Smith et al.

/ Sex Education Information on Internet

Health Education & Behavior (December 2000)

Perspective

The Content and Accessibility of

Sex Education Information on the Internet

Meghan Smith
Emily Gertz
Sarah Alvarez
Peter Lurie, MD, MPH

The objective of this study was to describe Web sites with sex education material and assess the accessibility
of specific information on the Internet. First, the authors conducted a review of Web sites using specific sex edu-
cation keywords. Second, 27 undergraduate students were asked to locate information on proper condom use
and sexually transmitted disease (STD) symptoms. The time, number of search attempts, and number of clicks
needed to identify each piece of information were recorded. The authors identified 41 sites with sex education
material from almost 6 million pages yielded by the keywords. Sixty-three percent of the 1,556 most compatible
pages were categorized as pornography. The students found the information on condom use and STD symptoms
in an average of 4 minutes, using fewer then six clicks and two searches. The authors concluded that general
information on sex education is difficult to locate on the Internet and often lacks essential elements, but accurate
and useful information on specific topics can be more easily obtained.

As the Internet becomes increasingly popular and accessible, more people are turning
to it for biomedical information. Sixty million U.S. adults used the Internet to locate
information about health care in 1998.1 More elementary and junior high schools are
going online (32% of Internet users are ages 18-242), and young adults, in particular, find
the Internet easy to use and understand, allowing the Internet to play a growing role as a
source of educational information, including sexual information. Many young adults feel
uncomfortable discussing sexual issues with their parents or other adults and prefer
exploring these issues in private. Consequently, they may increasingly turn to the Internet
with questions regarding sexuality. However, persistent differences in race- and
income-specific Internet access have been noted,3 and 59% of Internet users are men.1

Meghan Smith, Emily Gertz, and Sarah Alvarez were students at the residential college of the University of
Michigan, and Peter Lurie was with the Institute for Social Research, University of Michigan at the time this
research was conducted.
Address reprint requests to Peter Lurie, MD, MPH, Public Citizens Health Research Group, 1600 20th
Street, NW, Washington, DC 20009; phone: (202) 588-7781; fax: (202) 588-7796; e-mail: plurie@citizen.org.
The authors wish to thank their classmates and Dr. Max Heirich in the Residential College at the University
of Michigan for their helpful comments on earlier drafts of this manuscript.
Health Education & Behavior, Vol. 27 (6): 684-694 (December 2000)
2000 by SOPHE
684
 Smith et al. / Sex Education Information on Internet 685

Few studies have systematically reviewed health information on the Internet.

Impicciatore et al. assessed the reliability of information on the treatment of infant fever
available on the Internet and found that much of the information was inaccurate.4 Of the
41 Web sites surveyed, only 4 advised treatment in accordance with the major clinical
practice guidelines. Three of the Web sites recommended administering aspirin to chil-
dren with fever, increasing the risk of Reyes syndrome. Similar inaccuracies have been
found in surveys on Internet sources of information on childhood diarrhea5 and Ewings
sarcoma.6 Two articles have reviewed the availability of HIV/AIDS resources.7,8 One of
these studies assessed the quality of site information using a Likert scale and found the
quality to be generally good but not usually oriented toward women.7 Other authors have
used the Internet for gathering information through posted questionnaires.9,10
We are aware of no systematic studies concerning sex education information available
on the Internet. We undertook this study to assess the content and accessibility of sex edu-
cation information on the Internet and develop suggestions for how this information
might be improved. The study also presents methods for systematically evaluating the
content and accessibility of Internet sites for the health education field more generally.
This exploratory study uses sex education information on the Internet as a paradigm for
other efforts to convey health education information using this new medium.

METHOD

Web pages are reached using browser software (e.g., Netscape Navigator or Internet
Explorer) that provides access to several search engines. The user enters keywords,
resulting in a list of compatible pages from which the user can select with a mouse click.
Some search engines rate each identified page on a 0% to 100% scale of compatibility.
Within a Web site, which consists of a number of Web pages, the reader may continue
clicking to other pages established by the same group or to related sites established by
other groups. At any point, the user can begin another search with a new keyword or select
a different page from the list produced by the original search.
Two complementary studies were conducted. The first study, the Site Survey, was a
detailed review of Web sites with sex education information. The second study, the Infor-
mation Search, examined how quickly student volunteers were able to find specific items
of sexual information on the Internet.

Site Survey

We explored the Internet during November 1997 using the browser Netscape Naviga-
tor and the search engines Excite and Web Crawler. These search engines were selected
because both provide estimates of keyword compatibility.
We included only those pages with at least 70% keyword compatibility because we
believe that young adults are more likely to pick a new keyword or search engine than
search through pages with low compatibility. In most search engines, the number of pages
increases dramatically below 70%, and the specificity declines.
We used five keywords to search each engine: sexual health, sex education, sexual
intercourse, teen sex, and sex advice for teens. We omitted two of our originally planned
keywords, sex and sexuality. For the keyword sex, Excite and Web Crawler both displayed
more than 1,000 pages, but the highest compatibility found was 64%. The keyword sexu-
ality in Excite produced very similar results to those with sex. However, when we
686 Health Education & Behavior (December 2000)

searched sexuality with Web Crawler, unlike most of our keywords, there was a very large
number of pages with more than 70% compatibility, including a number of 100%
matches, as well as compatibility throughout the 90% range. These patterns were so dis-
similar from those with other keywords that we excluded these keywords.
As mentioned, Internet users at a specific Web page are often provided with a variety
of options, including a table of contents and/or links to other related sites. Because we
were examining specific sites (as opposed to only pages), we developed a four-clicks
rule: a maximum of four clicks in any direction from the Web page identified by the
keyword search was permitted. We believe that with so many Web pages from which to
choose, young adults unable to find the information quickly in one site will likely turn to a
completely new one.
Some Web sites require users to enter a password, have subscriptions, pay dues, or reg-
ister with the sponsoring organization to browse the Web site. We excluded these sites, as
we believe that young adults would in large part avoid them, but such sites were extremely
rare in our study. Only English-language sites were included.
Web sites were divided into 10 categories: advertisements, editorial commentaries,
sex education pages, personal home pages, news articles, organization position state-
ments, pornography, policy/curriculum statements, professional/educational announce-
ments, and not classifiable or inaccessible. We restricted our analysis to sites classified as
sex education or position statements. Sex education sites were defined as sites with a pri-
mary purpose of providing sexual health information. Position statements were defined
as sites operated by groups concerned with propagating particular views about sexual
health. While other categories did at times discuss educational topics (e.g., news articles
and advertisements), education did not appear to be their chief goal.
We developed a Web site scoring system that awarded the sites points on a yes/no basis
on 10 items, which were combined to form a 10-point content scale. To receive a point for
a given item, the Web site had to simply mention that item, regardless of its accuracy or
the level of detail. Content points were awarded for sexual biology, decision making
about sexual activity, sexual violence, homosexuality, condoms, description/illustration
of proper condom use, other contraceptives, sexually transmitted diseases (STDs), abor-
tion/adoption/delivery options, and other resources for sex education. Additional ques-
tions examined some of these items in more detail or sought other information concerning
sexual health.
Three investigators (Meghan Smith, Emily Gertz, Sarah Alvarez) examined approxi-
mately 100 Web pages together to establish consistent classification and scoring
approaches. Thereafter, each researcher worked independently. When particular ques-
tions arose, the three researchers made decisions on classification and scoring jointly.

Information Search

After receiving approval from the University of Michigans Behavioral Sciences Insti-
tutional Review Board, we recruited participants in a primarily freshman and sophomore
dormitory at the University of Michigan in March 1998. Halls for recruitment were
selected randomly. We knocked on all dormitory rooms in the selected halls, except those
belonging to resident advisers who are in at least their 3rd year of college. The researchers
explained the study to each potential participant and offered a $10 reimbursement if the
participant completed the study. Students first names and room numbers were recorded,
and a reminder letter was placed in their mailboxes before their scheduled study time.
Forty percent (16) of those agreeing to participate presented for their scheduled appoint-
 Smith et al. / Sex Education Information on Internet 687

ment. Eleven additional participants who were the friends or roommates of those initially
agreeing to participate were also included. The gender breakdowns of those initially
agreeing to be in the study (64% female) and those ultimately enrolled (67% female) were
similar. Fifty-four percent of residents in the dormitory are female, compared to 50% of
the entire undergraduate population.11
A computer classroom at the University of Michigan was reserved for two evenings.
All the computers used were Macintosh 7500/100s with 1.1 gigabyte hard drives and 32
megabytes of RAM. On entering the classroom, the participants signed informed consent
forms. The participants were asked to conduct separate searches to identify Web pages
with two pieces of information. One question asked for a textual or graphic description
of the proper way to put on a condom. The other question read, You have symptoms
which make you suspect that you have a sexually transmitted disease. Find a Web page
that describes the symptoms of STDs. These questions were selected because they were
the most commonly identified items in the Web sites in the Site Survey and because both
questions have objective answers that the researchers could readily confirm. Participants
were alternately assigned to start with the condom or STD question. The participants
were instructed to use only Netscape Navigator but were permitted to use any search
engine or keyword of their choosing and to start a new search at any time they wished.
Using specially designed data collection sheets, they were also instructed to record, as
they worked, their start and stop times and how many clicks were made from the page
identified by their keyword search. The researchers examined the Web pages identified
by the participants to confirm that accurate information had in fact been identified.
Data were entered into a spreadsheet and analyzed using SPSS. Correlations between
continuous variables were examined using Kendalls . The Wilcoxon rank sum test was
used to compare continuous variables from two categories.

RESULTS

Site Survey

The keyword searches yielded a total of 5,952,130 Web pages. It was impractical to
sort through all of these pages to identify duplicates. Four percent of Web pages with
compatibility scores greater than or equal to 70% were classified as sex education pages
and 1% as position statements, for a total of 41 relevant pages. Sixty-three percent of
pages were classified as pornography (see Figure 1).
The 41 sites received content scores ranging from 0 to 10 points, with a mean of 6.1
(standard deviation = 2.5). Only 3 Web sites scored 10 points. Figure 2 describes the fre-
quency with which each element of the 10-point content scale was included in the 41 sites.
STDs were most frequently mentioned (36 Web sites). However, 10 of the 36 sites con-
tained information only on HIV and not on other more common STDs. In sites that men-
tioned more than one STD, HIV was always included. Condoms were referred to in 32
sites, of which 20 provided instructions (graphic or textual) on proper use. Sixteen sites
provided estimates of condom efficacy; these estimates ranged from 77% to 99.9%. Con-
traceptives other than condoms were mentioned in 30 sites. Sexual biology was men-
tioned least frequently (10 sites). Homosexuality was mentioned in 26 sites. In all but 1 of
these sites, it was referred to either positively or neutrally. Although not included in our
10-item score, masturbation was mentioned in only 15 sites. When mentioned, it was pre-
sented in a positive or neutral light.
688 Health Education & Behavior (December 2000)

Figure 1. Classification of Web pages identified.

Information Search

Twenty-seven participants (18 women and 9 men) between 18 and 21 years of age
(mean = 19.0) completed the second study. Most participants (18) were everyday Internet
users, with the remaining volunteers reporting either weekly use (7) or rare use (2).
The search engine Yahoo! was most commonly selected (14 participants for the con-
dom question and 11 for the STD question). Metacrawler (used by 5 and 6 persons,
respectively) and Infoseek (used by 3 and 4 persons, respectively) were also used with
some frequency. Less commonly used search engines were Excite, Hotbot, Looksmart,
Lycos, and Alta Vista. Only 1 participant switched search engines while searching for
answers to a specific question; that participants data were coded as the original engine.
The most common keywords used for the condom question were the following: con-
doms (10 participants), condom usage (5), condom use (4), and how to use a condom (2).
The most common keywords for the STD question were the following: sexually transmit-
ted disease(s) (12 participants), STD (4), and STD symptom(s) (5).
The mean time to locate the answer to the condom question was 4.0 minutes, with a
range of less than 1 minute to 12 minutes. Users clicked a mean of 4.9 times (range = 1-15)
from the initial search result to find the appropriate information. In all cases, the answer
was found on or before the third search attempt (mean = 1.3 attempts). Participants took
approximately the same amount of time to answer the STD question (mean = 4.1 minutes;
range = 1-9). The mean number of clicks used was slightly higher (5.6), as was the num-
ber of searches (mean = 1.4 attempts, with a maximum of 4). However, there were no sta-
tistically significant differences between the ease of finding an answer to the condom
compared to the STD question, whether measured by time, clicks, or search attempts.
Time showed a strong, positive correlation with number of clicks (Kendalls = .58 for
the condom question and .61 for the STD question; p < .0001 for both). Time was less well
 Smith et al. / Sex Education Information on Internet 689

Figure 2. Mentions of specific educational items by selected Web sites.

correlated with the number of search attempts for both the condom question (Kendalls
= .28; p = .043) and the STD question (Kendalls = .32; p = .019). For the remainder of
this article, we report only the amount of time and the number of search attempts.
For the condom question, the 5 participants using Metacrawler found the information
fastest (2.0 minutes) and always on their first search attempt. For the STD question, the
three search engines did not differ substantially, with participants retrieving the informa-
tion in between 3.7 and 3.8 minutes, using one to four search attempts.
For both questions, men found the answers more quickly than women (2.6 minutes vs.
4.5 minutes for the condom question, p = .025; 3.3 minutes vs. 5.0 minutes for the STD
question, p = .095).
Experience with the Internet predicted search outcomes for the STD question but not
for the condom question. For the STD question, participants using the Internet daily
found the information in 2.8 minutes, compared with 6.8 minutes for those using the
Internet less frequently (p = .011). Participants not using the Internet daily also used more
search attempts to answer the STD question (daily use = 1.2 attempts; less than daily use =
1.9 attempts; p = .054).
Of the 54 sites identified in the Information Search, 4 could not be located subse-
quently, and 1 required the viewer to be older than age 18 and was thus excluded. After
excluding duplicate sites, 21 Web sites remained, of which 17 were classified as educa-
tional, 3 as advertisements, and 1 as a curriculum statement. Eight sites provided the 27
answers to the condom question, and 13 sites did so for the STD question; no site provided
the answers to both questions. The most frequently identified site for the condom ques-
tion was used by 14 participants, while 8 participants used the most frequently identified
site for the STD question. The median content scores for the sites containing the answers
to the condom and STD questions were 5.5 (range = 3-7) and 3.0 (range = 1-10),
respectively.
690 Health Education & Behavior (December 2000)

Only 1 of the 21 Web sites that provided an answer in the Information Search had been
identified in the Site Survey.12 This site, operated by Duke University, was given a rating
of 9 in the Site Survey. Evidently, the other sites identified by the participants in the Infor-
mation Search received less than 70% compatibility scores or were not identified at all by
our search engines and keywords.

DISCUSSION

The Internet is changing the way many of us receive information. Young adultsin
particular, those reluctant to raise sensitive or private questions with their parents or
teachersmay make use of this new resource to obtain sex education information.
Because the Internet can be searched in the privacy of ones own home, it may be particu-
larly appropriate for this purpose.
Our study showed that the Internet is most efficiently used when searching for specific
information concerning sexual health. The Site Survey demonstrated the difficulty of
locating comprehensive Web sites with sex education material. Of the Web pages sur-
veyed, only 41 were educational sites or position statements. These categories are inher-
ently subjective. Most Web pages (63%) identified by the keywords we used were
devoted to pornography, a finding that is likely to be of concern to parents. Difficulty
identifying relevant material amid the large amount of information available on the
Internet is not unique to reproductive health issues; in one study, only 7% of pages identi-
fied for orthopedic patients provided appropriate information.13
The study also revealed significant omissions in the content of many of the 41 sites. It
is important to emphasize the leniency of our content evaluation system, which does,
however, contain many elements of the Guidelines for Comprehensive Sexuality Educa-
tion, developed by the Sexuality Information and Education Council of the United States
(SIECUS).14 To receive a point, a Web site needed only to mention the designated infor-
mation; it did not need to be accurate, and no detail was required to receive a point. Thus,
even with a mean content score of 6.1, many sites were poor. We found some examples of
sex myths. For example, one Web site stated that casual sex takes the trust out of future
marriage. Those who can not control themselves before marriage wont be fully trusted
when difficult times come after marriage. Casual sex can become addictive.15 This Web
site was operated by a member organization of the United Kingdom Evangelical
Alliance.
Three sites received a score of 10. These sites were sponsored by Healthwise (an edu-
cational division of Columbia University),16 the Minnesota Organization on Adolescent
Pregnancy Prevention and Parenting (MOAPPP),17 and M-Web.18 The Healthwise site
provided several dozen subjects ranging from bumps around penis to no orgasm with
intercourse for the user to explore. The MOAPPP site was focused on teen sexuality and
provided a sophisticated and colorful site design that could link the user to MOAPPP fact
sheets. The M-Web site is now sponsored by an organization called Peer Partners, Inc. It
used arty graphics and had a sex-positive as opposed to a strictly educational orienta-
tion. It also had a search engine for searching the site.
A more efficient way to obtain sex education information was illustrated in the Infor-
mation Search. Accurate answers to specific questions about sexual health were found in
approximately 4 minutes. To our knowledge, there have been no formal studies of the
time to locate specific information on the Internet (N. Savio, HotWired Web site, written
communication, September 2, 1998). The 4 minutes required to locate accurate informa-
 Smith et al. / Sex Education Information on Internet 691

tion seems brief, particularly if compared to the amount of time required to locate similar
information in a library.
We did examine several potential predictors of Web searching proficiency, including
gender, Internet experience, and search engine. Gender was a predictor of search speed,
but stratified analyses revealed that this relationship might have been partly confounded
by Internet experience (data not shown). Due to the small sample sizes in many cells and
the lack of variability of the data on search attempts, these conclusions should be consid-
ered tentative and subject to replication. For example, for the comparison of the differ-
ence in search times between females and males for the condom question, the study had a
power of .29 to detect a statistically significant difference between the groups (alpha =
.05; 18 females and 9 males; standard deviation = 3.2; difference between means = 1.9).
The Internet is a constantly changing body of information. Our study was conducted at
a specific point in time, and similar searches repeated today might produce different
results. In September 1999, U.S. News and World Report19 mentioned three Web sites as
potential sex education resources for young people. In early October 1999, we applied
our content scale to these Web sites. Go Ask Alice,20 operated by Columbia University,
scored a 9; a Web site operated by pediatrician Dr. Alan Greene21 rated a 3 despite being
highly recommended by Yahoo!; and a Web site sponsored by the Kaiser Family
Foundation22 received a 6. We also scored two other well-known sites, one operated by
Planned Parenthood,23 which received a 6, and another by MTVs Dr. Drew Pinsky,24
which required a free sign-in and even then scored only a 1.
The results may also not be generalizable to other search engines or other topics. In
addition, the educational level and access to computers of these University of Michigan
students and the low response rate in the Information Search further limit generalizability.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Our experience suggests several ways the Internet can be more efficiently searched.
Looking for specific pieces of information rather than broad concepts appears to be more
efficient. We also found the keyword compatibility indices to be helpful. The manner in
which Web pages are rated for keyword compatibility differs for each search engine.
The search engine Excite, for example, searches through the entire Internet for pages that
(a) contain words that exactly match the keyword inquiry and (b) contain related informa-
tion but not necessarily the specific keyword. Higher compatibility ratings are awarded to
the pages most closely matching the keyword inquiry.25 Many search engines have infor-
mational pages that explain how the particular engine performs searches and awards com-
patibility scores. These can be used to maximize the likelihood that a search identifies
appropriate information.26
Clearly, the ability to identify relevant information is dependent on the indexing and
search capabilities of the Internet and its search engines. The almost complete lack of
overlap between the pages identified by the Site Survey and the Information Search
underlines this. A single comprehensive site might suffice if it were accessible through as
many search engines as possible.
The health education field should consider establishing such a site, as sites created by
medical societies are among the most-used health sites on the Internet.1 A health educa-
tors seal of approval for sites deemed to be of high quality based on objective criteria,
such as those we have begun to develop in this article, should also be considered to help
young people to use content rather than visual flair to distinguish between better and
692 Health Education & Behavior (December 2000)

worse sites. Health educators need to become familiar with the various Internet search
engines and their indexing functions and should develop and disseminate search strate-
gies tailored for particular topics. Workshops addressing this issue should become regular
features at conventions of health educators.
Some sites were organized in a more user-friendly manner than others. Indexes and
tables of contents are a good way to highlight the sites substance and facilitate naviga-
tion. Providing a search engine to search for specific topics within the site is also helpful.
The particular choice of language is important and must take the target audience into
account. For sex education sites, clear, colloquial, and blunt language may be the best way
for users to understand the material. Pictures, video clips, and animation are also very
effective ways to present information. There is experience incorporating feedback from
youth on software modules designed to provide them with information on sexual health,27
and these techniques may be adapted for the design of Web sites as well. However, much
work remains to be done in ensuring the quality of the medical information provided28,29
and developing scales to rate Web site quality.30,31
Our study leaves open the question of the usefulness of the Internet for health educa-
tion endeavors outside the unique realm of sex education. On one hand, the stigmatized
nature of sexuality makes the anonymity of the Internet an excellent option for young peo-
ple seeking answers to personal questions. On the other hand, the prevalence of pornogra-
phy on the Internet creates technical impediments to efficiently steer users to appropriate
sites. The presence of pornography represents a potential unintended consequence of
using the Internet for sex education. Many parents will have moral objections, will be
concerned about age appropriateness, and may feel that messages they strive to deliver at
home are being undermined. But people will use the Internet in large and increasing num-
bers, regardless of the concerns of health educators or parents.1 The question before
health educators is, therefore, not whether the Internet should be used as a health resource
but rather how its use can be optimized and, in the specific case of sex education, how par-
ents can become more involved in the process of helping their children navigate this
inherently unstructured medium. (Public opinion polls suggest that many would like par-
ents to play a more active role in sex education.32)
There is an urgent need for studies examining the role of the Internet in other areas of
health education. In addition, the greater familiarity with the Internet by men demonstrated
in our study suggests a limit to the usefulness of the medium, as do well-documented social
class and racial differentials in Internet access.1,3
Because of the explosive growth of the Internet, we recommend that health educators
repeat this study in the future. Serial cross-sectional studies of information on the Internet
on other topics such as drug use and mental illness would also be helpful to describe the
rate of growth of the medium, unique health education approaches used, and particular
problems identified. Future studies should use the kappa statistic to assess interrater reli-
ability more formally than we did. We also recommend that future researchers attempt to
develop a more structured approach to classifying sites, but we caution that this will be
difficult to do because some sites will have elements that fall into more than one category.
Finally, if researchers wish to examine the impact of factors such as gender, Internet expe-
rience, and search engine, they should use sample sizes larger than we could muster in this
exploratory study. Even given the limitations of the present study, however, we believe
that the basic picture that emerges herethat the Internet contains valuable health educa-
tion information but that it is disorganized and needs to be searched in particular ways
would not be substantially altered.
 Smith et al. / Sex Education Information on Internet 693

This exploratory study of sex education on the Internet has identified a number of
issues that are likely relevant to other areas of health education as well. The Internet is a
potentially useful venue for sex education information, but to be most useful, it should be
searched with specific questions in mind. The size of the Internet and the time needed to
navigate it may be daunting for young adults searching for broad information, but when
looking for specific information on sexual health, the Internet can be a valuable resource.

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