INTELLECTUAL AND DEVELOPMENTAL DISABILITIES ©AAIDD

2014, Vol. 52, No. 2, 85-97 DOI: 10.1352/1934-9556-52.2.85

Predictors of Access to Sex Education for Children With

Intellectual Disabilities in Public Schools
Lucy Bamard-Brak, Marcelo Schmidt, Steven Chesnut, Tianlan Wei, and David Richman

Abstract
Data from the National Longitudinal Transition Study—2 (SRI International, 2002) were analyzed
to identify variables that predicted whether individuals with intellectual disabiUty (ID) received sex
education in public schools across the United States. Results suggested that individuals receiving
special education services without ID were only slightly more likely to receive sex education than
students with mild ID (47.5% and 44.1%, respectively), but the percentage of students with
moderate to profound ID that received sex education was significantly lower (16.18%). Analysis of
teacher opinions and perceptions of the likelihood of the students benefiting from sex education
found that most teachers indicated that students without ID or with mild ID would benefit (60%
and 68%, respectively), but the percentage dropped to 25% for students with moderate to profound
ID. Finally, across all students, the only significant demographic variable that predicted receipt of
sex education was more expressive communication skills. Results are discussed in terms of ensuring
equal access to sex education for students with ID in puhlic schools.

Key Words: intellectual disabilify; sex education; public schools

In the United States, many parents have histori-
cally entrusted schools with their children's sex
education. In fact, the trend appears to be
increasing for parents to default to schools for this
important task, as demonstrated by empirical
research in the past decade as well as public
opinion polls (e.g., Eisenberg, Bemat, Bearinger, &
Resnick, 2008; Ito et al, 2006). The overwhelming
support that parents demonstrate for sex education
in school instead of at home could stem from many
reasons, such as religion of the parents or parental
fear that communicating about sex will adversely
influence sexual behaviors (Troth & Peterson,
2000). For example. National Abstinence Educa-
tion Association (2007) indicated tbat approxi-
mately 90% of parents support sex education in
schools. It is therefore important that public
schools make available to students tbe most
appropriate, comprehensive, and effective sex and
reproductive-bealtb education programs (Kirby,
2002). Regardless of tbe diverging opinions about
tbe scope and sequence of sex education (e.g.,
Darroch, Landry, & Singb, 2000; Eisenberg
et al, 2008; Howard-Barr & Jobnson-Moore,
2007; Landry, Darrocb, Singb, & Higgins, 2003;
Lindberg, Santelli, & Singb, 2006; Santelli et al,
2006), it is clear tbat tbe majority of parents in tbe
United States expect tbe public scbool system to
provide sex education in the schools.
In tbe extant literature, tbe prevalence rate of
sex education bas been encouraging. A report by
tbe Kaiser Family Foundation (KFF; 2002) indi-
cates tbat, upon completion of tbe 12th grade, 89%
of public-school students bad received some form of
sex education. Moreover, a subsequent report by
tbe Centers for Disease Control and Prevention
(Martinez, Abma, &. Copen, 2010) found that of
2,767 teenagers nationwide from ages 15 to 19, 96%
of female students and 97% of male students bad
received formal sex education by tbe age of 18.
While both reports appear encouraging, it is
difficult to ascertain if cbildren witb intellectual
disability (ID) bave been accounted for in tbeir
samples, nor can it be determined if tbe sex
education was offered at scbool or in an alternate
setting. Cbildren witb disabilities, wbetber pbysical
or mental, bave been excluded from sex education
due to tbe misconception tbat tbey are asexual
(DiGiulio, 2003; Robleder, 2010; A. Sullivan
& Caterino, 2008). Acknowledging tbat tbese

L. Barnard-Brak et al. 85
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2014, Vol. 52, No. 2, 85-97
children do not differ significantly from their peers
without disabilities in developing their own sexu-
ality, researchers have noted some unique chal-
lenges associated with the receipt of sex education
by children with ID. In particular, the sexual
expressions of individuals with ID have been
perceived as a potential danger (Howard-Barr,
Rienzo, Pigg, & James, 2005) because those
individuals are conceived of as either asexual or
oversexed and lacking control (Bailan, 2001).
Since the enactment of the Individuals With
Disabilities Education Act in 1975, along with its
subsequent revisions and amendments (U.S. De-
partment of Education, 1995), the percentage of
children with disabilities receiving an inclusive
education in schools has risen from 20% in 1970 to
95% in 2011 (National Center for Education
Statistics, 2011). The issue of patterns for charac-
teristics of students that do and do not receive sex
education thus merits much attention, considering
the increasing proportion of children with ID
included in the public school system. A review of
peer-reviewed literature failed to provide clarity on
this issue, sparking our interest in determining the
prevalence of sex education in public schools
among children with ID.
According to the Diagnostic and Statistical
Manual of Mental Disorders (5th ed.; DSM-5;
American Psychiatric Association [APA], 2013),
ID is evidenced in individuals by both intellectual
and adaptive functioning deficits in conceptual,
social, and practical domains. Since the publication
of the DSM-5, the term intellectual disability has
replaced the term mental retardation (MR) that was
used in earlier editions of the DSM. Consistent
with the earlier edition (DSM-IV-TR; APA, 2000),
tbe DSM-5 classifies ID into four levels according
to severity: mild, moderate, severe, and profound.
While the DSM-5 emphasizes tbe role of adaptive
functioning over IQ scores "because it is adaptive
functioning that determines the levels of supports
required" (p. 33), levels of MR/ID appear to be
similar in the DSM-ÍV-TR and DSM-5, respective-
ly, especially with regard to the level of support an
individual witb ID may need for achieving social
and academic tasks. Mild ID represents approxi-
mately 85% of all cases; individuals with mild ID
have the potential of developing academic skills
that may be equivalent to those of a typically
developing child in early middle school. Children
with moderate ID account for approximately 10%
of all cases and typically attain academic Eind
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language skills equivalent to those exhibited by a
second-grade child. Finally, individuals diagnosed
with severe or profound ID constitute approximate-
ly 4%-5% of all cases of ID and typically benefit
the most from an adaptive-skills curriculum that
focuses on teaching independent self-help skills, as
opposed to more traditional academic content.
Given the high inclusion rates of children with
mild to moderate ID in public schools, compliance
with federal law to meet tbeir sex education needs
is meindatory. Beyond its being a matter of the law,
several reasons arise for providing children with ID
access to developmentally appropriate sex educa-
tion. Kempton and Stiggall (1989) suggested that
sex education is essential for children with ID, as it
provides a basis of knowledge and skills that
enhance quality of life and aids in tbe prevention
of deleterious experiences associated with sexual
activity and the broader implications of being
aware of sexuality issues (see also Smart, 2009). As
indicated by previous studies, individuals with
developmental disabilities including ID are at a
greater risk of being sexually abused (e.g., Balader-
ian, 1991; Brunnberg, Bostrom, &. Berglund, 2009;
Hershkowitz, Lamb, & Horowitz, 2007; Levy &.
Packman, 2004; Sobsey & Doe, 1991). Chamber-
lain, Rauh, Passer, McCrath, and Burket (1984)
indicated that tbe incidence of experiencing sexual
abuse among children with ID is 25%, while others
(e.g., P. M. Sullivan & Knutson, 2000) have found
that children with ID are 4 times more likely to
experience sexual abuse than are typically devel-
oping children. Complicating these findings is the
notion that individuals with ID are likely victims of
repeated offenses, which often are underreported or
not reported at all (Sobsey & Doe, 1991). Further
evidence of inappropriate sexual interaction that
children with ID may experience is the high
incidence of sexually transmitted infections (STIs)
reported among this population. For example,
Mandell et al. (2008) found that, in a sample of
51,234 children ages 12-17, those receiving special
education services were at a greater risk of being
diagnosed with an STL Specifically, they identified
that girls with ID were 37% more likely to contract
an STI than were girls without ID.
Moreover, a lack of appropriate sex education
is cited as a culprit in exacerbating the deleterious
sexual experiences of children with ID. In a study
that assessed the sexual knowledge of individuals
witb ID, Calea, Butler, Iacono, and Leighton
(2004) found deficiencies in information pertaining
Sex Education
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, VoL 52, No. 2, 85-97
to various areas of sexual health including safer-sex
practices, puberty, menstruation, and menopause.
The authors suggest that these knowledge deficits
be countered with better or more adequate human-
relations interventions and sexual education pro-
grams, as the knowledge deficits present are
indications either that these individuals are not
involved in a sex education program or that the
knowledge being taught in the programs is not
heing understood and internalized. While the study
only involved adult participants, it is important to
consider the series of events that did or did not
occur that led these participants to the knowledge
that they had. Sex education for children can
promote awareness and knowledge construction of
sexual behaviors, STIs, and protection.
While sparse, there is evidence supporting the
efficacy of sex education programs for individuals with
ID (e.g., Caspar &. Glidden, 2001; Lumley, Milten-
berger. Long, Rapp, & Roberts, 1998; McDermott,
Martin, Weinrich, &. Kelly, 1999). For example,
Caspar and Glidden (2001) concluded that, after sex
education courses had been tailored to adults with
learning disabilities, the participants demonstrated
an increase in knowledge about sexuality. Nonethe-
less, few studies have examined the receipt of sex
education among children with ID utilizing a
nationally representative data set, especially accord-
ing to levels of severity (mild, moderate, etc.). Such
evidence is necessary for enhancing our understand-
ing of the topic.
Teacher perceptions of sex education for
children with ID are of interest based on the
Pygmalion effect, a term describing the effects of
interpersonal expectations (Rosenthal & Jacobson,
1992). An experimental study by Rosenthal and
Jacobson (1992) demonstrated that higher expec-
tations from the teacher enhance students' learning
because the teacher tends to create a warmer
socioemotional climate, teach more material, give
greater opportunities for responding, and provide
more differentiated feedback. Such evidence is
pertinent to the current topic because teachers
have been found to be unprepared to handle
sexuality issues with students with disabilities, or
to report a low comfort level in addressing sexuality
topics (Howard-Barr et al, 2005). Taken together
with the common misunderstanding that sex
education is not necessary for children with
disabilities, teacher perception of the efficacy of
sex education may influence how teachers organize
L. Bamard-Brak et al.
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sex education courses (e.g., classroom climate,
expectation, and feedback) for students with ID.
Closely related to teacher perceptions and
preparation is students' readiness to learn sex
education materials (Agran, Alper, iSiWehmeyer,
2002). The rationale is that limited cognitive or
language functioning (APA, 2013) of students with
ID may impede their understanding of sex educa-
tion content. That heing the case, students'
expressive and receptive communication abilities,
along with their perceived life skills, may also serve
as predictors for the receipt of sex education. As
children with disabilities are entitled to a free and
appropriate education that meets their specific
needs in the least restrictive environment, this
includes sex education that is available through the
general education curriculum for those that are
included in general education classes. The purpose
of the current study was to contribute to the
empirical research base on sex education for people
with ID by examining the patterns for the receipt of
that education. To achieve this purpose, three
research questions were examined. The first re-
search question concerned the frequency of receipt
of sex education according to level of ID: no ID,
mild ID, or moderate to profound ID. The second
research question concerned examining teacher
perceptions of the possible benefit to those
individuals not currently receiving sex education
of receiving that education. The third research
question concerned identifying the predictors of
whether an individual receives sex education,
according to level of ID.
Method
Sample
The data utilized for the present study were derived
from the National Longitudinal Transition Study-2
(NLTS2; SRI International, 2002). The data set
contains information of a total of 9,230 youths with
disabilities across the United States as a nationally
representative and community-hased sample. Of
the 9,230 youths, approximately 54.9% (n = 5,070)
had information regarding levels of intellectual
functioning and thus formed the sample of the
present study. Among the 5,070 participants,
55.3% (n = 2,800) were reported as heing male,
32.0% (n = 1,620) were reported as female, and
12.7% (n = 640) did not have gender information.
In terms of ethnicity as termed in the NLTS-2,
63.2% (n = 3,200) were reported as being White,
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2014, Vol. 52, No. 2, 85-97
followed by 17.4% (n = 880) as African American,
12.6% (n = 640) as Hispanic or Latino, 3.0% (n =
150) as American Indian or Alaska Native, 2.2% (n
= 110) as Asian, 0.5% (n = 20) as Native
Hawaiian or other Pacific Islander, and 5.1% (n
= 260) as another race or ethnicity. The sum of
participants across ethnic groups exceeds the
sample size, as the respondents were permitted to
indicate more than one ethnicity. The average age
of the youths was 15.7 years old (SD = 1.1). In
addition, 11.6% (n = 590) had mild ID and 13.0%
(n = 659) had moderate to profound ID; the
remaining 75.4% (n = 3,820) reported no ID. This
information regarding level of ID was reported from
the student's Individualized Education Program
(IEP) via the student's school-program question-
naire. The collapsed category of moderate to
profound ID is typically used for the purposes of
statistical analysis because of the low incidence
rates for the categories of severe and profound ID.
Table 1 provides demographic variables for indi-
viduals receiving special education services,
grouped by level of ID.
Measures
All measures were derived from the NLTS2. All
data were obtained from the first wave of the
NLTS2, with information regarding the receipt of
sex education being ascertained by the special
education teacher. The variable of ID was reported
by the parent and corroborated by the school-
program survey. To examine the receipt of sex
education, the NLTS2 contained an item respond-
ed to by special education teachers regarding
whether the student received sex education or
reproductive-health education (variable name:
nprlA4a_a). For the whole sample of students
with disabilities, approximately 43% (n = 2,140)
were reported as receiving sex education, while
approximately 57% (n = 2,830) were reported as
not. To examine teacher perceptions of the
possible benefit of the receipt of sex education,
the NLTS2 contained an item (variable name:
nprlA4b_a) responded to by special education
teachers regarding whether students not receiving
sex education or reproductive-health education
could benefit from such education ("For any
activity this student does not take part in, please
indicate in Column B whether you believe he or
she could benefit from it. ... Reproductive health
education or services"). For those who were not
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receiving reproductive-health or sex education in
the sample, approximately 54% (n = 1,450) were
reported by special education teachers as having
the potential to benefit from such education, while
approximately 46% (n = 1,240) were reported as
not having that potential.
In the examination of the receipt of sex
education among the sample, several potential
predictors were included. These predictors of
receipt of services included typical demographic
variables such as age, household income (categor-
ical version of the variable), and gender. Other
predictors included receptive and expressive com-
munication abilities, inclusive education, level of
social skills, and receipt of physical education. The
variable of receptive communication ability was
measured by teacher rating from the school-
program survey of how well the student understood,
with values ranging from 1 (indicating that the
student did not seem to understand at all) to 4
(indicating that the student understood just as well
as other children), as reverse-coded to aid in
interpretation. The variable of expressive commu-
nication ability was measured by teacher rating of
how clearly a child was observed to speak from the
school-program survey, with values ranging from 1
(indicating that the student did not speak at all) to
4 (indicating that the student had no trouble
speaking clearly), as reverse-coded to aid in
interpretation. We considered it important to use
teacher perceptions, practically speaking, as teach-
ers may be considered as (a) more objective than
parents and (b) gatekeepers in referring for many
services that parents may not know about or have
ever considered. The variable of inclusion was
created to represent a student's having instruction
in at least one of the following core academic
content areas in the general education classroom:
language arts, mathematics, science, and social
studies. Approximately 59% of the sample had
instruction for one or more of these classes in the
general education classroom. The variable of
classroom social skills was an existing scale in the
NLTS2 measuring in-class social behaviors as rated
by the teacher, with values ranging from 3 to 12 (M
= 9.21, SD = 1.96) for the sample. Each item was
rated on a four-point scale by teachers and covered
areas such as how well the student got along with
his or her peers, followed directions, and controlled
behavior. When data were obtained from general
and special education teachers, they were averaged
to produce a composite, as noted by Griffin, Taylor,
Sex Education
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2014, Vol. 52, No. 2, 85-97 DOI: 10.1352/1934-9556-52.2.85

Table 1
Demographics According to Degree of Intellectual Disability (ID)
Degree of ID
No ID Mild ID Moderate to profound
Demographics (n = 3,820) (n = 590) ID (« = 660)
Age (years)
14 650 (17.0%) 90 (15.2%) 90 (14.1%)
15 940 (24.5%) 130 (22.4%) 170 (25.0%)
16 1,000 (26.2%) 170 (28.7%) 180 (27.2%)
17-18 1,240 (32.3%) 200 (33.8%) 220 (33.7%)
Gender
Male 2,460 (64.3%) 330 (57.0%) 400 (61.2%)
Female 1,330 (34.7%) 250 (42.7%) 250 (37.8%)
No information 40 (1.0%) <10 (0.3%) <10(l.l%)
Ethnicity
White 2,580 (67.5%) 350 (59.0%) 420 (64.0%)
African American 670 (17.5%) 180 (31.1%) 130 (19.4%)
Hispanic 410 (10.8%) 40 (7.3%) 80 (12.3%)
Asian/Pacific Islander 90 (2.3%) <10 (0.9%) 10 (2.0%)
American Indian/Alaska Native 30 (0.7%) <10 (0.7%) <10 (0.8%)
Multiple/others 30 (0.7%) <10 (0.5%) <10 (0.6%)
No information 30 (0.7%) <10 (0.5%) <10 (0.9%)
Household Income
$25,000 and under 910 (23.8%) 220 (37.0%) 190 (28.7%)
$25,001-$50,000 970 (25.5%) 140 (24.6%) 170 (26.4%)
Over $50,000 1,180 (30.9%) 110(19.1%) 170 (25.6%)
No information 760 (19.8%) 110 (19.3%) 130 (19.3%)
Disability
Learning disability 500 (13.1%) <10(1.5%) <10 (0.3%)
Speech impairment 350 (9.2%) <10 (0.9%) 10 (1.7%)
Mental retardation 90 (2.4%) 300 (50.7%) 140 (20.8%)
Emotional disturbance 310 (8.1%) 10 (2.0%) <10 (0.2%)
Hearing impairment 470 (12.2%) 20 (3.8%) 20 (2.3%)
Visual impairment 300 (7.9%) 30 (4.8%) 80 (12.0%)
Orthopedic impairment 450(11.8%) 40 (6.5%) 60 (8.8%)
Other health impairment 520 (13.5%) 20 (3.4%) 10 (1.1%)
Autism 370 (9.6%) 50 (8.7%) 120 (18.4%)
Traumatic brain injury 180 (4.8%) 20 (2.9%) 10 (1.5%)
Multiple disabilities 230 (5.9%) 80 (13.1%) 200 (29.9%)
Deaf/blindness 60 (1.6%) 10 (1.7%) 20 (3.2%)

Urbano, and Hodapp (2014). Finally, as previous Harrison & HiUier, 1999; Hilton, 2003), the
literature has indicated that sex education is either variable of whether the student received physical
taught or desired to he taught in the context of education in the general education setting was
physical education (e.g., Darroch et al., 2000; included as a predictor in our analyses.

L. Bamard-Brak et al. 89
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 2, 85-97
Analyses
All analyses were performed in SPSS (v. 16.0) and
MPlus (v. 6.0). In applying weigbts to adjust for tbe
underestimation of standard errors, we specifically
utilized tbe scbool-program weigbt. Missing data
were bandied using tbe fuU-information/maximum-
likelibood metbod of estimation. Missing data
primarily resulted from our conceptual selection of
variables; for example, we limited our sample of
students witb ID to those tbat also bad inform.ation
reported regarding level of ID. To answer tbe first
and second researcb questions, we performed a 2 X
3 X' analysis for each question. A O coefficient was
calculated as tbe measure of association. Values of
0.10, 0.30, and 0.50 for the $ coefficient are
considered to be small, medium, and large,
respectively (Cohen, 1988). Upon a finding of
statistically significant results, standardized residu-
als were evaluated for eacb cell. Standardized
residuals larger tban tbe absolute value of 1.96
were considered as statistically significant at tbe .05
level or less. To answer tbe tbird and final researcb
question, a bierarcbical logistic regression was
conducted to separately predict tbe receipt of sex
education for tbe categories of no ID, mild ID, and
moderate to profound ID. Standardized regression
coefficients witb levels of statistical significance,
along witb odds ratios (e'^), will be reported and
interpreted in tbis article. Tbe expression e^
represents tbe odds tbat a certain factor of tbe
regression model influences tbe likelibood of
receiving sex education witbin tbe respective group
(e.g., mild ID), witb an e^ greater tban 1 indicating
an increase in tbe probability of receiving sex
education and an e° less tban 1 indicating a
decrease in probability. An e^ of 1 means tbat tbe
odds of occurrence are 1 : 1, wbicb is to say equal
likelibood of occurrence; an e^ of 2 suggests tbat tbe
odds of occurrence are 2 : 1, wbicb translates to a
100% increase in probability tbat it will occur (see
also Bland & Altman, 2000).
Results
Does the Presence and Level of ID Affect
the Proportion of Students Receiving
Sex Education?
From tbe column marginal frequencies, 43% of
individuals witb and without ID received sex edu-
cation. However, individuals witbout ID (47.5%)
were sligbtly more likely to receive sex education
tban individuals witb mild ID (44.12%) and were
90
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significantly more likely tban individuals witb
moderate to profound ID (16.18%), x\2) = 221.65,
p < .001, $ = 0.21. Even tbougb there were observed
differences in sex education between students witbout
ID and students witb mild ID, tbey were nonsignif-
icant, f (1) = 2.298, p = .12, 0) = 0.02. Table 2
provides tbe observed frequencies along witb values of
standardized residuals for eacb cell.
Are Teacher Perceptions About the
Student's Ability to Benefit From Sex
Education Associated With Receipt of
Sex Education?
From tbe column marginal frequencies, approxi-
mately 54% of tbe teacbers reported tbat a student
would benefit from sex education based upon
previous courses completed. However, a much
bigber percentage of teachers believed that tbe
benefit would only be for tbose students witbout ID
(60% of all witbout ID) or for tbose witb mild ID
(68% of all witb mild ID), compared to tbose witb
moderate to profound ID (25% of all witb moderate
to profound ID), f (2) = 233.13, p < .001, O =
0.30. Wbile the difference between students witb
no ID and students witb mild ID was statistically
significant, x ^ l ) = 6.86, p < .01, tbe association
was small {<S> = —0.06). Tbe difference in teacber-
perceived likelibood of a benefit from sex education
between students witb mild ID and students witb
moderate to profound ID was significant, x^(l) =
150.355, p < .001, d) = 0.42. Tbese results suggest
tbat some teacbers may be making judgments about
students' ability to benefit from sex education
curriculum, instead of assessing eacb student's
current level of sex education and designing
individualized instructional programs to meet tbose
students' needs. Table 3 provides tbe observed
frequencies along witb tbe values of standardized
residuals for eacb cell.
Do Student Demographic Variables
Influence the Probability of Receiving
Sex Education?
In answering tbe tbird researcb question, we
examined potential predictors of tbe receipt of sex
education. To assess model fit, values of Nagelkerke
R^ were evaluated for eacb model. Tbese values
were .021, .057, and .181 for tbe models witb no ID,
mild ID, and moderate to profound ID, respectively.
Tbese values of R^ indicate acceptable model fit for
tbe social sciences, witb values of .01, .09, and .25
Sex Education
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Table 2
Distribution for Degree of ID and Sex Education Received
Degree of ID
Receipt of sex education No ID" Mild ID Moderate to profound ID
Yes 1,780 260 no
% of degree 47.5% 44.1% 16.2%
Standardized residual (4.2) (0.4) (-10.4)
No 1,960 320 540
% of degree 52.5% 55.9% 83.8%
Standardized residual (-3.6) (-0.4) (9.1)
"These frequencies and percentages are unweighted.

indicative of small, medium, and large divergence,
respectively, according to Gravetter and Wallnau
(2010). For students with disabilities but without
ID, only receipt of physical education was a
statistically significant predictor of the receipt of
sex education. Tbe odds ratio was e^ = 1.11,
indicating a slight but statistically significant
increase in the likelihood of receiving sex educa-
tion. That is, as pbysical education increases by one
unit, there is an 11% increased probability tbat a
student without ID will receive sex education
(Table 4).
For students with mild ID, botb expressive
communication and social skills emerged as signif-
icant predictors from analyses. Tbe odds ratios were
1.36 for expressive communication and 0.72 for
social skills, indicating that as expressive commu-
nication ability increases by one unit, there is a
36% increased probability that a student with mild
ID will receive sex education, and that as social
skills increase by one unit, tbere is a 28% decreased
probability tbat tbe student will receive sex
education. For students with moderate to profound
ID, household income (e^ = 1.46), expressive
communication (e^ = 1.43), and physical educa-
tion (e^ = 1.33) emerged as statistically significant
predictors from our analyses. Tbe odds ratios
indicate larger influences of the predictors on the
receipt of sex education among students with
moderate to profound ID. For example, as expres-
sive communication ability increases by one unit,
tbere is a 43% improved probability that a student
witb moderate to profound ID will receive sex
education.
Discussion
One of the most striking findings from this study is
that a relatively high percentage of students
receiving special education services (via ID educa-
tional classification) did not receive any formal
sex education. For students witbout ID receiving
special education services, approximately 53% bad
not received sex education, which is similar to the
56% of students with mild ID. The similarity in
these percentages suggest tbat individual teachers,
schools, or school districts may be influenced by
factors other than the particular level of intellec-
tual functioning when determining who will

Table 3
Teacher Perceptions of Benefit of Sex Education for Students Not Receiving It
Degree of ID
Benefit of sex education No ID Mild ID Moderate to profound ID
Yes 1,110 210 130
% of degree 60.0% 67.9% 24.7%
Standardized residual (3.5) (3.3) (-9.2)
No 740 100 400
% of degree 40.0% 32.1% 75.3%
Standardized residual (-3.8) (-3.6) (9.9)

L. Barnard-Brak et al. 91
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2014, VoL 52, No. 2, 85-97 DOl: 10.1352/1934-9556-52.2.85

Table 4
Parameter Estimates From Logistic Regression Analyses by Model
Degree of ID Variable B SE Odds ratio (e")
No ID Age 0.059 0.029 1.07
Household income -0.009 0.036 0.99
Comorbid/coexisting disorders 0.129 0.071 1.06
Gender 0.104 0.068 1.05
Receptive communication -0.036 0.066 0.98
Expressive communication 0.079 0.057 1.05
Inclusion -0.074 0.085 1.00
Classroom social skills 0.083 0.001 1.09*
Physical education 0.247 0.099 1.10*
Mild ED Age -0.03 0.08 0.97
Household income -0.062 0.056 0.94
Comorbid/coexisting disorders 0.093 0.185 1.10
Gender 0.074 0.194 1.08
Receptive communication -0.001 0.167 ().99
Expressive communication 0.215 0.132 1.24*
Inclusion 0.003 0.211 1.00
Classroom social skills 0.092 0.001 1.10
Physical education 0.071 0.218 1.07
Moderate to profound ID Age 0.007 0.097 1.01
Household income -0.025 0.067 0.98
Comorbid/coexisting disorders 0.023 0.267 1.02*
Gender -0.019 0.255 0.98
Receptive communication -0.002 0.191 0.99
Expressive communication 0.032 0.145 1.03*
Inclusion -0.006 0.421 0.99
Classroom social skills 0.991 0.066 1.02
Physical education 0.023 0.273 1.02
*p < .05.

receive sex education. Students with moderate to
profound ID were much less likely to receive sex
education than were other students with ID;
approximately 84% of them did not receive sex
education. With approximately 90% of students
receiving sex education hy graduation (KFF, 2002),
it is still possible for students without ID and with
mild ID to receive some sort of sex education before
they complete the 12th grade or from another
source outside of the public school; however, the
significantly lower receipt by students with moder-
ate to profound ID is likely to continue through
graduation, especially given that we statistically
controlled for age in our analyses. The stark
differences in receipt of sex education (between
53% and 84%) would suggest that as the limitations
in cognitive functions and adaptive behaviors
become more severe, the likelihood of receiving
sex education decreases dramatically.
The receipt of sex education, like any other
kind of education, tends to be founded in the
fallacy of perceptions of student "readiness" to learn
the content. For many teachers, the types and
sophistication of communicative exchanges are
important factors in deciding student readiness for
general curriculum (Agran et al., 2002). Expressive
communication, in addition to class social skills, is
prevalent in predicting receipt of sex education for
students without ID and with mild ID. Expressive
communication only provides an impression of an
individual's ability to understand others or receive
communication by reciprocating via expression.

92 Sex Education
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 2, 85-97
Individuals with ID may suffer from expressive-
communication deficits, and teachers may thus also
assume that the students have the same difficulties
with receptive communication; however, receptive
communication is typically more developed (Dy-
kens, Hodapp, & Evans, 2006). The perception
that an individual's level of expressive communi-
cation represents his or her level of receptive
communication is also flawed when considering
the varied developmental patterns of students in
general regarding the use of language (see also
Rathus, 2011). Piaget (1976) believed that cogni-
tive representations and development came before
language development and use. This is supported by
Nelson (2005), who contends that individuals
develop linguistic abilities to describe what already
has a cognitive presence. Receptive communica-
tion is difficult to directly evaluate, but trying to
infer it as equal to the expressive communication
abilities of students might lead to students not
receiving sex education because they are perceived
as not being ready or able to understand content.
This approach is fundamentally flawed also. That
is, we argue that every student has the potential to
benefit from some form of sex education as long as
the instructional trials are matched to the individ-
ual student's strengths and weaknesses, just like in
any other educational content area. The goal is that
sex education not be viewed as a question of "Are
they ready to learn this information?" but instead
be approached as another skill that needs to be
taught through an IEP.
In addition to the number of students with ID
who did not receive sex education, the percentage
of special education teachers who believed that
these students would not benefit from sex education
is a substantial concern. For all the students
without ID that did not receive sex education,
40% of the teachers believed that they would be
unlikely to benefit from sex education. Addition-
ally, 32% of special education teachers of students
with ID believed that sex education would not
benefit students with mild ID, and 75% of them
believed that it would not benefit students with
moderate to profound ID. Yet prior research in sex
education for individuals with ID has clearly
demonstrated that these individuals have low prior
knowledge about, and are given fewer opportunities
to learn about, sexual behaviors and the potential
health risks associated with engaging in these
behaviors (Chen & Udry, 2002; McCabe, 1999).
While only 7% of the special education teachers
L. Bamard-Brak et al.
©AAIDD
DOI: 10.1352/1934-9556-52.2.85
reported having any professional preparation for
dealing with sex education, 54% of them believed
that sex education would be beneficial for students
(Howard-Barr et al., 2005). However, the discrep-
ancies between teacher perceptions of benefit to
students without ID, those with mild ID, and those
with moderate to profound ID require further
investigation to understand the underlying factors
and perceptions of the teachers about their
students.
In examining the need for sex education for
students receiving special education services who
do not have ID, who have mild ID, and who have
moderate to profound ID, the ramifications of not
providing that education should be considered. For
instance, individuals with ID have been reported as
3 times more likely to be sexually assaulted that
individuals without ID (Duh, 1999). The perpetra-
tors of this abuse have typically been peers and
caregivers (Crossmaker, 1991). The vulnerability of
individuals with ID appears to be exacerbated by
communication difficulties that may interfere with
reporting instances of abuse (Sobsey & Doe, 1991),
along with difficulties discriminating what behav-
iors constitute abuse and risk taking with regards to
unplanned pregnancies and STIs. Moreover, pro-
moting positive attitudes is also an essential
component of sex education, given that individuals
with ID appear to be significantly less accepting of
sociosexual situations as compared with peers who
do not have ID (Lunsky & Konstantareas, 1998).
Teachers and parents may be able to help prepare
these individuals to develop healthy relationships,
founded upon what is learned from sex education,
in an attempt to protect themselves from risky
situations (Howard-Barr et al., 2005). Of parents
and teachers, special education teachers would
ostensibly be best able to provide an objective
assessment of a student's current understanding of
sexual behaviors and his or her risk, so that they
could design an individualized approach to teaching
sex education to individuals with substantial
deficits in communication, intellectual abilities,
and adaptive behavior. An analysis of many studies
concerning the sexual behaviors of students with
and without disabilities has shown that sexual
education interventions delay sexual behaviors and
increase the use of contraceptives and condoms
(Kirby, Laris, & RoUeri, 2007). However, educators
may feel unprepared to teach this content or may
believe that teaching the content may promote
sexual behaviors (Howard-Barr et al., 2005).
93
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 2, 85-97
Results of the current study, in combination
with findings from past studies, should be of
concern, given recent findings that individuals
with moderate ID, when taught sex education,
exhibit increased capacity to make sexually related
decisions (Dukes & McGuire, 2009). Dukes and
McGuire individually taught four participants sex
education based on Living Your Life: The Sex
Education and Persoruil Development Resource for
Special Education Needs—Revised Edition (Bustard,
2003). After adapting the curriculum and instruc-
tional modality to suit the one-on-one format of
delivery and individual abilities, they used the
Sexual Consent and Education Assessment Knowl-
edge and Safety scales to assess potential post-sex
education gains in (a) knowledge of sexual safety
practices, (b) knowledge of the physical self,
(c) knowledge of sexual functioning, and (d)
knowledge of sexual choices and consequences
associated with each choice. Dukes and McGuire
found that all four participants with moderate ID
showed an increase in knowledge across all content
areas based on a relatively low-dosage intervention
(i.e., positive intervention effects were observed
after 1 or 2 weeks of twice-weekly individual 45-
min teaching sessions).
Similarly, McDermott et al. (1999) evaluated a
1-year individualized intervention program for
women with ID and found that an increase in
sexual knowledge was directly associated with a
greater number of instructional contacts. Lumley et
al. (1998) provided further light on the benefits of
sex education targeted to women and girls with
mild to moderate ID by demonstrating that these
individuals exhihited gains in knowledge from a
program focusing on the training of behavioral
skills (e.g., verbally rejecting an abduction lure,
leaving the person and scene, telling a familiar
adult about the incident) for preventing sexual
abuse. Taken together, these findings seem to
suggest that including sex education in IEPs along
with concentration on social/behavioral skills may
be a promising direction for future sex education for
children with ID. Lastly, whereas Dukes and
McGuire implemented these interventions with a
single individual at a time, future research in this
area should focus on ascertaining the effect size of
small-group teaching formats that more closely
resemble a special education instructional setting,
documenting variables that facilitate maintenance
of intervention gains, and moving beyond simply
OAAIDD
DOI: 10.1352/1934-9556-52.2.85
showing a change in knowledge by measuring overt
behavior during role plays.
Although the analysis of secondary data sets,
such as the NLTS2, can provide generalizable
findings due to their breadth of coverage, the data
are collected before the development of experimental
questions by individual researchers. Generalizability
is viewed as the capacity of the results from a study to
be transferred to other studies and other contexts.
While generalizability may be a strength of data sets
like these, the generalizability of the findings also
needs to be considered with careful attention. The
collection of data before the development of research
questions implies that certain variables, had we
decided they were important to the current study,
might not be included in the analysis due to their
lack of presence in the data set.
The coverage of variables and diverse contexts
allows the NLTS2 to be generalizable to other
institutions wishing to provide sex education to
students with ID. Future research should consider
examining these research questions across time,
given the longitudinal nature of NLTS2, which
could further describe the pattern of receipt of sex
education across time. However, as most interven-
tion programs that will be used to promote sex
education for these students will he small in size, it
is important to recognize the diversity of the
students involved. Individuals with ID have very
different strengths and weaknesses. The way in
which future curriculum on sex education is taught
needs to be focused on the abilities of the student at
hand and not on the general population. Addi-
tionally, the geographic boundaries of data collec-
tion (i.e., students located in the United States)
limited the scope of the study to the context of one
nation. While an international perspective may
bolster the findings of this study, the cultural norms
and perspectives regarding special education in the
United States limit the ability to translate findings
to other regions of the world.
In conclusion, many special education teachers
often feel unprepared to handle sexuality issues
with students with ID or to teach them sex
education. In addition to beliefs about benefit and
ability to teach sex education, many caregivers and
educators have infantilized individuals with ID
(Smart, 2009), which may prevent the introduction
of sex education, as these individuals are viewed
according to their "mental age" instead of their
chronological age. However, it is important to
recognize that students with ID have a right to
Sex Education
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 2, 85-97
know about tbeir bodies' functions and to be taugbt
bow to increase bygienic bebaviors and promote
safe, bealtby relationsbips witb otbers. Many
parents want to bave tbeir cbild in an environment
tbat empbasizes basic living and functional skills
(Palmer, Fuller, Arora, &. Nelson, 2001). Smart
(2009) claims tbat sex education is a vital part of
this environment in ensuring a quality of life tbat
allows individuals witb ID to bave meaningful and
safe intimate experiences. Tbe findings from tbis
study suggest tbat many students do not receive sex
education and tbat many teacbers believe tbat sex
education would benefit tbese students. In order to
increase tbe number of students receiving sex
education, professional development sbould include
collaboration between bealtb educators and special
education teachers. In providing developmentally
appropriate sex education for special education
students, special education teacbers may need
bealtb education collaborators witb tbis area of
content expertise to learn bow to impart tbis
knowledge effectively. Instead of searcbing for
alternatives to sex education, it is important to
reiterate tbat "parents, special education instruc-
tors, and institutions open tbe door to abuse by
sbying away from any biological instruction eitber
from a misplaced sense of propriety or an unaware-
ness of tbe importance of such instruction in
preventing sexual abuse" (Morano, 2001, p. 129).
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Authors:
Lucy Barnard-Brak (e-mail: lucy.bamard-brak@ttu.
edu), Texas Tech University, Educational Psychology
and Leadership, P.O. Box 41071, Lubbock, TX 79409,
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97
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