, hamjensgara and two-spirit).
Transgender (sometimes shortened to "trans") is an umbrella term used to describe a wide range of identities whose appearance and characteristics are perceived as gender atypical-including transsexual people, cross-dressers (sometimes referred to as "transvestites"), and people who identify as third gender. Transwomen identify as women but were classified as males when they were born, transmen identify as men but were classified female when they were born, while other trans people don't identify with the gender-binary at all. Some transgender people seek surgery or take hormones to bring their body into alignment with their gender identity; others do not.
Intersex people are born with physical or biological sex characteristics, such as sexual anatomy, reproductive organs, hormonal patterns and/or chromosomal patterns, which do not fit the typical definitions of male or female. These characteristics may be apparent at birth or emerge later in life, often at puberty. Intersex people can have any sexual orientation and gender identity.
Sexual orientation refers to a person's physical, romantic and/or emotional attraction towards other people. Everyone has a sexual orientation, which is part of their identity. Gay men and lesbians are attracted to individuals of the same sex as themselves. Heterosexual people are attracted to individuals of a different sex from themselves. Bisexual (sometimes shortened to "bi") people may be attracted to individuals of the same or different sex. Sexual orientation is not related to gender identity and sex characteristics.
Gender identity reflects a deeply felt and experienced sense of one's own gender. Everyone has a gender identity, which is part of their overall identity. A person's gender identity is typically aligned with the sex assigned to them at birth. Transgender (sometimes shortened to "trans") is an umbrella term used to describe people with a wide range of identities-including transsexual people, cross-dressers (sometimes referred to as "transvestites"), people who identify as third gender, and others whose appearance and characteristics are seen as gender atypical and whose sense of their own gender is different to the sex that they were assigned at birth. Trans women identify as women but were classified as Open Journal of Social Sciences males when they were born. Trans men identify as men but were classified female when they were born. Cisgender is a term used to describe people whose sense of their own gender is aligned with the sex that they were assigned at birth.
Gender identity is distinct from sexual orientation and sex characteristics.
Gender expression is the way in which we express our gender through actions and appearance. Gender expression can be any combination of masculine, feminine and androgynous. For a lot of people, their gender expression goes along with the ideas that our societies deem to be appropriate for their gender. For other people it does not. People whose gender expression does not fit into society's norms and expectations, such as men perceived as "feminine" and women perceived as "masculine" often face harsh sanctions, including physical, sexual and psychological violence and bullying. A person's gender expression is not always linked to the person's biological sex, gender identity or sexual orientation.
Homophobia is an irrational fear of, hatred or aversion towards lesbian, gay or bisexual people. Transphobia is an irrational fear, hatred or aversion towards transgender people. Biophobia is an irrational fear, hatred or aversion towards bisexual people 6 .

Methods
This article is based on primary as well as secondary sources of information.
Through electronic database and web-sites the literature searches were conducted. The information on the understanding of sex and gender among secondary level students was collected through a questionnaire consisting 3 questions, 2 of which were follow up questions of the 1 st question. Detail on the questionnaire is discussed in the findings part. Because the purpose of this study was to test the basic understanding of the difference between sex and gender among students, the need to add more question seemed irrelevant at this stage. The sampling method used was convenience sampling and the sample size was 80.
All the students were of secondary level, i.e. class 9 and 10. Considering the years spent in schools, age, experience and exposure with varied topics, this group of school going students were selected for the survey. The students were from private schools belonging to different parts of the country. This study has also analyzed the content of two subjects taught in the secondary level, Social Studies and Health, Population and Environment as these subjects have incorporated the content of society, health and population.
The reason to analyze these text books was to understand the source of information among students regarding the understanding of sex and gender and also to identify the sufficiency of the content in text books dealing with topics of sex and gender. This exploratory study has used both quantitative and qualitative methods as the data is gathered through questionnaire as well as through analyzing the content of two above mentioned text books of each class.

Findings and Discussion
The questionnaire consisted of only 3 questions. The first question was a close ended one which asked if the respondents knew the difference between sex and gender. The respondents had to tick the given "yes" or "no" option. The second question was an open ended question which asked the respondents to explain the difference between sex and gender provided they had ticked on the "yes" option of the first question. The third question was a multi select multiple choice question which asked the respondents to tick multiple answer options regarding the source of information (facebook, television, friends, family, text books etc.) through they got to know the difference between sex and gender. Based on these questions and text books' content review the findings were as follows: 1) Respondents' awareness on the difference between sex and gender: Out of the 80 respondents, 60 respondents said they were aware about the difference between sex and gender. But not all of them could explain the difference between the two. There were 15 students among those 60 respondents who were able to blurrily explain the difference. There were no respondents who could clearly explain the difference between sex and gender. Only 1 among the 15 students has mentioned intersex as a sex category along with male and female. 19 among the 60 respondents have explained gender categories as male and female and have skipped explaining the sex part. 26 among the 60 respondents have explained sex as a verb, the physical intercourse, and gender as the difference between male and female. The above data shows that approximately 19% of the total respondents had some level of understanding of the difference between sex and gender. A whopping 81% did not know the difference. Among the total respondents only 1 had mentioned intersex as a sex category. None of the respondents had clear idea about the understanding of sex and gender ( Figure 1).
2) Source of information on sex and gender: Out of the 15 students who have tried to explain the difference, only 5 of them have mentioned text books as the source of information through which they got to know about the difference between sex and gender. Among those who have tried to explain 56% have mentioned Facebook and television as the source of  clearly establish that only a handful of students understand that sex and gender are two different identities. And text books do not seem to be helpful in making students understand the basics of sex and gender. Social media and television on the other hand seem to be effective than text books. There are not enough audiovisual materials to teach sex education programme in Nepalese schools. Teachers have to rely on a textbook which hinders the effective teaching of sex education ( Figure 2).
Surprisingly no respondents mentioned teachers as a source of information. A big reason behind it could be the lack of interaction between teachers and students regarding topics of sexuality. Often teachers and students both feel embarrassed to discuss matters related to sexual and reproductive health. School teachers lack knowledge on sexuality, so they often try to skip chapters and discussions on sexuality. There is evidence that sex education can be ineffective whenever teachers lack confidence and up-to-date knowledge and therefore lose credibility with pupils (Lowden and Powney, 1994 Improving teachers' training and skills is particularly successful in boosting the confidence of those teachers who think that delivery of sex education curricula as most challenging (Dev, Teijlingen, Edwin and Simkhada, 2010). In a study in 2002 among adolescents in eight schools in the Nawalparasi District in the Western Region of Nepal, eight teachers responsible for teaching the subject Health, Population and Environment were interviewed. Survey data was collected from 451 students and four focus group discussions with 26 of the students were carried. The study found that adolescents in those eight schools did not appear to be getting the information they needed. Most of the teachers did not want to deal with sensitive topics and feared censure by their colleagues and society. Some lacked the skills to give such instruction. Many students also felt uncomfortable with the topics. The study shows that the challenge is to strengthen sex education, make it more appropriate for the students and ensure that teachers are more comfortable and able to give instruction on the topic (Pokharel, Kulczycki, & Shakya, 2006).
United Nations Population Fund along with the Ministry of Education, Nepal had conducted a review of curricula in the context of Comprehensive Sexuality Education (CSE) in the year 2014. CSE provides a full range of information, skills and values to enable young people to informed choices about their health and sexuality. It is rights-based, age appropriate and gender-sensitive education that covers six key concepts as per International Technical Guidance on Sexuality Education. According to the review, teachers with relevant academic qualification majors (Health and Physical Education; Population Studies by Tribhuvan University) were in decreasing trend and were often seen teaching different subjects. The review suggests that teacher training is a critical component of CSE implementation. Teachers who run CSE classes must have adequate training to deliver all components of CSE education using the right pedagogic techniques. Findings from the desk review show that the most concerning gap in CSE implementation is the lack of trained teachers delivering CSE 7 .
3) Text books' content review Going through the text books, one can understand why text books are not a reliable source of information among students when it comes to the subject of sex and gender. The text books have used the terms sex and gender repeatedly but the content appear very confusing. Below are some examples of such content. a) Content no 1 The scope of sexuality is broad. The education programme related to sexuality and its biological, social, cultural, psychological and emotional aspects is comprehensive sex education. Sexual and reproductive health, gender, reproductive rights, diversity, pleasure and relationship are the components of comprehensive sex education. It shows the broadness of sex education (Karn & Acharya, 2017). Review: In the above content from the subject Basic Health, Population and Environment Education of Grade 9, under the topic Sex Education, the scope of sexuality has been discussed but the entire content has missed out on defining sexuality. The word sexuality has been used multiple times but the meaning of sexuality has not been explored. In the entire chapter titled Adolescence, Sex and Reproductive Health Education the difference between sex and gender has not been discussed. b) Content no 2 Gender refers to attitudes, feelings, and behaviors that a given culture associates with a person's biological sex. Gender identity refers to a personal identification with a particular gender and gender role in the society (Shah, Niroula,  AIDs was first detected in the USA among the homosexuals. It was detected by Dr. Robert Gallo. Since then, it has been spreading rapidly throughout the world (Sherchan, Uprety, & Bishnu, 2017).
Review: In the above content from the subject Health, Population and Environment Education of Grade 10, under the chapter Adolescence, Sex and Reproductive Health Education of grade 10, sexually transmitted diseases have been discussed. The paragraph above has mentioned the term homosexual but nothing has been discussed on sexual orientation. One can only assume what homosexuals are if we look at the paragraph.
Going through the text books of grade 9 and 10, one can hardly find any content that focuses on explaining the difference between sex and gender. The three contents mentioned above evidently supports the analysis that contents are developed assuming students are already familiar with and are well aware of topics related to sexuality. But the data collected by this study paints a different picture.
Students are unaware of the basic, the most important, and the initial topic that precedes all the other topics and contents of sexuality education, i.e. the difference between sex and gender. The design and structure of the current school sex education curriculum, which was updated in 2011, is considered to be inconsistent and ineffective in promoting sexual health at the adolescent age (Shrestha, Otsuka, Poudel, Yasuoka, Lamichhane, and Jimba, 2013). The Government's effort on addressing the need of sexuality education does not seem sufficient. In an attempt to address the Sexual and Reproductive Health (SRH) issues of adolescent, Government of Nepal implemented a five-year national programme in 2010, known as Nepal Health Sector Programme (NHSP), to provide adolescent-friendly sexual and reproductive health (ASRH) services (Mishra, 2017).
The programme was carried out in the period of the Millennium Development Goals; however, it is in the essence of the Sustainable Development Goals Nepal in 2014 also shows that the inclusion of CSE topics in lower secondary and secondary levels in the formal school system in Nepal is encouraging even though it is not as comprehensive as given in the ITGSE. The study shows that Nepal has CSE related topics from grades 1 -10 curricula that are to a large extent in line with the ITGSE but there are inconsistencies in the CSE topics and their links to each grade/age appropriateness, in the six major areas assessed: 1) relationships, 2) values, attitudes and skills, 3) culture, society and human rights, 4) human development, 5) sexual behavior and 6) sexual and reproductive health (Shrestha, Otsuka, Poudel, Yasuoka, Lamichhane, and Jimba, 2013).
Right to sexuality education has been protected by several human rights re- Sexuality education is learning about mental, physical, emotional and social as-Open Journal of Social Sciences pects of sexuality. One of the key concepts of Comprehensive Sexuality Education (CSE) is culture, society and human rights. The right against discrimination, the right to the highest attainable mental and physical health, right to information, and right to equality is some of the many rights from which right to sexuality education is derived. According to the International Technical Guidance on Sexuality Education (ITGSE), CSE is rights-based, age appropriate and gender-sensitive education. One of the objectives of CSE programs is to empower young people to demand respect for their bodies and their rights and to fully and freely consent to relationships and sexual activity that is free of violence 10 .
Sexual health education in school is regarded as an effective way to increase young people's understanding of Sexually Transmitted Infections (STIs) including HIV (human immune deficiency virus) infection, unintended pregnancies and abortion, infertility and cancer (Gallant & Maticka-Tyndale, 2004). Despite limited research evidence of effect on improving sexual health outcomes, young people generally agree that secondary schools are suitable sites for sex education (Reeves, Whitaker, Parsonage, Robinson, Swale, & Bayley, 2006). A range of research evidence also indicates that school-based sex education has potential to prevent unwanted pregnancy and to promote positive sexual health at the individual, family and community or health system level (Butler, 2004;Saito, 1998 to name a few. Despite having one of the most progressive constitutions when it comes to rights of sexual minorities, there are plenty of areas the government needs to focus and prioritize. One of such areas is sexuality education. Comprehensive Sexuality Education can create a significant difference when it comes to making children aware, skillful and bring about behavioral change regarding sexual and gender identities and help them make better health choices. Understanding sex and gender is the base of sexuality education. Through this study one can get an idea on how ineffective and insufficient the curriculum and content are when it comes to sexuality education because the senior most students of schools are unaware about the basic topic which falls under sexuality education, i.e. understanding the difference between sex and gender. The International Technical Guidelines on Sexuality Education which is based on CSE has recommended incorporating the topic of learning the difference between sex and gender in school curriculum in primary level where the age of students is between 5 to 8 years. The findings of this study suggest that the curriculum on sexuality education of Nepal needs to be thoroughly revised taking ITGSE based on CSE into consideration. As the current school sex education curriculum, which was updated in 2011, is found to be inconsistent and ineffective in promoting sexual health at the adolescent age, the revision of curriculum should be carried out immediately. Revisions need to timely and age appropriate as well. Teachers' training is as important as the revision of curriculum. Teachers' training should not only focus on delivering the course but also on building strong interpersonal relationship with the students and environment of trust and friendship, so that the students can comfortably discuss and share matters re-lated to sexuality and sexual health. Because students these days have access to social media and television and the findings of the study also gives one an idea about how social media and television can be effective tools of education, the use of such media should also be explored and incorporated in the curriculum of sexuality education.