Teacher opinions on sexuality and Sexual Education of students with intelectual disability

Using a questionnaire for quantitative and qualitative analysis, this descriptive study investigated the opinion of 451 teachers about sexuality and sexual education of students with intellectual disabilities. The majority (94.2%) perceives the sexuality of their students with intellectual disabilities, identifies their desire to date (38.3%), occurrence of questions (35.8%), sexual games and masturbation (19.6%) and the inappropriate behavior (6.3%); before that, they have positive feelings (37.5%) and negative (53.8%). Teachers believe they can contribute to the sexual education of their students (87.8%), however, they considered necessary the own training (39.9%) or the support of the school and the family (24.4%). It is important to invest in continuous training in sexual education for teachers working in inclusive schools.

Currently, schools throughout the world need to undergo transformations, especially when we aim to universalize education and deal with the insecurity of undergraduates during their initial training; one way of contributing is continuing education of teachers, empowering them to face the complexity of the educational process.
On one hand, as stated by Saviani (2006), as we begin the twenty-first century, the democratic view of education has not been consolidatedas an inalienable human right.On the other hand, enrollment of previously excluded students from regular education has increased in recent decades.Among these, many are the students with intellectual disabilities.This process has been named Inclusive Education -an educational paradigm based on human rights that combines equality and difference as inseparable values and advances in relation to equalization of opportunities (Johnson & Nord, 2010/2011;Schreur & Engel-Yeger, 2010).This premise emphasizes the importance of training courses and studies that validate methodologies and teaching resources.The investigation of conceptions, attitudes and practices becomes relevant because it involves the commitment of an inclusive school for promoting change of discriminatory attitudes (Capellini, 2009).
The relationship between inclusive education and sexuality has been the focus of studies in the field of Education and Psychology.It is a current topic that cannot be overlooked when considering an inclusive society (Casarella, 2010;Heighway & Webster, 2008;Maia, 2010;Walker-Hirsch, 2007).Sexuality in a person with disabilities, like any other, is an inherent aspect and it cannot be neglected (Couwenhoven, 2007;Kaufman, Silverberg, & Odette, 2003;Maia, 2006;Hingburger & Schwier, 2007).
Nevertheless, there are still misconceptions regarding the sexuality of people with intellectual disabilities, particularly those related to an idea of asexuality or hypersexuality (Anderson, 2000;Giami, 2004;Heighway & Webster, 2008;Kaufman et al., 2003).According to Maia and Ribeiro (2010), myths surrounding the sexuality of people with intellectual disabilities have been handled by denial and suppression and many of the difficulties faced by professionals, families and the community result from biased conceptions and misinformation about the sexual nature of people with intellectual disabilities.
Like any other person, people with disabilities are exposed to the same social conditions, values, aesthetic standards, relationships and sexuality, i.e., they are beings who experience affection, crave for love and sexual relationships.In addition, they are also vulnerable and need clarification about sexuality from sexual education, which contributes to the formation of attitudes toward sexual prevention and reproductive health (Maia, 2011).
Many sexual behaviors of students with intellectual disabilities considered as inadequate by teachers are not behaviors resulting from deficiency, but rather a lack of guidance on sexuality that contributes to exhibitionism and public behavior (Casarella, 2010;Couwenhoven, 2007;Glat & Freitas, 2007;Kaufman et al., 2003;Schwier & Hingburger, 2007).Albuquerque and Almeida (2010) argue that it is common for teachers to face difficulties in the classroom regarding the sexuality of students, either due to the lack of knowledge or wrong beliefs.These matters influence the teaching practice leading to difficulties when offering guidance regarding the sexuality of students.The authors argue that the professional would benefit from training courses in the area.
In this sense, people with disabilities should receive the same sexual education as people without Estudos de Psicologia I Campinas I 32(3) I 427-435 I julho -setembro 2015 disabilities, i.e., the same objectives when offering guidance and information on prevention, and the educator have this important task (Maia, 2010;2012;Walker-Hirsch, 2007;Wilson & Burns, 2011).The authors Couwenhoven (2007), Heighway and Webster (2008) offer important didactic content and procedures for guiding sexual education programs of children and teenagers with intellectual disabilities.Melo (2007) states that 21 teachers in their study favored conversation as an intervention when offering sexual education to their students with intellectual disabilities; according to the author, the dialogue that teachers strive to accomplish is important regarding sexual manifestations of their students with disabilities.However, it is often considered repressive, negative, informal, based on common sense and with the purpose of limiting the expression of sexuality.
Several surveys indicate that teachers have difficulties and lack of training in this area (Casarella, 2010;Heighway & Webster, 2008;Maia, 2006;2011;Maia & Aranha, 2005;Walker-Hirsch, 2007).Melo and Bergo (2003) investigated statements of 15 teachers, who taught in special and regular classes, related to their teaching experience regarding sexual education.The interviewees were confused and bewildered regarding the sexual manifestations of disabled students.They assumed being evasive and silent when it comes to dialogue with students on the topic and have no teaching resources on sexual education for this population.The authors point out the need for training in this area.Maia and Aranha (2005) studied 40 teachers from five educational institutions from the city of São Paulo who reported sexual manifestations of their students with disabilities.Among the respondents, there were those who did not perceive the occurrence of sexual manifestations and those who noticed sexual comments and behaviors.According to the authors, sexual manifestations of students reported by teachers were consistent with those expected for the age group without evidence of atypical patterns; and a few cases of inadequate manifestations were reported, which were caused by environmental factors and not by features related to the disability.
The study of Albuquerque and Almeida (2010) describes an intervention course on sexuality for 21 teachers who teach teenagers with intellectual disabilities.These teachers showed improved performance as they were more prepared for classroom activities, evidencing the importance of the intervention.However, they still felt insecure and fearful regarding the sexuality issue when facing resistance from the school or students' family.
Given the importance of sexual education, particularly students with intellectual disabilities, the aim of this study was to investigate the opinion of teachers who participated in a continuing education course on inclusive practices on issues related to sexuality and sexual education of students with intellectual disabilities.Furthermore, whether and how these teachers perceived sexuality of their students with intellectual disabilities and what they thought about possible sexual education at school.

Method
This is a descriptive analytic exploratory study (Spata, 2005) conducted after approval of the Ethics Committee Universidade Estadual Paulista Júlio de Mesquita Filho (Process nº 192/46/01/10).Every research participant was informed about the use of their responses for research purposes and gave consent of voluntary participation by signing an Informed Consent.

Participants
The training course for teachers called "Practice in special and inclusive education in the area of mental disability" was developed in partnership with the Ministry of Education (MEC, Brazil) and held in 2010 with a workload of 180 hours using a distance education platform.The aim of the course was to enable access to information about the causes of intellectual disabilities, conceptual, historical and legal aspects of special education, as well as specific content such as: curriculum flexibility, creativity and games in pedagogical practice, sexual education, evaluation and planning of teaching, seeking to support pedagogical practice for diversity to ensure the learning of all students.
One thousand teachers, divided into 50 classes, enrolled in the course of which 845 agreed to participate by signing an informed consent.However, due to the number of course participants, we chose to work with 29 complete classes, totaling 518 course participants.Of these, 67 were excluded because they did not work with students with intellectual disabilities or worked with babies, resulting in a population of 451 participants, named in numerical sequence from P1 to P451 (P = teacher followed by the ordinal number).
The 451 course participants came from different Brazilian states, were mostly women (96.1%) and their mean age was 38.11 years, as follows: 30 and 39 years (45.6%);40 and 49 years (31.5%),20 and 29 years (13.3%),50 and 59 years (8.2%) and 60 years or more (1.4%).All worked with students with intellectual disabilities at different levels of education (kindergarten, elementary and average school) who attended Common/Regular Classroom, Resource/Services Room of Specialized Educational Support Resource/ Services Room (SESR) and/or School of Special Education.Because the studied population generally work at different levels of education, we did not calculate these percentages; furthermore, the inclusion criteria of the teacher was that he/she worked with at least one student with intellectual disabilities in the classroom, regardless of being the main teacher in the Common/Regular Class room or in other classes.
In this study, our interest was not to investigate the report of the teacher course "Practices in special and inclusive education in the area of mental disability" on sexual relationship and intellectual disability, but rather their perception and feeling toward their students with intellectual disabilities in general, without electing specific students from their professional practice.

Instruments
A questionnaire was used to collect data with several open questions and the following questions were examined in this study: 1) Do you realize the sexuality of your students with intellectual disabilities?How? 2) How do you feel regarding sexual manifestations of your students with intellectual disabilities?How easy or uncomfortable do you feel? 3) Could you contribute to the sexual education of your students with intellectual disabilities?How?What would you need to guide them in this area?

Procedures
Data collection was performed in the TelEduc environment portfolio.Throughout the course, the teachers conducted weekly activities such as storytelling, questionnaires, forums, chats, statements on the subject worked.In the case of the sexuality topic, the questionnaire was individually sent before discussing the module about the sexuality of the disabled person; after answering it, the results were posted on the platform so the researchers could access them.
The data analysis was quantitative and qualitative, which is called a sequential mixed method (Creswell, 2007;Lankshear & Knobel, 2008).The quantitative analysis referred to descriptive statistics from categories elaborated by the qualitative content analysis.This consisted of transcribing all the answers to spreadsheets for analysis and preparing mutually exclusive categories, as proposed by Bardin (1979).Since these were open-ended responses, all statements were grouped into common themes (qualitative analysis) for subsequent analysis of frequency.

Results
The results are presented in two axes and each of them will be explained in thematic categories, previously developed from the issues that bring together the subcategories, and the frequency of responses of the teachers, as follows: Axis 1) Sexuality of student with intellectual disabilities in the following categories: "teachers' perception regarding the sexuality of students with intellectual disabilities", "forms of expression of sexuality of students with intellectual disabilities perceived by teachers" and "feelings of teachers regarding the sexual behaviors of students with intellectual disabilities"; Axis 2) Sexual education for students with intellectual disability in the following categories: "contributions of teachers to sexual education of students with intellectual disabilities" and "terms of teachers for the accomplishment of sexual education with their students with intellectual disabilities".

Teachers' perception about the sexuality of their students with intellectual disabilities
The participants were asked if they perceived the manifestation of sexuality in their students with intellectual disabilities at school.Of the 451 teachers, 425 (94.2%) said they did; 19 (4.2%) said they did not; 7 (1.6%) did not answer or stated confusing and unrelated answers to the question.
In this sense, one can affirm that most participants realized that their students are sexual beings and that they express it at school.Among the teachers who realized, the majority emphasized that students manifest behaviors and verbalizations about sexuality (90.5%) because they show body development (2.5%), they consider sexuality as something inherent in human beings (4.9%), or even because students express gender relations (2.1%).Examples of responses: "Through conversations about the opposite sex" (P40), "When in adolescence the body begins to change, showing its growth and requiring adaptations, changes in relationships" (P430), "Whether it is a disabled person or not, sexuality is inherent in all" (P259) "[He likes] to embrace women tightly ... since they are men, they do not embrace"(P412).

Expressions of sexuality of students with intellectual disabilities perceived by teachers
When asked what kind of sexual behaviors they perceived in their students with intellectual disabilities, 16 participants responded that they do not identify those behaviors (3.5%) and 36 said they note sexual behaviors, but they did not identify what kind (7.9%).Most of the teachers (88.6%) responded that they identified various sexual behaviors among students with intellectual disabilities, as described in Table 1.
It can be stated, as reported by participants, that students express sexuality in everyday utterances (questions and conversations among themselves and with teachers), or reproducing social issues, such as concern for esthetics and physical beauty or the desire for dating.
To a lesser extent, some participants perceive more generalized sexual behaviors referring to explicit conduct of touching, display of genitalia, individual masturbation or exhibitionism.The sexual behaviors of students included exaggerated and inappropriate touching of themselves, without pointing out specific situations.Examples of statements illustrate the subcategory: "By masturbation" (P1), "Sometimes they do it alone or when caressing friends" (P94), "They always say that they want to date" (P43), "Express their wishes through speech [saying] that they will marry a handsome man (P99)", "Her sexuality is touching as well"(P279).

Feelings of teachers regarding the sexual behaviors of students with intellectual disabilities
Thirty-nine participants (8.7%) did not provide a straightforward opinion of their feelings

Frequency and percentage of responses from participants regarding expressions of sexuality of students with intellectual disabilities (N=399)
Concern with appearance, attitudes that express the desire for dating.or stated confusing responses.Others (91.3%) reported mixed feelings regarding the sexual behavior of students, as described in Table 2.
Positive feelings were grouped together (41.0%) and they expressed a favorable view toward the sexuality of students with intellectual disabilities, since participants showed an understanding that they should act normally, taking advantage of the situation to engage and guide.Negative feelings (59.0%) were grouped together and they expressed personal and professional difficulties that could lead to unfavorable attitudes toward the sexuality of students with intellectual disabilities.Some examples of these statements represent these categories (positive and negative feelings): "I try to act in the most natural way" (P47), "I do not have fear, nor difficulty and I say what is necessary in the most normal matter that I can when addressing it" (P149), "I was shocked because [the student] was only three years old" (P159),"I have difficulties due to my family background, we did not discuss the subject" (P9),"My main concern is whether they will assimilate properly, if I'm not awakening an inappropriate interest in them" (P72), "I'm afraid the family does not understand the real meaning of the work and see it in a distorted manner" (P26), "...Teachers are not fully prepared to address all situations" (P276).

Contribution of teachers to Sexual Education of students with intellectual disabilities
Participants were asked about a possible sexual education for their students with intellectual disabilities.Most believe they can contribute to the sexual education of their students or have already done so (87.8%), as participant P279 stated: "I can help guide my students in relation to sexuality through informal conversation, naturally approaching their curiosity".Sixteen teachers (3.6%) also believe they could contribute, but conditionally, depending on the situation, as stated by participant P465: "First I need to evaluate how families view such matters in practice so that I may develop constructive methods to work with sexual orientation".
Twenty-eight participants (6.2%) did not answer this question.Others (2.4%) assumed that they cannot guide their students, either because they do not believe this to be the role of the teacher or because they consider their students to be immature to receive information on sexuality.Examples: "I think this issue has to be dealt with by the parents" (P6); "I think they're too young" (P470).

Teachers' conditions for implementing sexual education of students with intellectual disabilities
The participants were asked what they considered important to be in charge of sexual education of their students with intellectual disabilities.Sixty-five (14.4%) did not answer this question and reiterated that they would not know how to do it and the others (85.6%) pointed to conditions grouped into the subcategories described in Table 3.
For 46.6% of the participants it would take a personal and professional investment in the teacher so that they could review their own personal education or formal learning, as in the example: "Can I contribute ignoring misguided thoughts about the mentally handicapped and their sexuality?"(P326),"If we had courses on the topic" (P437).
Other participants (28.5%) stated that it would be important to have support from the school and families considering the need of the students and school involvement would be necessary by inviting skilled professionals to discuss sexuality, in addition to permission from the family to work with the subject.Examples of statements: "Talks with experts, conversation with parents and guardians to help working with this issue that is so important to them" (P395), "First you have to call the parents and inform and guide them as well" (P143).There are participants (24.9%) who believe a project with planning and organization is needed, as reported by participant P145: "I'd feel better if my school had a specific project on this subject".
Teachers face the previously mentioned personal and professional difficulties, but although they are willing to collaborate with the education of their students, they argue that they would participate if they had personal and professional training after the consent of the family and school.

Discussion
The participants generally perceived the sexuality of their students with intellectual disabilities at school, either through their behavior and/or speech or the body development, a characteristic of puberty.As observed in the statements, the expression of sexuality in students with intellectual disabilities such as exhibitionism, comments on sexuality, interest in dating, etc., are not behaviors that differ from other students.Glat and Freitas (2007) also reported that the sexual behaviors of students with and without disabilities were the same, just as Maia and Aranha (2005) observed in the statements of teachers when conducting the research.
In the case of identified behaviors, there are statements on student attitudes that relate to the desire to date and maintain affective bonds, in addition to the concern with appearance.The authors Maia (2011) and Werebe (1984) argue that people with disabilities are equally exposed to social models, and also have the need to correspond to patterns of marital or esthetics.
In addition, sexual games/jokes among students with intellectual disabilities were also identified by participants and considering that they refer to exhibitionism and childish behavior, it is assumed that this contributes to the belief that sexuality, in the case of intellectual disabilities, is exacerbated.Other studies reported that it is common that teachers think people with intellectual disabilities have an atypical sexuality (Giami, 2004).Maia and Ribeiro (2010) conclude that this erroneous belief plays a prejudiced conception of the relationship between sexuality and disability.Authors such as Kaufman et al. (2003) and Schwier and Hingburger (2007) have emphasized that many behaviors considered unsuitable for young people with intellectual disabilities reflect their lack of sexual education.
The account of negative feelings and ambiguous perception of the participants on the sexuality of their students with intellectual disabilities was common.Although there are those who feel prepared and who believe dialogue with their students is needed, many are still astonished and constrain themselves and report difficulties addressing the sexuality of students with intellectual disabilities, as argued by Albuquerque and Almeida (2010) and Melo and Bergo (2003) in their studies with teachers.
Participants explicitly recognize the need for sexual education for their students with intellectual disabilities as argued by Couwenhoven (2007), Glat and Freitas (2007), Heighway and Webster (2008) and Maia (2012).However, teachers are still concerned to evaluate situations that it might or might not happen.It can be said that although they recognize it as relevant, they have difficulties in taking on the sexual education of students with intellectual disabilities, either for feeling lack of personal or academic preparation or even by fearing the reaction of the student's families, as observed by Albuquerque and Almeida (2010).
The participants' acknowledgement that they could help and/or take on the sexual education of students with intellectual disabilities was significant, which shows that they are aware of the sexuality of people with disabilities (Anderson, 2000;Casarella, 2010).It can be inferred that the teachers showed to be favorable of inclusive education and sexual education because they attended a training course in inclusive practices in which the program addressed sexuality and disability.Other research with teachers who have not participated in training courses in this area or in other can further this discussion.
Among the participants who were in favor of sexual education, there were those who pointed out the lack of academic knowledge and continuing education in the area, as stated by teachers in other studies (Albuquerque & Almeida, 2010;Maia & Aranha, 2005;Melo & Bergo, 2003).They also pointed out the social and personal difficulties for the development of this work, the need to receive support from the families and school, and projects designed to address sexual education, which are considered as pertinent.
Sexual education should be conducted in different social institutions, particularly including the family (Reis & Maia, 2012), and it is important that the school takes on the responsibility for their students with disabilities (Maia, 2006;2012;Walker-Hirsch, 2007;Wilson & Burns, 2011).
The data strengthens the argument that continuing training for teachers working with students with disabilities is necessary particularly in the common school (Capellini, 2009) respecting the principles of an inclusive school (Schreur & Engel-Yeger, 2010).Training should also include the topic of sexuality as an educational theme.
It can be concluded that the data show that participants perceive their students with intellectual disabilities as sexual persons, expressing curiosity and sexual behavior at school.They also stress that they recognize the need to provide sexual education to these students, although many do not feel prepared because they lack training.
Teachers participating in this study recognize the sexuality of their students with intellectual disabilities as well as the need to provide sexual education to these people, although they fear the difficulties in undertaking this task, either for personal reasons or lack of support from the family or school or academic training in this area.
Courses that include continuing education in their curriculum and discussions on sexual education and sexuality for people with intellectual disabilities are an important way of helping close this gap in the training of teachers who work in inclusive schools.
organs and involvement in play / sex games and episodes of masturbation.Nonspecific sexual behaviors assessed by teachers such as exaggerated and inappropriate touching.What did teachers observe in the sexual behavior of students with intellectual disabilities

Table 2
Frequency and percentage of responses from participants about their feelings regarding the sexuality of students with intellectual disabilities (N=412)

Table 3
Frequency and percentage of responses from participants regarding the necessary conditions for providing sexual education for students with intellectual disabilities (N=386)