Disability, Gender, and Inequities in Perceived Quality of Sexuality Education: A Cross-Sectional Population Study

Abstract

Sexuality education is a key component of sexual and reproductive rights; however, important inequities persist across populations, particularly among people with disabilities. This study examines perceived quality of sexuality education in Chile, with a primary focus on disability-related inequities and a specific analytic emphasis on women with disabilities. We analysed data from the 2022–2023 National Survey on Health, Sexuality, and Gender (n = 17,679). The outcome was self-reported perceived quality of sexuality education. Survey-weighted descriptive analyses and ordinal logistic regressions were conducted. One model included the full sample, and a second focused on women with disabilities (n = 2324). Predicted probabilities were estimated for key interactions. Nearly half of participants reported poor sexuality education (47.2%). Predicted probabilities indicated consistently lower probabilities of reporting good sexuality education among people with disabilities across gender groups and most age groups. Among women with disabilities, higher education (secondary: odds ratio (OR) = 2.53, 95% Confidence Interval (CI): 1.84–3.49; tertiary: OR = 1.74, 95% CI: 1.12–2.72), foreign nationality (OR = 2.87, 95% CI: 1.27–6.50), and good self-rated health (OR = 1.74, 95% CI: 1.14–2.66) were associated with higher perceived quality, indicating heterogeneity within this population. These findings highlight consistent disability-related inequities in the perceived quality of sexuality education and underscore the need for inclusive, accessible, and gender-sensitive approaches grounded in human rights.

1. Introduction

Sexuality education is widely recognised as a cornerstone for health, human rights, and gender equality. It is defined as a curriculum-based process that addresses the cognitive, emotional, physical, and social dimensions of sexuality, with the aim of equipping individuals with the knowledge, skills, attitudes, and values needed to realise their health, well-being, dignity, and rights throughout the life course [1]. Limited access to appropriate sexuality education has been linked to increased risks of exploitation, unintended pregnancies, and sexually transmitted infections, as well as reduced autonomy and agency [2]. Despite this broad global consensus on the value of comprehensive sexuality education, implementation remains uneven, and its content and delivery are strongly influenced by broader social and institutional dynamics. From a human rights perspective, these gaps raise concerns about the fulfilment of sexual and reproductive rights, particularly among populations facing structural barriers, including people with disabilities.

Women with disabilities are central to this debate, as they have historically been excluded from both sexuality education and sexual and reproductive health, based on assumptions of dependency, vulnerability, and asexuality [3,4,5]. Such marginalisation reveals that access to sexuality education is shaped not only by educational provision, but also by broader normative frameworks that define whose sexual lives are recognised as legitimate and worthy of inclusion [6,7]. Consequently, sexuality education may not only reach this population unevenly but also fail to reflect their lived experiences and address their needs, thereby limiting its relevance and effectiveness.

Research on disability indicates that exclusion from sexuality education stems less from individual deficits than from broader structural and normative barriers [3,8]. This perspective underscores how educational systems can actively reproduce patterns of marginalisation affecting people with disabilities through the ways sexuality is framed, taught, and made accessible [6,7]. Systematic reviews indicate that educational programmes frequently prioritise risk prevention and basic knowledge while neglecting relational, affective, and rights-based dimensions of sexuality, as well as failing to provide accessible and inclusive pedagogical approaches [9]. These patterns suggest that the limitations of sexuality education for people with disabilities are not merely gaps in provision, but manifestations of broader structural inequities embedded within educational and social systems [6]. These inequities are not uniform across social groups. In particular, women with disabilities may experience compounded disadvantages that shape access to sexuality education, the way such education is later evaluated, and how it is experienced and interpreted over the life course [10].

In Latin America, and in Chile specifically, global trends in sexuality education are shaped by specific historical and policy contexts. National policies have been marked by fragmentation, uneven implementation, and tensions between rights-based frameworks and more conservative or biomedical approaches [11,12]. While such policies affect the population broadly, women with disabilities may be disproportionately impacted, due to their heightened exposure to violence and the sexualisation of their bodies. They have also been historically marginalised from sexuality education and broader discussions on sexuality due to harmful stereotypes portraying them as asexual or as incompatible with dominant cis-heteronormative reproductive expectations [10].

Despite recent policy developments having incorporated gender and human rights perspectives, disability inclusion remains limited, and the actual delivery of sexuality education varies substantially across educational settings [13]. Research has highlighted both the promise of school-based programmes and the persistence of institutional and cultural barriers, such as limited teacher training and resistance to addressing diversity [13]. In addition, studies on sexual and reproductive health in Chile have documented exclusionary experiences among women with disabilities, illustrating how structural inequities extend beyond education into healthcare and other social domains [5]. Nevertheless, population-based evidence on how individuals retrospectively assess the sexuality education they received remains limited, particularly from an intersectional perspective [14,15]. Such evidence is particularly scarce for people with disabilities, and even more so for women with disabilities, both in Chile and internationally [16].

Addressing this gap is especially relevant for interdisciplinary research on sexuality, which conceptualises sexuality as a complex social phenomenon shaped by cultural, structural, and relational processes. Drawing on data from the 2022–2023 National Survey on Health, Sexuality, and Gender [17], this study examines self-reported perceived quality of sexuality education among the adult urban population of Chile, with a primary focus on disability-related inequities and a specific analytic emphasis on women with disabilities. First, it examines disability-related differences in perceived quality of sexuality education across gender groups in the adult population, and second, it examines the sociodemographic and health-related factors associated with more positive evaluations among women with disabilities. By adopting an intersectional approach and using nationally representative urban survey data, this study provides evidence on disability-related inequities in the perceived quality of sexuality education and informs more inclusive and rights-based sexuality education policies.

Theoretical Framework

The study is grounded in feminist disability studies, which conceptualise disability not only as a structural condition but also as a site where norms of embodiment, autonomy, and sexuality are actively produced and contested. Moving beyond the social model of disability [8], feminist and crip approaches emphasise that ableism operates alongside cis-heteronormativity to regulate sexual subjectivity, privileging forms of sexuality aligned with independence, rationality, and bodily normativity [3,18]. From this perspective, sexuality education is not simply unevenly distributed; it is intrinsically structured by normative assumptions that delimit who is recognised as a legitimate sexual subject. This framework is particularly relevant for analysing perceived quality, as subjective evaluations may capture whether individuals felt recognised, addressed, or excluded within prevailing normative frameworks of sexuality education [7].

To account for the relational and stratified nature of these processes, the study adopts an intersectional framework [19], understood not as the mere co-occurrence of social categories but as the interaction of systems of power that produce differentiated forms of marginalisation [20]. In the context of sexuality education, this approach is particularly relevant for analysing how disability intersects with gender to shape access to knowledge, recognition, and sexual agency. Feminist scholarship has shown that women with disabilities are positioned at the intersection of gendered and ableist norms that constrain their sexual autonomy and visibility [21]. Intersectionality also highlights within-group heterogeneity, challenging assumptions that social categories are homogeneous. It shows how multiple axes of power—such as education, migration status, and health—interact to produce differentiated, context-specific experiences among populations that are often treated as homogeneous [20,22]. This approach justifies the decision to examine women with disabilities as a distinct analytic group, whose experiences may be shaped by specific configurations of disadvantage and privilege.

Finally, this study is informed by a human rights framework, which positions access to comprehensive, inclusive, and non-discriminatory sexuality education as integral to the fulfilment of sexual and reproductive rights [1,23]. From this perspective, differences in the perceived quality of sexuality education may reflect structural inequities in the distribution of knowledge, recognition, and resources necessary for exercising sexual citizenship. Importantly, this approach shifts the analytical focus from individual-level deficits to systemic conditions that enable or constrain access to meaningful sexuality education. Bringing together feminist disability studies, intersectionality, and human rights enables a multi-level analysis that links individual evaluations to broader social, institutional, and normative conditions. This articulation aligns with interdisciplinary approaches to sexuality by situating sexuality education within wider debates on embodiment, justice, and social inclusion.

Not all these theoretical concepts are directly operationalised in the survey data. Feminist disability studies, crip theory, intersectionality, and human rights instead serve as interpretive frameworks for explaining inequities in perceived quality of sexuality education. The empirical analysis captures differences across social positions—disability, gender, age, education, nationality, and health status—but not ableism, cis-heteronormativity, recognition, accessibility, or sexual citizenship themselves, which remain theoretically informed explanations rather than directly observed variables.

2. Material and Methods

2.1. Data

The study employs data from the 2022–2023 National Survey on Health, Sexuality, and Gender (Encuesta Nacional de Salud, Sexualidad y Género, ENSSEX), a representative survey of the adult urban population of Chile [17]. The survey aimed to generate a baseline of scientific knowledge on health, sexuality, and gender in the country, contributing to an interpretative framework of their historical evolution, as well as improving the design and evaluation of public policies. It also sought to estimate the national prevalence of key indicators related to these domains and to describe sexual behaviours, as well as risk and protective practices associated with sexual and reproductive health. Moreover, the survey examined sexual trajectories and explored normative orientations regarding sexuality and gender across the population, according to sex, age, geographic distribution, and other sociodemographic characteristics [17].

Data were collected through face-to-face interviews using a structured questionnaire administered on tablets. The target population comprised individuals aged 18 years and older residing in urban areas across all regions of Chile. Fieldwork was conducted between 1 August and 8 December 2023. The survey employed a probabilistic, multistage sampling design, including the sequential selection of (1) municipalities; (2) census blocks; (3) households; and (4) individuals within households. Survey performance indicators, based on the American Association for Public Opinion Research (AAPOR) [24], showed a response rate (RR1) of 51%, a cooperation rate (COOP1) of 60%, a contact rate (CON1) of 85%, and a refusal rate (REF) of 34% [17]. These responses are comparable to those reported in large-scale population surveys and are generally considered acceptable in contemporary survey research, although response rate alone is not a definitive indicator of data quality.

The final sample included 20,392 participants, exceeding the target of 20,000 (achievement rate: 102%). The dataset comprises a total of 923 variables, including respondent characteristics, sociodemographic variables, and survey responses.

2.2. Variables

The dependent variable—‘sexuality education quality’—was based on the question: “Overall, how would you rate the sexuality education you received at your school?”. This question captures two related but distinct dimensions: first, access to sexuality education, defined as whether individuals were exposed to sexuality education, and second, perceived quality, understood as respondents’ subjective evaluation of the sexuality education they report having received. The outcome used in this study does not directly measure curriculum content, pedagogical quality, accessibility, or inclusiveness. Instead, it captures a retrospective evaluation that may reflect several overlapping aspects, including the extent of exposure, relevance of content, perceived inclusiveness, accessibility, and subjective satisfaction. The answers to the question on sexuality education quality were grouped as ‘bad’ (answers ‘very bad’ and ‘bad’), ‘average’ (answers ‘nor good nor bad’), and ‘good’ (answers ‘good’ and ‘very good’).

The independent variables were the following:

(a)

Gender: Gender was collected through self-identification during the interview. In the survey, gender identity was defined as “each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body”. Interviewers asked respondents which gender they identified with and recorded the answer provided. According to the interviewer manual, respondents’ answers and opinions were to be respected, and never ignored or falsified, as part of the ethical considerations of the survey [17]. The original response categories were man/woman/transmasculine or trans man/transfeminine or trans woman/no binary/other categories/and ‘not sure’ or ‘rather not say’; there were no ‘cis-man’ or cis-woman’ categories. For the purposes of statistical analysis, and due to the limited number of observations in several gender identity categories, categories other than ‘man’ and ‘woman’ were aggregated under the label ‘other gender identities’. This analytical grouping was constrained both by the structure of the original survey data and by statistical power considerations, which limited the feasibility of conducting robust disaggregated analyses across all gender categories. Consequently, the category ‘women’ in the analyses corresponds specifically to respondents recorded in the survey category ‘woman’, while respondents recorded as ‘transfeminine or trans woman’ were included within ‘other gender identities’ for statistical purposes. This categorisation should not be interpreted as a conceptual distinction between cisgender and transgender women, but rather as a methodological limitation related to the available sample distribution and analytic feasibility.

(b)

Disability: Disability is conceptualised as a multidimensional and socially shaped condition, consistent with the social model of disability reflected in the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) [25]. From this perspective, disability arises through the interaction between impairments and environmental, institutional, and attitudinal barriers that may restrict participation and inclusion. Empirically, disability status was assessed in the ENSSEX survey using questions on functional limitations based on the Washington Group Short Set on Functioning, which evaluates difficulties in seeing, hearing, walking or climbing steps, remembering or concentrating, self-care and communication [26]. The survey employed a nationally representative probabilistic design and survey weights were applied in all analyses, allowing weighted estimates for people with disabilities. Although information on specific functional domains was available, the present study focused on the overall disability indicator. This decision was made because there were substantial differences in the frequency of positive responses across functional domains, resulting in small subgroup sizes for some categories and limiting the robustness and comparability of domain-specific analyses. Individuals reporting ‘a lot of difficulty’ or ‘cannot do at all’ in at least one domain are typically classified as having a disability. In the ENSSEX (https://epi.minsal.cl/bases-de-datos/, accessed on 6 March 2026) dataset used in this study, the variable ‘disability’ was already constructed as binary (that is, ‘without disabilities’/‘with disabilities’) and provided in the database based on respondents’ answers to these questions. Therefore, this variable was directly used in the analyses without additional recoding.

(c)

Age: The continuous variable ‘age’ was transformed into categorical, with the following age groups: 18–29/30–44/45–59/60+. This transformation was already available in the ENSSEX dataset.

(d)

Civil status: The possible answers regarding civil status were married/living with another person without a civil union agreement/living with another person with a civil union agreement/annulled/separated/divorced/widowed/single/and ‘not sure’ or ‘rather not say’. The answers were recoded as married/living with another person (with or without a civil union agreement)/annulled, separated, divorced, widowed/and single.

(e)

Indigeneity: This variable was based on the question “In Chile, the law recognises ten indigenous groups: do you belong to one of them?”, with possible answers being yes/ no/‘not sure’ or ‘rather not say’.

(f)

Nationality: The possible answers regarding the question on respondents’ nationality were Chilean/foreigner.

(g)

Education: This variable was already available in the ENSSEX database, with answers primary or less/secondary/tertiary.

(h)

Health insurance: The possible answers for this variable were FONASA (public)/ISAPRE (private)/other systems/‘not sure’ or ‘rather not say’. This variable was included in the analyses because it acts as a proxy—together with education—on socioeconomic status.

(i)

Health self-assessment: This variable was based on the question “Generally, would you say that your health is…?”, with possible answers ‘poor’ (includes ‘very poor’ and ‘poor’ answers), ‘average’ (includes ‘not poor nor good’ answers), and ‘good’ (includes ‘good’ and ‘very good’ answers).

Case deletion—the default procedure in Stata/MP 19.0 program that analyses only observations with complete data for all variables included in the model—was minimal. Of the total sample (n = 20,392), the final regression models included 17,679 observations, meaning that 2713 participants (13.3%) were excluded due to missing data in at least one variable included in the analyses. Because some participants had missing data in more than one variable, the number of excluded observations does not correspond to the sum of missing values for individual variables. The proportion of missing data was: (a) sexuality education quality: 5.8%. As this percentage was the highest, the category ‘not sure’ (with the missing data) was included in the descriptive analysis; (b) gender: 0.11%; (c) disability: 0.03%; (d) civil status: 0.11%; (e) indigeneity: 2.4%; (f) nationality: 0.08%; (g) health insurance system: 4.4%; (h) education: 0.8%; and (i) health assessment: 0.9%. Given the large sample size, the statistical power of the analyses remains sufficiently high [27]. There was no statistically significant difference between the variables ‘sexuality education quality’ and ‘disability’, concerning people who replied to the question on sexuality education and those who did not (p = 0.857). Concerning age, 20.5% of people aged 60 and more replied to the question on sexuality education vs. 50.4% of people of the same age who did not reply (p < 0.001). With regards to education level, 14.8% of people with primary education answered the question on sexuality education vs. 36.5% of people with primary education who did not (p < 0.001). These findings suggest that non-response to the sexuality education question was more common among older adults and individuals with lower educational attainment, indicating the possibility of differential response patterns according to sociodemographic characteristics.

2.3. Statistical Analysis

For the descriptive analysis, chi-square tests were used to examine differences between people with and without disabilities—with a focus on disability and gender—according to the reported quality of sexuality education received. Ordered logistic regression models were estimated accounting for the complex survey design, while the proportional odds assumption was evaluated using a survey-weighted ordered model. Sensitivity analyses using the original five-category outcome variable were also conducted; however, these models showed substantial violations of the proportional odds assumption. Therefore, a collapsed outcome specification was used in the final analyses. Two ordinal logistic regressions were performed: both were employed to predict ‘sexuality education quality’ given sociodemographic and health characteristics, but the first one included the entire sample, that is, people with and without disabilities, while the second one included only women with disabilities. Interaction effects were also considered and presented.

Interaction terms between disability and gender, and between disability and age, were included simultaneously in the model estimated for the full sample based on the study objectives and previous literature. In the model restricted to women with disabilities, these interaction terms were not included because the analysis was already limited to a specific population subgroup. However, estimated probabilities of receiving good sexuality education were calculated according to education and age, and education and nationality, to further illustrate differences across groups.

We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [28] (Table S1, Supplementary Materials). All statistical analyses were performed using the Stata/MP 19.0 program (StataCorp LLC, College Station, TX, USA).

3. Results

The weighted prevalence of disability in the analytic sample was 16.3%.

Table 1. Sample characteristics.

	Assessment of Perceived Quality of Sexuality Education Received
	Bad n = 9625 (47.2%)	Average n = 5157 (25.3%)	Good n = 4427 (21.7%)	Not Sure n = 1177 (5.8%)	p Value
Disability
Without disabilities	7638 (42.4%)	4355 (26.4%)	3907 (23.8%)	921 (7.3%)	p < 0.001
With disabilities	1987 (56.1%)	802 (22.1%)	520 (14.7%)	256 (7.2%)
Gender
Men	3121 (42.9%)	1804 (27.0%)	1500 (23.2%)	365 (6.9%)	p = 0.007
Women	6435 (46.0%)	3334 (24.6%)	2909 (21.7%)	811 (7.7%)
Other gender identities	58 (64.9%)	16 (15.6%)	15 (11.4%)	3 (8.2%)
Gender#disability
Men without disabilities	2680 (41.6%)	1591 (27.3%)	1386 (24.4%)	303 (6.8%)	p < 0.001
Men with disabilities	439 (53.5%)	213 (24.7%)	114 (14.4%)	62 (7.4%)
Women without disabilities	4913 (43.2%)	2748 (25.5%)	2508 (23.4%)	615 (7.8%)	p < 0.001
Women with disabilities	1522 (56.6%)	584 (21.2%)	401 (15.0%)	194 (7.2%)
Other genders without disabilities	34 (47.3%)	13 (24.0%)	10 (15.2%)	3 (13.5%)	p = 0.006
Other genders with disabilities	24 (91.6%)	3 (2.8%)	5 (5.6%)	0 (0.0%)
Age groups
18–29	1786 (34.0%)	1636 (30.8%)	1699 (32.5%)	96 (2.7%)	p < 0.001
30–44	2296 (42.9%)	1608 (29.4%)	1273 (24.1%)	149 (3.7%)
45–59	2492 (47.6%)	1129 (25.2%)	864 (19.2%)	289 (7.9%)
60+	3053 (54.8%)	786 (16.1%)	591 (12.9%)	645 (16.2%)
Civil status
Married	2794 (48.7%)	1117 (23.3%)	965 (18.8%)	419 (9.2%)	p < 0.001
Living with another person	829 (38.3%)	606 (28.7%)	518 (26.5%)	107 (6.6%)
Separated, divorced, widowed	2212 (52.1%)	790 (20.2%)	539 (14.8%)	345 (12.9%)
Single	3784 (40.7%)	2640 (28.8%)	2401 (26.7%)	304 (3.9%)
Indigeneity
Not indigenous	1007 (43.4%)	559 (25.5%)	499 (24.5%)	124 (6.5%)	p = 0.357
Indigenous	8427 (45.0%)	4463 (25.6%)	3814 (22.1%)	1009 (7.3%)
Nationality
Chilean	9399 (45.8%)	4875 (25.5%)	4049 (21.3%)	1146 (7.4%)	p < 0.001
Foreigner	220 (20.9%)	281 (30.2%)	376 (44.4%)	29 (4.6%)
Education
Primary or less	2393 (58.8%)	555 (14.1%)	411 (10.9%)	507 (16.3%)	p < 0.001
Secondary	4228 (40.8%)	2720 (27.6%)	2496 (25.4%)	471 (6.3%)
Tertiary	2918 (43.0%)	1838 (28.4%)	1498 (23.8%)	187 (4.8%)
Health insurance
FONASA (public)	8226 (45.1%)	4315 (25.6%)	3630 (22.0%)	1000 (7.3%)	p = 0.805
ISAPRE (private)	693 (45.6%)	403 (27.3%)	301 (20.3%)	58 (6.8%)
Other	406 (43.3%)	225 (25.0%)	188 (23.2%)	54 (8.5%)
Health self-assessment
Poor	837 (58.5%)	176 (13.8%)	155 (14.2%)	148 (13.5%)	p < 0.001
Average	3059 (49.3%)	1528 (25.7%)	809 (13.9%)	491 (11.1%)
Good	5670 (41.7%)	3399 (26.7%)	3397 (26.4%)	530 (5.2%)

presents the sample characteristics of people with and without disabilities in the ENSSEX survey according to the perceived quality of sexuality education they received.

As can be observed from Table 1, nearly half of participants reported that the sexuality education they received was bad (47.2%), while 25.3% rated it as average, and 21.7% as good; 5.8% reported that they were not sure. Significant differences were observed by disability status (p < 0.001). Among respondents with disabilities, 56.1% reported having received bad sexuality education, compared with 42% among those without disabilities. Conversely, respondents without disabilities were more likely to report good sexuality education (23.8%) than those with disabilities (14.7%).

Differences were also observed by gender (p < 0.007). There was a slightly higher prevalence of men than women reporting good sexuality education (23.2% vs. 21.7%, correspondingly); there was a higher prevalence of women, on the other hand, reporting bad sexuality education (46.0% vs. 42.9%, correspondingly). Respondents identifying with other gender identities reported the poorest assessments, with 64% indicating bad sexuality education and only 11.4% reporting good sexuality education.

When examining gender and disability jointly, significant differences were also observed. Among men, those with disabilities were more likely to report bad sexuality education than men without disabilities (53.5% vs. 41.6%), and substantially less likely to report good sexuality education (14.4% vs. 24.4%, correspondingly, p < 0.001). Women with disabilities reported bad sexuality education more frequently than women without disabilities (56.6% vs. 43.2%, correspondingly), while the proportion reporting good sexuality education was considerably lower among women with disabilities (15.0% vs. 23.4%, p < 0.001). Respondents with disabilities who identified with other gender identities appeared to report particularly high levels of poor sexuality education (91.6%, p < 0.001); however, these findings should be interpreted cautiously due to the small subgroup size and limited statistical power.

Table 2. Adjusted ordinal logistic regression of perceived quality of sexuality education among people with and without disabilities.

	Perceived Quality of Sexuality Education
	OR	95% CI
Gender (ref. men)
Women	0.964	0.869–1.068
Other gender identities	0.481	0.228–1.015
Age groups (ref. 18–29)
30–44	0.661 ***	0.583–0.751
45–59	0.576 ***	0.494–0.672
60+	0.387 ***	0.320–0.467
Civil status (ref. married)
Living with another person	1.202 *	1.036–1.394
Separated, divorced, widowed	0.911	0.789–1.052
Single	1.001	0.879–1.140
Indigeneity (ref. not indigenous)
Indigenous	0.894	0.766–1.042
Nationality (ref. Chilean)
Foreigner	2.775 ***	2.254–3.417
Education (ref. primary or less)
Secondary	2.128 ***	1.839–2.462
Tertiary	1.838 ***	1.577–2.144
Health insurance (ref. FONASA, public)
ISAPRE (private)	0.893	0.747–1.068
Other	0.961	0.792–1.167
Health self-assessment (ref. poor)
Average	1.135	0.904–1.426
Good	1.462 **	1.176–1.817
Disability (ref. no disabilities)
With disabilities	0.480 ***	0.336–0.684
Disability#gender (ref. men without disabilities)
Women with disabilities	1.101	0.763–1.587
Other gender identities with disabilities	0.244	0.058–1.037
Disability#age (ref. 18–29 age group without disabilities)
30–44 age group with disabilities	1.337	0.922–1.938
45–59 age group with disabilities	1.546 *	1.088–2.197
60+ age group with disabilities	2.304 ***	1.589–3.342
N	17,679

Note 1: OR = odds ratio; CI = confidence interval. Two-sided tests. Significance: * p < 0.05; ** p < 0.01; *** p < 0.001.

presents the results of the adjusted ordinal logistic regression, which estimates the association between the independent variables and the odds of reporting a higher category of perceived quality of sexuality education rather than a lower category for people with and without disabilities. The proportional odds assumption was evaluated using the generalised ordered logit approach (gologit2 in Stata). Results indicated that the proportional odds assumption was not violated: adjusted Wald test (F(15, 274) = 0.60 and Prob > F = 0.875). There was no collinearity affecting the results, with the mean variance inflation factor (VIF) being 2.49.

Table 2 shows that disability status and the interaction between disability and age were significantly associated with perceived quality of sexuality education after adjustment for sociodemographic and health characteristics. In contrast, the interaction between disability and gender was not statistically significant. Predicted probabilities indicated that respondents with disabilities generally had lower probabilities of reporting good perceived quality compared with those without disabilities across gender groups (Figure 1a). Men without disabilities had the highest probability of reporting good perceived quality (24.4%; 95% CI: 23.0–25.9), while people with disabilities identifying with other gender identities had the lowest probability, although this estimate should be interpreted cautiously due to the small subgroup size (2.6%; 95% CI: 0.2–5.4). Among respondents with disabilities, the predicted probabilities were similar for women and men: 18.7% (95% CI: 16.6–20.8) among women with disabilities and 17.8% (95% CI: 13.3–22.4) among men with disabilities. Thus, the data suggest a clear disability-related difference in perceived quality, but do not show substantial differences between women and men with disabilities.

Predicted probabilities by age and disability status also showed important differences across groups (Figure 1b). Across most age groups, respondents with disabilities had lower probabilities of reporting good sexuality education compared with those without disabilities. Among respondents aged 18–29, the predicted probability of reporting good sexuality education was 32.1% (95% CI: 29.7–34.5) among those without disabilities, compared with 19.5% (95% CI: 15.7–23.3) among those with disabilities. Similar differences were observed among respondents aged 30–44 (24.1% vs. 17.7%) and 45–59 (21.7% vs. 17.8%). However, among respondents aged 60 years and older, predicted probabilities were similar between those with and without disabilities (17.8% vs. 15.8%, respectively), suggesting smaller disability-related differences in perceived sexuality education quality among older adults.

Table 3. Adjusted ordinal logistic regression of perceived quality of sexuality education among women with disabilities.

	Perceived Quality of Sexuality Education
	OR	95% CI
Age (ref. 18–29)
30–44	0.828	0.545–1.259
45–59	0.753	0.460–1.236
60+	0.782	0.440–1.389
Civil status (ref. married)
Living with another person	1.094	0.628–1.907
Separated, divorced, widowed	0.813	0.535–1.235
Single	1.134	0.773–1.664
Indigeneity (ref. not indigenous)
Indigenous	0.860	0.527–1.404
Nationality (ref. Chilean)
Foreigner	2.872 *	1.268–6.501
Education (ref. primary or less)
Secondary	2.533 ***	1.839–3.489
Tertiary	1.743 *	1.119–2.715
Health insurance (ref. FONASA, public)
ISAPRE (private)	0.625	0.352–1.108
Other	1.311	0.724–2.374
Health self-assessment (ref. poor)
Average	1.410	0.960–2.072
Good	1.743 *	1.141–2.663
N	2324

Note: OR = odds ratio; CI = confidence interval. Two-sided tests. Significance: * p < 0.05; ** p < 0.01; *** p < 0.001.

presents the results of the second ordinal logistic regression, which estimates the association between the independent variables and the odds of reporting a higher category of perceived quality of sexuality education rather than a lower category for women with disabilities, assuming proportional odds across outcome thresholds. The proportional-odds assumption was tested and met: adjusted Wald test (F(11, 272) = 0.83 and Prob > F = 0.608). There was no collinearity affecting the results, with mean variance inflation factor (VIF) being 1.70.

After adjusting for sociodemographic and health characteristics, several factors were significantly associated with reporting higher levels of perceived quality of sexuality education among women with disabilities. Foreign women with disabilities had 2.9 (95% CI: 1.268–6.501) times higher odds of reporting higher quality of sexuality education compared with Chilean women with disabilities. However, foreign women with disabilities represented a relatively small subgroup in the analytic sample (n = 60, that is only 2.6% of the sample), which may partly explain the wide confidence interval observed for this estimate.

Compared with women with primary education or less, those with secondary education had 2.5 (95% CI: 1.839–3.489) times higher odds of reporting higher perceived quality of sexuality education, while those with tertiary education had 1.7 (95% CI: 1.119–2.715) times higher odds. These findings indicate that women with secondary and tertiary education reported more favourable evaluations than those with only primary education or less; however, the association was stronger for secondary than for tertiary education, suggesting that the educational gradient was not strictly monotonic. Moreover, women with disabilities who evaluated their health as good had 74.3% (95% CI: 1.141–2.663) higher odds of reporting higher quality of sexuality education compared with those reporting poor health. No significant associations were observed for age, civil status, indigeneity, and health insurance.

Figure 2 presents the estimated probabilities for reporting good sexuality education for women with disabilities, with the interaction between ‘education and age’ (Figure 2a) and ‘education and nationality” (Figure 2b) as predictor variables.

Predicted probabilities indicate that educational attainment is positively associated with reporting good sexuality education across all age groups for women with disabilities (Figure 2a). Among respondents aged 18–29, the predicted probability of reporting good sexuality education was 11.3% (95% CI: 6.2–16.5) for those with primary education or less, increasing to 24.2% (95% CI: 17.1–31.3) for those with secondary education, and 18.1% (95% CI: 12.3–23.9) for those with tertiary education. A similar pattern was observed in older age groups, with probabilities remaining consistently lower among respondents with primary education—with the lowest probability for women older than 60 years of age with primary education or less (9.1%; 95% CI: 6.4–11.9)—and higher among those with secondary or tertiary education.

Predicted probabilities in Figure 2b indicate that educational attainment and nationality are associated with reporting good sexuality education among women with disabilities. Across all educational levels, foreign women showed higher predicted probabilities of reporting good sexuality education. For instance, among women with secondary education, the predicted probability was 41.6% (95% CI: 23.6–59.7%) for foreign nationals compared with 20.3% (95% CI: 16.8–23.8) among Chileans. Similar differences were observed for respondents with primary education or less (22.3% vs. 9.2%) and tertiary education (33.1% vs. 15.0%).

4. Discussion

In this study, we examined perceived quality of sexuality education among the adult urban population of Chile, with a particular focus on women with disabilities. Sexuality education is a vital educational component, but it is often ignored; even when it is available, people with disabilities are often excluded, either directly, through, for example, failure to empower meaningful participation, or indirectly through lack of representation and disability-inclusive material [29].

The descriptive results indicate that 56.6% of women with disabilities reported having received poor sexuality education, compared with 41.6% of men without disabilities. Predicted probabilities further showed that women with disabilities were less likely to report good perceived quality of sexuality education than both women and men without disabilities. However, among respondents with disabilities, the predicted probabilities were similar for women and men, and the disability-by-gender interaction was not statistically significant. Together, these findings suggest that disability status was the most consistent axis of difference in perceived quality of sexuality education in this study, while gender-related differences may operate through more complex dynamics shaped by gender, ableism, and cis-heteronormative norms within sexuality education experiences. Nevertheless, this does not imply that gendered processes are unimportant, as women with disabilities may still experience intersecting forms of disadvantage compared with women without disabilities and the broader population, as suggested by existing evidence on gender, disability, and sexual and reproductive rights inequities [30,31].

The intersection of disability and gender therefore requires further exploration using approaches that can better examine lived experiences, institutional practices, and mechanisms of exclusion. Existing literature suggests that gendered and cis-heteronormative biases in sexuality education can further marginalise women with disabilities and those with diverse gender identities [32].

The findings show inequities in retrospective evaluations. Importantly, these evaluations reflect sexuality education received across different historical periods and educational contexts, in some cases many years or decades before the survey was conducted. Therefore, the findings should not be interpreted exclusively as an assessment of the current Chilean sexuality education system, but rather as reflecting cumulative and cohort-based experiences of sexuality education over the life course. Differences across age groups may partly reflect broader historical and generational variations in the provision, content, and framing of sexuality education.

Although the survey does not directly measure curriculum content, teacher practices, accessibility adaptations, or formal exclusion, the less favourable evaluations reported by people with disabilities may reflect broader structural inequities within sexuality education systems, including inaccessible delivery, limited pedagogical adaptations, exclusionary curricula, and insufficient recognition of disability-related experiences. Collectively, the findings suggest that the sexuality education provided may not adequately meet the needs of this population.

The results are consistent with a growing body of international evidence documenting poorer access to, and lower quality of, sexuality education among people with disabilities [6,33], often linked to assumptions that they are asexual or not in need of sexuality education. Rather than individual-level deficits, these point towards systematic forms of exclusion embedded within educational systems and align with broader global reporting lower satisfaction and preparedness among students with disabilities regarding sexuality education [34].

The findings reveal important heterogeneity within the population of women with disabilities. Education, nationality, and self-rated health were all associated with perceived quality of sexuality education, suggesting that experiences and evaluations are stratified rather than uniformly limited. Previous evidence has linked educational attainment to improved access to sexuality education and health-related knowledge [33]. However, the educational pattern observed here should not be interpreted as a simple monotonic socioeconomic gradient, as women with secondary education reported more favourable evaluations not only compared with women with primary education or less, but also compared with those with tertiary education.

This unexpected pattern may reflect several mechanisms, including cohort effects and differences in historical school exposure to sexuality education. Moreover, women in different educational categories may have had substantially different life and educational experiences, including disability-related barriers to continuing education, which may influence how they evaluate the sexuality education they received. Previous research has shown that people with disabilities often face structural and educational barriers that influence educational attainment and trajectories, potentially shaping their broader educational experiences and perceptions [35,36]. In addition, because the outcome is retrospective and subjective, women with tertiary education may evaluate sexuality education against different expectations or standards. Therefore, these findings are best understood as evidence of educational heterogeneity in perceived quality, rather than as a linear association between socioeconomic position and better sexuality education.

The finding that foreign women with disabilities reported better outcomes is less straightforward and should be interpreted cautiously, especially given the small number of observations in this subgroup, as it may reflect selective migration processes or differences in prior educational experiences rather than improved inclusivity of the Chilean system. This contrasts with evidence from other contexts where migrant status is associated with additional barriers to health, education, and social services [37,38]. Further research is needed to explore the mechanisms underlying this association.

An unexpected finding relates to the association between age and perceived quality of sexuality education among people with disabilities, with older age groups reporting better outcomes. This runs counter to expectations that younger cohorts would benefit from the gradual expansion and strengthening of comprehensive sexuality education policies and provision over time [39], suggesting that the relationship between age and perceived sexuality education quality may require a more cohort-sensitive interpretation. One possible explanation is memory bias, with older participants evaluating past experiences differently. Alternatively, it may reflect shifts in how sexuality education has been conceptualised and delivered over time, including a tendency towards biomedical or risk-focused approaches that may not be perceived as comprehensive or relevant.

The findings resonate with broader evidence on the consequences of exclusion from comprehensive sexuality education. In the Chilean context, these inequities may also reflect policy and institutional frameworks that have historically prioritised narrow, biomedical approaches to sexual and reproductive health, often marginalising issues of consent, relationships, and diversity, particularly for people with disabilities [11,40]. More broadly, these results are indicative of entrenched forms of disablism within education and health systems [6,41], that play an active role in reproducing or challenging these inequities through the ways in which sexuality is taught, framed, and made accessible [7].

These findings highlight the need for future research capable of identifying the specific factors underlying less favourable perceptions of sexuality education among women with disabilities and other population groups. As the present study did not directly assess curriculum content, teacher practices, accessibility adaptations, or institutional forms of exclusion, it cannot determine which specific components of sexuality education may require redesign or improvement. Future qualitative, mixed-methods, and institutionally focused studies should examine whether negative evaluations are associated with exclusionary curricular content, inaccessible delivery, lack of disability-related representation, limited discussion of consent and relationships, or broader educational and socioeconomic inequalities. Such evidence would be necessary to inform more specific policy responses, including curriculum development, teacher training, accessibility adaptations, and monitoring systems grounded in disability rights, gender equality, and sexual and reproductive rights.

These responses would align with international recommendations emphasising comprehensive, rights-based, and inclusive sexuality education as a core component of sexual and reproductive health [1,23]. However, such efforts should also address broader structural factors—including socioeconomic stratification and unequal access to education—that shape both the provision and experience of sexuality education [9,42].

This study has several limitations. First, due to its cross-sectional design, we cannot infer causality. Second, the sample is limited to individuals residing in urban areas, and therefore it excludes rural populations where access to sexuality education may be more constrained and shaped by different structural conditions. Third, the outcome variable captures self-reported evaluations of sexuality education, reflecting subjective perceptions that may be influenced by individual expectations, memory bias, or social norms. Consequently, the findings should be interpreted as reflecting perceived quality rather than the actual provision of comprehensive sexuality education, especially since a considerable amount of time might have elapsed between provision of such education.

Fourth, although the survey included diverse gender identity categories, the small number of respondents in these groups required aggregation and limited the ability to fully capture gender diversity and intersectional experiences. Respondents who self-identified as ‘transfeminine or trans woman’ were classified separately from the category ‘woman’, which may inadvertently reinforce a cis-normative distinction between women and trans women; it is not known whether the latter category included only cisgender women or also some transgender women. Consequently, the findings concerning ‘women with disabilities’ should be interpreted as referring specifically to respondents recorded in the survey category ‘woman’, rather than reflecting the full diversity of women with disabilities. Future research should employ more gender-inclusive measurement strategies and ensure sufficient sample sizes to examine the experiences of transgender and gender-diverse people with disabilities separately.

Another limitation relates to the connection between our theoretical framework and its empirical operationalisation. Our analysis relies on sociodemographic predictors and self-reported perceived quality of sexuality education, so constructs such as ableism, cis-heteronormativity, recognition, accessibility, curricular inclusiveness, and sexual citizenship serve as theoretical lenses for interpreting observed inequities, not as mechanisms directly tested in the statistical models. Future research should investigate these processes more directly through qualitative, mixed-methods, longitudinal, and institutionally focused designs. Finally, the operationalisation of disability is a limitation. Disability was operationalised as a binary status variable, based on the survey’s constructed indicator, which allowed us to examine disability-related inequities in perceived quality of sexuality education. However, this measure does not capture the heterogeneity of disability experiences, specific impairment types, lived experiences of disability, or particular accessibility barriers.

Despite these limitations, the study has several strengths. It is based on a large, nationally representative survey of the adult urban population of Chile that used a probabilistic, multistage sampling design, allowing for robust and generalisable estimates of sexuality education experiences in the country. Importantly, the study adopts an intersectional perspective by examining disability status in relation to gender and by focusing specifically on women with disabilities—an under-researched population in the field of sexual and reproductive health. The inclusion of interaction terms and predicted probabilities further enhances the interpretation of inequities across groups. Finally, the findings provide timely and policy-relevant evidence to inform the development of inclusive, accessible, and gender-sensitive sexuality education programmes, contributing to ongoing debates on health equity and the rights of people with disabilities, and in line with international obligations such as the Convention on the Rights of Persons with Disabilities [25].

5. Conclusions

This study provides evidence of disability-related inequities in the perceived quality of sexuality education, disproportionately affecting people with disabilities. Subgroup analyses further reveal heterogeneity among women with disabilities by education, nationality, and health status. However, in the full model, women and men with disabilities showed similar predicted probabilities of reporting good quality of sexuality education, suggesting that the strongest observed pattern was associated with disability status rather than substantial gender differences within the population of respondents with disabilities. The educational differences should be interpreted cautiously, as they may reflect cohort effects, differences in school exposure, compositional factors, and the subjective nature of retrospective evaluations. However, addressing these inequities requires moving beyond universal frameworks towards explicitly inclusive, gender-sensitive, and intersectional approaches to sexuality education, grounded in human rights principles. Such efforts are essential not only to improve educational provision but also to advance sexual and reproductive rights and promote more equitable and inclusive societies.