Gay and lesbian rights groups had tried to combat violence by legislating against hate and supporting queer students in schools, but these projects did not address the root of the violence – the prejudice and hatred that children learned at an early age. To forestall hate crimes, queer rights advocates consequently turned their attention to educational curricula, lobbying schools to identify same-sex sexuality as a matter of benign difference. These advocates met with intense resistance, which restricted their ability to secure even limited reforms. What ultimately transformed the social and legal landscape were the straight family members of gays and lesbians, who came out in droves in the 1990s. These mothers and fathers drew national attention to the plight of their sons and daughters, helping make violence visible. They also helped the country see that support for families and support for gay and lesbian rights were one and the same.

Sexuality is one of the few curricular areas so constrained by policy that it often fails to resemble the topic students are interested in learning about or address the pressing concerns to which it was supposedly oriented. Focused on prevention of various sorts – and this often means prevention of all sexual activity, especially for youth – the more positive lessons about what sexuality can be for self-identity, relationality, community-building, and political life remain unaddressed. Though sexuality education has attempted to address the public goods of population health and individual development, too often it has done so without making clear concepts of gender, sex, ethical relationships, pleasure, and community. This chapter traces tensions in sexuality education from the start of its status as part of the official public school curriculum in the late nineteenth century to current debates that continue to shape how sexuality is defined and taught. We highlight continuities and ruptures that have characterized the global spread of sex education, showing how much of what happens in the Global South is shaped by legacies of colonialism and American political priorities. The chapter concludes by considering emerging challenges and opportunities for progress in sex education.

This chapter considers children’s right to education and the protection of children’s rights in a school environment. Despite the importance of education to children, their right to education and to participation in school is conspicuously absent from much legislation and policy concerning schools. This chapter considers the extent to which children are recognised as rights-holders at school. It starts by considering school attendance, truancy and the punitive approach to parents who are unable to secure their child’s regular attendance at school. It then considers pupil behaviour and school discipline. The prevalence of bullying and peer abuse in schools raises the importance of protecting the rights of affected pupils to an education in a safe environment that ensures that they are all respected. Responding to this behaviour also raises the rights of perpetrators, particularly in the context of school discipline, the use of force and power to search pupils. The chapter then considers the law on exclusion and the right to education. Finally, it considers the extent to which children have a right to attend sex education and the extent of parental right to object.

In this chapter, I suggest that sexual ethics as it is present in much sex education fails to address some common and formative aspects of many people’s sexual lives. I argue that the foundation of sexual ethics, as part of the ethical life more broadly, is best captured by the metaphor of vision. Any sexual ethics that treats isolated moments of sexual action as the focus of what it means to be sexually moral is insufficient because it ignores the influence that the way people see the world can have on their sexuality (and vice versa). Moral vision is shaped by character, and the way people engage their sexuality is a formative arena for character. So, sex education must address issues of character, and, conversely, attempts at character education must address the power sexuality possesses in the formation of persons.

The attitudes and legislative initiatives of the Irish government in the 1920s and 1930s cast a long shadow over the rest of the twentieth century. Lack of access to contraception combined with the power of Catholic teaching meant that there was considerable fear around pre-marital sex, which also influenced how sex education was disseminated in the period with a focus on morality rather than physiology. In the absence of formal sex education, young men and women were provided with moral codes regarding sexual activity, which were in turn policed by families and communities. This chapter shows how attitudes to sex in the period were clouded in a culture of fear which was perpetuated by Catholic Church teachings. Yet, at the same time, women’s magazines and television programmes such as The Late Late Show attempted to push against these boundaries through more open discussion of matters relating to sex and family planning.

The epilogue addresses the question of what can be ascertained from studying sex and reproduction in the longue durée. As demonstrated by the enduring reliance on abortion as birth control, family planning remains deeply gendered with women shouldering much of this burden. The persistence of eugenic ideas and the state’s intrusive but uneven policing of sexuality have been features of Chinese history since the early twentieth century. Despite ongoing changes in fertility policies, attitudes toward contraception and perceptions of what constitutes the ideal family remain diverse.

Chapter 6 traces the One Child Policy’s lifespan from its introduction in 1979 until its replacement with the Two Child Policy in 2015. I show that the extent to which the One Child Policy was actually enforced and the ways in which it was received differed significantly in Shanghai, Tianjin, and Luoyang. For some couples, particularly those in more economically developed cities like Shanghai and Tianjin, the policy simply affirmed personal convictions that smaller families are more economical and allow children to have better educational opportunities. In smaller cities like Luoyang, however, policy violations were more common as family size – as well as the existence of a male heir – remained more important than the opportunities allocated to those children. This chapter also interrogates the renewed interest in eugenics among parents wishing to “optimize” the qualities of their one and only child, as well as the limited scale and scope of sex education, a trend that exacerbated the reliance on abortion as premarital birth control.

How to talk about variations in sex development is a major theme for impacted individuals and families. This is the topic of Chapter 12. The author summarizes the research literature with caretakers and with adults about the difficulties of disclosure. Considerable criticism has been levied at health professionals for failing to role model affirming communication. For sure there are gaps in health professionals’ talk, but the biggest contributor to the difficulties is to do with the widespread misunderstanding about the biological variations. Psychological care providers are not there to put a cheerful gloss over clients’ negative expressions. However, they can be part of the favorable social condition in which a wider range of meanings about bodily differences are negotiated. In the practice vignette, the author highlights how tentative and uncertain the enabling process is, where a negative view of sex variations is still widely endorsed in the social context.

Chapter 11 of the book reviews potential psychological contributions in the highly charged process of assigning legal gender to a newborn with genital variations. Although a number of psychological theories exist for understanding gender development, it is the brain gender framework that has been singularly privileged in intersex and DSD medicine. However, the decades of research cannot contribute to the certainty professionals and caretakers seek. Psychological care providers (PCPs) have other frameworks to draw from in order to work ethically and pragmatically with families. In the practice vignette, the author envisions how a highly skilled PCP in a high-functioning DSD team could work substantially to help caretakers to cope with uncertainty and minimize the need for psychosocially motivated medical interventions. In the vignette, the psychological care path is in position before medical investigations begin. It remains highly active long after the medical and legal processes are completed. Although the vignette is built around a child diagnosed with 17β-hydroxysteroid dehydrogenase-3 deficiency, the care principles are relevant to legal binary gender assignment for children born with a range of sex development variations.

Difficulties with communication about bodily differences are strongly linked to sexual experiences. In Chapter 13, the author critiques the dominant ways of talking about sexuality in the wider society. These oppressive ideas can give rise to insecurities, self-objectification and body shame for people in general. Adults who have been medically managed are particularly vulnerable to the effects of objectification and shame. The author outlines typical components of sex therapy programs. However, rather than fix sexual problems, which can perpetuate people’s sense of inadequacy, the author suggests that psychological care providers support clients to process any trauma and develop a more relaxed and appreciative relationship with the body. This work, which requires generic therapy knowledge and skills, can be integrated with a range of specific sex therapy techniques and resources to reimagine a sexual future that focuses on bodily pleasure rather than gender performance. Although the practice vignette is built around a female couple, one of whom has partial androgen insensitivity syndrome, the care principles have wide applications for people with variations more generally.

Inconsolable distress is neither a universal nor inevitable response to inability to have biological children. In Chapter 14, the author criticizes research with clinic samples that has produced a problem-saturated account of childlessness that obscures a wide range of alternative responses. The author examines the influence of pronatalist ideology on people who are impacted by infertility including many people with sex variations. Away from the treatment context, psychological input can guide individuals, couples and groups to explore personal meaning of nonparenthood. It can facilitate service users to grieve for what is not possible, challenge feelings of deviance and shame, reengage with a range of life goals and, perhaps most important of all, recast adult identities. Through the practice vignette built around a heterosexual couple, one of whom has a late diagnosis of Klinefelter syndrome, the author teases out the difficulties of working psychologically in a treatment context, where complex existential issues and relational dynamics are compressed into the frame of pressurized treatment decisions.

Chapter 9 tackles the theme of choosing “normalizing” interventions, which applies to children and adults with variations. It explores the limits of choice regarding invasive and irrevocable “normalizing” interventions in the field of sex development. It considers the role of emotion in decision-making and the complexities of obtaining informed consent. In the practice vignette, demand for surgery by a young person (with CAH) is a foregone conclusion – a familiar scenario in DSD services and one that places the psychological care provider (PCP) in an ambiguous position. The service user also has clear psychosocial care needs. She brings a unique suite of intersecting social circumstances that place demand on the PCP to be fluid and responsive to the dynamic and challenging referral context. The PCP in the vignette does not have the answers, but it is hoped that the story opens up conversations on the theme.

Sexual practices are strongly influenced by social and cultural norms and hence encompass a wide degree of heterogeneity between different cultures. Cultural diversity in sexual practices is subject to an even more complex array of sociocultural, physical, and psychological influences in pregnancy. The literature in this area demonstrates both this diversity and also commonalities among cultures, with universally high rates of female sexual dysfunction (FSD), unnecessary avoidance of sexual activity in pregnancy due to ill-informed fears, and unmet desire for antenatal education and assessment of sexual issues by health practitioners. This chapter presents the current evidence on rates of sexual activity and FSD in pregnancy and influences upon these in different cultures. Increasing awareness of common rates of sexual activity in pregnancy may normalize a reduction in activity and consequently reassure couples that such changes are not necessarily indicative of relationship issues. Conversely, identifying and addressing preventable issues affecting sexual health in pregnancy could potentially improve parental well-being, strengthen family bonds, and positively impact the development of offspring.

How do we escape the trap?Many of the social, biological and environmental mechanisms that are driving down human fertility, are self-reinforcing. They operate to accelerate the rate of fertility loss, not stabilize it. Escape from this downward spiral will involve several initiatives that, working together, may provide a measure of control over the rate and depth of fertility decline. For example, we need a complete overhaul of sex education that recognizes the fragility of human fertility and is not so focused on the prevention of teenage pregnancies. We also need to raise the profile of reproductive toxicology so that we can secure better control over the release of potentially harmful compounds into the biosphere. There is a particular need to control male exposures to oestrogens and to counteract those elements of lifestyle, metabolism and the environment, responsible for creating oxidative stress in both the male and female reproductive tract. Accommodating the ART industry would be easier if we secured a deeper understanding of the causes of human infertility so that ART does not become the default therapy for every couple and, when it is used, that IVF is preferred over ICSI. Finally, we need to engineer new social structures wherein fertility is facilitated and encouraged.