SEX EDUCATION PROGRAMS AND THE MENTALLY RETARDED Paula E. Shindell, M.A.
Paula E. Shindell, M.A., is a candidate for the M.S. degree in Maternal and Child Health and Health Services Administration, Harvard School of Public Health.
A t the present time, there is a strong commitment in the mental health field to rehabilitate the retarded in order to move them from custodial care in institutions into the community. Whether living on their own, in halfway houses, or with adult caretakers, these individuals must be prepared to interact with others in their environment. I t is also possible that some number of the only slightly retarded will marry. At this point, both they and their families must be able to communicate effectively about highly sensitive issues-the meaning of family life, child care, possible sterilization, etc. Therefore, no normalization process can be considered complete andlor successful without consideration of its socialization component. Parents of retarded individuals are particu larly concerned with this aspect of the normalization process. They are fearful that their sexually mature adolescents w i l l have too l i t t l e u n d e r s t a n d i n g of the requirements o f heterosexual relationships, with inappropriate sexual behavior resulting. I n addition, they may feel inadequate to deal with anxieties expressed by their child. Kempton I explains that, in actuality, both retardates and normal individuals have similar sexual interests and desires. Parental observations, as reported by Hammar, et a/ substantiate this. Yet, retarded individuals, due to the nature of their handicap, present themselves as a particularly vulnerable group. Without exposure to information and training for sexually appropriate behavior, they often respond inappropriately to attention, give affection without reasonable discrimination, and d o whatever i s r e q u e s t e d of them w i t h o u t questioning. They are also more likely to believe myths because of an inefficiency in distinguishing between what is real and what is not. Last of all, they do not have, as many normal children do, opportunities to validate their 88
information and thereby increase their abilities to manage sexual drives and emotions via peer group interaction-due to the restriction of an institutional environment.' Prior to discussing the goals and objectives of a sex education program for the retarded, one has to understand what sex education is. One must answer the question of whether or not i t can andlor should be treated as part of general education or as a separate entity. Definitions range from an understanding of self and others as part of sexuality in general to an organized behavior m o d i f i c a t i o n program to prevent inappropriate sexual expression (masturbational andlor homosexual behavior) by institutional residents. Obviously, each of these divergent goals taken separately would require a different approach. Since behavior change is the ultimate goal of a l l educational programs, sex education can be approached no differently. Reich and Harshman state that the goals of sex education are the same for a l l individuals. I t should foster the development of sexually fulfilled persons who understand themselves, their values, and resulting behaviors. Selznick supports this by recommending that sex education be a part of a total instructional program, since there are social, emotional and developmental overtones attached to a l l learning experiences. Rosen approaches the problem somewhat differently. He believes that treatment of deviant sexual responses (i.e., the masturbational and homosexual behaviors often shown by institutional residents) and teaching of appropriate sexual roles and behavior are simply two aspects of the same problem. H e recommends a c o n d i t i o n i n g program in which various therapy techniques (systematic desensitization, role-playi ng , reinforcement, etc.) are used to achieve the disappearance of deviant behaviors. As these become more aversive, acceptable behavior is substituted. The two, previously mentioned, aspects of this problem are most certainly related, but attacking the situation as a single entity may be oversimplification. Without FEBRUARY 1975 VOLUME X L V NO. 2
adequate environmental change, and recognition of such within a total instructional program, such conditioning may only lead to an increase in anxiety when the retardate tries to function appropriately within an inappropriate environment. (The appearance of homosexuality in a sex-segregated institution cannot be considered unreasonable, while auto-erotic behavior may be a function of the inability of an individual of low intelligence to relate outside hi mse If.) Sex e d u c a t i o n p r o g r a m s , as a l l other instructional procedures, must be geared to the level of the individual. Problems such as d e c r e a s e d a t t e n t i o n span, l e a r n i n g a n d socialization difficu Ities, and the inability, at times, to comfortably accept new situations are not specific to the intellectually impaired. The special considerations come into play i n the determination of appropriate methods to deal with these situations. To effect a positive learning situation, Kempton I suggests that much of what is used in normal classrooms can be used with the educable retarded, only adapted to a simpler method of presentation. Repetition is recommended, along with major use of visual aids. (Retarded individuals have a great deal of trouble with abstraction and respond much better to visual and tactile stimulation.) The general approach is to move from simple explanations to the most complex level the individual is capable of understanding. One can begin with self and self-care, moving on through biological explanations, social and emotional implications, and social and biological implications whenever indicated. Selznick supports this idea by stating that one might, for example, begin with a simple lesson on the correct names of the visible parts of the body. This provides a vocabulary for asking questions, and is a basis from which individuals begin to understand differences between males and females. Those capable of achieving a higher level of understanding, and indicating by their questions a need for more information, can move on to the meanings of these visible differences i n the biological andlor social-emotional areas. A s the children grow physically, bodily changes can be explained and integrated into the total curriculum. Selznick also includes i n her description of a comprehensive program, preparation for marriage and child care, and the sociology of the family as a social institution. Too much emphasis upon these areas as “normal” may provoke anxiety in those who THE JOURNAL OF SCHOOL HEALTH
cannot function efficiently at such a level. Retarded marriages also report a higher success rate when no children are involved, as they provide an added stress with which these individuals are often unable to cope.6 Retardates who do develop a heterosexual orientation suitable for consideration of marriage can, and should, receive additional counseling. Until this point is reached, however, the educational program will most profitably be focused on sexuality and human relations (and their biological bases i f such information is needed), without inclusion of value judgments. Retarded individuals living in the community are often difficult to reach with birth control services and sex education programs. A s a precommunity, i n s t i t u t i o n a l approach t o this problem, one state school for the retarded in New England is actively engaged in the development of a sex e d u c a t i o n c o m p o n e n t f o r i t s normalization program. Three areas of consideration have been integ rated-i nstru ction, services, and general environment. Classes on sex education are held which include open discussion not only of factual information, but also of fears, values, and attitudes relevant to human relationships. Sessions are also conducted for parents of the residents i n an effort to integrate their all-important influence into the child’s total program. Supportive of the residents’ attempts to explore the concept of sexuality, the institution provides opportunities for heterosexual contacts in the nature of Friday night dances, coed field trips, coed classes, etc. I n general, teaching students about their bodies and the need to care for them can serve to integrate concepts of hygiene with development of self-respect and self-worth. Relative to specific health services, a gynecology clinic is now open at the school for residents, though general clinic hours are restricted to only two per week. Specific services provided, reasons for check-ups, etc., can a l l be integrated into the i n s t r u c t i o n a l s e c t i o n of the p r o g r a m a t appropriate times. A s such, a l l three elements of the program interrelate, providing residents with a total and positive learning experience to be carried over into community life. Balester‘s questioning of sex education for the retarded (how and why) is not equivalent to questioning whether a l l children are entitled to information about sexuality and human development. It is merely a statement that sex education may deceive people, particularly parents, as being the panacea for a l l of their 89
fears a n d problems. H i s belief is that the limitations of s u c h an approach have not been validly assessed. A search of the literature i n this area tends to support this last point. However, the ramifications of the statement are really m u c h greater than those expressed. Many of the characteristics mentioned i n this paper as descriptive of the retarded are also applicable to normal individuals. The sex education programs presently being used in regular classrooms have not been evaluated sufficiently to determine their value and/or effectiveness. Yet “normal” behavior and “normally-oriented” programs are used as the baseline from w h i c h programs for the retarded are derived. The programs are taken whole, and then scaled down to a lower intellectual level for use with the intellectually h a n d i c a p p e d . D e t e r m i n a t i o n of i n s t r u c t o r qualifications (if any) should not b e made u n t i l these issues of what should be taught a n d how are resolved. T o sum u p the problem i n one sentence, i f that is possible: T o represent sex e d u c a t i o n as a n attempt to influence the sexual behavior of the retarded because there seem to b e no alternatives approaches justification, to p r o p o s e i t w i t h o u t e x p r e s s n g limitations approaches deception.’
Planned Parenthood of Southeastern Pennsylvania, 1973. 2. Hammar SL, Wright LS, Jensen DL: Sex education for the retarded adolescent: a survey of parental attitudes and methods of management in fifty adolescent retardates. Clin Pediat (Phila) 6:621627, 1967. 3. Reich M, Harshman H: Sex education for handicapped children, reality or repression? J Spec Ed 5373-377, (Winter) 1971. 4. Selznick H: Sex education and the mentally retarded. Exceptional Children 32:640843, (May) 1966. 5. Rosen M: Conditioning appropriate heterosexual
6. 7. 8.
9. 10. 11.
12.
REFERENCES 1. Kempton W: Guidelines for Planning a T aining
Course on Human Sexuality and the R E arded,
behavior in mentally and socially handicapped populations. Train Sch Bull 66:172-177 (Feb) 1970. Bowden J, Spitz H, Winters J: Follow-up of one retarded couple’s marriage. Ment Retard 9:4243, (Dec) 1971. Balester RJ: Sex education: fact and fancy. J Spec Ed 5355-357, (Winter) 1971. de la Cruz F, LaVeck G, (eds): Human Sexuality and the Mentally Retarded, Brunner/Mazel, Inc., New York, 1973. Delp HA: Sex education for the handicapped. J Spec Ed 5363-364, (Winter) 1971. Gordon S: Missing in special education: sex. J Spec Ed 5:351-354, (Winter) 1971. Money J: Special sex education and cultural anthropology with reference to mental deficiency, physical deformity and urban ghettos. J Spec Ed 5369-372, (Winter) 1971. Morlock D, Tovar C: Sex education for the multiply handicapped as it applies to the classroom teachers. Train Sch Bull (Vinel) 68:87-96, (Aug) 1971.
CALL FOR RESOLUTIONS Annually the American S c h o o l Health Association addresses itself t o significant problems i n the field of c h i l d health a n d s c h o o l health education. T h e f u l l span of the discussion o n many of these p r o b l e m s is made k n o w n through a series of Resolutions passed by the G o v e r n i n g C o u nci I. T h e membership i s invited t o suggest problems w h i c h m i g h t serve as the basis for a c t i o n of this sort. S u c h suggestions s h o u l d b e transmitted to the Chairman of the Research Committee for 1975, Dr. Fred V. Hein, American S c h o o l Health Association, Kent, Ohio 44240.
90
FEBRUARY 1975 VOLUME X L V NO. 2
Paula E. Shindell, M.A., is a candidate for the M.S. degree in Maternal and Child Health and Health Services Administration, Harvard School of Public Health.
A t the present time, there is a strong commitment in the mental health field to rehabilitate the retarded in order to move them from custodial care in institutions into the community. Whether living on their own, in halfway houses, or with adult caretakers, these individuals must be prepared to interact with others in their environment. I t is also possible that some number of the only slightly retarded will marry. At this point, both they and their families must be able to communicate effectively about highly sensitive issues-the meaning of family life, child care, possible sterilization, etc. Therefore, no normalization process can be considered complete andlor successful without consideration of its socialization component. Parents of retarded individuals are particu larly concerned with this aspect of the normalization process. They are fearful that their sexually mature adolescents w i l l have too l i t t l e u n d e r s t a n d i n g of the requirements o f heterosexual relationships, with inappropriate sexual behavior resulting. I n addition, they may feel inadequate to deal with anxieties expressed by their child. Kempton I explains that, in actuality, both retardates and normal individuals have similar sexual interests and desires. Parental observations, as reported by Hammar, et a/ substantiate this. Yet, retarded individuals, due to the nature of their handicap, present themselves as a particularly vulnerable group. Without exposure to information and training for sexually appropriate behavior, they often respond inappropriately to attention, give affection without reasonable discrimination, and d o whatever i s r e q u e s t e d of them w i t h o u t questioning. They are also more likely to believe myths because of an inefficiency in distinguishing between what is real and what is not. Last of all, they do not have, as many normal children do, opportunities to validate their 88
information and thereby increase their abilities to manage sexual drives and emotions via peer group interaction-due to the restriction of an institutional environment.' Prior to discussing the goals and objectives of a sex education program for the retarded, one has to understand what sex education is. One must answer the question of whether or not i t can andlor should be treated as part of general education or as a separate entity. Definitions range from an understanding of self and others as part of sexuality in general to an organized behavior m o d i f i c a t i o n program to prevent inappropriate sexual expression (masturbational andlor homosexual behavior) by institutional residents. Obviously, each of these divergent goals taken separately would require a different approach. Since behavior change is the ultimate goal of a l l educational programs, sex education can be approached no differently. Reich and Harshman state that the goals of sex education are the same for a l l individuals. I t should foster the development of sexually fulfilled persons who understand themselves, their values, and resulting behaviors. Selznick supports this by recommending that sex education be a part of a total instructional program, since there are social, emotional and developmental overtones attached to a l l learning experiences. Rosen approaches the problem somewhat differently. He believes that treatment of deviant sexual responses (i.e., the masturbational and homosexual behaviors often shown by institutional residents) and teaching of appropriate sexual roles and behavior are simply two aspects of the same problem. H e recommends a c o n d i t i o n i n g program in which various therapy techniques (systematic desensitization, role-playi ng , reinforcement, etc.) are used to achieve the disappearance of deviant behaviors. As these become more aversive, acceptable behavior is substituted. The two, previously mentioned, aspects of this problem are most certainly related, but attacking the situation as a single entity may be oversimplification. Without FEBRUARY 1975 VOLUME X L V NO. 2
adequate environmental change, and recognition of such within a total instructional program, such conditioning may only lead to an increase in anxiety when the retardate tries to function appropriately within an inappropriate environment. (The appearance of homosexuality in a sex-segregated institution cannot be considered unreasonable, while auto-erotic behavior may be a function of the inability of an individual of low intelligence to relate outside hi mse If.) Sex e d u c a t i o n p r o g r a m s , as a l l other instructional procedures, must be geared to the level of the individual. Problems such as d e c r e a s e d a t t e n t i o n span, l e a r n i n g a n d socialization difficu Ities, and the inability, at times, to comfortably accept new situations are not specific to the intellectually impaired. The special considerations come into play i n the determination of appropriate methods to deal with these situations. To effect a positive learning situation, Kempton I suggests that much of what is used in normal classrooms can be used with the educable retarded, only adapted to a simpler method of presentation. Repetition is recommended, along with major use of visual aids. (Retarded individuals have a great deal of trouble with abstraction and respond much better to visual and tactile stimulation.) The general approach is to move from simple explanations to the most complex level the individual is capable of understanding. One can begin with self and self-care, moving on through biological explanations, social and emotional implications, and social and biological implications whenever indicated. Selznick supports this idea by stating that one might, for example, begin with a simple lesson on the correct names of the visible parts of the body. This provides a vocabulary for asking questions, and is a basis from which individuals begin to understand differences between males and females. Those capable of achieving a higher level of understanding, and indicating by their questions a need for more information, can move on to the meanings of these visible differences i n the biological andlor social-emotional areas. A s the children grow physically, bodily changes can be explained and integrated into the total curriculum. Selznick also includes i n her description of a comprehensive program, preparation for marriage and child care, and the sociology of the family as a social institution. Too much emphasis upon these areas as “normal” may provoke anxiety in those who THE JOURNAL OF SCHOOL HEALTH
cannot function efficiently at such a level. Retarded marriages also report a higher success rate when no children are involved, as they provide an added stress with which these individuals are often unable to cope.6 Retardates who do develop a heterosexual orientation suitable for consideration of marriage can, and should, receive additional counseling. Until this point is reached, however, the educational program will most profitably be focused on sexuality and human relations (and their biological bases i f such information is needed), without inclusion of value judgments. Retarded individuals living in the community are often difficult to reach with birth control services and sex education programs. A s a precommunity, i n s t i t u t i o n a l approach t o this problem, one state school for the retarded in New England is actively engaged in the development of a sex e d u c a t i o n c o m p o n e n t f o r i t s normalization program. Three areas of consideration have been integ rated-i nstru ction, services, and general environment. Classes on sex education are held which include open discussion not only of factual information, but also of fears, values, and attitudes relevant to human relationships. Sessions are also conducted for parents of the residents i n an effort to integrate their all-important influence into the child’s total program. Supportive of the residents’ attempts to explore the concept of sexuality, the institution provides opportunities for heterosexual contacts in the nature of Friday night dances, coed field trips, coed classes, etc. I n general, teaching students about their bodies and the need to care for them can serve to integrate concepts of hygiene with development of self-respect and self-worth. Relative to specific health services, a gynecology clinic is now open at the school for residents, though general clinic hours are restricted to only two per week. Specific services provided, reasons for check-ups, etc., can a l l be integrated into the i n s t r u c t i o n a l s e c t i o n of the p r o g r a m a t appropriate times. A s such, a l l three elements of the program interrelate, providing residents with a total and positive learning experience to be carried over into community life. Balester‘s questioning of sex education for the retarded (how and why) is not equivalent to questioning whether a l l children are entitled to information about sexuality and human development. It is merely a statement that sex education may deceive people, particularly parents, as being the panacea for a l l of their 89
fears a n d problems. H i s belief is that the limitations of s u c h an approach have not been validly assessed. A search of the literature i n this area tends to support this last point. However, the ramifications of the statement are really m u c h greater than those expressed. Many of the characteristics mentioned i n this paper as descriptive of the retarded are also applicable to normal individuals. The sex education programs presently being used in regular classrooms have not been evaluated sufficiently to determine their value and/or effectiveness. Yet “normal” behavior and “normally-oriented” programs are used as the baseline from w h i c h programs for the retarded are derived. The programs are taken whole, and then scaled down to a lower intellectual level for use with the intellectually h a n d i c a p p e d . D e t e r m i n a t i o n of i n s t r u c t o r qualifications (if any) should not b e made u n t i l these issues of what should be taught a n d how are resolved. T o sum u p the problem i n one sentence, i f that is possible: T o represent sex e d u c a t i o n as a n attempt to influence the sexual behavior of the retarded because there seem to b e no alternatives approaches justification, to p r o p o s e i t w i t h o u t e x p r e s s n g limitations approaches deception.’
Planned Parenthood of Southeastern Pennsylvania, 1973. 2. Hammar SL, Wright LS, Jensen DL: Sex education for the retarded adolescent: a survey of parental attitudes and methods of management in fifty adolescent retardates. Clin Pediat (Phila) 6:621627, 1967. 3. Reich M, Harshman H: Sex education for handicapped children, reality or repression? J Spec Ed 5373-377, (Winter) 1971. 4. Selznick H: Sex education and the mentally retarded. Exceptional Children 32:640843, (May) 1966. 5. Rosen M: Conditioning appropriate heterosexual
6. 7. 8.
9. 10. 11.
12.
REFERENCES 1. Kempton W: Guidelines for Planning a T aining
Course on Human Sexuality and the R E arded,
behavior in mentally and socially handicapped populations. Train Sch Bull 66:172-177 (Feb) 1970. Bowden J, Spitz H, Winters J: Follow-up of one retarded couple’s marriage. Ment Retard 9:4243, (Dec) 1971. Balester RJ: Sex education: fact and fancy. J Spec Ed 5355-357, (Winter) 1971. de la Cruz F, LaVeck G, (eds): Human Sexuality and the Mentally Retarded, Brunner/Mazel, Inc., New York, 1973. Delp HA: Sex education for the handicapped. J Spec Ed 5363-364, (Winter) 1971. Gordon S: Missing in special education: sex. J Spec Ed 5:351-354, (Winter) 1971. Money J: Special sex education and cultural anthropology with reference to mental deficiency, physical deformity and urban ghettos. J Spec Ed 5369-372, (Winter) 1971. Morlock D, Tovar C: Sex education for the multiply handicapped as it applies to the classroom teachers. Train Sch Bull (Vinel) 68:87-96, (Aug) 1971.
CALL FOR RESOLUTIONS Annually the American S c h o o l Health Association addresses itself t o significant problems i n the field of c h i l d health a n d s c h o o l health education. T h e f u l l span of the discussion o n many of these p r o b l e m s is made k n o w n through a series of Resolutions passed by the G o v e r n i n g C o u nci I. T h e membership i s invited t o suggest problems w h i c h m i g h t serve as the basis for a c t i o n of this sort. S u c h suggestions s h o u l d b e transmitted to the Chairman of the Research Committee for 1975, Dr. Fred V. Hein, American S c h o o l Health Association, Kent, Ohio 44240.
90
FEBRUARY 1975 VOLUME X L V NO. 2
