Understanding Appropriate and Applicable Sex Education Instruction for People With Intellectual Disability

Recruitment and Participants

We used purposeful sampling for recruitment (Maxwell, 2012) by contacting sex educators through personal networks and internet searches who we believed met our inclusion criteria: (a) at least 18 years of age, (b) worked in the United States, and (c) taught sex education to individuals with intellectual disability. To increase our sample size, we used snowball sampling (Biernacki & Waldorf, 1981) by asking participants to refer us to other colleagues.

In total, we interviewed 58 sex educators who were, on average, 40 years old (range: 21–78) with 9 years of experience (range: 1–37). Most identified as White (90%), although participants also identified as Hispanic/Latine (3.4%), Black (1.7%), Asian (1.7%), and Middle Eastern (1.7%). The sample was predominantly female (81%), with some male (9%) and non-binary or transgender (10%) participants. All participants had some college education, and 74% held a Master’s or Doctoral degree. See Table 1 for more demographic details.

OPEN IN VIEWER

Table 1.

Demographic Characteristics and Service Delivery Models of Participants.

Demographic characteristic	n (%)
Education
Some college	2 (3.4%)
Bachelor’s degree	13 (22.4%)
Master’s degree	33 (56.9%)
Doctoral degree	10 (17.2%)
Years of experience
1–5 years	28 (48.3%)
6–10 years	13 (22.4%)
11–15 years	7 (12.1%)
16–20 years	4 (6.9%)
20+ years	6 (10.3%)
Educational background
Mental health	16 (27.6%)
Special education	15 (25.9%)
Public health	10 (17.2%)
Applied behavior analysis	9 (15.5%)
Medical health	2 (3.4%)
Occupational therapy	2 (3.4%)
Therapeutic recreation	2 (3.4%)
Other	2 (3.4%)

While some sex educators were certified sex educators through the American Association of Sexuality Educators, Counselors, and Therapists or held degrees in public health, other sex educators had limited formal training in providing sex education. Sex educators worked in both community and school settings. Sex educators worked with a wide age range of students: 91% worked with individuals 18 years of age and older, and 66% worked with individuals under age 18. Although several sex educators described working with children as early as preschool, most sex educators who worked with individuals under age 18 reported working with middle and high schoolers. All participants educated students with intellectual disability. Some students had additional diagnoses such as autism, cerebral palsy, Down syndrome, and sensory impairments.

Procedure

A standing advisory board of autistic adults served as consultants. They (a) approved the research topic, (b) reviewed and edited the interview protocol, and (c) provided feedback on preliminary findings. Upon approval from our university’s Institutional Review Board, we obtained participants’ consent. We met with each participant via teleconferencing software. Using a semi-structured interview protocol, we spoke with sex educators about their experiences providing sex education to individuals with intellectual disability. See Supplementary Material for details of the interview protocol. Interviews typically lasted between 45 and 60 minutes. Participants received a $15 gift card for their time. Audio files from each interview were downloaded and transcribed professionally. Identifying information was removed from each transcript. To protect the identities of our participants, we replaced names with pseudonyms.

Data Analysis

Although the theory of reasoned action informed our research question and interpretation, our analytic process was inductive (i.e., data-driven) following Braun and Clarke’s (2021) guidelines. First, we read the interview transcripts, identified components of each transcript that stood out to us, and wrote memos detailing connections between interviews and identifying our lingering questions. Our memos contained reflections on concepts described by the sex educator, a discussion of ideas we felt were critical to highlight from the sex educator, and notes detailing ideas we found confusing. Next, we developed codes by identifying patterns. To identify patterns, we reviewed the memos for several interviews at a time—typically two to three interviews to allow us to look deeply at connections between sex educators—and discussed patterns we noticed (i.e., ideas brought up by the sex educator or noted in our memos that appeared across multiple sex educators). Upon identifying a pattern, we assigned words to describe the pattern. We provided a definition that included establishing the boundaries (e.g., what would be considered part of the pattern and what would be considered outside the scope of the pattern). As we analyzed the memos from additional interviews, we revised the definitions of identified patterns. We continued reviewing additional interviews until we could not identify any new patterns. Finally, we reviewed the definitions we had developed for each pattern and made any necessary edits to ensure they reflected the interviews we had reviewed.

We then returned to the corpus of data and coded all data with the codes we had developed. To code the corpus of data, we worked with two undergraduate student research assistants. We introduced the coding guide to the research assistants and discussed examples of each code. After they felt comfortable with the coding guide, they were each asked to code interviews. Weekly, we reviewed the research assistants’ coding and met with them to discuss the codes, review any discrepancies, and note confusing passages. The guide was not a set framework, and through the discussions, we revised the codes’ definitions and boundaries. Finally, we grouped these codes into themes we had constructed from the interview transcripts. Codes were grouped into themes when they provided greater meaning when put together.

Trustworthiness and Credibility

During data collection, we used rigorous methods to enhance trustworthiness and credibility. For example, we utilized purposive and snowball sampling to identify participants who would be most informative in answering our research questions (Moser & Korstjens, 2018). In addition, we constructed a semi-structured interview protocol that allowed sex educators to converse about their practices and bring up important topics (Busetto et al., 2020).

To enhance the trustworthiness and credibility of our findings, we utilized several strategies, including peer debriefing, member checks, and triangulation of data (Lincoln & Guba, 1986; Morse, 2015). We used peer debriefing to receive feedback from impartial third-party professionals (Lincoln & Guba, 1986), which reduces bias and enhances internal validity (Morse, 2015). After we analyzed our data and developed an initial set of themes and definitions, we invited a network of peers who were experts in qualitative research and disability to review our findings, help identify biases, and detect confusing descriptions or errors. In addition, we conducted member checks by inviting several of the participants we interviewed to review our initial set of themes. Member checks allowed us to garner participants’ reactions to our interpretation and analysis of their experiences and assess whether participants saw their instructional practices highlighted within our themes (Lincoln & Guba, 1986). Finally, throughout the research process, we utilized investigator triangulation to ensure a diversity of researcher perspectives by having two researchers with different experiences—one with a special education background and one with a sex educator background—involved in the data collection and analysis (Schippling, 2017). Both authors regularly met to review each interview transcript, identify important quotes and themes, and discuss theme definitions until we reached a consensus. We also met weekly with the undergraduate research assistants who coded the dataset to review assigned codes, discuss questions, and resolve conflicts.

Deciding How to Individualize: “A Lot of My Students Have Receptive Skills, but Don’t Have a Lot of Verbal Skills. I Don’t Need Them Verbal.” (n = 56; 96.6%)

To ensure that students were receiving meaningful and accessible instruction, sex educators individualized instruction. We identified three sub-themes sex educators used when selecting and designing content: consideration of the student’s disability, learning differences, and communication needs.

When specifically asked whether the student’s disability impacts what is taught, sex educators were divided. Some sex educators indicated the student’s disability had no bearing on the educational content of their lessons. Frequently, these sex educators responded with statements similar to Riley, a sex educator with 5 years of experience, “It doesn’t affect what I teach; it affects how I teach it. It affects how much it has to be broken down into simpler language with more concrete examples before going too abstract.” These sex educators asserted that while their instructional methods might look different, the educational content of their lessons would be no different for students with or without intellectual disability. Nicole, a sex educator with 14 years of experience, expanded on this, “So honestly, I would use the same materials as I would with anyone else [who does not have a disability]. It’s just the way I explain it. The words that I use . . .” Like many sex educators we spoke to, Nicole indicated simplifying language was an essential aspect of providing instruction to her students; however, her instruction was not otherwise altered by the individual’s disability. In addition to language, sex educators named other instructional strategies to support students with intellectual disability. As explained by Jacqueline, a sex educator with 5 years of experience, “Everyone pretty much ultimately needs the same information, but for some folks, it might just take a little longer—like more review and repetition, or more different teaching styles, to get them there.” Like Riley and Nicole, Jacqueline did not modify sex education content due to a student’s disability but made instructional modifications that would better support their understanding.

Other sex educators noted a nuanced relationship between disability and personal history and experience, which might affect educational content. Alex, a sex educator with 1 year of experience, highlights this relationship:

So I wouldn’t say, necessarily, that their disability, per se, impacts what gets taught, but it does definitely impact what they’ve had contact with in their learning history. I think it definitely impacts the behaviors that they’re already engaging in in their environment. And so just centering on what’s going to be most meaningful.

While disability was not the sole reason Alex changed their educational practice, disability impacted instructional choices. The quote is alluding to the societal stigma that exists around individuals with disabilities. For instance, the infantilization of individuals with intellectual disability can lead to restrictions preventing access to normative educational or social experiences, which could affect what sex education instruction is applicable.

While sex educators had varying viewpoints about whether a student’s disability influenced lesson content, all agreed it was important to consider the learning differences of the student when designing instruction. These instructional design decisions were sometimes made in advance based on what the sex educator knew about the students. Quinn, a sex educator with 2 years of experience, explained, “If they’re a better visual learner, then I’ll bring more visual materials. If they’re better audio learners, I’ll bring a video to make sure that there’s the audio component.” When information was available about the students and their disabilities before the lesson, sex educators tried to ensure that they designed instruction to be accessible for those students.

However, at times, sex educators individualized their instruction in the moment based on student understanding and reaction to the content. Maria, a sex educator with 1 year of experience, modified content to aid comprehension of a lesson about gender identity and sexual orientation:

But for some students they weren’t getting anything out of it because it was too fluid. We had to break it down and assign rules to it. [Gender identity] is something that doesn’t really play by the rules, and so it doesn’t feel right to boil it down so much, but at the same time, you kind of have to, or some students aren’t going to get anything from it.

The statement from Maria is indicative of the struggle some sex educators face when teaching socially complex phenomena and presenting them in straightforward, concrete ways. Sex educators explained instruction sometimes needed to be modified for a student’s disability to improve understanding. Individualization for understanding was not the only example of accommodation. For instance, with 8 years of experience, Chris discussed how he worked with a student with cerebral palsy to help the student masturbate more successfully:

So I taught him basically to find the parts of his hands that felt good or soft—because a lot of parts of his hands were calloused . . . So he had homework where he explored on his own to find which part of the hands to use, came back to session, and then we did that [modeling masturbation] with the model dong [sic].

In this quote, Chris described individualizing instruction for a student who needed support with masturbating by breaking down the task and providing space for modeling and practice.

Communication needs were also considered when individualizing content. For students who communicated through assistive technology devices, sex educators described needing to create a safe classroom space to support these students. Mia, who has 2 years of experience teaching sex education, explained how to establish such a space: “So that looks like having his communication partner with him and having an agreement sort of made before class begins at all about respecting people’s styles and giving people time to communicate.” Mia suggested that establishing norms at the beginning of the course and ensuring respect for people with different communication needs was essential for establishing a safe space.

Another strategy that sex educators described to support nonspeaking students was to incorporate activities that allowed choice responses. For instance, Elena, a sex educator with 5 years of experience, described an activity using an eyepiece, “So I will say like, ‘Okay, so this one is public, and this one is private,’ and I’ll show them a picture and have them eye gaze for me. And then I’m able to get their answer that way.” Other sex educators like Kaylee, who had 14 years of experience teaching sex education, described using manipulatives or visuals to allow students to express their understanding and engage with lessons, “We use choice activities and sorting activities.” Choices for responses were also used, such as by Evelyn, a sex educator with 2 years of experience, “If they don’t want to write, they can say something out loud. Or if they cognitively are not able to communicate an answer, to have someone write it down, they could draw a picture.” To address the communication needs of students, sex educators such as Elena, Kaylee, and Evelyn emphasized diversity of activities and responses.

Sex educators like Victoria, who has 32 years of experience, also talked about encouraging students to use nonverbal communication to address lesson objectives:

Okay, I’m coming into your space. What do you do? A lot of my students have receptive skills but don’t have a lot of verbal skills. I don’t need them verbal. I need you to show me because perpetrators don’t care if you’re verbal or not. They’re going to perpetrate.

Sex educators prioritized students’ ability to communicate understanding of the lesson through whatever means best supported the student.

This theme highlights the instructional strategies sex educators utilized to individualize and ensure appropriate content for students. Sex educators discussed whether educational content should be selected based on the student’s disability or whether content should be modified to be accessible for all students, regardless of disability. However, all sex educators agreed that accommodating the student’s individualized needs and learning preferences was essential for learning. Sex educators also reported developing instructional activities that best supported the students’ communication needs. The next theme will examine how sex educators made content applicable to the lives of their students and the challenges they faced to accomplish this goal.

Applicability to Real Life: “I Want to Teach Them Behaviors They Can Use” (n = 46; 79.3%)

In addition to individualizing instruction, sex educators wanted to ensure that educational content was applicable to students’ lives and made decisions about what was applicable to the students they supported. We identified three sub-themes about how sex educators determined applicability to students’ lives: personal beliefs and values, through the input of stakeholders, including students, parents, and teachers, and the consideration of cultural inclusion.

Sex educators had different strategies for selecting content they believed would be applicable to the lives of their students based on the sex educator’s personal beliefs and values. For some, educational content was designed considering what the sex educator believed the student needed. With 10 years of experience, Rachel described targeting the topic of relationships because she believed her students needed support in this area:

People who have maybe PCAs [personal care assistants] or a para or a direct support person. They think, oh, these are best friends. So we really talk about, “What’s a professional relationship, a friendship? What does it mean to have a romantic partner?” Your romantic partner has to know they are your romantic partner. We get a lot of “Taylor Swift is my girlfriend.” I’m like, “Oh, she’s not.”

Rachel’s experience teaching sex education to individuals with intellectual disability led her to determine that addressing relationships was essential and applicable to her students’ lives.

Other sex educators decided which content to cover based on topics they valued. Sex educators like Amelia, who had 1.5 years of experience, described a desire to empower their students, which sometimes meant contending with heteronormative and ableist systems:

The assumption that people with disabilities are asexual and that they don’t ever question their gender and sexuality. So it’s really important to me that I stress to people, “If you question X, Y, and Z, that’s okay. If you have variations in physical body parts other than what you’re seeing in these pictures, that’s okay.

Amelia’s values and understanding of best practices in sex education instruction drove her to select applicable educational content for her students—instruction that normalized human differences. To combat systemic discrimination, some sex educators, like Grace, who had 3 years of experience, purposefully selected media content for their instruction that depicted interracial, same-sex couples of different ages to “normalize the fact that not everybody is white and heteronormative.” Sex educators viewed media selection within their instruction as a critical component of ensuring content was applicable to all students.

Sometimes, sex educators selected content with the input of other stakeholders. In some instances, this was from the student. As Simone, a sex educator with 3 years of experience, explained, “Whatever they ask about, whatever they’re interested in is important for them to know . . . I try not to dictate or predetermine what those important topics are.” Sex educators believed that by allowing students to select lessons and topics, the students would be more likely to be able to apply the lessons they learned to their lives.

In addition to students helping select content, sex educators reported that parents, caregivers, or students’ teachers sometimes requested specific topics be covered because of a concern or problematic behavior. Therefore, sex educators tried to address these topics within their instruction. For example, Kari, a sex educator with 1.5 years of experience, described a common parental request, “We’ve had a lot of parents approach us because they’re concerned that their kid is not choosing ethical pornography, and they just don’t know how to have that conversation.” Kari incorporated instruction to address these concerns with their students.

While sex educators did select content using their values and by consulting with other stakeholders, they also sought to make sex education more applicable to the lives of their students by using strategies to make their instruction more culturally inclusive. For example, Mia described her instruction as “values inclusive,” going on to define this as, “Regardless if a family has a different religious background or you have some cultural expectations that may be unique or whatever it is, we accept everybody, and we don’t teach values.” Sex educators like Mia described providing factual content and encouraging students to discuss values, such as sex before marriage, with family members.

In addition, sex educators reflected on their practices to enhance accessibility and applicability for all. Emily, who has 5 years of experience, discussed this reflective practice, “I’m trying to understand how to express and explain the fact that sexuality in the U.S. is predicated on anti-Blackness and anti-indigeneity. How do I do that in a way that is meaningful?” Like other sex educators we interviewed, Emily believed developing anti-racist instruction to support all students was essential. However, she was unsure how to design this instruction to ensure it was applicable to students.

Although sex educators wanted to design instruction applicable to the lives of their students, they sometimes faced barriers. Chris expressed this concern, “We can’t teach people about sex and sexuality and then not give them access . . . I want to teach them behaviors they can use.” Later in the interview, Chris provided a specific example of this challenge, describing a time when he taught a student internet safety practices for meeting strangers from dating apps:

“We wanted you to teach him all of that so that he knew to stay away.” And I’m like, “No, no, no, no. No. He didn’t learn this for nothing.” . . . If you’re just going to take this away anyway, why’d you make him learn?

As highlighted by Chris, it was important to sex educators to provide skill sets students could use in their daily lives. However, caregivers were sometimes less open to giving students space to implement the knowledge they gained from sex education classes.

Finally, despite a desire to ensure that content was applicable and relevant for their students, sex educators sometimes noted moments when their instructional practice did not achieve this goal. Jeanne, a sex educator with 20 years of experience, described a story involving one of her students when she realized an error in her instructional method:

I kept saying to an individual—a deaf individual with intellectual disabilities who was preparing to go away for a weekend with his girlfriend, “Always use a condom. Always use a condom.” . . . He came back the next week, and he was like, “Well, here was the problem. I couldn’t get the condom to stay on . . . When we were done, it wouldn’t stay on. You said to always leave the condom on.” He was so literal. He thought the whole time, like the whole weekend. And I’m like, “Oh, crap.” . . . That’s on me.

Other sex educators provided similar stories to Jeanne’s in which they discovered that, despite their best efforts, their students had misunderstood the instruction. These learning moments helped sex educators revise their instruction, ensuring that it was more straightforward and comprehensible, thus increasing the applicability of the instruction to students’ lives.

This theme highlights how sex educators prioritized educational topics perceived as most applicable to their students. Sex educators noted various ways in which they made decisions around what was applicable to their students, specifically referring to their own beliefs and values, as well as accepting input from stakeholders, including the students, caregivers, and teachers. However, caregivers, teachers, and sometimes the sex educators themselves could serve as a barrier to students receiving applicable instruction or engaging in experiences in which they could apply sex education lessons to their lives. The next theme describes how sex educators conceptualized age to select content they believed would be appropriate for students.

Conceptualizations of Age: “Depends on the Age and How Much the Person’s Going to Understand” (n = 30; 51.7%)

Adjacent to the discussion of applicability was the idea of age. As sex educators considered the design and implementation of sex education instruction, they focused on what was appropriate for the student, which often led to a discussion of age, albeit at a lower level of respondents than the other themes. For instance, when Patricia, a sex educator with 3 years of experience, was asked how she would design a consent lesson, she responded, “So, that’s a little bit of an interesting question because it really depends on the age and how much the person’s going to understand.” We identified three sub-themes for how sex educators considered age: within the context of the law, the individual’s chronological age, and perceived development.

Sex educators considered the context of the law when making decisions about content. A clear delineation for sex educators was the legal age of majority and the legal age of consent. Thus, sex education content was designed with state and U.S. laws in mind. For some sex educators, this influenced the types of images they showed to their students. Sienna, a sex educator with 12 years of experience, described how she considered the age of majority when selecting appropriate images, “You can’t use educational porn for somebody under the age of 18. It’s just against the law in the United States.” When offering visuals for students, sex educators described the need to consider the legality of the provided materials.

How sex educators approached specific topics or content was dependent on the student’s age and existing laws. Peyton, who has 2 years of experience, identified subject matter that might be discussed differently for those above and below the age of majority, “If you’re talking about sexting and everyone’s over the age of 18, that’s a different landscape than if folks are under 18.” Recognizing the potential legal ramifications of sexting under the age of 18, Peyton’s approach to this topic was different for adults compared with minors. Addressing the legality of an individual’s actions and helping students to know the laws were essential to sex educators.

For other sex educators, age was not just considered in the context of law. Sex educators debated whether instruction should be designed based on the individual’s chronological age or their perceived development, which sex educators frequently referred to as developmental age—a construct that examines the relationship between one’s intelligence quotient (IQ), skill level, and chronological age to compare individuals with intellectual and developmental disability to those without disabilities (Russo et al., 2021).

Proponents of designing instruction to target chronological age suggested that providing age-appropriate instruction is a form of respect, as was indicated by Camille, a sex educator with 20 years of experience:

A lot of people struggle with not seeing [sic] people with disabilities as children and so treat them as children, and that we really need to treat them as their age . . . I think that’s a piece that’s important: we treat people with disabilities with respect and age awareness.

In this quote, Camille explained that many people infantilize individuals with intellectual disability and do not offer age-appropriate instruction, which is disrespectful to the individual.

For other sex educators, age-appropriate instruction was also related to the student’s social and sexual experiences. Kaylee emphasized this idea, “If they’re 20 years old having 20-year-old experiences, whether they are developmental age seven, they need the information that a 20-year-old needs desperately. But we just need to adapt it.” These sex educators indicated that providing sex education instruction based on chronological age-related normative experiences was necessary for the safety of the students they taught.

Other sex educators disputed using chronological age, instead arguing that curricula should be modified for the student’s perceived development. Simone described her process for creating lessons for her adult students, whom she described as developmentally around middle school age, “So, then we develop lessons and activities in a way that we would for middle school students . . . I can’t talk to someone with a disability as I would a 47-year-old because, cognitively, we’re not 47.” Sex educators who ascribed to the concept of developmental age considered instruction appropriate when it matched the student’s perceived development. Another sex educator, Cindy, also made this apparent when she described being inspired to start teaching sex education after witnessing sex education instruction in her high school classroom that she felt was inappropriate for her students, “One of the activities was on internet safety. None of my students could even go to the bathroom by themselves. Internet safety wasn’t necessarily the most relevant topic for them.” Like Simone, Cindy believed sex education needed to be tailored to students’ perceived development. In this example, Cindy used other adaptive functioning skills (i.e., ability to use the bathroom) to determine what sex education content should be taught.

Sometimes, sex educators did not explicitly name developmental age but implied it by describing the relationship between the student’s development or ability and the instructional content. For Naomi, a sex educator with 3 years of experience, working with a teenage student whom she described as “extremely low” meant making modifications to the content:

He’s not able to read or write and doesn’t retain information really at all. So we’ll have an in-depth conversation over a therapy session, and then the next session he has no recollection of what we spoke about. So, at that point, it’s just doing the best that we can. I don’t focus on complex topics. I focus more on, I guess, more basic concepts of where does a baby come from? And what is a condom and why should you wear it? And things that would be more applicable maybe to an elementary level.

Although Naomi does not explicitly name developmental age, she describes altering the content of her lessons to match her perceptions of the student’s perceived ability level (i.e., elementary).

This theme captures the contrast in how sex educators conceptualized age to make decisions about providing appropriate sex education. Aside from considering the legal age of majority, some sex educators wanted to ensure their students had access to age-based normative content. In contrast, others restricted content based on a perception of mental age. In both cases, sex educators wanted to ensure they were providing appropriate information; however, they had different frameworks for determining how to select content appropriately. Some sex educators relied on a framework that valued normative instruction, while others used a deficit framework to limit access to educational content. The first three themes have addressed instructional design; however, the next theme focuses on how sex educators assess their instruction.

Strategies and Challenges of Assessment: “I Don’t Know How to Measure Sexuality” (n = 54; 93.1%)

We identified three sub-themes through which assessment occurred: anecdotal evidence, informal and ongoing assessments, and summative assessments. Although some sex educators felt quite confident in their ability to assess student learning, other sex educators felt the assessment was challenging and even questioned its validity.

Many sex educators described using anecdotal evidence to assess instructional practice and student learning. These data were often collected from caregivers, staff, or students and related to events outside the classroom settings. For example, Denise, a sex educator with 37 years of experience, described a student revealing sexual abuse to her parent as evidence of effective instruction, “A girl who the grandpa actually was touching her inappropriately. And the girl came downstairs and said, ‘Mom, so-and-so touched my private parts, and that’s mine, and he broke the rules.’” Denise viewed this disclosure as evidence the student had internalized the sex education instruction she had received.

In addition to disclosures of abuse, sex educators pointed to success stories they heard about their students. Angela, a sex educator with 30 years of experience, described one story, “I heard actually from the boyfriend. He was like, ‘You ruined my date . . . I put my arm around her, and she said, Angela told me you have to ask. Otherwise, you can’t do that.’ I was like, ‘Okay, it’s working!’” Hearing anecdotal stories of students who referenced course material, like Angela’s student, helped sex educators feel validated that their instruction was working.

Other sex educators pointed to being asked to provide more instruction as an indicator of efficacy. Reese, a sex educator with 10 years of experience, described organizations inviting her back as a sign of success, “I would say nine times out of 10, people will reach back out to us. So, to me, that is at least some measure of success or at least people like what we did enough to call us back.” Sex educators believed being asked to provide additional classes or having students continue to attend their classes were signs their instruction was reaching the target audience.

Another way sex educators assessed students was through informal and ongoing assessments. These assessments were typically quick activities or checks that occurred within the classroom setting and could be as simple as listening to discussions, such as described by Maria, “Reading how people are reacting in the discussion—are people saying things that are relevant? Are people saying things that make sense?” Sex educators also asked questions to check for understanding, which Evelyn described: “So with a question or a prompt if they’re able to answer something correctly, that’s a really good sign. Also, at the end of our lessons, we will have review questions and do it as a group.” Sex educators used informal assessments like homework or exit slips to assess learning. For example, Charlotte, a sex educator with 4 years of experience, described how homework assignments clarified students’ thought processes, “When they submit their homework assignments, I can see from there, based on their answers, where they are. I can see if they totally get it, if they kind of get it, or if they’re totally off base.” Sex educators believed these assessments provided a clear picture of whether students were grasping the material and if they needed additional support to develop their understanding further.

In addition to anecdotal, ongoing, and informal assessments, sex educators utilized summative assessments to assess instruction and student learning. For many sex educators, these assessments were pre- and post-tests administered before and after instruction. David, a sex educator with 10 years of experience, explains this pre- and post-test process:

At the beginning of the course, when we kind of ask them all the questions of what do they know about—we have a bunch of things we ask them about. At the end of the course, we go back to those same questionnaires and look at them and how they may answer again and compare the answers and see what they think.

Sex educators viewed pre- and post-tests as an opportunity to see how students’ knowledge and understanding changed throughout the instructional period.

Other sex educators utilized quizzes or exams to assess student learning. For example, Jeanne described her final exam, “It was the steps of putting on a condom. And I blew it up, and they had to put them in order.” Jeanne believed that a summative assessment to demonstrate understanding would provide insight into students’ learning. Other sex educators assessed student learning through practical means, such as by connecting with students via social media to assess internet safety, like Chris:

I’m going to go online. I’m going to act like Selina Kyle from Catwoman, and I’m going to flirt with Bobby Joe over here. And when I flirt with Bobby Joe, I’m going to see if I can get him to give me his PPI [private, personal information] within three exchanges.

By contacting students online, Chris could assess if they had learned important concepts, such as safeguarding their personal information online.

The level of confidence sex educators felt toward the assessment of their instruction and student learning broadly varied. While some sex educators believed they knew how to assess students effectively, others were less confident. For example, Jacqueline described the challenge of determining if students experienced lasting change, “We can show that people have increased knowledge . . . It’s pretty hard for me to say like, ‘Yep, this person got six sessions, and in two years, they’re still going to be using condoms all the time.’” In this quote, Jacqueline indicates that, while it is easy to evaluate increases in knowledge, it may be very difficult or impossible to assess the lasting benefits of sex education—such as ensuring long-term safe sex practices.

The student’s disability could also influence the efficacy a sex educator felt toward their instruction. For example, Rose, a sex educator with 6 years of experience, described a time when she struggled to assess student learning, “A group of students that we had a couple times were all nonverbal students. It was never totally clear how much they were retaining from class to class or from week to week.” Multiple sex educators indicated uncertainty with how to assess students who did not communicate verbally or who had low literacy skills.

Some sex educators questioned the purpose or validity of assessment. For example, Cole, a sex educator with 10 years of experience, described the limitations of assessing student learning, “Safe sex is easy with, I think, maybe doing some pre-teaching or just some role-play demonstration, how you do this. Obviously, you can’t be there for the act, so that becomes a unique challenge.” Cole recognized that, although he could teach skills to his students, he didn’t necessarily have the ability to assess the implementation of those skills.

Sex educators recognized that increased student knowledge may not lead to behavioral changes. In addition, some sex educators questioned whether it was appropriate to utilize traditional means of assessment within the sex education field. Chloe, a sex educator with 15 years of experience, expressed this concern:

You could measure it like vagina means A, B, or C. It’s social-emotional stuff. I can measure how many DRs [direct referrals] a kid gets. I can measure that they have gone out to lunch with their friends, but I don’t know how to measure sexuality. How would anybody do that? I sure as hell don’t want anybody putting any measure up to me on that.

Sex educators like Chloe questioned what parts of sex education should be assessed and whether aspects of sex education were too individualistic or too private for assessment.

This theme outlines the multiple assessment strategies sex educators use to ensure students are learning. Sex educators use assessment because they want to confirm that their individualizing of instruction, making content applicable to students’ lives, and gearing instruction toward the students’ age or development are making a difference in students’ lives. However, sex educators face multiple challenges in assessing their instruction, including a lack of self-efficacy and an inability to verify behavior changes in specific settings or the long term.

Limitations and Directions for Future Research

While our sample size is large within the qualitative tradition, we utilized snowball sampling to identify participants. It is feasible that sex educators’ professional networks are made up of other sex educators who share similar values and teaching methods, thus influencing our analyses as we spoke with like-minded individuals. To increase the number of networks we connected with, we also used internet searches to identify sex educators. However, this strategy could also introduce bias, as it is more likely to lead us to sex educators who teach sex education full-time as opposed to sex educators who only teach sex education as one piece of their job. Our sampling strategy may, in part, explain why our sample only includes a few school-based educators who address sex education as a component of their job but are not typically full-time sex educators. Future research should explore the effects of sex educator background on student learning. In addition, despite the advancements in assessment options, future research needs to explore bridging the gap between assessment, research, and practice, as well as the validity of these assessments in school-age populations.

Community participation in this study was limited. We consulted with a standing advisory board of people with disabilities on this research. However, we did not utilize a fully participatory action research approach, a critical practice in the intellectual disability community (Frawley & O’Shea, 2020). Furthermore, no one on the advisory board identified as having an intellectual disability. Thus, they were only able to consult on having the lived experience of being disabled and not of having intellectual disability specifically.

Future research can explore the relationship between providing sex education and access to avenues for prosocial sexual expression. Furthermore, future research should examine the experiences of professionals who provide sex education within a school to understand the unique needs of those sex educators compared with those who provide drop-in, clinical, or community-based instruction. In our study, most sex educators who were teaching students receiving special education did so on a drop-in instructional basis. Many also taught in community settings–their interviews discussed their instruction holistically. Thus, we were unable to disentangle school-based versus community-based instructional strategies. Educators working in both school and community-based settings also caused enmeshment of youth-focused and adult-focused instruction; however, regardless of age, sex educators often described providing the first opportunity for formal sex education. Due to this characteristic of our data, our analysis explores patterns of similarity rather than differences across sex educators.

Finally, future research should explore the training needs of sex educators to ensure implicit and explicit ableist beliefs are challenged. Helping sex educators to recognize and address their biases is critical as prior research has shown that sex educator and curriculum biases can negatively impact the self-esteem and sexual expression of individuals with intellectual disability (Saxe & Flanagan, 2014; Schaafsma et al., 2014; Schmidt et al., 2021).

Implications for Policy and Practice

The findings of our study have important implications guided by the theory of reasoned action (Bartholomew et al., 2011). Along the dimension of self-efficacy, our study is one of the few that has identified how practicing sex educators conceptualize individualization. Learning from their collective expertise of how they considered students’ disability, learning differences, and communication needs could improve the self-efficacy of future sex educators. Sex educators, who do not always have a background in special education, may need explicit examples of how to apply educational strategies and communication adaptations to sex education content. Applying Universal Design for Learning principles and ensuring instruction incorporates multiple learning modalities could be a good starting point for sex educators to increase access for students with intellectual disability (Schmidt et al., 2021). Use of a formal needs assessment can also help sex educators individualize content (McDaniels & Fleming, 2016).

Along the dimension of perceived social norms, sex educators in our study highlighted the need to provide instruction that people with intellectual disability could use in their daily lives, which necessitates avenues for prosocial sexual expression. In this finding, they highlight the need for a change in social norms, which would, based on the theory of reasoned action, improve sex education. Individuals with intellectual disability, especially adult advocates, have long maintained that families and support service providers often limit these opportunities (e.g., McCarthy et al., 2022). Sex educators are in a unique position to advocate for the sexual rights of students and adults to receive comprehensive sex education. The limitations imposed by families and service providers are codified in policies that exclude students with intellectual disability from receiving sex education while in school and beyond (Holmes et al., 2022). In addition, students with intellectual disability may be more likely to receive interventions focused on menstrual care and hygiene rather than more comprehensive forms of sex education (Stoffers et al., 2023). It is clear that without formal mandates, students with disabilities will be excluded from sex education; thus, specific mandates that students who receive special education be offered comprehensive sex education are necessary. Schools can be a critical sex education resource for students with disabilities (Stoffers et al., 2023); however, individuals with intellectual disability have indicated that school-based sex education instruction may be unhelpful or inaccessible (Frawley & Wilson, 2016). School-based sex educators can support the identification of appropriate and accessible curricula (Sinclair et al., 2015). In addition, writing sex education instruction into a student’s individualized education plan can ensure access, and providing holistic instruction that addresses the specific needs of the student can increase applicability.

Furthermore, sex educators should rely on national standards to guide their selection of sex education content to (a) better ensure people are provided with education that supports prosocial sexual expression and (b) limit their own biases. The National Sex Education Standards (Future of Sex Education Initiative, 2020) provide guidance on the essential content and skills needed in K-12 settings. When providing sex education based on these standards, educators should rely on high-leverage practices that have been successful in other sex education programs such as individualization, modeling, goal setting, and guided practice (Schaafsma et al., 2013; Wolfe et al., 2019).

Along the dimension of attitudes, some of the sex educators in our study held conceptualizations of age that limited the content and quality of their instruction. This finding suggests an opportunity for continued professional development, which has also been highlighted by young people with intellectual disability that sex educators need training to ensure their instruction is not limited and focused on risk aversion (Frawley & Wilson, 2016). Another strategy would be instructional models that empower people with intellectual disability to be sex educators. For example, Frawley and O’Shea (2020) describe a program in Australia called Sexual Lives and Respectful Relationships that has a train-the-trainer program which has supported 60 people with intellectual disability to become sex educators. Finally, sex educators can partner with families and caregivers using a team approach to person-centered planning (Sinclair et al., 2015) to ensure family and caregiver biases do not prevent students from accessing prosocial sexual expression in their daily lives.