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Enhancing Comprehensive Sexuality Education for Students with Disabilities: Insights from Ontario's Educational Framework

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21 August 2023

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24 August 2023

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Abstract
Comprehensive sexuality education (CSE) is an important framework utilized worldwide to provide students and young people with accurate, affirming, and socially conscious sexuality education. However, there is still a lack of CSE curricula in school contexts that is relevant for students with various disabilities. This article takes the Ontario, Canada context as an example of where and how CSE can improve to be more inclusive for students with disabilities. This article reviews the current context of CSE in Ontario, Canada, including its controversies while providing recommendations for meeting the needs of students with various disabilities, including psychological, intellectual, and physical disabilities. This article aims to provide recommendations that are relevant for scholars, researchers, and policymakers in various international contexts for improving CSE for students with disabilities in schooling.
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Subject: Public Health and Healthcare  -   Other

1. Sexuality Education in Ontario: Addressing the Nexus of Disability, Gender, and Sexuality in Canadian Curricula

Conversations surrounding comprehensive sexuality education (CSE) have gained momentum internationally. Esteemed organizations, notably the United Nations Educational, Scientific, and Cultural Organization, are pioneering international guidelines and frameworks to address sexuality and gender in diverse educational settings [1]. While disability is recognized as a fundamental facet of an individual's identity and well-being [2], the discourse on the requirements of individuals with disabilities within the realm of CSE remains conspicuously sparse in the Canadian milieu [3]. A significant portion of the literature on sexuality education for students with disabilities underscores the needs of those with intellectual disabilities, especially in social and emotional dimensions [4]. Such dialogues are indispensable for educators, necessitating tailored pedagogies for students with a spectrum of disabilities—ranging from psychological and developmental to intellectual and physical. Furthermore, there's an imperative to equip special and inclusive education teachers with the skills to navigate the confluence of disability, gender, and sexuality in their pedagogical practices [5].
This article endeavors to elucidate the distinct needs of individuals with varied disabilities in the context of CSE within educational institutions. Building upon extant Canadian scholarship, we delineate the prevailing landscape of CSE in Canadian schools [5], with a particular emphasis on the nexus between disability and CSE [4]. We spotlight the conspicuous absence of robust guidelines and curriculum frameworks tailored for students with disabilities. There's a pressing need to approach sexuality education for this demographic in a nuanced manner, eschewing a monolithic representation of disability. This exposition primarily offers a critique of the current state of sexuality education in Ontario, Canada, proffering recommendations to address the multifaceted needs associated with disability.
Our discourse commences with a panoramic view of school-based CSE in Ontario, Canada, encompassing recent curricular evolutions and controversies. Subsequently, we explore the representation—or lack thereof—of disability in Canadian sexuality education curricula [3,4]. The narrative then transitions to delineate the specific requirements and propositions for an enhanced CSE tailored for students across various disability categories, including psychological/mental, physical, intellectual, and the intersections of 2SLGBTQIA identities with disability. In culmination, this review proffers holistic recommendations to foster a more inclusive and affirming school-based sexuality education paradigm for students with disabilities. While the insights presented predominantly pertain to Ontario, Canada, the implications resonate universally, shedding light on the intricate interplay of gender, sexuality, and disability in educational pedagogies and curricula.

2. Linguistic Choices and the Social Model: Navigating Disability Discourse in Sexuality Education

This article adopts a "person-first" linguistic approach, emphasizing the individual prior to their disability (e.g., "person with a disability"). Concurrently, we recognize the salience of "identity-first" language, which empowers individuals to embrace disability as an integral facet of their identity. The juxtaposition of preferences between person-first and identity-first terminologies has engendered debates within disability scholarship. Historically, proponents of person-first language posited that it foregrounds the individual over the disability. However, critical scholars and advocates, particularly from the autistic community, contend that the individual and their disability are inextricably linked, and identity-first language venerates these disabled identities [6,7]. Yet, others [8] advocate for the coexistence of both linguistic frameworks, given the heterogeneity of preferences within the disabled community. They recommend soliciting individuals' linguistic preferences, underscoring the primacy of choice in self-identification.
In our discourse, we interpret disability through the lens of the social model. This perspective delineates disability as a socio-cultural construct, arising from the interplay between individual impairments—functional limitations—and societal barriers and exclusions [9]. To genuinely champion the rights of disabled individuals and dismantle the physical, attitudinal, and environmental impediments they face, it is imperative to challenge prevailing societal norms that dichotomize 'normal' from 'abnormal' in the realms of physiologies, sexualities, and relationships [10]. Applying the social model to sexuality education offers a framework to scrutinize how students with disabilities might be marginalized through peer exclusion [11] and educators' lack of preparedness in addressing gender and sexuality nuances [12]. Notably, there is a conspicuous dearth of Canadian scholarship on equipping future educators to adeptly navigate sexuality education for students with disabilities in their pedagogical endeavors [13]. In this regard, Canada mirrors global trends, reflecting an overarching need to contemporize school-based sexuality education curricula in alignment with international CSE benchmarks, while concurrently catering to the diverse needs of students across the disability spectrum [14,15,16].

3. Ontario's Sexuality Education Landscape: Challenges, Politics, and the Imperative for Inclusivity

Sexuality education in Ontario, Canada, is delineated by provincially curated curricula, specifically the "Health and Physical Education" documents, bifurcated for Grades 1-8 and 9-12 [17,18]. The curriculum for Grades 1-8 underwent a revision in 2019, following the election of the incumbent Premier of Ontario, Doug Ford, and the provincial Conservative Party. This revision, influenced by Conservative and populist sentiments, relegated certain topics, including gender identity, to higher grade levels, deviating from the 2015 curriculum update [19,20]. Conventionally, sexuality education is imparted within the purview of physical education, with specialized lessons on health and sexuality delivered by physical education instructors. However, the modality of the instruction varies across Canadian provinces; some students recount receiving minimal instruction, sometimes restricted to a single workshop [21].
Despite the 2015 curriculum overhaul and subsequent 2019 modifications to the Grades 1-8 document, a significant number of Ontario schools persist in endorsing abstinence-centric sexuality education, a paradigm misaligned with comprehensive sexuality education (CSE) principles [22]. Amidst the fervent discourse on revising Ontario's sexuality education curricula, the unique requirements of students with disabilities and the imperative to capacitate special education educators and parents have been overlooked [23]. While the revamped curriculum does incorporate 'prompts' tailored for students with disabilities, it offers scant guidance addressing their multifaceted needs—spanning social, psychological, emotional, physical, and developmental domains—in the context of gender and sexuality [4].
Sexuality education remains a contentious and politically charged subject across various Canadian provinces [24,25]. Nonetheless, contemporary studies underscore a predominant endorsement of school-based sexuality education by parents across different provinces and territories, albeit with Ontario registering the least parental support [26]. Parents apprehensive about curriculum content often resort to perusing the documents or "fact-checking" to gain clarity. However, the efficacy of such endeavors in allaying parental anxieties remains a matter of debate [27]. Parents of students with disabilities might grapple with their own reservations or stigmas related to sexuality, potentially inhibiting open dialogues with their offspring [28]. Yet, a burgeoning cohort of students with disabilities is actively championing disability advocacy in the realm of sexuality education, striving to illuminate the confluence of disability and sexuality within educational settings [29]. A concerted effort is imperative to render Ontario's sexuality education more inclusive for students with disabilities and to foster meaningful engagement with their parents [4].
Subsequently, this article delves into the potential of school-based sexuality education—in Ontario and globally—to be more inclusive and resonant for students spanning diverse disability spectra. Our discourse encompasses mental/psychological disabilities, physical disabilities, intellectual disabilities, and the confluence of 2SLGBTQIA (Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual) identities with disability in the educational milieu. We conclude with overarching recommendations to integrate students with disabilities seamlessly into CSE.

4. Mental Health and Sexuality Education: Historical Perspectives, Contemporary Challenges, and the Need for Holistic Integration in Ontario's Curriculum

Recent modifications to the Ontario Health and Physical Education curriculum have incorporated discussions on mental health and well-being as integral components of health education [17,18]. The term "mental health" is a multifaceted construct, subject to varied interpretations across diverse socio-cultural and political landscapes [30]. In this paper, while employing the term "mental health," we recognize its fluid definition and emphasize that "mental health" and "mental illness" can be both intersecting and distinct entities. For instance, an individual diagnosed with a mental health condition can still maintain a positive self-image and well-being [31]. Contemporary curriculum documents in Ontario address topics like mental health literacy, socio-emotional development, and potential suicidal ideation among students [44]. However, these documents lack comprehensive guidance on discussing suicidality in an affirming, non-pathologizing manner and do not delve into the nexus between mental well-being and sexuality, as well as other dual diagnoses (e.g., mental health and autism, etc.).
Historically, in its nascent stages during the early twentieth century, mental health was intertwined with sexuality education, albeit through a pathologized and medicalized lens [32]. Subsequent curriculum updates in Canada and the U.S. shifted focus towards sexually transmitted infections and sexuality, predominantly from an abstinence perspective. This evolution omits discussions on the confluence of mental well-being and human sexuality [33,34,35]. Existing literature predominantly underscores the concerns of in-patient mental health service users, with a recurrent theme being the influence of psychiatric medications on sexual functioning [36,37,38].
Regarding students diagnosed with mental health conditions or those with mental disabilities, literature exploring the interplay between their sexual health needs and mental well-being is scant. However, some scholars highlight the potential benefits of the BETTER model in contexts involving individuals with mental health variations, emphasizing its efficacy in facilitating discussions on sexuality and its intricate relationship with mental health [39]. The BETTER approach, encompassing open dialogues on sexuality, its significance, resource provision, tailored conversations, education on safe sexual practices, and documentation, can be instrumental for educators, especially when engaging with students with mental health variations [39]. Educators must be cognizant of the intricacies involved in imparting sexuality education to students with diverse mental health backgrounds, including those with potentially traumatic experiences related to sexuality [40].
Recent Canadian studies underscore the significance of addressing mental health as an indispensable facet of sexuality and health education, advocating for a holistic approach to well-being [41]. A salient challenge for individuals with mental health variations is the potential ostracization in interpersonal, romantic, and sexual relationships upon revealing their mental health struggles [42]. Discussions should also encompass the interplay between mental distress and sexual decision-making, emotional regulation during intimate moments, condom usage, and libido fluctuations [42]. Psychosis symptoms can profoundly influence body perception, impacting an individual's self-concept and body relationship [43]. Educators must prioritize these specific intersections when broaching topics of mental health, well-being, and self-image in sexuality education sessions.

5. Physical Disabilities in Sexuality Education: Addressing Stigma, Barriers, and the Need for Inclusive Pedagogies in Ontario

Within the purview of physical disability, this article reflects students with auditory, visual, mobility, and/or health conditions, which may be permanent or episodic in nature [59]. Sexuality education for students with physical disabilities requires consideration within CSE, yet remains conspicuously absent within the Ontario curriculum [17,18]. This omission perpetuates stereotypical assumptions of asexuality and societal stigma surrounding the sexual health rights and needs of persons with physical disabilities [45]. Consequently, lacking clear focus on physical disabilities inhibits students' capacity regarding informed consent, discussions on healthy relationships, sexual safety and pleasure, in addition to eschewing conversations around bodily autonomy.
Nuanced pedagogical approaches addressing the needs of students with physical disabilities are necessary within a CSE framework. Curricula that vehemently dispel misconceptions of inherent asexuality or incapacity of forming intimate relationships align with research acknowledging minimal differences in sexual behavior between adolescents with and without physical disabilities [47,48]. While the rates of sexual activity and contraception use are comparable, students with physical disabilities may experience disparate pubertal and/or hormonal challenges than their peers, yet these concerns are absent from the curriculum [47,48,49]. This is particularly concerning regarding representation and discussions of hormonal contraceptive use, for example, due to possible contraindications with other medications or medical needs of these students. Articulating the importance of obtaining medical guidance during these conversations may be prudent.
Comparable statistics regarding sexual orientation for students with and without physical disabilities has been discussed in the literature [48]. Thus, it is important to address sexuality in a way that reflects positive representations and understandings of 2SLGBTQIA identities and sexualities as it pertains to individuals with physical disabilities. Additionally, conversations on the sexual development of students with physical disabilities, albeit limited, reflect the influence of societal stigmatization and medical trauma [49], underscoring the pressing need for CSE to adopt a trauma-informed pedagogical approach. These approaches are salient for students with physical disabilities to help facilitate conversations around safety and boundaries which are particularly relevant given the nature of their disabilities, and how under the auspices of medical treatment, they may be touched without their consent [3]. Ensuring clear differentiation between medical intervention and sexual intimacy, in addition to bolstering consent and bodily autonomy is paramount.
Attitudinal barriers permeate sexuality education, particularly regarding asexuality and ineptitude of these students, implicitly suggesting it superfluous to hold conversations around sexual well-being for youth with physical disabilities [17,18]. These omissions limit opportunities for representation and positive self-regard, in addition to stifling sexual agency among youth [46]. Beyond mindset, physical barriers also pose challenges for students with disabilities including student absenteeism due to myriad health reasons [50] and the inaccessible nature of physical education classes for some students [21,51]. Addressing barriers to inclusion for students with sensory needs, including those who are deaf/hard of hearing or blind/low vision, for example through the use of augmentative communication devices could enable their participation in CSE. Beyond assistive technology, specialized training for educators may also help to dismantle barriers for these students.

6. Intellectual Disabilities and Sexuality Education in Ontario: Bridging Gaps, Challenging Stigmas, and Crafting Inclusive Pedagogies

Intellectual disabilities (IDs), as conceptualized within the domain of sexuality education in Ontario, Canada, encompass a range of disorders characterized by restricted cognitive capacities and difficulties in adaptive behaviours. These constraints can influence a student's capacity to comprehend, assimilate, and implement knowledge pertinent to sexuality education. Within the Ontario educational paradigm, students with intellectual disabilities might require specialized pedagogical strategies to ensure they are provided with a thorough, relevant, and efficacious sexuality education. This perspective underscores the imperative for precise, inclusive definitions and methodologies tailored to the distinct educational needs of these students. The aim is to ensure they possess the requisite knowledge and competencies for informed, secure, and constructive sexual interactions, both interpersonally and intrapersonally. Moreover, this context highlights the significance of acknowledging the potential ramifications that diverse definitional interpretations might have on instructional methodologies and, subsequently, on student outcomes. It advocates for a flexible and inclusive curriculum that caters to the multifaceted needs of the entire student body, including those with intellectual and neurodevelopmental disabilities [52,53].
Sexuality education plays a pivotal role in fostering holistic development, with its significance amplified for students with IDs [52]. While Ontario, Canada, has made strides in refining its curriculum to be more inclusive [53], a comprehensive examination of the literature indicates that students with ID continue to face challenges that remain inadequately addressed [54]. Furthermore, the broader narrative surrounding sexual health education for youth with Autism and other disabilities, it underscores the prevalent issues of stigma, de-sexualization, and other barriers that impede their sexual health and well-being [45].
A substantial body of research conducted in Ontario illuminates the universal importance of sexuality education [53]. However, there exists a conspicuous gap in addressing the nuanced needs of students with ID [54]. These students often grapple with comprehending concepts such as bodily autonomy, consent, and the complexities of relationships [55]. The confluence of disability and gender further exacerbate their experiences, often leading to feelings of marginalization in romantic and sexual contexts [45]. While the Ontario curriculum does encompass these themes, the pedagogical approaches and resources may not always align with the learning requirements of students with ID [52], resulting in exclusionary practices due to a lack of specialized educator training [53]. The primary challenge is not the absence of sexuality education but its adaptability and inclusivity for students with ID [54,55]. However, the current curriculum and teaching methodologies in Ontario fall short in catering to their unique needs [52] as the present monolithic pedagogical approach is insufficient.
It is necessary to recognize that students with ID have unique learning needs and develop a curriculum that is tailored to their cognitive abilities, ensuring that concepts are presented in an accessible and comprehensible manner. Educators must be equipped with specialized training to effectively teach students with ID. This includes understanding the nuances of intellectual disabilities and employing teaching strategies that resonate with these students. It would be beneficial for disabled students to foster collaboration between educators, caregivers, and experts in the field. Such a multi-faceted approach ensures that the educational experience is holistic and addresses all facets of the student's well-being. This approach would recognize and address the overarching challenges faced by youth with Autism and other disabilities, such as societal stigma and fetishization by ensuring that the curriculum promotes inclusivity and counters these challenges. A next step for educators who teach sexuality education in schools would be to establish a feedback mechanism where students with ID and their caregivers can provide insights into the effectiveness of the sexuality education program. This ensures continuous improvement and adaptability.
Future research should prioritize understanding the distinct needs and challenges of students with ID in Ontario [54]. Collaborative efforts between educators, caregivers, and experts in the field can pave the way for a more inclusive curriculum [55]. Exploring the effectiveness of varied teaching strategies, curating specialized resources, and assessing the role of caregiver involvement can provide invaluable insights [52]. Through such comprehensive research endeavors, we can aspire to bridge existing gaps and ensure that students with ID, as well as the broader community for youth with Autism, receive the comprehensive sexuality education they rightfully deserve [45,53].

7. 2SLGBTQIA and Disability: Navigating the Dual Realms of Ableism and Queerphobia in Healthcare and Society (Adam)

The intersection of 2SLGBTQIA identities with disability reveals the amplified challenges from both ableism and queerphobia [56]. Both groups have historically faced discrimination, but their confluence can lead to unique challenges, especially in healthcare systems that might not cater to their specific needs [56]. Societal stigmas related to disability can intensify feelings of undesirability, especially in romantic contexts [45]. Recent academic discussions emphasize the diverse experiences within these groups, with challenges varying based on disability type and sociopolitical contexts [57]. Despite these adversities, there is a commendable resilience and advocacy from various organizations supporting these intersecting communities [58]. There is a pressing need to educate health providers on the sexual health of individuals with disabilities and to involve them in creating tailored health programs [45].

8. Further Recommendations

While this article has covered some of the important considerations when creating an affirming sexuality education curriculum for students with various disabilities, there are further considerations that are necessary to address. For example, previous research has described how educators in schools often feel unprepared to support the development of sexuality for students with visual impairments, often listing a lack of inclusive resources in classroom contexts that provide materials in Braille, as well as the provision of educational sexual models, or lifelike anatomic models of human genitalia, that students with visual impairments can feel and touch [60]. Other published articles on the intersections of students with visual impairments and sexuality education emphasize the importance of providing teachers with training to check their biases and assumptions to ensure that students with visual impairments receive the same education as their non-disabled peers [61].
Other research notes the nuances of sexual consent for those who are d/Deaf and hard-of-hearing, and the specific need to discuss sexual consent and communication in the context of sign language [62]. As well, it is important to have explicit conversations with d/Deaf and hard-of-hearing children about HIV/AIDS, STIs, and other everyday conversations that children who are hearing might be exposed to through pop culture and media that is targeted towards those who are hearing [63]. Further research notes the specific need to prepare teachers who are employed at deaf schools to teach and address sexuality education while acknowledging the limitations of approaches in mainstreamed school settings for students who are d/Deaf and/or hard-of-hearing [64].
Ultimately, sexuality education in schools is still highly contested and there is little unified understanding of what teaching gender and sexuality in school looks like or the best pedagogical approaches for teaching sexuality education to students [65]. While the recent update to the Ontario Health and Physical Education curriculum documents illustrates a move towards more inclusive and affirming sexuality education in schools, there is still much work to be done to ensure that teachers feel comfortable addressing sexuality and gender in schools and that the specific needs of students with disabilities as it pertains to gender and sexuality are addressed [23]. While many Ontario advocates are asking for more detailed and comprehensive guidelines for students with disabilities in Ontario schools [66,67], there has not been any new updates to the school-based sexuality education curriculum documents to provide more inclusive information for students with disabilities. Such revisions will ensure that sexuality education is in alignment with the governing United Nations codes, such as the United Nations Convention on the Rights of the Child (UN CRC) [68] and the United Nations Conventions on the Rights of Persons with Disabilities (UN CRPD) [69].

9. Conclusion

CSE is being addressed in an international context in an increasing degree, with UNESO releasing a new document with international guidelines and information regarding CSE in various geopolitical and international contexts [70]. In Ontario, Canada, despite most parents supporting sexuality education in schools [26], it remains a controversial issue in the public imaginary and political debates [19]. It is an urgent necessity to address the needs of students with various disabilities as it pertains to gender and sexuality in schools to ensure that students are properly represented in school curriculum documents and that their own interests and curiosities as it pertains to the development of their gender and sexuality are addressed. We hope that this article provides important information that can improve comprehensive sexuality education in schools in both an Ontario, Canada context, and internationally.
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