Sex and Relationship Education for Individuals with Disabilities: A Review of the Literature Through an Ecological Systems Lens

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The paper shared is very relevant in today's times when in th 21st century, we still consider persons with disabilites as asexual. As rightly pointed out that researches focus on anatomy of male-female body,menstrual hygiene  and protective measures from abuse. It is imperative to have a holistic approach towards sexual development of persons with disabilities as well as anybody else. A formal curriculum for sex and relationship education (SRE) is the need of the hour for persons with ID or on the spectrum.The synthesis of researches with the lens of Bronfenbrenner's Ecological theory was very interesting. There could be comparative table of commonalities/ features and challenges observed in the various researches analyzed. Review of researchers could be done from other countries as well to portray a global representation on the theme selected.

Author Response

Review 1

The paper shared is very relevant in today's times when in the 21st century, we still consider persons with disabilities as asexual. As rightly pointed out that research focus on anatomy of male-female body, menstrual hygiene  and protective measures from abuse. It is imperative to have a holistic approach towards sexual development of persons with disabilities as well as anybody else. A formal curriculum for sex and relationship education (SRE) is the need of the hour for persons with ID or on the spectrum. The synthesis of research with the lens of Bronfenbrenner's Ecological theory was very interesting. There could be comparative table of commonalities / features and challenges observed in the various research analyzed. Review of research could be done from other countries as well to portray a global representation on the theme selected.

Response: Thank you for your feedback and this very helpful suggestion. We have included a table (Table 1) that outlines challenges in the current literature base, supporting evidence, practical solutions, and future directions.  We have included research from other countries for global representation of SRE. We feel this table provides a helpful overview of the points we highlight in the paper and improves the overall accessibility of the paper content for our readers. 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The article is relevant and meets the journal's profile.

The manuscript is of a theoretical character, and sufficient scientific publications on the research topic have been analysed. 
The authors of the article indicate that they have direct practical experience and have encountered various categories of persons with disabilities, including in the context of sexual culture, diversity and relations between them.

The challenges and difficulties faced by persons with disabilities, including in education and interaction, are substantiated.  
The consideration of this problem in the context of Bronfenbrenner's model of ecological systems is noteworthy, since the interaction between and within the environment shapes the individual trajectory of a person with a disability.

Suggestions for improving the content of the article: 
1. The scientific novelty of this study should be emphasised in the abstract.
2. The article should indicate how the study can affect the practical solution of the problem, i.e. its practical orientation for the creation of inclusive sexual health education programmes taking into account the needs of people with disabilities.
3. The manuscript describes this problem in the United States. It would be interesting if the authors could partially show how this works in other countries, whether there is already a positive experience with sex and relationship education for people with disabilities, or vice versa, whether there are even greater difficulties and bullying against them, based on gender or nosology.

Author Response

Review 2

The manuscript is of a theoretical character, and sufficient scientific publications on the research topic have been analyzed. The authors of the article indicate that they have direct practical experience and have encountered various categories of persons with disabilities, including in the context of sexual culture, diversity and relations between them.

The challenges and difficulties faced by persons with disabilities, including in education and interaction, are substantiated.  The consideration of this problem in the context of Bronfenbrenner's model of ecological systems is noteworthy, since the interaction between and within the environment shapes the individual trajectory of a person with a disability. Suggestions for improving the content of the article: 

1. The scientific novelty of this study should be emphasized in the abstract.
2. The article should indicate how the study can affect the practical solution of the problem, i.e. its practical orientation for the creation of inclusive sexual health education programmes taking into account the needs of people with disabilities.
3. The manuscript describes this problem in the United States. It would be interesting if the authors could partially show how this works in other countries, whether there is already a positive experience with sex and relationship education for people with disabilities, or vice versa, whether there are even greater difficulties and bullying against them, based on gender or nosology.

Response: Thank you for your helpful feedback. We have incorporated your suggestions for improving the content of the article in the following ways:

1. We have further emphasized the scientific novelty of our study within the abstract, highlighting our direct and practical experiences and the noteworthiness of situating SRE in the context of a systems framework. 
2. We have included a table (Table 1) that outlines challenges within the literature, supporting evidence, practical solutions, and future directions.
3. We have added text related to issues faced by the international community throughout the paper as well as within the section on the Macrosystem.  Since effective SRE tactics are largely impacted by cultural factors, we feel that the inclusion of this content has made our paper more relevant and expansive than before. We thank you.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

1.  At line 84 ID should be identified if that's the first mention, as done at line 96.
2.  I don't know why but when I tried to submit my comments the first time, all those  comments disappeared.  My concern surrounds the Comparison Level for Alternatives for disabled persons.  If they see themselves as having fewer "shots" at a healthy romantic relationship than their peers, they may feel both time compression and a need to go after the first or early "nice fish" that come along, who respect them despite their limitations.  However, that feeling may dissuade potential suitors who want to be loved for themselves and not just for being the most available at the moment.  The person rushing into a relationship may come across as too needy and not having as much value otherwise.  Just some issues to consider adding to the discussion, keyed to the developmental processes of romantic relationships as they might differ between non-disabled and disabled.  

Author Response

Review 3

1.  At line 84 ID should be identified if that's the first mention, as done at line 96.

Response: Thank you for closely reviewing our paper. We have written “intellectual disability (ID)” at line 84 since this was the first time of mention. We have removed ‘intellectual disability’ from line 96 and have written ID instead.

2.  I don't know why but when I tried to submit my comments the first time, all those  comments disappeared.  My concern surrounds the Comparison Level for Alternatives for disabled persons.  If they see themselves as having fewer "shots" at a healthy romantic relationship than their peers, they may feel both time compression and a need to go after the first or early "nice fish" that come along, who respect them despite their limitations.  However, that feeling may dissuade potential suitors who want to be loved for themselves and not just for being the most available at the moment.  The person rushing into a relationship may come across as too needy and not having as much value otherwise.  Just some issues to consider adding to the discussion, keyed to the developmental processes of romantic relationships as they might differ between non-disabled and disabled.  

Response: You brought up an interesting and important issue that has encouraged a lot of discussion/debate within our group. People with disabilities have unique social-sexual experiences/perspectives that may not be shared with neurotypical people. One of the practical solutions that we hope comes from this paper is to highlight the need for social-sexual education that is uniquely designed for people with disabilities, not just modified sex ed. The SRE programs that have the most success take into account the unique lived experience of people with disabilities. We have discussed further in our discussion section. Thank you for bringing this up. 

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

The authors have produced a thoughtful paper on sexual and relationship education among people with intellectual disabilities. I especially like the theory-informed approach to the literature review. This subject can clearly benefit from more attention, and this study is a solid step in that direction.  

My primary concern with this paper concerns the lack of description concerning the generation of the literature reviewed within it and minimal attention to the analytical approaches employed to render the findings. The Sexes website (https://www.mdpi.com/journal/sexes/instructions) mentions Reviews as one of its submission categories, and this certainly fits that category. Although the article may not aspire to be a scoping or systematic review, please see the PRISMA guidelines discussed on the Sexes journal website.

This paper would be significantly improved by following the PRISMA guidelines that are feasible and suitable to its purpose. At the very least, I'd suggest addressing items 6 and 7 in the PRISMA guidelines (item 6: https://knowledgetranslation.net/wp-content/uploads/2019/05/PRISMA-ScR_TipSheet_Item6.pdf; item 7: https://knowledgetranslation.net/wp-content/uploads/2019/05/PRISMA-ScR_TipSheet_Item7.pdf). Discuss inclusion and exclusion criteria. Please explain what databases were searched, the search terms used, the search dates, etc.  And specify the number of articles in the initial searches and the final sample of articles once all criteria were applied. While this article does not use empirical data (and that's fine), review rigor and replicable knowledge is achieved when the methodological procedures used to conduct the review are explicated.

I recognize that this study is not a scoping review or systematic review. However, the authors might consult some previous review articles in Sexes that reveal their methods. See, e.g.,  https://www.mdpi.com/2411-5118/6/3/32. Best wishes on the development of this important paper. 

Author Response

Reviewer 4

The authors have produced a thoughtful paper on sexual and relationship education among people with intellectual disabilities. I especially like the theory-informed approach to the literature review. This subject can clearly benefit from more attention, and this study is a solid step in that direction.  

My primary concern with this paper concerns the lack of description concerning the generation of the literature reviewed within it and minimal attention to the analytical approaches employed to render the findings. The Sexes website (https://www.mdpi.com/journal/sexes/instructions) mentions Reviews as one of its submission categories, and this certainly fits that category. Although the article may not aspire to be a scoping or systematic review, please see the PRISMA guidelines discussed on the Sexes journal website.

This paper would be significantly improved by following the PRISMA guidelines that are feasible and suitable to its purpose. At the very least, I'd suggest addressing items 6 and 7 in the PRISMA guidelines (item 6: https://knowledgetranslation.net/wp-content/uploads/2019/05/PRISMA-ScR_TipSheet_Item6.pdf; item 7: https://knowledgetranslation.net/wp-content/uploads/2019/05/PRISMA-ScR_TipSheet_Item7.pdf). Discuss inclusion and exclusion criteria. Please explain what databases were searched, the search terms used, the search dates, etc.  And specify the number of articles in the initial searches and the final sample of articles once all criteria were applied. While this article does not use empirical data (and that's fine), review rigor and replicable knowledge is achieved when the methodological procedures used to conduct the review are explicated.

I recognize that this study is not a scoping review or systematic review. However, the authors might consult some previous review articles in Sexes that reveal their methods. See, e.g.,  https://www.mdpi.com/2411-5118/6/3/32. Best wishes on the development of this important paper. 

Response: Thank you for reviewing our paper and for this suggestion. Although we do see the value and importance of performing a formal literature review following the PRISMA guidelines, our paper was not initially intended to be a scoping systematic review of the literature. Rather, we feel it provides a descriptive look at the current literature base through a systems lens (between 2013-2025), highlighting the multiple layers of influence that shape individual experience of SRE for people with disabilities. We have added a note at the end of the paper as a limitation of the work, cautioning the reader that our paper is more of an informal review rather than an exhaustive list of the literature.

Author Response File: Author Response.pdf

Round 2

Reviewer 4 Report

Comments and Suggestions for Authors

Good job with this revision. The points of elaboration are valid and the new table is very helpful. I remain enthusiastic about this paper. 

Some additional search process detail remains a necessary addition. I am not at all insisting that PRISMA guidelines be followed. That said, the paper needs a brief footnote (perhaps to Table 1) or a quick few sentences that simply indicate what databases and search terms were used to generate this literature. I'd suggest something succinct, like this:

"The literature reviewed in this study was secured from searches conducted using databases such as [name some/all databases here]. The following are examples of search terms used to generate the studies reviewed here: [identify sample search terms here]. Additional literature was also gathered through a careful review of bibliographic citations featured in articles secured from these database searches."

I recognize that the authors conducted a conceptually driven review, which I really like. But some additional explication on the search process is needed. Feel free to tailor this statement to reflect your actual practices and the search logic. As it stands, this remains rather opaque. 

Author Response

Revisions #2 

Good job with this revision. The points of elaboration are valid and the new table is very helpful. I remain enthusiastic about this paper.  

Some additional search process detail remains a necessary addition. I am not at all insisting that PRISMA guidelines be followed. That said, the paper needs a brief footnote (perhaps to Table 1) or a quick few sentences that simply indicate what databases and search terms were used to generate this literature. I'd suggest something succinct, like this: 

"The literature reviewed in this study was secured from searches conducted using databases such as [name some/all databases here]. The following are examples of search terms used to generate the studies reviewed here: [identify sample search terms here]. Additional literature was also gathered through a careful review of bibliographic citations featured in articles secured from these database searches." 

I recognize that the authors conducted a conceptually driven review, which I really like. But some additional explication on the search process is needed. Feel free to tailor this statement to reflect your actual practices and the search logic. As it stands, this remains rather opaque.  

Response: Thank you again for carefully reviewing our paper and for providing us with example text to include in our review. We have added a paragraph to the limitations section outlining the databases we used as well as our search terms.