Sexuality and Disability

, Volume 37, Issue 3, pp 353–382 | Cite as

Autism and Intellectual Disability: A Systematic Review of Sexuality and Relationship Education

  • Giorgia Sala
  • Merrilyn Hooley
  • Tony Attwood
  • Gary B. Mesibov
  • Mark A. StokesEmail author
Original Paper


Individuals with neurodevelopmental disorders, including Autism (ASD) and intellectual disability (ID), have a right and need for appropriate sexuality and relationship education (SRE). These individuals often have the same desires as typically-developing people to express their sexuality and form intimate relationships; and may have an increased risk of sexual exploitation and abuse. While there are various materials recommended for teaching SRE to these groups, there is a lack of empirical evaluation of such. A systematic review was carried out on peer-reviewed articles published in English between 1980 and March 2018 to identify what SRE programs have been evaluated empirically, highlighting their content, methods of delivery, efficacy in changing knowledge and behavioural outcomes, and limitations. Thirty-three studies were retained for inclusion which quantitatively evaluated SRE interventions delivered to individuals diagnosed with ID (approximately 63%) and ASD. Most of the studies evaluated stand-alone programs derived from mixed sources within the broader SRE literature. They focused more on biological content (e.g., anatomy, puberty, reproduction) and self-awareness/safety (e.g., boundaries, assertiveness, privacy) than personal sexuality (e.g., sexual orientation, masturbation) and relationships (e.g., dating, emotions, parenting). Most programs improved outcomes, however the overall quality of included studies was poor. Limitations included scant description of theoretical and ethical paradigms within programs and use of non-validated outcome measures. Recommendations for future research and clinical implications are discussed.


Autism Intellectual disability Sexual education Sexuality Disability Australia 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
    American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Association, Washington, DC (2013)CrossRefGoogle Scholar
  2. 2.
    Chen, J.A., Swarup, V., Geschwind, D.H., Belgard, T.G., Peñagarikano, O.: The emerging picture of autism spectrum disorder: genetics and pathology. Annu. Rev. Pathol. Mech. Dis. 10(1), 111–144 (2015). CrossRefGoogle Scholar
  3. 3.
    Kenny, L., Hattersley, C., Molins, B., Buckley, C., Povey, C., Pellicano, E.: Which terms should be used to describe autism? Perspectives from the UK autism community. Autism [Internet] 20(4), 442–462 (2016). CrossRefGoogle Scholar
  4. 4.
    Baio, J., Wiggins, L., Christensen, D.L., Maenner, M.J., Daniels, J., Warren, Z., et al.: Prevalence of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2014. MMWR Surveill Summ. 67(6), 1 (2018). CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Zablotsky, B., Black, L.I., Blumberg, S.J.: Estimated prevalence of children with diagnosed developmental disabilities in the United States, 2014–2016. NCHS Data Brief. (291): 1–8 (2017). Available from:
  6. 6.
    McPartland, J.C., Law, K., Dawson, G.: Autism spectrum disorder. In: Friedman, H.S. (ed.) Encyclopedia of Mental Health, 2nd edn, pp. 124–130. Elsevier, Waltham (2016)CrossRefGoogle Scholar
  7. 7.
    Sullivan, A., Caterino, L.C.: Addressing the sexuality and sex education of individuals with autism spectrum disorders. Educ. Treat Child. [Internet] 31(3), 381–394 (2008). CrossRefGoogle Scholar
  8. 8.
    Brown-Lavoie, S., Viecili, M., Weiss, J.: Sexual knowledge and victimization in adults with autism spectrum disorders. J Autism Dev. Disord. [Internet] 44(9), 2185–2196 (2014). CrossRefGoogle Scholar
  9. 9.
    Murphy, G.H., O’Callaghan, A.: Capacity of adults with intellectual disabilities to consent to sexual relationships. Psychol. Med. [Internet] 34(7), 1347–1357 (2004). CrossRefGoogle Scholar
  10. 10.
    Tamas, D., Brkic, N., Milana, J., Tamas, D.: Professionals, parents and the general public : attitudes towards the sexuality of persons with intellectual disability. Sex. Disabil. (2019). CrossRefGoogle Scholar
  11. 11.
    Gougeon, N.A.: Sexuality and autism: a critical review of selected literature using a social-relational model of disability. Am. J. Sex. Educ. [Internet] 5(4), 328–361 (2010). CrossRefGoogle Scholar
  12. 12.
    Fernandes, L., Gillberg, C., Cederlund, M., Hagberg, B., Gillberg, C., Billstedt, E.: Aspects of sexuality in adolescents and adults diagnosed with autism spectrum disorders in childhood. J. Autism Dev. Disord. [Internet] 46(9), 3155–3165 (2016). CrossRefGoogle Scholar
  13. 13.
    Schöttle, D., Briken, P., Tüscher, O., Turner, D.: Sexuality in autism: hypersexual and paraphilic behavior in women and men with high-functioning autism spectrum disorder. Dialogues Clin. Neurosci. 19(4), 381 (2017)PubMedPubMedCentralGoogle Scholar
  14. 14.
    Pecora, L.A., Mesibov, G.B., Stokes, M.A.: Sexuality in high-functioning autism: a systematic review and meta-analysis. J. Autism Dev. Disord. [Internet] 46(11), 3519–3556 (2016). CrossRefGoogle Scholar
  15. 15.
    Thompson, V.R., Stancliffe, R.J., Broom, A., Wilson, N.J.: Barriers to sexual health provision for people with intellectual disability: a disability service provider and clinician perspective. J. Intellect. Dev. Disabil. [Internet] 39(2), 137–146 (2014). CrossRefGoogle Scholar
  16. 16.
    Stokes, M., Newton, N., Kaur, A.: Stalking, and social and romantic functioning among adolescents and adults with autism spectrum disorder. J. Autism Dev. Disord. [Internet] 37(10), 1969–1986 (2007). CrossRefGoogle Scholar
  17. 17.
    Schaafsma, D., Kok, G., Stoffelen, J., Curfs, L.: People with intellectual disabilities talk about sexuality: implications for the development of sex education. Sex. Disabil. [Internet] 35(1), 21–38 (2017). CrossRefGoogle Scholar
  18. 18.
    Barnett, J.P., Maticka-Tyndale, E.: Qualitative exploration of sexual experiences among adults on the Autism spectrum: implications for sex education. Perspect. Sex. Reprod. Health [Internet] 47(4), 171–179 (2015). CrossRefGoogle Scholar
  19. 19.
    George, R., Stokes, M.A.: Gender identity and sexual orientation in autism spectrum disorder. Autism 22(8), 970–982 (2018). CrossRefPubMedGoogle Scholar
  20. 20.
    Byers, E., Nichols, S.: Sexual satisfaction of high-functioning adults with autism spectrum disorder. Sex. Disabil. [Internet] 32(3), 365–382 (2014). CrossRefGoogle Scholar
  21. 21.
    Byers, E., Nichols, S., Voyer, S.: Challenging stereotypes: sexual functioning of single adults with high functioning autism spectrum disorder. J. Autism Dev. Disord. [Internet] 43(11), 2617–2627 (2013). CrossRefGoogle Scholar
  22. 22.
    George, R., Stokes, M.A.: Sexual orientation in autism spectrum disorder. Autism Res. 11(1), 133–141 (2018). CrossRefPubMedGoogle Scholar
  23. 23.
    Hénault, I.: Asperger’s syndrome and sexuality: from adolescence through adulthood. Jessica Kingsley Publishers, London (2006)Google Scholar
  24. 24.
    Attwood, S., Powell, J.: Making sense of sex: a forthright guide to puberty, sex and relationships for people with Asperger’s syndrome. Jessica Kingsley Publishers, London (2008)Google Scholar
  25. 25.
    Travers, J., Tincani, M., Whitby, P.S., Boutot, E.A.: Alignment of sexuality education with self determination for people with significant disabilities: a review of research and future directions. Educ. Train. Autism Dev. Disabil. [Internet] 49(2), 232–247 (2014)Google Scholar
  26. 26.
    Koller, R.: Sexuality and adolescents with autism. Sex. Disabil. [Internet] 18(2), 125–135 (2000). CrossRefGoogle Scholar
  27. 27.
    Tullis, C.A., Zangrillo, A.N.: Sexuality education for adolescents and adults with autism spectrum disorders. Psychol. Sch. [Internet] 50(9), 866–875 (2013). CrossRefGoogle Scholar
  28. 28.
    Khemka, I., Hickson, L., Reynolds, G.: Evaluation of a decision-making curriculum designed to empower women with mental retardation to resist abuse. Am. J. Ment. Retard. [Internet] 110(3), 193 (2005).;2 CrossRefGoogle Scholar
  29. 29.
    Travers, J., Tincani, M.: Sexuality education for individuals with autism spectrum disorders: Critical issues and decision making guidelines. Educ. Train. Autism Dev. Disabil. 45(2), 248–293 (2010)Google Scholar
  30. 30.
    Hénault, I.: Understanding relationships and sexuality in individuals with high-functioning ASD. In: Scarpa, A., Williams White, S., Attwood, T., Scarpa, A., Williams White, S., Attwood, T. (eds.) CBT for Children and Adolescents with High-Functioning Autism Spectrum Disorders, pp. 278–299. Guilford Press, New York (2013)Google Scholar
  31. 31.
    Blanchett, W.J., Wolfe, P.S.: A review of sexuality education curricula: meeting the sexuality education needs of individuals with moderate and severe intellectual disabilities. Res. Pract. Pers. Sev. Disabil. 27(1), 43–57 (2002). CrossRefGoogle Scholar
  32. 32.
    Schaafsma, D., Kok, G., Stoffelen, J.M.T., Curfs, L.M.G.: Identifying effective methods for teaching sex education to individuals with intellectual disabilities: a systematic review. J. Sex. Res. 52(4), 412–432 (2015). CrossRefPubMedGoogle Scholar
  33. 33.
    Attwood, T.: The complete guide to Asperger’s syndrome. Jessica Kingsley Publishers, London (2006)Google Scholar
  34. 34.
    Esmail, S., Darry, K., Walter, A., Knupp, H.: Attitudes and perceptions towards disability and sexuality. Disabil. Rehabil. 32(14), 1148–1155 (2010). CrossRefPubMedGoogle Scholar
  35. 35.
    Stone, S.D.: Reactions to invisible disability: the experiences of young women survivors of hemorrhagic stroke. Disabil. Rehabil. 27(6), 293–304 (2005). CrossRefPubMedGoogle Scholar
  36. 36.
    McLay, L., Carnett, A., Tyler-Merrick, G., van der Meer, L.: A systematic review of interventions for inappropriate sexual behavior of children and adolescents with developmental disabilities. Rev. J. Autism Dev. Disord. 2(4), 357–373 (2015). CrossRefGoogle Scholar
  37. 37.
    American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 3rd edn. American Psychiatric Association, WashingtonDC (1980)Google Scholar
  38. 38.
    Thomas, B.H., Ciliska, D., Dobbins, M., Micucci, S.: A process for systematically reviewing the literature: Providing the research evidence for public health nursing interventions. Worldviews Evid. Based Nurs. 1(3), 176–184 (2004)CrossRefPubMedGoogle Scholar
  39. 39.
    Cunningham, A., Sperry, L., Brady, M.P., Peluso, P.R., Pauletti, R.E.: The effects of a romantic relationship treatment option for adults with autism spectrum disorder. Couns. Outcome Res. Eval. 7(2), 99–110 (2016). CrossRefGoogle Scholar
  40. 40.
    Valenti-Hein, D.C., Yarnold, P.R., Mueser, K.T.: Evaluation of the dating skills program for improving heterosocial interactions in people with mental retardation. Behav. Modif. [Internet] 18(1), 32–46 (1994). CrossRefGoogle Scholar
  41. 41.
    Visser, K., Greaves-Lord, K., Tick, N.T., Verhulst, F.C., Maras, A., Vegt, E.J.M.: A randomized controlled trial to examine the effects of the Tackling Teenage psychosexual training program for adolescents with autism spectrum disorder. J. Child Psychol. Psychiatry [Internet] 58(7), 840–850 (2017). CrossRefGoogle Scholar
  42. 42.
    Graff, H.J., Moyher, R.E., Bair, J., Foster, C., Gorden, M.E., Clem, J.: Relationships and sexuality: How is a young adult with an intellectual disability supposed to navigate? Sex. Disabil. 36(2), 175–183 (2018). CrossRefGoogle Scholar
  43. 43.
    Hayashi, M., Arakida, M., Ohashi, K.: The effectiveness of a sex education program facilitating social skills for people with intellectual disability in Japan. J. Intellect. Dev. Disabil. 36(1), 11–19 (2011). CrossRefPubMedGoogle Scholar
  44. 44.
    Box, M., Shawe, J.: The experiences of adults with learning disabilities attending a sexuality and relationship group: “I want to get married and have kids”. J. Fam. Plan. Reprod. Health Care 40(2), 82–88 (2014). CrossRefGoogle Scholar
  45. 45.
    Dekker, L.P., van der Vegt, E.J.M., Visser, K., Tick, N., Boudesteijn, F., Verhulst, F.C., et al.: Improving psychosexual knowledge in adolescents with autism spectrum disorder: pilot of the tackling teenage training program. J. Autism Dev. Disord. [Internet] 45(6), 1532–1540 (2015). CrossRefGoogle Scholar
  46. 46.
    Pask, L., Hughes, T.L., Sutton, L.R.: Sexual knowledge acquisition and retention for individuals with autism. Int. J. Sch. Educ. Psychol. [Internet] 4(2), 86–94 (2016). CrossRefGoogle Scholar
  47. 47.
    Corona, L.L., Fox, S.A., Christodulu, K.V., Worlock, J.A.: Providing education on sexuality and relationships to adolescents with autism spectrum disorder and their parents. Sex. Disabil. [Internet] 34(2), 199–214 (2016). CrossRefGoogle Scholar
  48. 48.
    McDermott, S., Kelly, M., Spearman, J.: Evaluation of a family planning program for individuals with mental retardation. Sex. Disabil. [Internet] 12(4), 307–317 (1994). CrossRefGoogle Scholar
  49. 49.
    Robinson, S.: Effects of a sex education program on intellectually handicapped adults. Aust. N. Z. J. Dev. Disabil. [Internet] 10(1), 21–26 (1984). CrossRefGoogle Scholar
  50. 50.
    Penny, R.E.C., Chataway, J.E.: Sex education for mentally retarded persons. Aust. N. Z. J. Dev. Disabil. [Internet] 8(4), 204–212 (1982). CrossRefGoogle Scholar
  51. 51.
    Garwood, M., McCabe, M.P.: Impact of sex education programs on sexual knowledge and feelings of men with a mild intellectual disability. Educ. Train. Ment. Retard. Dev. Disabil. [Internet] 35(3), 269–283 (2000)Google Scholar
  52. 52.
    Visser, K., Greaves-Lord, K., Tick, N.T., Verhulst, F.C., Maras, A., van der Vegt, E.J.M.: Study protocol: a randomized controlled trial investigating the effects of a psychosexual training program for adolescents with autism spectrum disorder. BMC Psychiatry [Internet] 28(15), 207 (2015). CrossRefGoogle Scholar
  53. 53.
    Egemo-Helm, K.R., Miltenberger, R.G., Knudson, P., Finstrom, N., Jostad, C., Johnson, B.: An evaluation of in situ training to teach sexual abuse prevention skills to women with mental retardation. Behav. Interv. [Internet] 22(2), 99–119 (2007). CrossRefGoogle Scholar
  54. 54.
    Miltenberger, R.G., Roberts, J.A., Ellingson, S., Galensky, T., Rapp, J.T., Long, E.S., et al.: Training and generalization of sexual abuse prevention skills for women with mental retardation. J. Appl. Behav. Anal. [Internet] 32(3), 385–388 (1999). CrossRefGoogle Scholar
  55. 55.
    Kim, Y.-R.: Evaluation of a sexual abuse prevention program for children with intellectual disabilities. Behav. Interv. [Internet] 31(2), 195–209 (2016). CrossRefGoogle Scholar
  56. 56.
    Wells, J., Clark, K.D., Sarno, K.: A computer-based interactive multimedia program to reduce HIV transmission for women with intellectual disability. J. Intellect. Disabil. Res. 56(4), 371–381 (2012). CrossRefPubMedGoogle Scholar
  57. 57.
    Dukes, E.: BE M (2009) Enhancing capacity to make sexuality-related decisions in people with an intellectual disability. J. Intellect. Disabil. Res. [Internet] 53(8), 727–734 (2009). CrossRefGoogle Scholar
  58. 58.
    Lindsay, W.R., Bellshaw, E., Culross, G., Staines, C., Michie, A., et al.: Increases in knowledge following a course of sex education for people with intellectual disabilities. J Intellect Disabil. Res. [Internet] 36(6), 531–539 (1992). CrossRefGoogle Scholar
  59. 59.
    Caspar, L.A., Glidden, L.M.: Sexuality education for adults with developmental disabilities. Educ. Train. Ment. Retard. Dev. Disabil. [Internet] 36(2), 172–177 (2001). CrossRefGoogle Scholar
  60. 60.
    Rushton, J.: Learning together. Nurs. Times 90(9), 44–46 (1994)PubMedGoogle Scholar
  61. 61.
    Lumley, V.A., Miltenberger, R.G., Long, E.S., Rapp, J.T., Roberts, J.A.: Evaluation of a sexual abuse prevention program for adults with mental retardation. J. Appl. Behav. Anal. [Internet] 31(1), 91–101 (1998). CrossRefGoogle Scholar
  62. 62.
    Haseltine, B., Miltenberger, R.G.: Teaching self-protection skills to persons with mental retardation. Am. J. Ment. Retard. 95(2), 188–197 (1990)PubMedGoogle Scholar
  63. 63.
    McDermott, S., Martin, M., Weinrich, M., Kelly, M.: Program evaluation of a sex education curriculum for women with mental retardation. Res. Dev. Disabil. [Internet] 20(2), 93–106 (1999). CrossRefGoogle Scholar
  64. 64.
    Plaks, M., Argaman, R., Stawski, M., Qwiat, T., Polak, D., Gothelf, D.: Social-sexual education in adolescents with behavioral neurogenetic syndromes. Isr. J. Psychiatry Relat. Sci. 47(2), 28–34 (2010)Google Scholar
  65. 65.
    Mueser, K.T., Valenti-Hein, D., Yarnold, P.R.: Dating-skills groups for the developmentally disabled: social skills and problem-solving versus relaxation training. Behav. Modif. 11(2), 200–228 (1987). CrossRefPubMedGoogle Scholar
  66. 66.
    Sheppard, L.: Growing pains: a personal development program for students with intellectual and developmental disabilities in a specialist school. J. Intellect. Disabil. [Internet] 10(2), 121–142 (2006). CrossRefGoogle Scholar
  67. 67.
    Zylla, T., Demetral, G.D.: A behavioral approach to sex education. Sex. Disabil. 4(1), 40–48 (1981). CrossRefGoogle Scholar
  68. 68.
    Foxx, R.M., McMorrow, M.J., Storey, K.: Rogers BM (1984) Teaching social/sexual skills to mentally retarded adults. Am. J. Ment. Defic. [Internet] 89(1), 9–15 (1984)Google Scholar
  69. 69.
    Foxx, R.M., Faw, G.D.: An eight-year follow-up of three social skills training studies. Ment. Retard. [Internet] 30(2), 63–66 (1992)Google Scholar
  70. 70.
    Foxx, R.M., McMorrow, M.J.: Teaching social skills to mentally retarded adults: Follow-up results from three studies. Behav. Ther. 8, 77–78 (1995)Google Scholar
  71. 71.
    Robinson, S.: Effects of a sex education program on intellectually handicapped adults. Aust. N. Z. J. Dev. Disabil. 10(1), 21–26 (1984). CrossRefGoogle Scholar
  72. 72.
    Lindsay, W.R., Michie, A.M., Staines, C., Bellshaw, E., Culross, G.: Client attitudes towards relationships: changes following a sex education programme. Br. J. Learn. Disabil. 22(2), 70–73 (1994). CrossRefGoogle Scholar
  73. 73.
    Lee, Y.K., Tang, C.S.: Evaluation of a sexual abuse prevention program for female Chinese adolescents with mild mental retardation. Am. J. Ment. Retard. [Internet] 103(2), 105–116 (1998).;2 CrossRefGoogle Scholar
  74. 74.
    Bejerot, S., Eriksson, J.M.: Sexuality and gender role in autism spectrum disorder: a case control study. PLoS One [Internet] 9(1), e87961 (2014). CrossRefGoogle Scholar
  75. 75.
    Walker-Hirsch, L., Champagne, M.P.: The circles concept: Social competence in special education. Contemp. Issues Sex. Educ. 49(1), 65–67 (1991)Google Scholar
  76. 76.
    Helmich, J.: What is comprehensive sexuality education? Going waaaaay beyond abstinence and condoms. Am. J. Sex. Educ. 4(1), 10–15 (2009). CrossRefGoogle Scholar
  77. 77.
    Saxe, A., Flanagan, T.: Unprepared: an appeal for sex education training for support workers of adults with developmental disabilities. Sex. Disabil. [Internet] 34(4), 443–454 (2016). CrossRefGoogle Scholar
  78. 78.
    Wolfe, P.S.: The influence of personal values on issues of sexuality and disability. Sex. Disabil. 15(2), 69–90 (1997)CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Giorgia Sala
    • 1
  • Merrilyn Hooley
    • 1
  • Tony Attwood
    • 1
  • Gary B. Mesibov
    • 1
  • Mark A. Stokes
    • 1
    Email author
  1. 1.School of Psychology, Faculty of HealthDeakin UniversityBurwoodAustralia

Personalised recommendations