A Scoping Review of School-Based Sexuality Education for Children With Disabilities

Abstract

Individuals with disabilities often have limited access to school-based sexuality education (SE). This scoping review identified the characteristics of school-based SE intervention programs implemented for students with disabilities. Six electronic databases were searched for peer-reviewed articles: 30 articles published between 1969 and 2020 met inclusion criteria. Some interventions included children from multiple disability categories (n = 6) or were unclear about disability diagnoses (n = 3). Other interventions focused on specific disabilities, including intellectual and developmental disability (n = 8), learning disability (n = 4), autism (n = 3), physical disability (n = 3), emotional disturbance (n = 2), and hearing impairment (n = 1). Topics of instruction included comprehensive sexuality education (n = 8), the human body (n = 8), safety (n = 8), hygiene and menstrual care (n = 6), and social and relationship skills (n = 5). Few studies addressed students’ intersectional identities.

Keywords

sex education students with disabilities school-based intervention scoping literature review

Comprehensive sexuality education (CSE), an evidence-informed approach to addressing sexual health and well-being through age- and developmentally appropriate instruction that advances universal human rights (United Nations Educational, Scientific and Cultural Organization [UNESCO], 2018), effectively reduces sexual risk-taking behaviors (Haberland & Rogow, 2014). CSE delays initiation of sex and reduces the frequency of sexual activity among young people, which are associated with sexually transmitted infections (STIs) and unintended pregnancy (UNESCO, 2021). Although CSE encourages a focus on diversity, many available programs have little focus on race, sexual orientation, gender identity and disability (Miedema et al., 2020). Intersectionality, or the understanding of how our varied political and social identities affect our experiences and behaviors as it relates to inequality, exploitation, injustice, and oppression, is important but often left out of sexuality education (SE). Identities, such as having a disability or holding a racial, sexual orientation, or gender minority identity are linked to greater risks to sexual health (Jungels & Bender, 2015; McNeill, 2013; Proulx et al., 2019). Furthermore, young people with disabilities and/or who identify as lesbian, gay, bisexual, transgender, queer, + (LGBTQ+) report less satisfaction with SE than their peers (UNESCO, 2021).

Unfortunately, SE is not always comprehensive and may vary by location (e.g., Sexuality Information and Education Council of the United States [SIECUS], 2021; UNESCO, 2021). Still, many children worldwide are receiving some form of SE in school: Of 155 surveyed countries, 85% have policies mandating SE in educational curriculum (UNESCO, 2021), but children with disabilities are frequently neglected from their country’s SE efforts (SIECUS, 2021). Despite the role schools play in providing SE, little is known about school-based SE programs for students with disabilities, such as what topics are covered, whether the program meets the criteria for CSE, and which disabilities are targeted. The purpose of this article is to examine the characteristics of school-based SE programs serving students with disabilities.

Sexuality Education and Disability

Individuals with disabilities are at increased risk of sexual victimization and poorer sexual health outcomes than typically developing peers (Michielsen & Brockschmidt, 2021). For example, women with disabilities ages 17 to 34 are more likely to report nonvolitional sex and a greater number of STIs (Holdsworth et al., 2018). In addition, compared with typically developing peers, 13- to 20-year-olds with mild and moderate intellectual disabilities are more likely to have unsafe sex and women with mild and moderate intellectual disabilities are more likely to have been pregnant by the age of 20 (Baines et al., 2018). SIECUS (2021) indicates that 40 to 70% of girls with disabilities and 30% of boys with disabilities are likely to experience sexual abuse before they turn 18, which has been, in part, attributed to a lack of access to CSE.

Barriers to SE exist for people with disabilities, including a lack of self-efficacy in teaching SE amongst parents and teachers (Michielsen & Brockschmidt, 2021), myths that people with disabilities are child-like, asexual, or hypersexual (SIECUS, 2021), and restrictions of sexuality through limited privacy and supervised socialization (Travers et al., 2014). Such restrictions may prevent the social skill development necessary to engage in healthy relationships, negatively affecting confidence and sexual identity development (Murphy & Young, 2005). Without these skills, people with disabilities are less likely to be able to make informed decisions that lead to platonic, romantic, and sexual relationships (Travers et al., 2014).

Comprehensive Sexuality Education and Schools

The United Nations Population Fund (Haberland & Rogow, 2014) clarifies CSE as interventions that: (a) are centered on ensuring the human rights of all individuals; (b) use evidence-based information concerning human rights, gender norms, and power in relationships; the human body, puberty, and reproduction; relationships, communication, and decision-making; and sexual health; (c) focus on gender (i.e., gender norms and gender equality) as a stand-alone topic and also integrated across other CSE topics; (d) provide a safe and healthy learning environment; (e) implement effective and interactive teaching approaches to help learners personalize information, and strengthen communication, decision-making, and critical thinking; (f) include youth advocacy and civic engagement to empower learners to lead beyond the curriculum; (g) are culturally appropriate and tailored as needed for distinct subpopulations.

Schools are uniquely advantaged to provide CSE because they can implement long-term formal curricula and teachers are trusted sources of information (UNESCO, 2018). In many countries, students attend school during critical periods of development as they acquire skills, attitudes, and healthy practices that are likely to continue into adulthood (World Association for Sexual Health, 2008). However, schools face many barriers to offering CSE, such as statutes or policies that forbid or do not mandate CSE (Travers et al., 2014). Globally, members of marginalized populations, such as individuals with disabilities, are least likely to have access to any type of SE, and few countries report feeling as though they are successfully reaching young people from marginalized communities to provide SE (Haberland & Rogow, 2014).

For students with disabilities, the SE literature focuses primarily on those with intellectual and/or developmental disabilities (e.g., Sala et al., 2019; Schaafsma et al., 2015). Previous literature reviews indicate only a few studies of students with intellectual disabilities focused on CSE and, while school-based SE curricula have demonstrated general effectiveness, they fail to address the specific needs of those with intellectual and developmental disabilities (McDaniels & Fleming, 2016). Research also notes that the literature lacks a focus on the intersections of sexuality, disability, and we argue race/ethnicity, suggesting a lack of recognition of people with disabilities as sexual beings with multiple identities (Jungels & Bender, 2015). Finally, many of these studies go beyond the school setting and review literature that includes community settings. Although these studies are helpful to understanding SE for those with disabilities, they do not provide information specific to school environments.

Current Review

In examining the effectiveness of a SE intervention or program, researchers often take a variety of participant characteristics into account. For example, sexual risk reduction interventions were more effective when they attended to the needs that matched for age, gender, and ethnicity (Pedlow & Carey, 2004) Similarly, in special education research, including participant characteristics is an important starting point in understanding intervention recruitment, retention, as well as generalization to diverse populations (West et al., 2016). However, reviews on special education research often indicate an underrepresentation of ethnically and linguistically diverse children within intervention research (Sinclair et al., 2018).

This review attempts to understand school-based SE for children with special needs. We attended to participants’ demographic characteristics, such as age, gender, race/ethnicity, and disability categories. As CSE highlights need to reduce discrimination and improve health outcomes of individuals with different sexual orientations and gender identities, we also included reports of sexual orientation. Finally, although UNESCO (2018) released its first set of guidance for CSE in 2009, it is unclear how these recommendations may have influenced SE content for students with disabilities, so we examined changes in SE content over time. Thus, we asked:

What are the characteristics of students with disabilities who are receiving school-based (K–12) SE interventions?

a. Which populations of students with disabilities are represented in the literature?

b. How does the literature address intersectional student identities (i.e., students of color with disabilities, those who identify as LGBTQ+)?

What are the characteristics and target outcomes of school-based (K–12) SE interventions for students with disabilities?

a. What content is provided as part of SE interventions for students with disabilities?

b. How many published interventions provide CSE for students with disabilities?

c. How has the content of SE interventions for students with disabilities changed?

Method

A scoping review is useful for mapping existing research, as well as identifying research gaps, particularly in understudied areas (Arksey & O’Malley, 2005). As the first known review of school-based sex education interventions for individuals with disabilities, our intent was to understand what research exists in the field. Characteristic of a scoping review, we focused on the nature, features, and volume of existing work (Khalil et al., 2016).

Inclusion Criteria

Consistent with Aromataris and Munn’s (2020) scoping review framework, we developed unambiguous inclusion criteria aligned to our research questions: (a) available in English, (b) published in a peer-reviewed journal, (c) in a kindergarten through 12th-grade school context, (d) an intervention that included SE, and (e) serving participants with a documented disability. Although we did not restrict by publication date, the last source search was conducted on January 5, 2021. To assess inclusion eligibility, sexuality education was defined using UNESCO’s (2018) definition as pertaining to “the understanding of, and relationship to, the human body; emotional attachment and love; sex; gender; gender identity; sexual orientation; sexual intimacy; pleasure and reproduction” (p. 17). School was broadly defined to include any location where a child was receiving their primary academic instruction—including hospitals, psychiatric treatment centers, or residential schools. Studies that met our inclusion criteria but also reported on additional populations of students (e.g., students without disabilities) or additional interventions outside of the school context were included if the study disaggregated results, which occurred in two studies (Hilberink et al., 2013; O’Donnell et al., 1999).

Given the limited existing research in this area and the interest to broadly understand what SE for students with disabilities looks like in schools, we did not establish exclusionary parameters around study design or specific outcome for this scoping review. All studies that met our inclusion criteria were included regardless of methodology or measured outcome.

Initial Search

Scoping reviews often use a broad search strategy that specifics participants, concept, and context (Khalil et al., 2016). Using this strategy, the first author searched six electronic databases using the terms: sex education OR sex educator OR sex educators OR sexual education OR sexuality education OR sexuality educators AND Intervention* OR program AND disability OR disabilities OR disabled OR special needs OR special education AND school OR class* OR K–12. Additional searches were conducted replacing the disability language with each of the 13 Individuals with Disabilities Education Act disability categories. Online supplemental Appendix A includes a list of databases, search terms, and results. To check for accuracy, the authors re-ran each search, finding one discrepancy (accuracy = 98.8%). We rechecked and resolved the discrepancy.

Screening and Extended Search Procedures

The diagram in Figure 1 reflects our search process. Our initial search contained a review of citations from seven relevant literature reviews of SE and disability, as well as the results from the electronic database search. During the initial screening, the first author reviewed article titles, abstracts, and methods sections against the inclusion criteria to eliminate studies that did not meet the criteria. We excluded one article we were unable to access. Ultimately, 12 articles were included, and 15 articles were marked as unsure. The first two authors then discussed each study coded as unsure, leading to the exclusion of 11 and inclusion of 4.

Figure 1.

Flow Diagram of Study Selection Process.

Consistent with scoping review methodological recommendations, we extended the search through hand-searching journals and reviewing references (Arksey & O’Malley, 2005). We hand searched three journals: Sexuality and Disability, Journal of School Health, and Exceptional Children. Sexuality and Disability and Journal of School Health were selected because they were the most frequently cited journals among the initial set of included articles. Exceptional Children was selected due to its prominence within the field of special education. The first author, fourth author, and an undergraduate student looked through every issue published for each journal through December 2020 and noted any articles that focused on SE in a school context for students with disabilities. Four articles were included. Two were marked as unsure and later excluded after discussion between the first two authors.

In addition, the first author ran each included study through a Web of Science works cited search on February 5, 2021. Five articles were included and two were labeled as unsure. Discussion between the first two authors led to including one article and excluding the other.

Finally, all included articles’ references were examined, resulting in the inclusion of four more articles. Our search yielded a subset of articles focused on menstrual care and hygiene, which caused debate about inclusion eligibility. Ultimately, we decided that menstrual care and hygiene fit under the UNESCO (2018) SE definition, under “understanding of, and relationship to, the human body,” and we included such articles. A total of 30 articles were included.

Data Coding

We created a coding sheet, informed by recommendations for extracting data in scoping reviews (Aromataris & Munn, 2020), to record descriptive information including demographic information of participants, intervention characteristics, and study outcomes. A full list of the data we extracted is available in online supplemental Appendix B. The first three authors coded for these criteria.

Demographics

To understand who receives SE interventions, we coded for the following demographic information: number of participants; age; gender; sexual orientation; race/ethnicity; and disability categorization and severity. We also noted whether the article made mention of LGBTQ+ populations at any point within the text.

Intervention characteristics

Characteristics of the intervention included delivery agent (who provided the intervention); dosage (frequency and duration); setting of intervention (primary location); and targeted outcomes of SE. We described the targeted outcomes using five categories: CSE (includes all six key concepts of CSE including human development, relationships, personal skills, sexual behavior, sexual health, and society and culture, as defined by the 2004 SIECUS guidelines), the human body (human anatomy and/or topics related to reproduction), safety (personal safety, sexual safety, or self-protection), hygiene and menstrual care (personal care and cleanliness), and social skills (love and relationships, appropriate social behaviors and interactions, and/or managing personal mental health and stress).

Study outcomes

Outcomes reported by SE interventions were coded for quantitative (e.g., changes in behavior, efficacy, and understanding) and qualitative (e.g., student, teacher, and parent opinions about the intervention and its effectiveness) results.

Interrater reliability

In a scoping review, it is recommended that at least two members of the review team conduct a trial to extract data (Aromataris & Munn, 2020). To trial data extraction, the first three authors triple-coded 7 of the 30 included articles, attaining an intercoder agreement of 92%. Disagreements in coding were reviewed and discussed. After interrater reliability was established, the remaining articles were divided among the authors. Each remaining article was double-coded: Authors 1 and 2 double-coded seven articles and had an interrater reliability of 86%; Authors 1 and 3 double-coded eight articles and had an interrater reliability of 89%, Authors 2 and 3 double-coded eight articles and had an interrater reliability of 80%. After all coding was complete, all three authors met and reviewed the disagreements within the double coding, looked back within the articles, and came to agreement on the final codes.

Results

Characteristics of Students With Disabilities Receiving SE

In this review, 955 children and adolescents were represented in the included studies, excluding students from O’Donnell and colleagues’ (1999) study, which reported a total sample size of general and special education students, but did not specifically report how many students had disabilities. Participants were between 7 and 22 years; however, only Farley and Goddard (1970) included children under the age of 10. Although more studies served a greater percentage of male students (n = 14) than served a greater percentage of female students (n = 8), nearly one quarter of the studies did not report information about students’ gender identity. Table 1 identifies the reported characteristics of students with disabilities.

Table 1.

Characteristics of Students With Disabilities in Studies Dealing with Sexuality Education.

Study	Location	n	Ages	Disability type	Gender	Race
Altundag & Çalbayram, 2016	Turkey	54	13–17	ID	M: 0; F: 54	NR
Bahner, 2018	Sweden	6	18	Physical disabilities	M: 5; F: 1	NR
Bloom, 1969	United States	64	16–19	EBD, physical disability	M: 69%; F: 31%	NR
Dryden et al., 2014	United States	57	13–21	LD, ASD, vision impairment	M: 33; F: 24	Black: 44%; Latinx: 28%; White: 18%; Other: 11%
Dryden et al., 2017	United States	47	17.4	LD, ASD, vision impairment	M: 26; F: 21	Black: 45%; Latinx: 26%; White: 19%; Other: 11%
Epps et al., 1990	United States	3	15	ID^a	M: 0; F: 3	NR
Farley & Goddard, 1970	United States	16	7–13	EBD, LD	NR	NR
Haight & Fachting, 1986	United States	6	15–17	LD	M: 3; F: 3	NR
Hamre-Nietupski & Ford, 1981	United States	NR	12–16	ID^a, EBD, physical disability, visual/hearing impairments	NR	NR
Hilberink et al., 2013	Netherlands	6	14–16	Physical disabilities	M: 3; F: X	NR
Jhai, 2017	Taiwan	8	15–18	Deaf/hearing impaired	M: 8; F: 0	NR
Kalma, 1976	United States	8	16–21	EBD	M: 2; F: 6	NR
Kirbas et al., 2022	Turkey	65	10–18	ID	M: 0; F: 65	NR
Lee & Tang, 1998	China	77	11–15	ID^a	M: 0; F: 72	Asian (Chinese): 100%
Lutzer & Day-Vines, 2001	NR	24	NR	NR	M: 0; F: 24	NR
Martorella & Portugues, 1998	Argentina	8	12–15	LD	NR	NR
Murray, 2019	Canada	101	16–21	DD	NR	NR
Newens & McEwan, 1995	England	15	16–18	LD	M: 13; F: 2	NR
O’Donnell et al., 1999	United States	1,157	12–13	NR	M: 47.2%; F: X	Black: 79%; Latinx: 16%
Partak & Berner, 1977	United States	14	10–14	EBD, DD	M: 11; F: 3	NR
Pask et al., 2016	United States	6	15–17	ASD	M: 6; F: 0	White: 100%
Pritchard et al., 2011	NR	1	16	LD, ADHD, attachment disorder	M: 1; F: 0	NR
Pritchard et al., 2016	United Kingdom	1	17	ASD	M: 1; F:0	White: 100%
Reed et al., 1992	United States	158	12–18	NR	M: 33%; F: 67%	Black: 18%; White: 31%; Asian: 33%; Other: 18%
Richman et al., 1986	United States	3	17–18	ID^a	M: 0; F: 3	NR
Schoenholtz et al., 1989	United States	15	15–18	EBD	M: 8; F: 7	NR
Sener et al., 2019	Turkey	87	15–22	ID	M: 59; F: 28	NR
Sheppard, 2006	Australia	90	11–15	IDD	M: 48; F: 20	NR
Thornton, 1979	United States	8	NR	Physical disabilities	NR	NR
Tissot, 2009	England	7	11–19	ASD	M: 6; F: 1	NR

Note. n indicates the number of students included in the study. The reported n from the O’Donnell et al. (1999) study includes general education and special education participants as the study did not report on sample size for only special education students. Some students’ ages were reported as a range while others were reported as a mean. Race/ethnicity percentages are rounded and may not equal exactly 100%. ID = intellectual disability; M = male; F = female; NR = not reported; EBD = emotional and behavioral disorder; LD = learning disability; ASD = autism spectrum disorder; DD = developmental disability; ADHD = attention-deficit/hyperactivity disorder; IDD = intellectual and developmental disability.

These studies used prior diagnosis language of mentally retarded. We updated the language to reflect current terminology.

Disability representation in the included literature

Disability diagnoses of students varied: Some studies offered interventions to students from multiple disability categories while other studies focused on specific disability diagnoses including intellectual and developmental disability, learning disability, physical disability, autism, emotionally disturbed, and deaf/hearing impaired. In addition, of the 18 studies that reported on participants’ disability severity, two studies served students with profound disabilities, nine studies served students with severe disabilities, five studies served students with moderate disabilities, and five studies served students with mild disabilities. Some studies served students from more than one category.

Addressing intersectionality

Participant identities were largely unreported: Only seven studies reported students’ race or ethnic identity. Nine studies mentioned LGBTQ+ populations—such as within the literature review (e.g., Haight & Fachting, 1986), by suggesting that LGBTQ+ students’ needs were not being met (e.g., Bahner, 2018), or by noting educators’ or parents’ discomfort with SE addressing LGBTQ+ populations (e.g., Newens & McEwan, 1995; Partak & Berner, 1977). Two studies reported serving LGBTQ+ students: Tissot (2009) described restricting a consensual relationship between two gay adult students because sexual activity was not allowed on the residential school grounds, while Pritchard et al. (2016) reported providing instruction specific to the student’s sexual identity. Only one article (Bahner, 2018) described taking an intersectional approach to examine disability and other social identities within SE.

Characteristics and Targeted Outcomes of School-Based SE Interventions

Table 2 reports the characteristics and target outcomes of the interventions. Researchers or teachers were the most common delivery agents. Most interventions were delivered in special schools for students with disabilities, but some took place in special education classrooms within public schools. Only one study provided SE to students with disabilities within the general education classroom (O’Donnell et al., 1999). The dosage of intervention varied: Some interventions occurred in a couple of sessions while others lasted multiple weeks or over a year.

Table 2

Characteristics of Sexuality Education Interventions.

Study	Dosage	Outcome	Agent	Setting
Altundag & Çalbayram, 2016	NR	HMC	Researcher	Special school
Bahner, 2018	2×/term	CSE	School personnel	Special school/residential center
Bloom, 1969	12 weeks	CSE	NR	Home-based special program
Dryden et al., 2014, 2017	Ten 90-min sessions	Saf	Instructor	Public school
Epps et al., 1990	4 days/week	HMC	Graduate students	Individual (1:1); general ed school
Farley & Goddard, 1970	NR	HB	Researcher	Self-contained classroom
Haight & Fachting, 1986	6 weeks—25 min/day	CSE	Researcher	Small group special class
Hamre-Nietupski & Ford, 1981	NR	CSE	Teachers	Public school
Hilberink et al., 2013	12 weeks—7 classes/90-min	SS	Psychologists, social workers, sexologist, teacher	Special school
Jhai, 2017	12 classes (25 hr)	SS	Psychologist, school counselor, graduate student	Small group; school for the deaf
Kalma, 1976	3 weeks—14 classes, 1 hr	HB	Teacher	Long-term treatment hospital
Kirbas et al., 2022	2 days/week, 1 hr/day	HMC	Researcher	Special schools
Lee & Tang, 1998	Two 45 min classes	Saf	Researcher	Special schools
Lutzer & Day-Vines, 2001	8 weekly classes	HB	Community partner, teachers, college students	Special school
Martorella & Portugues, 1998	3 student workshops	HB	Staff	Special school
Murray, 2019	Five 1-hr classes	Saf	Community partner and college student	High school
Newens & McEwan, 1995	Five 1–1.5 hr classes	Saf & HB	Nurse, teacher, researcher	Community center/special school
O’Donnell et al., 1999	40 lessons/year; 3 hr/week	CSE	Teachers	General classroom
Partak & Berner, 1977	2 weeks, 9 daily classes	HB	Teachers and counselors	Residential treatment center
Pask et al., 2016	Three 45-min modules	CSE	Therapeutic staff team	Special education classroom
Pritchard et al., 2011	80 weeks	Saf	School and residential staff	Individual (1:1); residential school
Pritchard et al., 2016	30 min classes 1×/wk.	CSE	Specialist teacher	Individual (1:1); residential school
Reed et al., 1992	3 days, 3 classes	Saf	Health professional	School-based health clinic
Richman et al., 1986	30 min sessions	HMC	NR	Individual (1:1); prevocational program
Schoenholtz et al., 1989	Eight 1-hr. classes	SS and HB	Researchers and class leaders	Special school
Sener et al., 2019	10 weeks, 2 days/week, 40 min	HMC	Researchers	Special school
Sheppard, 2006	20 weeks, 45-60 min 1×/week	CSE	Teachers	Special school
Thornton, 1979	NR	SS	Nurse and student teacher	High school
Tissot, 2009	NR	SS, Saf, HMC, and HB	Residential staff, therapy team, parents	Residential school

Note. NR = not reported; HMC = hygiene and menstrual care; CSE = comprehensive sex education; Saf = safety; HB = human body; SS = social skills.

Sexuality education content

Well distributed between the five identified SE categories, eight interventions focused on CSE, eight focused on the human body, eight focused on safety, six focused on hygiene and menstrual care, and five focused on social and relationship skills.

When we looked at interventions’ targeted outcomes by disability category, we found that 83% of hygiene and menstrual care interventions included individuals with intellectual and developmental disabilities. Of the studies focusing on the human body, students with emotional disturbances were represented in 40% of studies. Students with physical disabilities were most often represented in social skills interventions (40%) and CSE interventions (23%) while students with learning disabilities were most often represented in safety interventions (29%).

Students with intellectual and developmental disabilities, autism spectrum disorder, learning disability, and emotional disturbance were most frequently represented in the SE literature. Of the 10 studies including children with intellectual and/or developmental disabilities, 2 provided CSE. Of the eight studies including children with autism spectrum disorder, two provided CSE. Of the eight studies including children with learning disabilities, one provided CSE. Of the seven studies including children with emotional disturbances, two provided CSE.

Content changes over time

Although the importance of CSE was highlighted in 2009 when UNESCO (2018) published its first edition of guidance for CSE, we did not see a change in CSE in our sample across time. Dividing the reports published before 2009 (n = 17) and those published in 2009 or later (n = 13), we found that 29% (n = 5) of studies before 2009 and 23% (n = 3) of studies published in 2009 or after offered CSE. Interventions about the human body made up the greatest percentage of studies before 2009 (41%, n = 7) and the least percentage of studies published in 2009 or later (8%, n = 1). Studies about hygiene and menstrual care before 2009 were less common (12%, n = 2), but made up nearly one third of studies published in 2009 or after (31%, n = 4). Similarly, a smaller percentage of safety interventions were published before 2009 (18%, n = 3) than in 2009 or later (38%, n = 5). Finally, although almost the same number of social skills interventions were published before 2009 (n = 2) and in 2009 or after (n = 3), the social skills interventions made up a smaller percentage of articles before 2009 (12%) than in 2009 or after (23%). It is notable that 13 studies were published in the 12 years between 2009 and 2020 as compared with 17 studies published in the 40 years between 1969 and 2008, suggesting that SE for individuals with disabilities is becoming a more commonly researched area.

For inclusion of participant social identities beyond disability, we looked at the articles before (n = 8) and during or after 1989 (n = 22), when the term intersectionality was introduced (Crenshaw, 1989). Racial identity was presented in 0% of the articles before 1989 and 32% during or after 1989. Interventions that addressed LGBTQ+ populations were presented in 25% of articles before 1989 and 18% of articles during or after 1989.

Discussion

A descriptive review of the included articles indicated that most SE interventions delivered instruction to adolescent-age students and targeted students with various disability classifications. Intersectional identities were rarely addressed in the literature. Researchers and teachers most often delivered interventions, which focused on different aspects of SE. Although UNESCO first published guidance for CSE in 2009 (UNESCO, 2018), there was little difference between the number of interventions providing CSE pre-2009 and post-2009. Racial identity of participants was more commonly reported after intersectionality was coined in 1989, but there was no difference between pre-1989 and post-1989 in interventions addressing LGBTQ+ populations.

Notably, one study included children under the age of 10, which is concerning as the onset of puberty for boys and girls is occurring at earlier ages for those in industrialized countries—as early as age 8 for girls (Biro et al., 2010) and age 10 for boys (Herman-Giddens et al., 2012). Moreover, developing relationship and safety skills early in life can serve as a protective factor.

Although research indicates unequal SE access among disability categories (Michielsen & Brockschmidt, 2021) with those with more severe disabilities and greater communication impairments less likely to have access (Barnard-Brak et al., 2014), more included studies in this review reported serving children with severe or profound disabilities as compared with mild disabilities. Limited research on children with mild disabilities is concerning because it is unclear where these children are receiving SE. School-based sexuality educators may take on a variety of roles in the school environment from teacher to counselor to nurse; however, they may lack disability-specific knowledge to support students’ mastery (Bolin et al., 2018). It is feasible that students with mild disabilities are receiving SE alongside their general education peers but are not receiving a curriculum that will accommodate their specific needs to build understanding.

Intersectionality

Participant identities in the literature were largely unreported. Few studies reported participant race or sexual orientation, and most focused on binary gender categories. Like all other populations, individuals with disabilities have multiple social and political identities, including race, class, religion, physical appearance, gender, sex, and sexuality. According to Crenshaw (2017), these multiple identities affect our experiences and behaviors as it relates to inequality, exploitation, injustice, and oppression. Without the identification of these social identities, we cannot truly examine how these identities influence SE for those with disabilities.

Students of color report having markedly different experiences within SE programs than their White counterparts based on stereotypes that they are already sexually active or are dangerous to others (Hoefer & Hoefer, 2017). Unfortunately, few studies in this review reported race or ethnicity of students included in the interventions, making it difficult to draw conclusions about the types of SE available to students with disabilities from different racial or ethnic backgrounds. However, SE, in general, often does not provide the representation of members of minority populations, nor do they encourage discourse on the development of sexual identity or acknowledge and discuss disparities in sexual rights (Elia & Tokunaga, 2014).

Unfortunately, the omission of LGBTQ+-inclusive SE is also commonplace in the general education literature, although such omissions can perpetuate homophobia and negatively affect LGTBQ+ students who may receive inadequate SE and feel ignored or shamed (McNeill, 2013). Meanwhile, LGBTQ+-inclusive SE is associated with reduced suicidal thoughts, fewer bullying experiences among lesbian and gay youth, and lower rates of depressive symptoms among bisexual youth (Proulx et al., 2019). Although guidelines for CSE stress the provision of accurate information about sexual orientation and gender expression (SIECUS, 2004), few studies included in this review incorporated a social justice perspective. Less than one-third of interventions mentioned the existence of the LGBTQ+ population, often as a moment of acknowledgment and frequently positioning those who identify as LGBTQ+ as atypical.

Need for Comprehensive Sexuality Education

Only eight studies included in this review offered CSE, while the remaining 22 studies focused on the human body, safety, hygiene and menstrual care, and social skills. Emphasis on prevention, such as prevention of sexual abuse and STIs, can exaggerate risks and may not be effective in prevention or reduction of sexual behaviors that lead to unintended pregnancy or disease transmission (SIECUS, 2004). In addition, sole focus on prevention with little support and guidance in healthy relationship development can ignore the fact that individuals with disabilities have sexual needs and desires. For example, the need for more CSE programming was indicated by participants in Murray’s (2019) sexual abuse prevention program. In the program, students with developmental disabilities were taught strategies to avoid and report sexual abuse; however, after the intervention, students reported an interest in receiving education to “know more about having a ‘girlfriend’ or ‘boyfriend’” (Murray, 2019, p. 1007).

Finally, there are not enough studies published for any single disability category to generalize, but it is possible that students from certain disability categories have less access to CSE in schools than others. For instance, in this review, we found students with intellectual and developmental disabilities were most likely to receive hygiene and menstrual care interventions while students with physical disabilities were most likely to receive CSE.

Limitations and Implications

Our inclusion criteria and requirement for data to be aggregated for students with disabilities could limit the number of studies in the analysis. In addition, the exclusion of gray literature and non-English articles could introduce bias to our findings.

Our study offers several future directions for researchers investigating similar interventions. Although quality assessment is not a feature of scoping reviews (Arksey & O’Malley, 2005); future research should conduct a quality appraisal or the SE literature to identify methodological concerns. In addition, we encourage future research that examines the nuances of intervention delivery components. For example, intervention dosage was not examined in any of the available literature. In some articles (e.g., Sheppard, 2006), participants did note the need for more time to cover intervention topics. Examining whether changes in frequency and weeks of the intervention result in differential outcomes for subgroups of participants can support practice. Future research could also examine how interventions engage family members to gain buy-in or provide input on content and how this affects intervention effectiveness.

Examining whether intervention effects differ based on student characteristics such as race/ethnicity, disability type, age, and sexual orientation would also be helpful to the field. Our review did not acknowledge or include all critical social identities that may influence experiences with SE instruction. Thus, we encourage future research on how identities such as those related to socioeconomic status, religion, and native language status influence experiences with SE. Finally, three studies included in this review cited the heterogeneity of students as a challenge to assessment (Dryden et al., 2014, 2017; Murray, 2019). Future research should evaluate inclusive assessment tools that can support learners with varied needs and disabilities.

Only one study provided SE instruction to students with disabilities within the general education classroom and reported findings specific to students with disabilities (O’Donnell et al., 1999). In 2020, 66% of students with disabilities received instruction within the general education setting for 80% or more of the day, while only 3% of students were served in special schools (National Center for Education Statistics, 2022). Since many students with disabilities are included in the general education classroom, we can assume that at least some of these students are receiving SE with their typically developing peers. Unfortunately, the effectiveness of these interventions for students with disabilities receiving education in the general education setting is lacking as information on aggregated results for this population are often not reported.

Policies should be devised to mandate CSE and include language requiring all students, including those with disabilities, to have access to CSE. We encourage practitioners to provide comprehensive and inclusive SE that challenges ableist and heteronormative attitudes. Educators can incorporate disability-specific instruction in SE in classrooms of students of all ability levels and combat ableist stereotypes by highlighting the sexuality of people with disabilities. In addition, we recommend practitioners use their understanding of educational best practices to develop materials to ensure accessibility for all learners. Finally, we recommend that students gain access to CSE early and often. Available, consistent, and accessible SE for individuals with disabilities can support the development of healthy relationships throughout the lifespan.

Supplemental Material

sj-docx-1-sed-10.1177_00224669221134532 – Supplemental material for A Scoping Review of School-Based Sexuality Education for Children With Disabilities

Supplemental material, sj-docx-1-sed-10.1177_00224669221134532 for A Scoping Review of School-Based Sexuality Education for Children With Disabilities by Melissa Stoffers, Tia Navelene Barnes, Yu Xia and Jurni Jackson in The Journal of Special Education

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material is available on the Journal of Special Education webpage with the online version of this article.

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