The Birds and the Bees: Teaching Comprehensive Human Sexuality Education

Abstract

Mrs. Webb is an experienced seventh-grade special education teacher. Although her school offers human sexuality education, most of her students with intellectual disabilities do not take the course. There have been concerns that the general sex education curriculum, which has not been adapted for children with intellectual disabilities, is inappropriate, but Mrs. Webb knows that this information is important to her students. She has never taught human sexuality, but she has to deal with issues related to sexual expression every year. Mrs. Webb wants to be proactive about implementing human sexuality education; however, she is not sure where to begin.

The United States has a long, complicated history with sex education as, often, different stakeholders advocate dissimilar educational frameworks (Irvine, 2004). Although controversies remain in defining the boundaries of sex education, there is a movement both nationally and internationally to define sex education comprehensively (Haberland & Rogow, 2015). The United Nations Fund for Population (UNFPA) provides operational guidance on how to define comprehensive sexuality education. Comprehensive sexuality education helps individuals to (a) acquire accurate information about sexual and reproductive health, (b) explore and nurture positive values and attitudes toward their sexual and reproductive health, and (c) develop life skills that encourage sexual health and safety (UNFPA, 2014). The broad, holistic view of sex education by UNFPA reflects a comprehensive understanding of human sexuality (Sexuality Information and Education Council of the United States [SIECUS], n.d.):

Human sexuality encompasses the sexual knowledge, beliefs, attitudes, values, and behaviors of individuals. Its various dimensions involve the anatomy, physiology, and biochemistry of the sexual response system; identity, orientation, roles, and personality; and thoughts, feelings, and relationships. Sexuality is influenced by ethical, spiritual, cultural, and moral concerns.

The SIECUS and the American Academy of Pediatrics have position statements affirming that individuals with intellectual and developmental disabilities (IDD) need comprehensive human sexuality education (Murphy & Elias, 2006; SIECUS, n.d.).

Barriers to Sexuality Education

There are significant barriers to individuals with IDD receiving comprehensive sexuality education (Stinson, Christian, & Dotson, 2002). Although all states are involved at some level in providing sex education to public school children (National Conference of State Legislators, 2016), youth with IDD are often precluded from receiving comprehensive sexuality education. Special education teachers may not feel they are qualified to teach comprehensive sexuality education. A study of 494 Florida special education teachers reported that educators believed their training on sexuality topics was inadequate (Howard-Barr, Rienzo, Pigg, & James, 2005). Special education preservice teachers receive little, if any, formal training on sexuality topics. For example, May and Kundert (1996) studied special education training programs and found 41% of their students received no course work on comprehensive sexuality education. Additionally, special educators may have difficulty obtaining appropriate resources that are empirically supported and aligned with educational standards for teaching sex education (Travers, Whitby, Tincani, & Boutot, 2014). In the absence of adequate training and resources, misconceptions about human sexuality and IDD persist, including, for example, that individuals with IDD are asexual. These biases are themselves barriers (Sinclair, Unruh, Lindstrom, & Scanlon, 2015).

Implications

There are several implications associated with poor or no sexuality education. Without adequate resources and training, when sex education is provided, personal values may dictate the information presented to individuals with IDD (Wilson & Frawley, 2016). A lack of intentional, accurate messages about sexuality can communicate that the sexual expression of individuals with IDD is deviant (Gomez, 2012). Additionally, when individuals with IDD are not supported proactively with sexual expression, it can lead to problematic sexual behavior (Stokes, Newton, & Kaur, 2007). Comprehensive human sexuality education is a useful strategy for both facilitating prosocial sexual behavior and reducing problematic sexual behavior (Curtiss & Ebata, 2016). Individuals with IDD are at risk for sexual violence, manipulation, and coercion, and education can be a powerful self-protective tool (Barger, Wacker, Macy, & Parish, 2009). Comprehensive sexuality education is important for addressing these concerns. Sinclair and colleagues (2017) recommend five stages for implementing a comprehensive sexuality education curriculum: (a) connect with school boards and district personnel, (b) connect with school administrators, (c) plan for instruction with general education teachers, (d) engage families and caregivers in planning, and (e) engage students in planning and instruction. Although it is often a challenge, some individuals with IDD do receive comprehensive sexuality education and are able to show increases in sexual knowledge (McDermott, Martin, Weinrich, & Kelly, 1999).

Figure 1 provides a framework for providing comprehensive human sexuality education to individuals with IDD. There are two main components in this framework: (a) goals for healthy sexual development throughout the life span and (b) dimensions of sexuality instruction. For each dimension of instruction, there are specific strategies and resources that can be used by special educators. By following the recommendations in this framework, special educators will be more confident in teaching human sexuality to their students with IDD.

Figure 1.

Framework for providing human sexuality education to individuals with intellectual and developmental disabilities

Goals for Healthy Sexual Development Throughout the Life Span

From early childhood through adulthood, there are important goals for sexual development. Before adolescence, children cannot experience erotic feelings, but they are sexual in the broadest sense of the word. They are exploring their bodies and figuring out what they can do. They develop gender awareness and identity. In early childhood, the goal of healthy sexual development is that children are allowed to explore developmentally appropriate information about sexuality safely. This includes their attitudes, values and beliefs, relationships, and interpersonal skills (SIECUS, 1998). As children get older, they begin to take responsibility for their sexuality as they learn to understand boundaries. With adolescence comes all the changes associated with puberty and the beginning of erotic feelings. Adolescents must learn to cope with changes to continue on the path toward being a sexually responsible adult. In adulthood, people with IDD live their story: They safely express their sexuality, whatever that may mean for them (SIECUS, 2004). The goals are additive; exploring, understanding, and coping never stop as adults express their sexuality congruent with their values. Regardless of the age of the child, there are three dimensions of human sexuality instruction that special educators can use to support the development of healthy sexuality for their students: (a) providing information, (b) sending messages, and (c) teaching skills.

After assessing the needs of her students and consulting the SIECUS Guidelines for Comprehensive Human Sexuality Education, Mrs. Webb decides she will teach an 8-week unit with the following topics: an introduction to human sexuality, anatomy, puberty, reproduction, crushes, body image, hygiene, and a closing session. Mrs. Webb knows that positive relationships with parents are essential (Epstein, 2001), so she sends a letter home to parents outlining the material that will be covered during the unit and how they can help to reinforce this information at home. To facilitate this conversation at home, Mrs. Webb suggests “conversation topics” for parents to discuss with their children, such as sharing their own puberty stories by answering the questions, “How did you know you had started puberty? How old were you? What were the best and worst things about puberty? Who did you go to for guidance when you were experiencing puberty?”

Providing Information: Formal Lessons on Sexuality Topics

Because human sexuality is a taboo topic, the language used to express sexual information is often vague and relies on implicit deductions to explain sexuality topics. The implicit messages make learning about human sexuality difficult for all students but especially those with IDD. Due in part to implicit messages, individuals with IDD have been found to demonstrate less knowledge about sex and sexuality (Sinclair et al., 2015). However, special educators can make the implicit explicit by providing information using formal lessons on sexuality topics. Formal lessons provide information on human sexuality in order to increase knowledge in a structured, intentional, and systematic manner. Before teaching formal lessons, special educators may need guidance on how to select content and strategies for instruction related to formal sexuality instruction.

The language used to express sexual information is often vague and relies on implicit deductions…[this] makes learning about human sexuality difficult for all students but especially those with IDD.

Selecting Content

There are several resources to support special educators with selecting content. When considering human sexuality from a broad, comprehensive perspective, there are many topics that fall under the umbrella of comprehensive sexuality education. SIECUS (2004) provides guidelines that are available online. The guidelines cover 39 different topics, which fall under six broad concepts: human development, relationships, personal skills, sexual behavior, sexual health, and society and culture. For each topic, SIECUS identifies developmentally appropriate content. Special educators can use the developmental progression of information for each topic to help target their instruction to meet individual developmental needs. Although useful, 39 topics may not be feasible for all educators. A survey of 43 practitioners who received training on comprehensive human sexuality education affirmed each of the SIECUS topics as being relevant to individuals with IDD; however, the following areas were rated the most relevant: communication, sexual abuse, help-seeking behavior, decision making, contraception, values, sexually transmitted diseases, assertiveness, love, and romantic relationships (Curtiss & Ebata, 2016). These topics can help guide special educators on where to focus their instruction. Additionally, there have been curricula developed for providing human sexuality education for individuals with IDD (for a review, see Treacy, Taylor, & Abernathy, 2017). Educators may still need to individualize instruction due to the wide range of individual differences among individuals with IDD. There is no sexuality topic that is inherently inappropriate for individuals with IDD; however, information must be truthful, direct, and relevant.

Strategies

In terms of the strategies used to provide comprehensive sexuality education, special educators are in an excellent position because they often have the role of working with content teachers to differentiate instruction (Sinclair et al., 2017). Furthermore, many of the strategies special educators use to effectively differentiate in other academic contexts can be applied to comprehensive sexuality education (Sinclair et al., 2017). For example, Figure 2 shows how a checklist worksheet can be modified to a pictorial sorting activity for younger students or nonreaders. The following strategies have been reported in studies that found increases in sexual knowledge: (a) the use of anatomically detailed dolls and drawings (Lunsky & Benson, 2000), (b) individualized instruction (Dukes & McGuire, 2009), (c) prolonged engagement (Lindsay, Bellshaw, Culross, & Staines, 1992), (d) direct instruction design (Wells, Clark, & Sarno, 2012), and (e) directed conversations (McDermott et al., 1999).

Figure 2.

Changes that happen during puberty in checklist and sorting task form, from Curtiss (2013)

When preparing for a puberty lesson, Mrs. Webb reviews several example lesson plans. She compares them to the Guidelines for Comprehensive Sexuality Education (SIECUS, 2014) and the National Sexuality Education Standards (Future of Sex Education Initiative, 2012). Both sets of standards suggest that children should be able to explain physical, social, and emotional changes that occur during puberty as well as variations between individuals, especially between males and females. She decides she will use sorting tasks for her students. First, she has them do a sorting task where they are provided with a series of changes that happen during puberty, with each change on a separate note card. She instructs students to sort the changes into three piles with a partner: changes that happen to just people with penises, changes that happen to just people with uteruses, and changes that happen to everybody. For the next activity in this lesson, Mrs. Webb reviews the changes that they had previously discussed and asks the students to do a new sorting task on their own. This time, they sort the changes into three piles: this change has already happened to me, this change will happen to me, this change will never happen to me. For the next lesson, using the same changes and the same type of sorting activity, Mrs. Webb asks the students if they are excited about the change, are anxious about the change, or have no feeling about the change. Together, these three activities illustrate differences in the experience of puberty, the emotional aspect of puberty, and that puberty consists of a series of changes. Mrs. Webb is using repetition and spacing (Riches, Tomasello, & Conti-Ramsden, 2005) to help her students identify the changes associated with puberty.

Sending Signals: Informal Messages That Communicate Values

Although providing information through formal lessons is an important aspect of comprehensive human sexuality education, most of the messages sent about human sexuality are informal. The second dimension of human sexuality instruction is sending signals. Facial expressions, wording, tone, what is talked about, and what is not talked about all teach human sexuality. Despite informal signals being the most common way of communicating about sexuality, these messages are often unintentional and reflect educators’ values about sexual expression, which also has implications for their formal instruction. A study of special education teachers found that their values about human sexuality predicted their instructional practices (Howard-Barr et al., 2005). In addition, Curtiss and Ebata (2016) found negative correlations between both knowledge seeking and collaborating when practitioners endorsed traditional values about comprehensive sexuality education.

Informal communication can be used as an instructional tool by making the unintentional intentional to affirm sexual expression. Simple changes in wording can communicate vastly different messages about sexuality (see Table 1 for examples). It is important to use informal communication intentionally to normalize and validate sexual thoughts and feelings. That means that educators have to stay calm when dealing with sexual expression. Maintaining a neutral tone can be especially difficult, as sexual expression can often happen at inopportune times and places; however, having already established appropriate avenues for discussing human sexuality, like formal comprehensive sexuality education, teachers can redirect appropriately. Both formal lessons and informal messages contribute to the ability to teach the skills related to healthy human sexuality.

Table 1.

How Language Communicates Sexual Values

Age	Situation	Response that communicates shame about sexual expression	Response that communicates affirmation of sexual expression
Early childhood: Explore	Young child finds her vulva when using the restroom	“That’s yucky. Don’t touch.”	“That’s your vulva. It’s special.”
Middle childhood: Explore and learn boundaries	Child stimulates genitals during class	“Bad touch. Safe hands.”	“At home in your room.”
Adolescence: Explore, learn boundaries, and cope with changes	Adolescent gets an erection during class	Ignore it.	Explain in private, “It’s normal to get sexy feelings. Sometimes when you get sexy feelings, your penis will get bigger. When this happens at school, take deep breaths until it goes away.”
Adulthood: Explore, learn boundaries, cope with changes, and live your story	A young adult seems to have a crush on another student	Separate the individuals.	“Do you think that is someone you would like to go on a date with?”

Throughout the sex education unit, Mrs. Webb uses reflective practice (Amulya, 2004) to understand her own biases and assumptions regarding human sexuality topics and how she could be unintentionally sending these messages to her students. Reflective practice is the process of learning through reflection to understand a person’s perspective through examining struggles, dilemmas, uncertainty, and breakthroughs (Amulya, 2004). During the puberty unit, Mrs. Webb realizes that she often assumes her students are having negative emotions associated with puberty and does not address that students may be excited or proud of the changes in their bodies. She recalls a situation last year when one of her students started menstruating. The student loved carrying her purse on the days she was having her period as it was where she stored her feminine hygiene products. Mrs. Webb told the student that she needed to be more private but realized that she might have unintentionally sent the message that the student should be ashamed of menstruation. Mrs. Webb makes an intentional effort to adjust both her formal instruction and the signals she sends to validate the full range of emotions associated with puberty. For example, in the puberty lesson, she made sure to address the emotional aspect in a way that presented the full range of emotions. In her incidental interactions with students, she challenges herself to validate anxiety, fear, and embarrassment as well as pride, excitement, and anticipation.

Teaching Skills: Intentional Strategies That Promote Prosocial and Reduce Problematic Sexual Behavior

In addition to formal lessons that provide information and informal messages that communicate values, youth with IDD need to be taught skills that promote prosocial (e.g., flirting, dating, consent) and reduce problematic (e.g., stalking, staring, harassing) sexual behavior. Teaching skills refers to how educators use routines, intervention strategies, reinforcement, practice, and environmental changes to affect behavior. Many of the same strategies used to teach skills unrelated to sexuality, such as modeling, guided practice, reinforcement, and corrective feedback, may also be effective teaching skills related to sexuality topics (Schaafsma et al., 2015). Because of the stigma associated with sexual behavior, there can be a hesitation to address the function of the behavior directly. A stage-based behavior change model (Prochaska et al., 1994) can help educators understand how to match an instructional strategy based on the needs of the individuals and make the indirect direct. Like other behaviors, if the function of the behavior is not addressed, then it is unlikely the individual will learn the appropriate skills needed for changes in behavior.

There are five stages of behavior change: precontemplation, contemplation, preparation, action, and maintenance. Table 2 outlines the stages of the behavior change along with the goal of the educator, strategies that could be used, and examples of both promoting and reducing behavior around sexuality. Each of the suggested strategies in Table 2 is drawn from Wong and colleagues’ (2015) evidenced-based practices for individuals with autism spectrum disorder and Schaafsma and colleagues’ (2015) effective methods for teaching comprehensive sexuality education to individuals with IDD. In this model, precontemplation is the stage where the individual has not yet considered changing behavior or is unaware of the need to make a change. Contemplation is the stage where the individual has started thinking about changing behavior but is still continuing with the behavior. There is no commitment to changing the behavior yet. Preparation is when an individual is committed to change and learning how to take action to make a behavior change. The behavior continues at this time. Action is when the individual makes a behavior change. Maintenance is sustaining the behavior change. Individuals can progress through the stages and also regress to a previous stage, as behavior change is a complex process. When an instructional strategy is ineffective, it is often because there is a mismatch between the strategy and the individual’s stage of behavior change. For example, the educator may use a preparation strategy, like targeted reinforcement, but the student is in the precontemplation phase.

Table 2.

Stage-Based Behavior Change

Stage	Goal of instruction	Potential strategies	Example: Promoting prosocial behavior	Example: Reducing problematic behavior
Precontemplation: Unaware of the change	Awareness	• Pro/con list • Social story	Laura is in middle school. She sometimes notices boys and thinks they are cute, but she does not consider talking to them. She does spend a lot of her time thinking about boys. She will look at them and giggle. Her teacher notices that she has a crush and helps her create of list of pros and cons of talking to a boy she thinks is cute.	Paul has a crush on girl at school. He has been getting to school early and staying late so he can make sure to see her on her way to and from school as well as following her between classes. He tends to look at her intensely when he sees her, and it makes her uncomfortable. Paul’s teacher writes him a social story about how people feel when they get stared at. His teacher talks to him about his feelings.
Contemplation: Aware but no commitment to changing yet	Planning	• “Choose Your Own Adventure” • 5-point scale • Action plan	Laura knows she could talk to a boy she likes, but she is not sure that she wants to yet. Her teacher writes her a “Choose Your Own Adventure” story to help her imagine different scenarios and how she might react.	Paul knows that his crush feels uncomfortable but does not understand why staring is a problem as he is not doing anything to hurt her. Paul’s teacher makes him a 5-point scale to help him understand how his crush feels and Paul’s behavior choices (see Figure 3 ). They create an action plan for how Paul will go from class to class.
Preparation: Learning how to take action to make the change	Practice	• Role-play • Controlled environment • Targeted reinforcement • Prompting	Laura decides she does want to talk to a boy she thinks is really cute. She and her teacher come up with a script of what she wants to say, and they practice the script.	Paul is disappointed that he will not get to see his crush as often, but he does not want to scare her. He wants to start taking a new way to class, but he feels the temptation to follow her. Paul’s teacher prompts Paul which route he will take between classes. Paul’s teacher gives him the option of walking on his own or with a peer. At the end of the day, if Paul follows his route, he gets to post a selfie on his Instagram account (one of his favorite reinforcers).
Action: Changing behavior	The instructor does not have a direct role in the action phase. It is the responsibility of the individual to take action.	• Work on supplemental skills • Provide supplemental education • Emotional support • Encouragement	Laura talks to the boy she has a crush on. They do have a brief conversation, but Laura feels really embarrassed. Laura’s teacher tells her that feeling embarrassed is very normal. She talks to Laura’s parents about starting some formal human sexuality education so Laura understands the changes that are happening in her body and with her feelings.	Paul no longer follows his crush between classes or stares at her intensely when he sees her. Paul’s teacher has been working with him to learn how to initiate conversations with people he likes.
Maintenance: Sustaining change or new skill	Independence	• Continue preparation strategies as needed • Replacement behavior	Laura decides she does not like to talk to boys. Instead of entering the maintenance phase, she returns to the contemplation phase. Laura’s teacher affirms her choice.	Paul still thinks about his crush a lot and misses seeing her. Sometimes he is afraid he cannot control the urge to see her. Paul and his teacher come up with a plan for what he will do when he has those feelings. Paul will write her letters but keep those letters in a safe space at home. He will not put her name on them. Writing the letters helps with Paul’s feelings.

Like other behaviors, if the function of sexualized behavior is not addressed, then it is unlikely that the behavior will change. Therefore, educators must make the indirect direct. Consider one of Mrs. Webb’s students who is staring excessively at another student:

Mrs. Webb has noticed that one of her students is staring excessively at another student. She believes her student has a crush but thinks that he may be unaware of his staring (precontemplation phase). Mrs. Webb makes time to have a discussion with that student. Although her class has not reached the “crush” unit in their human sexuality class, “getting crushes” was one of the changes associated with puberty she included in the sorting activities. She meets with her student and refers back to the activity. The student confirms having a crush. Mrs. Webb normalizes having a crush and discusses several prosocial things individuals with crushes can do, such as thinking about the person a lot, trying to learn more about the person, and joining in with activities. They also talk about things that might make someone feel uncomfortable, like staring, following someone around, or talking to the person too much. Her student seems to understand, but his staring continues (contemplation phase). Mrs. Webb gives him a visual (Figure 3) to help him understand how staring makes someone feel and what he can do to change his behavior. She uses the visual to prompt him when she notices him staring (preparation phase). Eventually, he starts using the strategies on the visual independently (action phase). By this time, the class has gotten to the “crush” unit, so he is also being supported with understanding and managing crushes (maintenance phase).

Figure 3.

Paul’s looking guide, from Curtiss (2013)

Using Comprehensive Sexuality Education to Promote Sexual Safety

Sexual abuse is an important facet for comprehensive human sexuality education. For the general population, the lifetime rate of victimization is estimated to be 27% for women and 16% for men (Finkelhor, Hotaling, Lewis, & Smith, 1990). Due to impairments related to communication and social isolation, children with disabilities are at greater risk. It is estimated that they are 1.7 times more likely to experience sexual abuse (National Center on Child Abuse and Neglect, 1993). Sexual perpetrators rely on a culture of shame, guilt, and secrecy around sexuality in order to prevent disclosure. Only 38% of child victims disclose that they have been sexually abused (London, Bruck, Ceci, & Shuman, 2003), and youth with IDD have additional barriers to disclosure, such as a reliance on caregivers and a lack of sexual knowledge (Ammerman, Van Hasslet, Hersen, McGonigle, & Lubesky, 1989).

Providing information, sending signals, and teaching skills are all crucial for instruction to promote sexual safety. Formal lessons that give information about the names of body parts, sexual rights, and physical intimacy are important for promoting sexual safety. There are specific curricula providing information on sexual safety, such as “We Can Stop Abuse” (Laesch & Paceley, 2004), “ESCAPE-NOW” (Khemka & Hickson, 2015), and “Living Safer Sexual Lives” (Johnson, Frawley, Hillier, & Harrison, 2002). Perpetrators of sexual violence often use sophisticated strategies of coercion and manipulation to gain and keep access to victims that limit the ability of victims to prevent and stop the cycle of abuse. Thus, the formal instruction that teaches individuals with IDD to resist sexual assault has limited potential for ending sexual violence but can increase disclosure, especially as part of comprehensive human sexuality education (Barger et al., 2009).

Often, the informal messages sent about sexuality reinforce the culture of secrecy about sexual abuse. By intentionally sending the message that it is safe to talk about topics of sexuality, the stage is set for disclosure. There are messages that can be sent that specifically reinforce sexual safety. The Texas Center for the Judiciary funded a resource guide for responding to abuse against children with disabilities, which offers several suggestions for safety planning (SafePlace, 2014). These strategies are meant to be incorporated into everyday informal interactions and include the following:

Name the full range of emotions and give permission to express them (e.g., “It is okay to be sad. I am here with you.”).

Practice consent (e.g., ask before you touch a child).

Set up opportunities for children to say “no.”

Respond to peer-based harassment.

Students can also be taught safety planning skills. A safety plan is a set of specific steps people can take if they feel unsafe. A safety plan includes (a) deciding who they can call for help, (b) making sure they have the phone number available, and (c) practicing the call. It can consist of role-playing how to say “no” and how to leave a situation. Bowen’s (2000) “Taking Care of Me” curriculum offers a systemized way to create and practice safety plans. The Waisman Center has also created “S.A.F.E.,” a comprehensive training guide for safety awareness and planning (Hafner, 2005).

Conclusion

From early childhood through adulthood, special educators play an essential role in the healthy sexual development of individuals with IDD. In many cases, their expertise in providing instruction makes them the most effective team member in this role. Human sexuality instruction is multidimensional. It encompasses providing information, sending signals, and teaching skills. Formal lessons on sexuality topics make the implicit assumptions regarding human sexuality explicit. Informal messages communicate values about sexuality, whether or not they are intentional. Direct instruction around prosocial sexual behavior can address and prevent problematic sexual behavior. This framework can be a useful guide for providing human sexuality instruction.

Footnotes

Sarah L. Curtiss, DOCTRID-MSU Hegarty Postdoctoral Research Fellow, College of Education, Michigan State University.

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