The present paper investigates the existing literature in order to identify potential components for the development of Sexual Health Programs (SHP) for Special Education (SE) students. Sexual Health Education programs (SHE programs) are considered a recognized and accepted practice in educational systems in Israel and around the world (
Keywords: Sexual Health EducationSpecial Educationpre-service teachersliterature review
Special education, as defined in the Special Education Law of Israel (Israel Ministry of Education, 1988), consists of "systematic instruction and treatment given to every child with special needs ... according to the needs of the child...". Special needs (SN), in this context, are mental, physical, emotional, cognitive, behavioural, communication skills, and other forms of disability (Israel Ministry of Education, 1988). Children with SN may be integrated into the educational system in various ways, from being placed in special education schools fitted to their unique need, to being integrated into regular classrooms, generally accompanied by a SN helper or integration expert (Lauderdale-Littin, Howell, & Blacher, 2013).
In recent years, Sexual Health Education programs (SHE programs) have become a recognized and accepted practice in educational systems in Israel and around the world (Weisblay, 2010). The main purpose of SHE programs was to provide students with knowledge and the ability to defend themselves against sexual violence, sexually transmitted diseases and unwanted pregnancies, as well as to offer information and knowledge of healthy, responsible sexual behaviours (Brosch, 2007; Washington State Department of Health, 2011; Winges-Yanez, 2014). The range of goals for SHE programs is broad, from basic knowledge in the field of sexuality to moral and ethical education. According to Brosch (2007), the most common goals of SHE programs are: 1. Increasing student knowledge about sex in order to reduce unwanted effects; 2. Developing healthy and responsible sexual behaviour towards self and others; 3. Developing positive attitudes towards sexuality; 4. Developing insight into individual and group sexual attitudes; 5. Developing a stable personal system of values in relation to sexuality and its many expressions.
Brosch (2007) notes that SHE within the school settings is especially important in comparison to sexual education in more private frameworks, since it is done within the peer group, which can be significant factor in the process of socialization during adolescence. Adolescents learn norms of behaviour and receive emotional and social reinforcement while formulating their own identity and sexual identity, from the peer group. Therefore, SHE within schools promotes the personal wellbeing of the students and their mental strength. Nevertheless, at least in Israel, it seems that teachers do not always feel that they have enough training to deal with SHE and may often feel embarrassed when dealing with the subject (Brosch, 2007).
Sexual Health Programs in Special Education
Generally, SHE programs aim to facilitate the formation of students’ self and sexual identity and their mental strength and impart knowledge and tools that help them reduce undesirable phenomena and develop responsible behaviour (Brosch, 2007). However, it appears that SHE programs may be of particular importance to people with disabilities and to special education students, for a number of reasons. Hence, there is evidence that different developmental disabilities may create difficulties in the development of communication skills, leading to impulsive or inappropriate social behaviours, which influence sexual expressions as well. This may reflect on the ability to develop social relationships, including romantic relationships. It may also lead to inappropriate sexual behaviour towards others. At the same time, those with special needs are at a greater risk of becoming victims of abuse or sexual exploitation (Minch, 2011).
Esmail, Darry, Walter, and Knupp (2010) note that people with disabilities often receive most of their information about sexuality from sexual health education programs, and therefore their perceptions of sexuality are often only theoretical. In addition, it is noted that people with disabilities, often lack knowledge of how to combine their disability with sexual activity, or are embarrassed and do not know how to discuss it with potential partners. It appears that people with disabilities and special education students need information as to how their disabilities may affect sexuality and how they can create intimate interpersonal relationships, both on the physical-biological aspect of sexual conduct, but also in relation with prevention of risks and exploitation. In addition, since people with disabilities receive almost no information from other sources, the need for SHE in educational institutions is even more necessary, even beyond the need and general benefit of sex education as part of the school curriculum (Brosch, 2007).
Despite the importance and need for sex education programs for students with special needs, it appears that not many formal SHE programs exist, aimed specifically for special needs’ students (Barnard-Brak, Schmidt, Chesnut, Wei & Richman, 2014). The present study seeks to review the current academic literature on this subject, in order to examine whether there is a lack of formal SHE programs for special needs students.
In the current literature review, several studies examined the difficulties teachers and caregivers may encounter when teaching sex education in special education frameworks. First, most of the studies indicated that teachers feel that they lack sufficient training in teaching sexual health education to special populations and that receiving a tailored training improves the teachers' feelings about teaching SHE in special education settings (Kim, 2009; Chirawu et al., 2014; East & Orchard, 2014). Other studies have found that educators and caregivers mostly support SHE for people with disabilities, but at the same time fear that engaging in sexual issues can harm students. For example, it may lead to inappropriate behaviour or sexual exploitation (Wilkenfeld & Ballan, 2011; Rohleder, 2010; Minch, 2011). In addition, two studies have found that because of the special characteristics of populations with special needs, teachers may be particularly embarrassed to teach certain contents of SHE to this population (Minch, 2011; Chirawu et al., 2014). Other studies which have examined the attitudes of teachers, professionals, as well as the general population towards the sexuality of people with disabilities, also suggest a similar possibility of being embarrassed by the need to teach sexuality-related content to people with disabilities (Sinclair et al., 2015; Esmail et al., 2010).
Some of the studies in this literature review dealt directly with the question of what content and components are lacking in existing SHE programs, based on the beliefs of teachers, therapists, and special needs teachers, while other studies have focused on the special needs of special education students and those with disabilities concerning sexual health education. However, both types of research are equally relevant to the study question, since there are almost no formal programs of SHE for special education frameworks. Every significant component of such a program should be mapped as a potentially important component. Of the studies reviewed which examined the attitudes of teachers towards people with special needs, four studies pointed out the need to teach contents such as personal hygiene and the prevention of health hazards (Ang and Lee, 2016; Chirawu et al., 2014; Löfgren-Mårtenson, 2012). Another component identified in three studies is the issue of sexual harassment and sexual exploitation (Minch, 2011; McDaniels and Fleming, 2016). This is also the focus of the sole existing sexual health education program for special education found in the current survey (Manor-Binyamini et al. Al., 2013). Another component that appeared in two studies, that has been identified as lacking, is the provision of tools for appropriate interpersonal and social communication, with an emphasis on romantic relationships (Sinclair et al., 2015; Minch, 2011). An additional component identified in one study is the lack of the physical impact of disability on sexuality (Esmail et al., 2010).
Purpose of the Study
This study aims to identify the special challenges that such programs may pose to educators and caregivers, as well as the important and central factors that these programs include (if they exist) or should include (if they do not exist), both with respect to educators / caregivers and with respect to the special needs of the students.
Literature search was conducted by means of a search through several academic databases. These included: ProQuest – Education database, ProQuest – ERIC, Psychnet, EBSCO Host – Psychology and Behavioural Science Knowledge. The literature search was based on the combination of the following keywords: Sex education, special education, pre-service teachers. Based on the keywords search, hundreds of studies were identified. Only articles written in English and that provided full-text access were included in the final review. Studies that did not deal with special education or dealt only with a specific group (i.e. HIV positive, LGBT - lesbian, gay, bisexual, and transgender), or specific categories of disabilities (e.g. deaf, visually impaired), were excluded. After the first review of the abstracts, 19 articles remained. Five articles were rejected for the following reasons: four dealt with sexuality of adults with disabilities and one was a review of sexuality programs. In the end, fourteen articles remained relevant to the literature review. The selection process is illustrated in figure
Distribution of articles by study population
The majority of the studies were conducted among teachers and caregivers in the field of special education (Table
Distribution of articles according to the students' disabilities
Two studies dealt with sexual SHE for students with learning disabilities. The majority of the studies (six) addressed intellectual disabilities (one of which compared students with intellectual disabilities to students without disabilities). Two dealt with developmental disabilities, one dealt with intellectual and developmental disabilities, one dealt with physical disabilities, and two studies dealt with disabilities of various types without detailing or separating the disabilities involved (Table
Distribution of studies according to the age of the special education students
Not all studies explicitly indicated the age of the students. Two studies were literature reviews, so the ages of the students varied. One study did not specify the age of the students, one study referred to persons with disabilities in a variety of ages. No research has addressed a population younger than elementary school students. Table
Distribution of studies according to data collection method
Two studies were literature reviews and one was an educational experiment. One study was a nationwide survey. Three studies used questionnaires (one used online questionnaires and the experimental study used questionnaires before and after the experimental manipulation). One was a quantitative long-form study. One study was described as "a survey that combines quantitative and qualitative methods". Five studies included interviews (one of which used structured interviews and the rest of which used open or semi-structured interviews). Two of these studies included both interviews and the use of focus groups.
Distribution of studies by type of analysis
Three studies were quantitative, one of which was a variant analysis, the other corneal analysis, and the third used factor analysis. Two of the studies used correlation analysis (chi square) and the third used factor analysis. One study included both quantitative analysis (prevalence and factor analysis) and qualitative content analysis. The rest of the studies were qualitative, so they included content analysis and narrative analysis.
Regarding the geographical distribution targeted by the studies included in the review, one study was conducted in Malaysia, one in Israel, one in Sweden, one in the Netherlands, one in Korea, two in South Africa, two in Canada, four in the United States, and one was a review of worldwide literature on the subject. In terms of the distribution of studies by the time of publishing, one study was published in 2009, two studies were published in 2010, two studies were published in 2011, one study was published in 2012, one study was published in 2013, four studies were published in 2014, one study was published in 2015 and two studies were published in 2016.
This paper presents an initial systematic review of the literature on sexual health education in special education frameworks. The review shows that in special education frameworks there is a real need and importance in programs for the study of sexual health education, both in the context of knowledge acquisition, insight and the formulation of values, and in the context of preventing exploitation and dangerous or inappropriate behaviours. Nevertheless, this review shows that there are almost no formal sex education programs for special education (Barnard-Brak, Schmidt, Chesnut, Wei & Richman, 2014). In fact, the current review only revealed one study describing a specific formal sexual education program, a case study of a special education school in Israel where a sexual health education program was implemented, focusing mainly on the prevention of sexual harassment of students. (Manor-Binyamini et al., 2013)
Besides the special importance of sexual health education for students with special needs, it appears that there are factors that may make the provision of sex education to these populations particularly challenging. According to Brosch (2007), teachers in the general educational system may feel embarrassed and uncomfortable when they are required to teach content related to sex education, even in regular educational settings. People with disabilities may be perceived as "asexual" or as having no sexual desire or needs (Esmail, Darry, Walter, & Knupp, 2010). In light of this perceptions, educators may feel embarrassed or uncomfortable when they are required to teach SHE to students with special needs, sometimes even more than when they are required to do so in the regular educational system. The current review confirms this assumption and provides examples of special education teachers and caregivers who do indeed feel awkward when they are required to teach SHE (Minch, 2011; Chirawu et al., 2014).
Moreover, the current review shows that just as teachers in the regular educational system feel that they lack formal training that enables them to teach SHE, so do teachers and caregivers in special education feel that they lack appropriate training (European Parliament, 2013). They feel that they are often forced to deal with issues related to sexuality despite feeling that they lack suitable training in this field. Parents hesitate to teach sex education to children and adolescents with disabilities, and prefer to leave the subject to those who they believe will be "better qualified" for this, while in practice both parents and professionals lack training on proper access to sexual health education for people with disabilities (Kim, 2009, Chirawu et al., 2014; East and Orchard, 2014).
The review indicates that many educators seem to be ambivalent in their feelings about sexual health education for people with disabilities. On one hand, they recognize this need, and support it, but on the other hand, they fear the negative consequences of teaching sexual health education and sexual content accessible to people with disabilities (Wilkenfeld and Ballan, 2011; Rohleder, 2010; Minch, 2011). Therefore, students with special needs represent a population for whom SHE is necessary and even more important than for the general population, both because it may be an almost exclusive source of information on sexuality (Esmail et al., 2010) and because it is a population at high risk of sexual exploitation or of unintentional sexual behavior (Minch, 2011). At the same time, it is a population that presents a complex and challenging sexual health education task for teachers and caregivers, even more so than teaching sex education in regular frameworks.
As mentioned above, the literature reviewed in this study shows that there is a vast need for formal programs of this kind in educational settings for populations with special needs, and that most of the existing programs tend to focus on "soft" or technical content, such as maintaining intimate hygiene habits, interpersonal communication between the sexes, or medical issues, while content dealing with sexuality is almost ignored in the context of special education programs for sex education and even creates feelings of discomfort among teachers Eg, (Chirawu et al., 2014). In this context, Ang and Lee (2016) note that teachers' discomfort with teaching sexual content, or the feeling that sexual content is essentially “inappropriate” for special education students may be related to the degree of conservatism of the society, which is consistent with the conclusion of Schaafsma et al (2014) on the impact of social norms when teaching sexual health education by caregivers.
As for the feelings of the disabled persons themselves, Esmail et al. (2010) notes that people with disabilities, particularly those with physical disabilities, report that they lack a reference to how their disability may affect sexual relations. Another major factor that is currently lacking in most special education programs and which is perceived as important both by the special needs population and by teachers and caregivers, even in more conservative societies, is the prevention of health risks (Ang and Lee, 2016). It also seems important to respond to one of the risk factors of populations with special needs, which is sexual harassment and exploitation (Manor-Binyamini, Schreiber-Divon, Stein, 2013; Minch, 2011).
In conclusion, this work is an attempt to systematically examine the existing research on sexual health education in special education frameworks. First, an attempt was made to define and understand the nature of special education and sexual education. While continuing to map and systematically review the existing research on the subject, this is an attempt to answer the question of what difficulties teachers and caregivers may encounter when teaching sexual health education in special education frameworks. The review shows that, with the exception of a few scant programs, there are almost no formal programs for teaching SHE to special needs populations. The lack of programs is particularly striking, given the need for special education populations to receive formal sex education within the school, which seems even more urgent and important when compared to students in regular settings. As noted, the review attempts to identify and describe the specific difficulties that teachers and caregivers may encounter in teaching sexual health education within special education frameworks. It includes, among other things, the issue of dealing with "difficult" issues of sexuality, including the concern regarding exposing students to sexual contents and the issue of teaching the subject of SHE to special needs populations. Special education students are sometimes perceived as "non-sexual" or "asexual", as well as the belief of the teaching staff, that they lack sufficient training on the subject.
In addition, an attempt was made to map and locate the relevant components for integration into future sexual health education programs. The topics that were found to be important for both staff and students are: issues of health and hygiene, interpersonal communication in the context of romance and sexuality, prevention of sexual harassment and exploitation, and the impact of disability on sexuality.
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18 December 2019
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Kivkovich, N., & Chis, V. (2019). The Contribution Of Using Geometry Learning Strategies Program In The Learning-Teaching Process. In V. Chis, & I. Albulescu (Eds.), Education, Reflection, Development – ERD 2017, vol 41. European Proceedings of Social and Behavioural Sciences (pp. 432-440). Future Academy. https://doi.org/10.15405/epsbs.2018.06.51