Introduction
Sex education is a long-life process, which begins from birth [1], and it is almost ignored due to the children’s immaturity in preschool age [2]. However, preschool sex education is important in promoting sexual health [3]. 
During this period, sex education must concentrate on sex recognition, sex role, and related concepts [4]. Various viewpoints are proposed regarding the content and the starting age of teaching sex issues [2, 5]. In Western countries like the US and Sweden, it started for preschool children, and other countries began to follow the same principle. About the start time, there is disagreement among the experts. Some believe that early education on sex issues not only harms the sex identity of children, which is intact (virginity), and causes psychological stimulation. Although such people emphasize sex education in children, they believe it should be postponed to the primary school period [6]. The evidence indicates that children learn sex education at home, initiate sex discussions later, and start their sex relationships at older ages when inclined to riskier sex behaviors [7]. 
In a study, 84.3% of people believed that parents are more responsible for the sex education and training of their children than schools’ trainers [2]. However, they reluctantly talk about the sexual behavior with the children; the feeling of shame, sadness, and lack of required skills prevents them from doing it [8]. 
Empowering families is essential regarding the role of parents in sex education and improving the sexual health of children [9]. In the family, the role of the mother is more important than other family members [10]. However, almost all mothers evade discussing sexual issues with their children and feel these talks are conducive to sex issues [11].
To support mothers in this regard and train them as a plain, inexpensive instrument to guarantee the health of society, understanding mothers’ perspectives about sex education, responsibility, and the starting time is of growing concern and importance. Although quantitative research allows a deep understanding of thoughts, it does not reveal people’s opinions. However, in qualitative methods, people’s views on behaviors are examined, and then the effects of behavior are further interpreted [12, 13]. Despite several studies on mothers’ perspectives on preschool sex education [1, 2, 7], these studies disregarded kindergarten trainers. This qualitative study aims to determine the mothers’ and trainers’ points of view regarding the sex education of 3-5 years old children. 

Materials and Methods
This research used a constructive paradigm and qualitative approach to investigate mothers’ and trainers’ perspectives. The participants were 20 mothers and 10 kindergarten teachers with at least 3 years of related work experience. Sampling was based on inclusion criteria and maximum diversity. The inclusion criteria for mothers were having 3-5 years old children. At first, of 293 kindergartens in Karaj City, Iran, 4 kindergartens were purposefully selected. Wide diversification was considered, and the samples were selected from various parts of the city. Then purposeful sampling methods were adopted to select the participants. The first author interviewed the mothers and kindergartens trainers, in a private room in the kindergarten from March 21, 2017, to August 23, 2017.
To collect data, semi-structured and deep interviews (face-to-face) were performed within 4 months. Interviews continued until data saturation by an educated individual in this field with a bachelor’s degree (first author-MS student-female). Questions were openly asked during the interview, and regarding the responses received from the people, more in-depth questions were asked, such as “can you tell me about preschool sex education? If it is possible, explain further?” Mothers also responded to some questions regarding their sociodemographic characteristics. Interviews continued until data saturation (additional data are being found whereby the sociologist can develop properties of the category). After 18 interviews, data saturation was achieved, but additional two participants were interviewed to verify that redundancy had indeed been reached. Interviews took 45-60 minutes. Due to the high level of sensitivity of the study subject, the interviewer used one’s highest communicative capability to make a relationship with mothers and kindergarten authorities. At first, the aim of the study was explained to the mothers. The interviews were recorded after permission and informed consent was taken from participants after explaining the purposes and method of the study was obtained from mothers and the kindergarten trainers, which was typed instantly. Also, field notes (as a means of documenting needed contextual information) were taken by the interviewer immediately after each interview. The interviewer performed the interviews with mothers and kindergarten trainers in a specific room in the kindergarten. 
Also, a semi-structured topic guide was provided. The manual included questions on sexual health knowledge, perception of personal knowledge, the content of any sexual health education, source of sexual and sexual health information, confidence in providing preschool sex education, and sex education providers. The topic guide was developed in accordance with the research questions and was pilot tested on 5 mothers with preschool children. Interviews were conducted in Persian except for one, in which the interviewee requested the use of English. Recorded interviews were transcribed verbatim, anonymized, and translated where necessary. Qualitative content analysis was employed for analyzing data. After collecting data and transcribing verbatim, the researchers separately read the transcription several times to reach a general understanding and extract the meaning units.
Then researchers summarized the meaning units and identified the codes. Afterward, the codes (92 codes) were compared, categories and subcategories were extracted, and themes and subthemes were organized.
The content analysis was based on Griesheim and Lundman’s [14] method. By defining a framework for coding, the second researcher, without any knowledge about the main coding of the researcher, did the recording and analysis to ensure the results [15].
The reliability of the data was tested by re-reading and re-coding by the researchers a few days after primary coding and comparing these two steps. The stability and consistency of the data were approved. The data obtained from the interviews was delivered to the participants to approve the reliability based on their feedback. The dependability of data was investigated by an external check. To analyze and review the contradiction in coding, the text of a few interviews was given to another researcher to code it independently. To approve transferability, the details have been explained by prolonged engagement in the field, persistent observation, triangulation, negative case analysis, checking interpretations against raw data, and member checking.

Results
In this study, 20 mothers aged 27 to 51 participated, 50% had bachelor’s degree coming from the middle class, the rest had diplomas and under diplomas, and one was a general practitioner. Other demographic characteristics are presented in Table 1.

Mothers had a fair share of daughters and sons. Most kindergartens trainers were under 40 years old, and most had bachelor’s degrees. After analyzing 92 codes, three main categories and one to three subcategories were extracted (Table 2).

The concept of sex education was a main category. Based on the results, mothers did not have a certain definition for sex education. Sex education had particular titles based on growth conditions in each age range. Considering aspects of sex education in the preschool period, mothers only knew one or rarely two or more aspects. This category had Two subcategories, which ranged based on the abundance as below.
“Private organs” is one subcategory of this category. About 90% of interviewed mothers know this issue as a fundamental subject in sex education, emphasizing that genitalia are a private organ, and most of the mothers with daughters are more concerned about their children’s vulnerability than mothers with sons. A young mother with a 3-year-old daughter said: “I must inform her of private organs of her body and tell her to protect it. She must know this is important when I am not with her.”
Mothers’ reaction is a code in this subcategory. Another aspect of sex education emphasized by the mothers in this study was to answer the sex questions of the children. About 30% of mothers were aware and efficient in answering the children’s questions. Most could not talk with their children about sex issues because of information deficiency or other matters like shame. The mother’s reaction to facing such a situation was expressed by changing the topic or even anger.
A 27-year-old woman, with a bachelor’s degree, with two children (3 years and 7 years old) said: “When I can’t answer, I become mad, I lose my temper, and at last, I say these words are bad; you will grow up and learn.”
“Knowing natural behaviors” was another subcategory of this category. Mothers under study rarely know their children’s natural and curious behaviors and how to face them, and most of them compare their behaviors with that of adults. However, this curiosity was accepted and even encouraged for other issues. In a country like Iran, where sexual issues are considered taboo, religion, and culture often overshadow people’s education. A 30-year-old mother with a bachelor’s degree said: “Whenever my 4-year-old son touches his genitalia, I pin a needle to his hand since this is a sin.”
These reactions from the mother’s side do not correct the child’s behaviors but exacerbate his behaviors. Some mothers emphasized the guilty aspect of this sexual behavior (touching the genitalia) to the extent that these behaviors cause a sense of guilt.
A kindergarten trainer over 40 years old pointed out that “I see many children have behaviors like kissing, hanging, and so on.” Based on the findings of this study, the mothers did not consider sex education essential for a 3-year-old child. 
A mother (38 years old, with more than a bachelor’s education) stated, “I told my 3-year-old daughter about her private organ, but it seemed she didn’t get it at all. I saw no curiosity in her, and she has not become aware of this part of her body.” While based on the results of this study and the mothers studied, 4-year-old children show much sensitivity about sex issues. As the child’s living environment becomes devoid of stimulants of sex behavior, like people around satellite programs, the sex education age increases with curious and informed friends. The mothers believed that most 5-year-old children must receive sex education since the living environment of such children is no longer limited. A 38-year-old kindergarten trainer indicated, “The age of 3 is not the right age to start a sex education, and an older age should be considered for education.” A 32-year-old mother said: “I think the age of 5 is a good time to start sex education in Iranian children because, before that, my son didn’t care what I told him was related to sex issues.”
“Sex distinction” was a code of this subcategory. This issue has no such importance in the majority of mothers’ perspectives. Most preferred to be patient so that life experiences create knowledge in children, and some preferred their children not to know these differences.
A mother with two children (a 16-year-old son and a 4-year-old daughter) said, “I didn’t let my son know the difference between himself and his sister from childhood until he grew up; after that, one day, I suddenly found that he, at age 15, is browsing websites looking for woman’s anatomy, which has been unexpected and shocking to me.”
The “age to start sex education” was another category. This category consisted of only one subcategory titled starting sex education. About 80% of mothers believed that education must start from the family since it is the child’s first social environment. In addition, sex education has a close relationship with culture, so it must start considering the context of culture and the family. Most mothers agreed with the start of sex education in the family, except some who were unaware of or avoided the topic due to some issues. Among them were mothers who found the importance of this matter that the condition to address the issue is provided in the family, even in nonverbal behavior.
A mother with strong religious beliefs said, “my son loves his kindergarten trainer, and I trust her, but education has a lot of considerable and in-depth points rooted in upbringing and the culture of a trainer, and I don’t like my son’s trainer educating my son.” “Sex education consideration” was another category that has three subcategories.
A lot of considerations in the education of preschool children should be done by a knowledgeable and reliable person fully familiar with the child’s family culture.
“Truth and sometimes lie” is one of the sex education considerations. The interviewed mothers believed that “you must not tell a lie to children, but tell all of the truth” and that this is a reality. 
A 36-year-old mother said: “The minds of kids do not have the power to resolve all the issues, but the child is informed as much as he (she) can understand. Sometimes providing extra information makes children more curious (diploma education).”
Some mothers resolve their unawareness regarding sex questions by telling lies. A 32-year-old mother said: “In response to my daughter’s question (at age 3) about her sex organ difference between her and her brother’s, I had to say… your sex organ will become like your brother’s. My daughter is now 7 years waiting for this change to happen.”

“The closest person responsible for sex education” was another subcategory of this category. Based on the findings of this study, some believed that the mother is responsible for the child’s sex education. In contrast, some believed in sex analogy, i.e. the mother is responsible for the sex education of the daughter and the father for the son. Based on the study results, mothers assumed responsibility for their education even if mothers could not educate their children or had low self-efficacy. They said with concern, “I must learn,” although they preferred postponing the education of children in this regard until they learn, unaware that children will pass growing steps and will not wait for them to teach.
Based on a lot of considerations, cultural inhibitors should be considered in sex education among preschooler children. Socialization begins in infancy and early childhood.

Discussion
Based on the perspectives of the mothers studied, proper age to commence sex education is four years old, while based on studies concerning this subject, sex distinction starts from three. Superego appears from age 3-5 actually the same social values and moral restrictions enforced by the society help control the ego [16]. As the sex education of parents based on social learning [17], sex education is defined at this age. Age 4-5 is the time when the libido center is transferred to the genital area. Children’s attention is paid to their genitals and they become curious about issues like birth, sex and the differences. The time, which these growth changes happen, is under discussion [17].
Kurtuncu reported in a descriptive study based on doctors and nurses’ perspectives in turkey that sex education is necessary at age 3-6, and must start with special questions of children. On provider’s perspectives, less than half of the parents believed that parents must provide children with required information [2]. Research in Australia revealed that most of the parents agreed on the commencement of sex education in primary schools [18]. 
Along with the results of santos et al study which stated “Parents around the world engage in the practice of parenting by lying [19].” In the current study some mothers answered incorrectly to the questions like “where have I come from?” 
It is obvious that telling lies and dishonesty in answering the children’s curious questions can end in many inappropriate consequences as in the case of the girl who is waiting for her genitals to become like boys. The parents are requested to mind honesty and give natural examples (like childbirth in animals, hatching of birds etc.) in answering children’s questions. Based on Sadegh Moghadam's findings less than half of the mothers change the subject in response to these questions, the fewer of the participants in this study punish the children, approximately half of them just say you will know it by yourself when you grow up, and also less than half of the mothers answer correctly [20]. Based on the findings of this study and a study in 2020 by Barimani Aboksar et al. [21], educational environments have some limitations to provide sex education services, and family is the best environment for this type of education. 
Some researchers in this regard believe that training should be considered for parents and kindergarten trainer [22, 23], Although many factors like economic situation, family management style, sex preferences in family, family relationship status and dependence between family members have been mentioned [24]. Related to trainers, they must be able to distinguish normal and abnormal sexual behaviors and respond to children based on their age [19]. Sex studies on children in countries with religious and cultural beliefs like Iran are rare, and mothers intervene more than fathers in sex issues in Iran [25]. therefore, we suggested that educators and mothers be provided with training programs on “Sex education in children ages 3–5 years. This period is the most golden period of education, and children are in the best period for growth and learning, and they quickly accept correct behavioral and educational patterns.
Based on the study results, mothers do not have appropriate definition for sex education.
Among the topics of sex education at this age (3-5 years), mothers emphasize knowing the private organs and the importance of answering the child's questions. The appropriate age for sex education commencement is over three and is completely relevant to the conditions and environment of children’s life. By maintaining Iran’s Islamic conditions and culture, children become curious later. All mothers believed that the closest person in one’s family must implement education to the child. It is suggested that we enable mothers to bring up the children much better by providing short-term educations and personalized and immediate consultations to them, and educate our children by the preservation and excellence of Islamic Iranian culture in a language adjusted for children. Cultural and religious taboos were among the limitations of the study, which were resolved by justification of mothers and kindergarten trainers. Conducting such research in Iran as a religious country is one of the noticeable strengths of this study.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by Alborz University of Medical Sciences (Code: IR.ABZUMS.REC.1396.95).

Funding
This study was supported financially by the Research Deputy of Alborz University of Medical Sciences.

Authors' contributions
Conceptualization, study design, interview with participants and implemention: Maryam Sarikhani and Maryam Safarnavadeh; Supervision, writting the article: Leili Salehi; Data analysis and final approvall: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We want to thank all mothers who participated in this study.

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