“Who here has been in love?” Anniek Pheifer asks a crowd of Dutch elementary school students.

It’s a Spring morning in Utrecht, and the St. Jan de Doper elementary school gym is decked in heart-shaped balloons and streamers. Pheifer and Pepijn Gunneweg are hosts of a kids television program in the Netherlands, and they’re performing a song about having a crush.

Kids giggle at the question. Hands — little and bigger — shoot up.

Welcome to “Spring Fever” week in primary schools across the Netherlands, the week of focused sex ed classes… for 4-year olds.

Of course, it’s not just for 4-year-olds. Eight-year-olds learn about self-image and gender stereotypes. 11-year-olds discuss sexual orientation and contraceptive options. But in the Netherlands, the approach, known as “comprehensive sex education,” starts as early as age 4.

You’ll never hear an explicit reference to sex in a kindergarten class.In fact, the term for what’s being taught here is sexuality education rather than sex education. That’s because the goal is bigger than that, says Ineke van der Vlugt, an expert on youth sexual development for Rutgers WPF, the Dutch sexuality research institute behind the curriculum. It’s about having open, honest conversations about love and relationships.

By law, all primary school students in the Netherlands must receive some form of sexuality education. The system allows for flexibility in how it’s taught. But it must address certain core principles — among them, sexual diversity and sexual assertiveness. That means encouraging respect for all sexual preferences and helping students develop skills to protect against sexual coercion, intimidation and abuse. The underlying principle is straightforward: Sexual development is a normal process that all young people experience, and they have the right to frank, trustworthy information on the subject.

“There were societal concerns that sexualization in the media could be having a negative impact on kids,” van der Vlugt said. “We wanted to show that sexuality also has to do with respect, intimacy, and safety.”

Beyond risk prevention

The Dutch approach to sex ed has garnered international attention, largely because the Netherlands boasts some of the best outcomes when it comes to teen sexual health. On average, teens in the Netherlands do not have sex at an earlier age than those in other European countries or in the United States. Researchers found that among 12 to 25 year olds in the Netherlands, most say they had “wanted and fun” first sexual experiences. By comparison, 66 percent of sexually active American teens surveyed said they wished that they had waited longer to have sex for the first time. When they do have sex, a Rutgers WPF study found that nine out of ten Dutch adolescents used contraceptives the first time, and World Health Organization data shows that Dutch teens are among the top users of the birth control pill. According to the World Bank, the teen pregnancy rate in the Netherlands is one of the lowest in the world, five times lower than the U.S. Rates of HIV infection and sexually transmitted diseases are also low.

“We have to help young people navigate all the choices they face and stand up for themselves in all situations, sexual and otherwise,”

There are multiple factors that likely contribute to these numbers. Easy access to contraception is one. Condoms, for example, are available in vending machines, and the birth control pill is free for anyone under age 21. But there’s also a growing body of research that specifically credits comprehensive sexuality education. A recent study from Georgetown University shows that starting sex ed in primary school helps avoid unintended pregnancies, maternal deaths, unsafe abortions and STDs.

Proponents of the Dutch model argue that their approach extends beyond those risks. Their brand of sex ed reflects a broader emphasis on young people’s rights, responsibility and respect that many public health experts say is the foundation of sexual health.

A 2008 United Nations report found that comprehensive sex ed, when taught effectively, allows young people to “explore their attitudes and values, and to practice the decision-making and other life skills they will need to be able to make informed choices about their sexual lives.” Students who had completed comprehensive sex education in the Netherlands were also found to be more assertive and better communicators, according to an independent health research agency that conducted a study of the Dutch programs.

“We have to help young people navigate all the choices they face and stand up for themselves in all situations, sexual and otherwise,” said Robert van der Gaag, a health promotion official at Central Holland’s regional public health center.

‘Little butterflies in my stomach’

At the St. Jan de Doper school, a group of kindergartners sit in a circle, as their teacher, Marian Jochems, flips through a picture book. The pages contain animals like bears and alligators hugging.

“Why are they hugging?” she asks the class.

“Because they like each other,” one girl answers.

Jochems asks them to think about who they like the most. Several kids say their mom or dad. One girl names her little sister. A few name other children at school.

“How does it feel when that person hugs you?” Jochems asks.

“I feel warm from the inside,” one boy replies. “It’s like there are little butterflies in my stomach.”

Lessons like this are designed to get kids thinking and talking about the kind of intimacy that feels good and the kind that doesn’t. Other early lessons focus on body awareness. For example, students draw boys’ and girls’ bodies, tell stories about friends taking a bath together, and discuss who likes doing that and who doesn’t. By age seven, students are expected to be able to properly name body parts including genitals. They also learn about different types of families, what it means to be a good friend, and that a baby grows in a mother’s womb.

“People often think we are starting right away to talk about sexual intercourse [with kindergartners],” van der Vlugt says. “Sexuality is so much more than that. It’s also about self image, developing your own identity, gender roles, and it’s about learning to express yourself, your wishes and your boundaries.”

That means the kindergartners are also learning how to communicate when they don’t want to be touched. The goal is that by age 11, students are comfortable enough to navigate pointed discussions about reproduction, safe sex, and sexual abuse.

Let’s not talk about sex

In the United States, sexual education varies widely from state to state. Fewer than half of U.S. states require schools to teach sex ed, according to the Guttmacher Institute, a global nonprofit that researches sexual and reproductive health. Just last month Congress extended the Personal Responsibility Education Program (PREP), which funds comprehensive adolescent sexual health initiatives across the country. At the same time they increased funding for programs that promote sexual abstinence until marriage to $75 million a year. And Deb Hauser, president of Advocates for Youth, a nonprofit dedicated to sexuality education, says that sex ed in the U.S. still overwhelmingly focuses on minimizing the risk of pregnancy and STDs from heterosexual intercourse.

And nearly four in 10 millennials report that the sex education they received was not helpful, according to a survey by the Public Religion Research Institute.

“We have failed to see that sexual health is far more than simply the prevention of disease or unplanned pregnancy,” says Hauser. That narrow focus, she says, leaves young people with few skills to cope with their feelings and make decisions in sexual encounters.

Not everyone agrees. In fact, comprehensive sex ed has yet to take hold in most parts of the country. Utah, for example, requires that abstinence be the dominant message given to students. It bans discussing details of sexual intercourse and advocating for homosexuality, the use of contraceptives or sexual activity outside of marriage.

Utah state representative Bill Wright has further tried to restrict sex ed. In 2012, he proposed a bill requiring that abstinence only be taught and that it be an optional subject. It passed but was vetoed by the governor.

Sex ed is “not an important part of our curriculum,” Wright said. “ It is just basically something out there that takes away from the character in our schools and takes away from the character of our students.”

Utah is far from alone. Half of U.S. states require that abstinence be stressed. “We have created generations of people who are not comfortable with their own sexuality,” says Dr. David Satcher, the former U.S. Surgeon General. That extends to parents and teachers, he says.

In other places, the tide is shifting toward an approach closer to that of the Dutch. Two of the largest school districts in the country — Chicago Public Schools and Florida’s Broward County — have recently mandated sex education for elementary school students. Chicago Public Schools requires at least 300 minutes a year of sex education for kindergarten through fourth grade students and twice as much time for fifth through twelfth graders. In 2014, schools in Broward County began teaching sex education at least once a year in every grade, and the curriculum includes information about topics like body image, sexting and social media.

In the Netherlands, schools aim to educate parents too. Parents nights are held to give parents tools to talk to their kids about sex. Public health experts recommend that parents take cues from their kids and make it an ongoing conversation, rather than one awkward, all-encompassing “birds and the bees” talk. For example, they advise, if you walk in on your child masturbating, don’t react shocked; don’t punish or scold them. Have a talk about where it is appropriate for such behavior to occur.

“We talk about [sex] over dinner,” said one father at a Spring Fever Parents Night. Another said he recently answered questions about homosexuality posed by his twin 6-year-olds during bath time.

Lessons in love

Sabine Hasselaar teaches 11-year-olds. In a recent class, Hasselaar posed a series of hypothetical situations to her students: you’re kissing someone and they start using their tongue which you don’t want. A girl starts dancing close to a guy at a party causing him to get an erection. Your friend is showing off pornographic photos that make you feel uncomfortable.

The class discusses each scenario. “Everyone has the right to set their own limits and no one should ever cross those limits,” Hasselaar says.

There is an anonymous ‘Question Box.’ in her class during “Spring Fever” week. Students submit questions that teachers later address in class. “Nothing is taboo,” Hasselaar says. One of her students, for example, wrote: “I think I am lesbian. What should I do?”

Hasselaar addressed the issue in class: “It’s not strange for some girls to like other girls more than boys. It’s a feeling that you can’t change, just like being in love. The only difference is that it’s with someone that is the same sex as you.”

And in fact, most of the questions from her students aren’t about sex at all. “Mostly they are curious about love. I get a lot of questions like, “What do I do if I like someone?” or ‘How do I ask someone to go out with me?’”

Questions like these are taken just as seriously as the ones about sex.

“Of course we want kids to be safe and to understand the risks involved with sex, but we also want them to know about the positive and fun side of caring for someone and being in a healthy relationship,” van der Vlugt says.

That’s why you’ll find teachers discussing the difference between liking someone (as a friend) and liking someone. There’s even a lesson on dating during which a teacher talked about how to break up with someone in a decent way: “Please, do not do it via text message,” the teacher said.

“In the Netherlands, there’s a strong belief that young people can be in love and in relationships,”

After elementary school, these students will likely go on to receive lessons from a widely-used curriculum called Long Live Love.

“In the U.S., adults tend to view young people as these bundles of exploding hormones. In the Netherlands, there’s a strong belief that young people can be in love and in relationships,” says Amy Schalet, an American sociologist who was raised in the Netherlands and now studies cultural attitudes towards adolescent sexuality, with a focus on these two countries.

“If you see love and relationships as the anchor for sex, then it’s much easier to talk about it with a child,” Schalet says. “Even a young one.”