Relationships and Consent Education for Adolescents with Intellectual Disability: A Scoping Review

Abstract

Adolescents with intellectual disability have a right to sexuality education, including relationships and consent education. This scoping review explored relationships and consent education for adolescents with intellectual disability. We searched across four databases (Scopus, Medline, Web of Science and PubMed) to identify studies focusing on the provision of, experiences with and needs of education on relationships and consent for adolescents aged 12–19 with intellectual disability. Based on the inclusion criteria, 20 studies were eligible to be included in the review. The findings suggest that despite adolescents’ strong desire for comprehensive, evidence-based education on relationships and consent, the depth and content of the education provided varied by the provider type. Many educators and parents felt unprepared to address complex relationship and consent topics, resulting in inconsistent and often risk-focused education. The review indicated the need for more tailored resources, engaged learning methods, increased training and support for providers, and collaborative approaches between different providers. Future consent and relationships education could benefit from moving from a risk-based approach to focus on personal development and the promotion of sexual well-being for adolescents with intellectual disability.

1. Introduction

Sexuality education is an inalienable right for all adolescents, including those with intellectual disability (Rowe & Wright, 2017). The major internationally accepted human rights bodies, including the United Nations Convention on the Rights of the Child, the Convention on the Elimination of All Forms of Discrimination against Women, and the United Nations Convention on the Rights of Persons with Disabilities, have acknowledged these rights (Michielsen & Brockschmidt, 2021; United Nations Educational Scientific and Cultural Organisation [UNESCO], 2015; United Nations General Assembly [UNGA], 1979, 1989, 2006). Relationships and consent are key concepts recommended by UNESCO under comprehensive sexuality education curricula (Herat et al., 2018; United Nations Educational Scientific and Cultural Organisation [UNESCO], 2018). UNESCO’s international technical guidance on sexuality education covers relationships as Key Concept 1, addressing families, friendship, love, romantic relationships, tolerance, inclusion, respect, long-term commitments, and parenting. Consent, privacy, and bodily integrity fall under Key Concept 4, focusing on violence and safety. This concept highlights the importance of understanding and respecting these rights while communicating boundaries within relationships (Herat et al., 2018; United Nations Educational Scientific and Cultural Organisation [UNESCO], 2018). Relationships and consent education are now mandatory in primary and secondary school curricula in several countries, including Australia, the UK, Ireland, and Canada. These topics are typically taught by Health and Physical Education teachers and are often integrated into sexuality education or programs aimed at preventing gender-based violence (United Nations Educational Scientific and Cultural Organisation [UNESCO], 2018).

Adolescence is a crucial life stage for learning and understanding the development of relationships and consent (Kågesten & van Reeuwijk, 2021). According to the World Health Organization (WHO), “Adolescence is the phase of life between childhood and adulthood, from ages 10 to 19. It is a unique stage of human development and an important time for laying the foundations of good health” (World Health Organization [WHO], 2006). Good quality and developmentally appropriate CSE, including relationships and consent, is one of the vital elements of adolescent health interventions (World Health Organization [WHO], 2006).

Adolescents with intellectual disability have similar sexual desires to those of other adolescents. An intellectual disability is the limitation of intellectual functioning that occurs before, during, or shortly after birth and is life-long. It affects mild, moderate, severe or profound cognitive impairment, particularly in learning, problem-solving, judgement, self-care and communication (American Psychiatric Association, 2022; Brown et al., 2020). Despite increased awareness and international pledges to advance the sexual and reproductive health of people with intellectual disability, they have inadequate access to sexuality education and information (Nelson et al., 2020). Their sexuality is often overlooked and described as challenging (Nelson et al., 2020). The sexual autonomy and well-being of these adolescents are not frequently recognised (Harden, 2014). For young people with disabilities, CSE is a powerful tool that empowers them to seek help and make informed, respectful choices about relationships, sexuality, and health (Herat et al., 2018; United Nations Educational Scientific and Cultural Organisation [UNESCO], 2018). CSE equips adolescents, including those with intellectual disability, with accurate, age-appropriate knowledge, positive values, and skills to maintain healthy relationships. It also encourages reflection on social norms and cultural values, helping young people navigate emotions, power imbalances, and relationships with peers, parents and others. A rights-based approach in CSE boosts awareness of sexual rights, improves communication about relationships, and enhances confidence in managing risky situations, leading to better psychosocial well-being and positive behavioural changes (Herat et al., 2018; United Nations Educational Scientific and Cultural Organisation [UNESCO], 2018).

However, systemic barriers, including insufficient content of the relationship and sexuality education programs by the teachers and the lack of accessible resources, inhibit access to relationships and sexuality education for individuals with intellectual disability (Strnadová et al., 2022a; United Nations Educational Scientific and Cultural Organisation [UNESCO], 2015). Due to cognitive and communication barriers, some may not be able to understand others’ intentions and approaches, recognise disinterest, maintain boundaries or communicate rejection in romantic relationships. They still need support to develop practical skills for navigating relationships, understanding consent, and communicating a firm yes or no in a relationship (Lindsey & Harding, 2021; Murphy, 2003; Travers & Tincani, 2010). Specialised education on respectful relationships, dating, consent and boundaries, communication skills, and consensual sexual activity within a disability-specific context is essential. However, little is known about what adolescents with intellectual disability know about relationships and consent and how they acquire this knowledge. There are a number of providers of this education, but evidence about the challenges and barriers they experience and the resources available to them is scarce (Family Planning NSW, 2020). To understand the complexity surrounding the relationships and consent education of adolescents with intellectual disability, it is crucial to consider the views of adolescents and the people who care for them (Algood et al., 2011; DiClemente et al., 2013).

This review maps the existing literature on the provision of, experiences with and needs for relationships and consent education for adolescents aged 12–19 with intellectual disability (‘adolescents’ thereafter). We aimed to describe: 1. What adolescents know and would like to know about relationships and consent, how they acquire that knowledge; 2. The content of relationships and consent education currently delivered to adolescents by education and care providers (‘providers’ thereafter); 3. The self-perceived competence of providers in delivering relationships and consent education; and 4. Barriers and enablers in the provision of relationship and consent education and resources available to providers.

2. Materials and Methods

We undertook a scoping review guided by the methodological framework established by Arksey and O’Malley (2005) and Joanna Briggs Institute (JBI) guidance (Peters et al., 2015). This review’s reporting follows the criteria set out in the PRISMA-ScR 2018 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines (Tricco et al., 2018). The research questions were formulated using the Population, Concept, and Context framework according to JBI guidance (Peters et al., 2015).

This review focuses on key concepts related to relationships and consent, as outlined in UNESCO guidance: relationships; values, rights, culture and sexuality; violence and staying safe; skills for health and well-being; and sexuality and sexual behaviour (United Nations Educational Scientific and Cultural Organisation [UNESCO], 2018).

2.1. Literature Search Strategy

A systematic search of primary peer-reviewed publications was conducted in Scopus, Web of Science, Ovid (MEDLINE), and PubMed in July 2024. We used key terms related to relationships and consent education to identify relevant literature and combined them into a search formula with Boolean terms (AND and OR) and wild cards. The following formula was used for search in Scopus:

TITLE-ABS-KEY (((sex* OR consent OR relationship) AND (education)) AND ((adolescen* OR students OR young AND people OR youth OR pubescen* OR teenager*) AND (intellectual AND disability))) AND PUBYEAR > 2010 AND PUBYEAR < 2025 AND (LIMIT-TO (LANGUAGE, “English”)).

Similar search terms and strategies were adapted to other databases. Citation chaining (backward and forward) was performed on identified publications to maximise search results.

2.2. Selection of Publication

This review’s population of interest is adolescents with intellectual disability (with or without autism) aged 12–19 and their parents, teachers, disability and healthcare providers. Pre-defined inclusion and exclusion criteria guided the screening of identified articles. Included were original peer-reviewed articles; articles published in English from 2010 inclusive; studies conducted in high- and middle-income countries; studies of any design including program descriptions (excluding case reports, editorials, opinion papers, and reviews of any type); studies reporting on adolescents with intellectual disability with or without other conditions such as autism spectrum disorder or other multiple disabilities, and studies where samples included adolescents aged 12–19 or their parents, teachers, healthcare providers, disability providers and/or carers. Included were studies focused on relationships and consent education, including current knowledge, desired knowledge, knowledge acquisition, content delivered, educator competence, barriers, and supports. Excluded were studies that reported on adolescents with autism spectrum disorder and other multiple disabilities without intellectual disability, covered broader age ranges and did not allow data extraction specifically for the 12–19 age group, and studies presenting combined analyses for paediatric populations and adults alongside the 12–19 age group. Following the search, all identified citations were imported into the Covidence systematic review software (Veritas Health Innovation; https://www.covidence.org/, accessed on 23 October 2024), and duplicates were removed. The selection process included three steps: two reviewers performed primary screening of titles, abstracts, and full text for eligibility. The third reviewer resolved disagreements between the two reviewers.

2.3. Charting the Data/Data Extraction

Data were extracted into Microsoft Excel. We extracted details about the study, participants, concept, context, study methods, and key findings relevant to the review questions. The following variables were extracted from the studies: publication description (author, year of publication, country of research), study design, education setting, disability status, study focus, sample description (population groups, sample size), content on relationships and consent, and key results in relation to the research questions.

2.4. Data Analysis and Presentation

Key concepts and themes were created using a thematic analysis approach (Willig & Rogers, 2017). To address possible bias, the research team reviewed, confirmed, and reached a consensus on the final themes (Brown et al., 2020; Willig & Rogers, 2017). We followed the Key concept areas recommended by the International Technical Guidance on Sexuality Education (United Nations Educational Scientific and Cultural Organisation [UNESCO], 2018). Of the eight topic areas recommended by UNESCO, we selected five that were relevant to this study. These included: 1. Relationships; 2. Values, rights, culture and sexuality; 4. Violence and staying safe; 5. Skills for health and well-being; and 7. Sexuality and sexual behaviour.

3. Results

3.1. Literature Search Results

As demonstrated in Figure 1, we identified 1126 literature records: 386 in Web of Science, 335 in Scopus, 267 in PubMed, 104 in Medline and 34 via citation chaining. After removing 261 duplicates via Covidence, we screened 865 unique titles and abstracts.

Figure 1. PRISMA flowchart of literature search. Adapted from Covidence.

From the title and abstract screening, we excluded 823 publications. We assessed the full text of 42 studies against our inclusion and exclusion criteria and excluded 22 papers. Reasons for exclusion were: a different topic focus, a different population (adult or paediatric), an excluded study design, or a year of publication before 2010. Twenty studies met the inclusion criteria and were retained in this review.

3.2. Summary of the Studies/Characteristics of Included Publications

Table 1 summarises the characteristics of the included papers. The research presented in the selected papers was conducted in 11 countries, with the majority (n = 6) in the United States. The rest of the research was from Canada (n = 2), Australia (n = 2), the United Kingdom (n = 2), Germany (n = 2), Latvia (n = 1), Ireland (n = 1), Turkey (n = 1), Lithuania (n = 1), Brazil (n = 1), and Sweden (n = 1). Three papers were published between 2012 and 2014 (Dupras & Dionne, 2014; Lafferty et al., 2012; Löfgren-Mårtenson, 2012), six were published between 2015 and 2018 (Finlay et al., 2015; Kucuk et al., 2017; Miller et al., 2017; O’Neill et al., 2016; Povilaitiene & Radzeviciene, 2015; Pryde & Jahoda, 2018) and over 50% (n = 11) of the studies were published in the past five years (2019–2024) (Colarossi et al., 2023; Eyres et al., 2022; Frank & Sandman, 2019; Greene et al., 2024; Heifetz et al., 2020; Laganovska & Kviese, 2021; Mendes & Denari, 2023; Retznik et al., 2021, 2022; Strnadová et al., 2022b; Wolfe et al., 2019).

Table 1. Characteristics of the published papers included in the review.

Authors, Year	Country of Research	Study Design 1	Education Setting 2	Disability Status 3	Study Focus 4	Sample Description 5
Empirical studies
Colarossi et al. (2023)	USA	FGD	H	ID	Youth and parent views on sexual health topics and preferred learning tools for adolescents with ID	P: Adolescents (14), parents (16), n = 30
Dupras and Dionne (2014)	Canada	FGD	H	ID	Parental involvement in sexuality education for children with ID	P: Parents, n = 10
Eyres et al. (2022)	USA	I	H	ID	Parental experiences in providing sexuality education to children with ID	P: Parents, n = 9
Finlay et al. (2015)	UK	I, O	Sch	ID	Delivery of sexual health education to young people with ID, focusing on barriers and comprehension	P: Adolescents (8), teachers (4), n = 12
Heifetz et al. (2020)	Canada	I, S	Inst, H	ID+	Romantic conceptualisation and relationship education for adolescents with ID	P: Adolescents (31), parents (31), n = 62
Kucuk et al. (2017)	Turkey	QEDs	Inst, H	ID	Effectiveness of sexual abuse prevention education for children with ID	P: Adolescents (15), Parents (13), n = 28
Lafferty et al. (2012)	Ireland	I, FGD	Inst, H, Sch	ID	Attitudes of carers, direct care staff, and professionals towards RSE for teenagers and young adults with ID	P: Carers (26), professionals (24), frontline staff (24), n = 74
Laganovska and Kviese (2021)	Latvia	S	Sch	ID	Teachers’ opinions on sexual education for adolescents with ID	P: Special education teachers, n = 72
Löfgren-Mårtenson (2012)	Sweden	I	Sch	ID	Strengthening sexual health among young people with ID through their experiences	P: Adolescents, n = 16
(Mendes and Denari (2023)	Brazil	I	Sch	ID	Discourses on intellectual disability, sex, and sexuality among teachers	P: Special education teachers, n = 5
Miller et al. (2017)	USA	I, S	Inst, H	ID+	Knowledge of personal safety and sexuality among children with ID referred to an abuse prevention program	P: Adolescents (37), parents (37), n = 74
O’Neill et al. (2016)	Australia	I	H	ID+	Experiences of mothers supporting adolescents with ID through puberty and emerging sexuality	P: Mothers, n = 6
Povilaitiene and Radzeviciene (2015)	Lithuania	I	H, Sch	ID	Attitudes of teachers and parents towards sexuality education for adolescents with mild ID	P: Teachers (66), parents (34), n = 100
Pryde and Jahoda (2018)	UK	I	H	ID+	Explore mothers’ views on the sexuality of sons with ASD and ID	P: Mothers, n = 5
Retznik et al. (2021)	Germany	I	Inst, Sch, H	ID	Relationships, sexual activity, and contraception experiences of adolescents with ID	P: Adolescents, n = 42
Retznik et al. (2022)	Germany	I	H	ID	Caregivers’ views on intimate relationships, partner selection, and future outlook for youth with ID	P: Mothers (33), carers (9), n = 42
Strnadová et al. (2022b)	Australia	I, FGD	Sch	ID	Teachers’ experiences with sex education and challenges in developing autonomy for students with ID	P: Teachers, n = 10
Program descriptions
Frank and Sandman (2019)	USA	Prgm	H	ID	Creation of the Home B.A.S.E. curriculum for parents of adolescents with ID	Program for parents of adolescents
Greene et al. (2024)	USA	Prgm	Sch	ID+	Development of a framework for supporting adolescents with ID in sexual consent	P: Special education teachers, n = 25
Wolfe et al. (2019)	USA	Curr	Sch	ID+	Review of socio-sexuality education curricula for students with ID	No participants reported

¹ Study design: FGD—Focus group discussions, I—Interviews, O—Observation, S—Survey, QEDs—Quasi-experimental design, Prgm—Program, Curr—Curriculum evaluation; ² Education setting: H—Home, Inst—Institution, Sch—School; ³ Disability status: ID—Intellectual disability, ID+—Intellectual disability with multiple disorders; ⁴ Study focus: RSE—Relationships and sexuality education, ASD—Autism Spectrum Disorder, Home B.A.S.E—Home based adolescent sexuality education; ⁵ Sample description: P—Population, n—Sample size.

The research methods varied, including 13 studies of qualitative design (interviews, focus groups, and observations (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Finlay et al., 2015; Lafferty et al., 2012; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; O’Neill et al., 2016; Povilaitiene & Radzeviciene, 2015; Pryde & Jahoda, 2018; Retznik et al., 2021, 2022; Strnadová et al., 2022b); two with mixed methods (Heifetz et al., 2020; Miller et al., 2017); two program descriptions (Frank & Sandman, 2019; Greene et al., 2024); and one study, each employing curriculum evaluation (Wolfe et al., 2019), a quantitative study design (Laganovska & Kviese, 2021), and a quasi-experimental approach (Kucuk et al., 2017).

Ten studies specifically focused on adolescents with intellectual disabilities (Colarossi et al., 2023; Dupras & Dionne, 2014; Finlay et al., 2015; Frank & Sandman, 2019; Kucuk et al., 2017; Laganovska & Kviese, 2021; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Povilaitiene & Radzeviciene, 2015; Strnadová et al., 2022b), six on adolescents with intellectual disability and other conditions, including autism spectrum disorder (Greene et al., 2024; Heifetz et al., 2020; Miller et al., 2017; O’Neill et al., 2016; Pryde & Jahoda, 2018; Wolfe et al., 2019), and four included mixed groups of adolescents and young adults with intellectual disability and sometimes with other multiple conditions (Eyres et al., 2022; Lafferty et al., 2012; Retznik et al., 2022). Seven publications described home-based educational settings (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Frank & Sandman, 2019; O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2022), seven school-based settings (Finlay et al., 2015; Greene et al., 2024; Laganovska & Kviese, 2021; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Strnadová et al., 2022b; Wolfe et al., 2019), and six mixed settings (homes, schools, and institutions) (Heifetz et al., 2020; Kucuk et al., 2017; Lafferty et al., 2012; Miller et al., 2017; Povilaitiene & Radzeviciene, 2015; Retznik et al., 2021). Among the mixed settings, one study focused on accommodation and day centre providers (Lafferty et al., 2012), another on a child rehabilitation centre (Kucuk et al., 2017), and another at a mental health clinic where clinicians trained adolescents in personal safety with parental support (Miller et al., 2017).

The reviewed studies focused on various aspects of sexuality and relationships for individuals with intellectual disabilities, such as how relationship and sexuality education (RSE) is provided and perceived by different stakeholders, including carers, professionals and educators (Lafferty et al., 2012; Löfgren-Mårtenson, 2012; Strnadová et al., 2022b); parental involvement (Dupras & Dionne, 2014; Eyres et al., 2022; O’Neill et al., 2016); curriculum development and evaluation (Frank & Sandman, 2019; Greene et al., 2024; Wolfe et al., 2019); consent and autonomy (Greene et al., 2024; Heifetz et al., 2020); sexual abuse prevention (Kucuk et al., 2017) and lived experiences of individuals with intellectual disability, including caregivers’ perspectives (Pryde & Jahoda, 2018; Retznik et al., 2021, 2022).

3.3. What Adolescents Know and Would Like to Know About Relationships and Consent, How They Acquire That Knowledge

Table 2 describes our findings on what adolescents currently know and what they would like to know about relationships and consent. Adolescents expressed a desire to receive accurate (Lafferty et al., 2012), evidence-based (Frank & Sandman, 2019), age-appropriate (Lafferty et al., 2012) information that can provide a foundational understanding of concepts before moving to complex topics (Finlay et al., 2015). Overall, they would like to receive comprehensive sex education (Retznik et al., 2022; Strnadová et al., 2022b).

Table 2. What adolescents currently know and would like to know about relationships and consent.

Concept	Current Knowledge	Desired Knowledge
Relationships	Sexual and romantic relationships: Varying understanding of relationships (Finlay et al., 2015; Heifetz et al., 2020), including some awareness of relationship beginnings (Retznik et al., 2021), dating, romantic vacations, holding hands (Löfgren-Mårtenson, 2012), love and emotional connections (Retznik et al., 2022), intimacy (Retznik et al., 2021), development of relationships (Colarossi et al., 2023), companionship and commitment, but confusion around dating stages (Heifetz et al., 2020) Shallow awareness of romantic concepts (Dupras & Dionne, 2014) Basic awareness of respect in relationships but limited understanding of complex relationship dynamics (Mendes & Denari, 2023; Strnadová et al., 2022b)	Dating and relationships: Understanding relationships (Frank & Sandman, 2019; Mendes & Denari, 2023; Povilaitiene & Radzeviciene, 2015; Wolfe et al., 2019), including intimacy, love (Löfgren-Mårtenson, 2012), partnerships and family (Retznik et al., 2021), dating (Eyres et al., 2022; Heifetz et al., 2020), commitment (Heifetz et al., 2020) and being a good partner (Eyres et al., 2022) Developing skills for dating (Colarossi et al., 2023), initiating and maintaining relationships (Heifetz et al., 2020) and managing relationships (Dupras & Dionne, 2014) Building healthy relationship dynamics (Retznik et al., 2022)
Values, rights, culture and sexuality	Traditional views on gender roles and associate happiness with a heterosexual relationship, marriage and their own living space (Kucuk et al., 2017) Significantly better romantic awareness from social observation, peers/friends and the media (Heifetz et al., 2020) Romantic relationships conceptualised as serious, stable, committed for life and offering primarily companionship (Heifetz et al., 2020)	Difference between romantic relationships and friendships, including their role and functions (Heifetz et al., 2020)
Violence and staying safe	Varying (Finlay et al., 2015; Strnadová et al., 2022b), mixed (Miller et al., 2017), foundational (Colarossi et al., 2023) and unclear understanding of consent (Dupras & Dionne, 2014), with a lack of clarity on its nuances (Retznik et al., 2022) Misinformation received from the media (Lafferty et al., 2012), with basic awareness of internet safety (Strnadová et al., 2022b) Limited awareness of safe and protective behaviours (Strnadová et al., 2022b), unclear understanding of exploitative behaviours (Laganovska & Kviese, 2021), limited knowledge and skills regarding personal safety (Miller et al., 2017)	Legal aspects of consent (Eyres et al., 2022; Greene et al., 2024; Pryde & Jahoda, 2018; Wolfe et al., 2019) Sexual abuse and its risk factors, personal safety skills to protect themselves against violence, STIs, and unwanted pregnancies (Miller et al., 2017; Laganovska & Kviese, 2021) Safe behaviours (Strnadová et al., 2022b) Establishing safe boundaries (Kucuk et al., 2017)
Skills for health and well-being	Varying (Löfgren-Mårtenson, 2012; Povilaitiene & Radzeviciene, 2015; Pryde & Jahoda, 2018) and limited understanding of diverse relationship norms (Retznik et al., 2022) Mixed understanding of touch (Miller et al., 2017; O’Neill et al., 2016), inadequate knowledge (Kucuk et al., 2017) and struggles distinguishing good and bad touch (Kucuk et al., 2017) Mixed understanding of personal safety (O’Neill et al., 2016)	Norms around social (Dupras & Dionne, 2014; Wolfe et al., 2019) and sexual behaviours (Pryde & Jahoda, 2018; Wolfe et al., 2019), interaction (Löfgren-Mårtenson, 2012), negotiating touch (Kucuk et al., 2017; O’Neill et al., 2016) Skills for safety and well-being in relationships, including effective communication (Frank & Sandman, 2019; Retznik et al., 2022), dating (Colarossi et al., 2023), establishing safe boundaries (Kucuk et al., 2017), navigating romantic challenges (Retznik et al., 2021), managing relationship challenges and breakups (Retznik et al., 2022), conflict resolution (Colarossi et al., 2023) Skills for decision-making (Greene et al., 2024) Skills for online safety (Heifetz et al., 2020; Strnadová et al., 2022b)
Sexuality and sexual behaviour	basic knowledge of sexual behaviour (Greene et al., 2024) Basic awareness of emotional connections (Retznik et al., 2022) and emotional regulation (Strnadová et al., 2022b), but a lack of practical strategies to manage feelings and emotions (Strnadová et al., 2022b)	Emotional regulation (Lafferty et al., 2012; Povilaitiene & Radzeviciene, 2015; Strnadová et al., 2022b) and emotional intelligence (Strnadová et al., 2022b)

Adolescents had limited access to education on relationships and consent. They often lack having a trusted adult to discuss these topics (Löfgren-Mårtenson, 2012). Informal sources of information frequently lack depth (Löfgren-Mårtenson, 2012). Home-based education by parents and caregivers was often reactive and based on inquiries (Lafferty et al., 2012; Mendes & Denari, 2023). Parents, especially mothers, struggled with family communication and sharing information about sexuality, relationships, and consent (Lafferty et al., 2012; Pryde & Jahoda, 2018). Consequently, family education was often patchy and inadequate (Dupras & Dionne, 2014; Lafferty et al., 2012). Parents of adolescents recognised the need for more structured education (Dupras & Dionne, 2014) and individualised, interactive, sensory-friendly resources tailored to their needs (Colarossi et al., 2023; O’Neill et al., 2016).

School-based relationships and consent education are often inconsistent. While some programs, like the Ask Me First Choices program, a four-module sexual consent intervention specifically designed for use with students receiving special education services in the USA (Greene et al., 2024), are well-structured and education in this area is generally seen as inadequate and reliant on caregivers (Retznik et al., 2022). The reviewed publications highlighted a need for structured curricula tailored to adolescents with intellectual disability (Laganovska & Kviese, 2021), adaptable to their learning needs (Greene et al., 2024), and with ongoing monitoring of their understanding (Finlay et al., 2015). Successful programs should include appropriate educational materials, visual aids, role plays, and formative assessments (Strnadová et al., 2022b).

There has been minimal research on relationships and consent education in clinical settings. Only Miller et al. (2017) described a community mental health clinic program providing tailored education and personal safety training for adolescents with intellectual disability.

Adolescents with intellectual disability primarily learn about relationships and consent from parents, teachers, and via observation. They also rely on external sources (Povilaitiene & Radzeviciene, 2015). Their values, attitudes and cultural beliefs are influenced by the information they receive from peers, media and social observation (Heifetz et al., 2020; Povilaitiene & Radzeviciene, 2015; Retznik et al., 2021). In a Canadian study by Heifetz et al., adolescents gained better romantic awareness from social observation, peers, and media than learning from their parents (Heifetz et al., 2020). Most adolescents learned about romantic relationships from their parents, highlighting potential gaps in formal sex education. Discussing relationships with parents did not correlate with advanced dating stages, as adolescents viewed relationships as lifelong commitments focused on companionship (Heifetz et al., 2020). Some adolescents held traditional views on gender roles, linking happiness to heterosexual relationships, marriage and personal living space (Retznik et al., 2021). This suggests the need for education distinguishing romantic relationships from friendships, covering their roles, the diversity of sexuality, and the right to enjoy sexual pleasure and protect oneself from sexual abuse (Retznik et al., 2021).

Research suggests that education at home and school is more effective when provided concurrently and in agreement (Eyres et al., 2022). This approach includes traditional instruction, workshops, video demonstrations, storybook readings, discussions, and take-home assignments for parental reinforcement (Eyres et al., 2022; Finlay et al., 2015; Frank & Sandman, 2019; Kucuk et al., 2017; Retznik et al., 2021).

3.4. Content of Education Delivered to Adolescents by Education and Care Providers

Table 3 describes topics in relationships and consent education that are being delivered to adolescents by provider type. The relationship and consent education provided to adolescents varies by provider type. Parents covered the foundational, practical, and ethical aspects of relationships, focusing on safety, consent, and personal rights. Key topics included building friendships, dating safety, communication skills, safe boundaries (Colarossi et al., 2023; Kucuk et al., 2017), and public versus private behaviour (Lafferty et al., 2012; Pryde & Jahoda, 2018). They addressed managing relationships, understanding “no”, touching rules and personal space (Dupras & Dionne, 2014). Consent, boundaries, appropriate sexual behaviour (Eyres et al., 2022; O’Neill et al., 2016; Retznik et al., 2022), and the respectful initiation and ending of relationships were highlighted (Heifetz et al., 2020).

Table 3. Relationships and consent education topics being delivered to adolescents by provider type.

Concept	Teachers	Parents	Disability Care Providers	Healthcare Providers
Relationships	Families (Lafferty et al., 2012; Wolfe et al., 2019) Friendship (Lafferty et al., 2012; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Povilaitiene & Radzeviciene, 2015; Strnadová et al., 2022b; Wolfe et al., 2019) Love and romantic relationships (Finlay et al., 2015; Lafferty et al., 2012; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Strnadová et al., 2022b; Wolfe et al., 2019) Inclusion and respect (Lafferty et al., 2012; Mendes & Denari, 2023; Wolfe et al., 2019)	Families (Kucuk et al., 2017; Wolfe et al., 2019) Friendship (Colarossi et al., 2023; Frank & Sandman, 2019; Heifetz et al., 2020; Kucuk et al., 2017; Wolfe et al., 2019) Love and romantic relationships (Colarossi et al., 2023; Dupras & Dionne, 2014; Frank & Sandman, 2019; Heifetz et al., 2020; O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2021, 2022; Wolfe et al., 2019) Inclusion and respect (Colarossi et al., 2023; O’Neill et al., 2016; Retznik et al., 2022; Wolfe et al., 2019) Long-term commitments and parenting (O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2021, 2022)	Families (Kucuk et al., 2017) Friendship (Kucuk et al., 2017) Love and relationship (Kucuk et al., 2017) Tolerance (Kucuk et al., 2017) Inclusion and respect (Kucuk et al., 2017)	Not reported
Values, Rights, Culture and Sexuality	Values and sexuality (Finlay et al., 2015; Laganovska & Kviese, 2021; Povilaitiene & Radzeviciene, 2015; Wolfe et al., 2019) Human rights and sexuality (Finlay et al., 2015) Culture, society and sexuality (Povilaitiene & Radzeviciene, 2015; Wolfe et al., 2019)	Values and sexuality (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Heifetz et al., 2020; O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2021, 2022; Wolfe et al., 2019) Human rights and sexuality (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Frank & Sandman, 2019; Wolfe et al., 2019) Culture, society and sexuality (Heifetz et al., 2020; Wolfe et al., 2019)	Human rights and sexuality (Lafferty et al., 2012) Values and sexuality (Lafferty et al., 2012)	Human rights and sexuality (Lafferty et al., 2012)
Violence and staying safe	Consent, privacy and bodily integrity (Finlay et al., 2015; Greene et al., 2024; Lafferty et al., 2012; Laganovska & Kviese, 2021; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Povilaitiene & Radzeviciene, 2015; Strnadová et al., 2022b; Wolfe et al., 2019) Safe use of information and communication technologies (Finlay et al., 2015; Löfgren-Mårtenson, 2012; Strnadová et al., 2022b; Wolfe et al., 2019)	Consent, privacy and bodily integrity (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Frank & Sandman, 2019; Lafferty et al., 2012; O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2021, 2022; Wolfe et al., 2019) Safe use of information and communication technologies (Colarossi et al., 2023; Wolfe et al., 2019)	Consent, privacy and bodily integrity (Kucuk et al., 2017) Safe use of information and communication technologies (Finlay et al., 2015)	Consent, privacy and bodily integrity (Miller et al., 2017)
Skills for health and well-being	Norms and peer influence on sexual behaviour (Greene et al., 2024; Löfgren-Mårtenson, 2012; Povilaitiene & Radzeviciene, 2015; Wolfe et al., 2019) Decision-making (Finlay et al., 2015; Greene et al., 2024; Povilaitiene & Radzeviciene, 2015; Wolfe et al., 2019) Communication, refusal and negotiation skills (Finlay et al., 2015; Greene et al., 2024; Mendes & Denari, 2023; Povilaitiene & Radzeviciene, 2015; Strnadová et al., 2022b; Wolfe et al., 2019) Media literacy and sexuality (Finlay et al., 2015) Finding help and support (Greene et al., 2024; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Povilaitiene & Radzeviciene, 2015; Strnadová et al., 2022b; Wolfe et al., 2019)	Norms and peer influence on sexual behaviour (Dupras & Dionne, 2014; Heifetz et al., 2020; Pryde & Jahoda, 2018; Retznik et al., 2021; Wolfe et al., 2019) Decision-making (Colarossi et al., 2023; Dupras & Dionne, 2014; Frank & Sandman, 2019; Retznik et al., 2021, 2022; Wolfe et al., 2019) Communication, refusal and negotiation skills (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Frank & Sandman, 2019; Kucuk et al., 2017; O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2021, 2022; Wolfe et al., 2019) Media literacy and sexuality (Heifetz et al., 2020) Finding help and support (Colarossi et al., 2023; Frank & Sandman, 2019; Heifetz et al., 2020; Kucuk et al., 2017; O’Neill et al., 2016; Wolfe et al., 2019)	Communication, refusal and negotiation skills (Finlay et al., 2015) Finding help and support (Kucuk et al., 2017)	Communication, refusal and negotiation skills (Miller et al., 2017) Finding help and support (Miller et al., 2017)
Sexuality and sexual behaviour	Sexual behaviour and sexual response (Finlay et al., 2015; Lafferty et al., 2012; Laganovska & Kviese, 2021; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Povilaitiene & Radzeviciene, 2015; Strnadová et al., 2022b; Wolfe et al., 2019)	Sexual behaviour and sexual response (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Frank & Sandman, 2019; O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2021; Wolfe et al., 2019)	Sexual behaviour and sexual response (Kucuk et al., 2017; Lafferty et al., 2012)	Not reported

Parents also covered cultural beliefs and social norms, including ethical considerations (O’Neill et al., 2016; Pryde & Jahoda, 2018), human rights as to sexuality and privacy (Frank & Sandman, 2019), and the roles and responsibilities within family structures related to friendships and relationships (Kucuk et al., 2017; Lafferty et al., 2012). Emotional connections and types of romantic relationships were discussed (Retznik et al., 2021), though deeper romantic topics were often avoided (Heifetz et al., 2020). Some parents emphasised long-term commitments, hopes for their children’s lasting relationships, capacity for intimacy, and partner selection, but these topics were not explicitly taught as part of educational content (O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2021, 2022). Parents sought guidance and support to effectively cover these aspects of relationship education.

Teachers provided a structured educational framework focusing on social skills, relationship dynamics, understanding emotions, consent, communication, and safe behaviours with varying comfort levels and details. Key concepts included friendships and how they can evolve into romance, dating dynamics and emotional implications (Lafferty et al., 2012; Löfgren-Mårtenson, 2012), positive and negative aspects of relationships (Laganovska & Kviese, 2021), public versus private behaviour (Eyres et al., 2022), basic safety principles, and consent (Finlay et al., 2015; Laganovska & Kviese, 2021; Mendes & Denari, 2023; Strnadová et al., 2022b). Two studies investigated the inclusion of self-awareness, self-advocacy and self-determination in the educational content and highlighted that few teachers covered these topics (Eyres et al., 2022; Strnadová et al., 2022b). Teachers introduced concepts of sexual consent, decision-making strategies, communication of consent and resources for sexual abuse support (Greene et al., 2024; Wolfe et al., 2019) while also developing social skills and understanding peer pressure and societal norms (Povilaitiene & Radzeviciene, 2015). Family dynamics, diverse family values, and anti-bullying content were integrated into the curriculum, although sexual behaviour content was often covered reactively following incidents (Lafferty et al., 2012). Personal beliefs, inclusivity and respect, safe online behaviour, and support resources were emphasised (Lafferty et al., 2012; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Wolfe et al., 2019).

Healthcare and disability providers focused on empowering adolescents to recognise and respond to inappropriate behaviours, emphasising skills development for their health and well-being (Finlay et al., 2015; Kucuk et al., 2017; Lafferty et al., 2012; Miller et al., 2017). The clinician-led education curricula focused on consent and personal boundaries (Miller et al., 2017), including identifying appropriate versus inappropriate touches, understanding one’s body, and developing safety skills. Other topics were effective communication, refusal of unwanted advances, and negotiation skills, which parents can reinforce at home. The program also covered recognising adult helpers, such as parents, school staff, relatives, professionals, and peers (Miller et al., 2017). Some healthcare providers emphasised a human rights perspective for adolescents with intellectual disability, but education offered on these topics was limited (Lafferty et al., 2012). Clinicians often focused on legal and safety requirements rather than personal development (Lafferty et al., 2012) and did not include topics on relationships, values, culture and sexuality (Lafferty et al., 2012; Miller et al., 2017).

Educators from the disability services covered body privacy and safety, family roles, safe and unsafe friendships, appropriate boundaries, and consent (Kucuk et al., 2017). Key areas included respecting personal space, acceptance in friendships, self-respect, body parts, good versus bad touch, and personal rights regarding one’s body. Children learned their right to privacy and safety, how to say “no” to unwanted touching and communicate discomfort and seek help, including asking for assistance from family members during health examinations (Kucuk et al., 2017). Special education teachers, youth workers, and outreach workers covered personal values and their impact on decision-making, including sexual rights, consent, bodily autonomy, appropriate behaviours, and healthy relationships (Finlay et al., 2015). Key areas included managing sexual anxiety, setting boundaries, making informed choices, and developing effective communication, assertiveness, and negotiation skills (Finlay et al., 2015).

3.5. The Self-Perceived Competence of Education and Care Providers in Providing Relationships and Consent Education

Many teachers and family carers feel ill-equipped in providing relationships and consent education due to a lack of formal training (Lafferty et al., 2012) but were aware of the challenges (Povilaitiene & Radzeviciene, 2015; Wolfe et al., 2019). Some showed mixed feelings of empowerment and uncertainty (Eyres et al., 2022; Povilaitiene & Radzeviciene, 2015). Some teachers felt confident in basic topics but relied on external professionals for complex issues (Mendes & Denari, 2023). Special education teachers in the USA demonstrated varying confidence levels and expressed an interest in training on Universal Design for Learning principles (Greene et al., 2024). Parents delivered education based on their knowledge and comfort rather than formal training (Heifetz et al., 2020). Mothers lacked confidence and were anxious to discuss sensitive topics (Dupras & Dionne, 2014; O’Neill et al., 2016; Pryde & Jahoda, 2018). Clinicians, on the other hand, did not explicitly state their self-perceived competence (Miller et al., 2017).

In a positive light, some educators and parents used structured approaches to education, indicating high competence levels (Kucuk et al., 2017). Some schoolteachers felt competent, in general, but faced challenges with nonverbal students (Strnadová et al., 2022b), while others highlighted varying levels of self-perceived competence, particularly in emotional and relationship education, and difficulty assessing comprehension (Dupras & Dionne, 2014; Willig & Rogers, 2017). They also knew where to find information on sexuality education (Laganovska & Kviese, 2021).

Teaching Methods Used or Preferred by Providers

Current teaching methods differed among providers. Two program intervention studies emphasised using the Universal Design for Learning principle, including the use of reference aids, visual instructions, case studies, role play, small group discussions, videos and take-home assignments (Frank & Sandman, 2019; Greene et al., 2024; Wolfe et al., 2019). These studies also advocated for extension activities and Treatment and Education of Autistic and related Communication-handicapped children (TEACCH) methods, including practical intervention guides with questions and answers (Frank & Sandman, 2019; Wolfe et al., 2019). Some teachers and family carers commonly used advocacy groups, peer tutors, and person-centred plans, recommending gender-specific courses provided through gender-homogeneous groups and gender-specific educators (Lafferty et al., 2012; Löfgren-Mårtenson, 2012; Retznik et al., 2021). Some also used effective strategies like the Stein and Glen Story Map Method to write a series of stories and picture books to teach adolescents about sexual abuse. Similarly, homework rewards, positive reinforcement and modelling, and interactive multimodal teaching tools like drama, vignettes, scenarios, and social stories were effectively used (Colarossi et al., 2023; Eyres et al., 2022; Finlay et al., 2015; Kucuk et al., 2017; Miller et al., 2017).

School teachers used well-developed guidelines and pedagogical methods, including tiered and spiral curricula and recommended age-appropriate learning and consistent vocabulary (Finlay et al., 2015; Laganovska & Kviese, 2021; Strnadová et al., 2022b). They used individualised learning plans, and tailored programs like the ‘Circles program’, which teaches adolescents about personal boundaries, consent, and protective behaviours, by helping them to identify the circles of people in their life and different roles and rules in their relationships with family, friends and strangers (Strnadová et al., 2022b). Some teachers also used Mind maps, formative assessment over formal assessment, breaking content down via content adjustment, exit slips and Know Want Learned charts, which help students organise information before, during, and after learning about a topic (Strnadová et al., 2022b). Parents were more likely to use the reactive teaching approach, often waiting for the adolescents to start the conversation (Dupras & Dionne, 2014; Heifetz et al., 2020; Pryde & Jahoda, 2018; Retznik et al., 2021). Clinicians providing training at mental health clinics also used vignettes, short-answer questions, scenarios and recommended formative assessments focusing on in-session tasks (Miller et al., 2017). Providers also preferred proactive, inclusive, and tailored teaching methods with various multimodal teaching approaches (Colarossi et al., 2023).

3.6. Barriers, Enablers and Resources Available to Education and Care Providers Regarding Relationship and Consent

3.6.1. Barriers

The lack of training and support in delivering relationship and consent education was perceived as a key barrier across different education and care providers (Greene et al., 2024; Lafferty et al., 2012; Laganovska & Kviese, 2021; Mendes & Denari, 2023; Wolfe et al., 2019). There is a scarcity of educational resources and comprehensive educational materials (Colarossi et al., 2023; Eyres et al., 2022; Kucuk et al., 2017; Lafferty et al., 2012; O’Neill et al., 2016; Povilaitiene & Radzeviciene, 2015; Pryde & Jahoda, 2018; Strnadová et al., 2022b) that are tailored to the needs of individuals with intellectual disability, age-appropriate (Eyres et al., 2022; Lafferty et al., 2012; O’Neill et al., 2016; Povilaitiene & Radzeviciene, 2015; Pryde & Jahoda, 2018), and culturally and linguistically appropriate (Colarossi et al., 2023). Cultural and societal attitudes, including personal and religious beliefs, may affect educators’ comfort and willingness to teach sexuality content and hinder open discussion. Family attitudes, including the perceived socio-sexual inadequacy of individuals with intellectual disability, myths and fears about their sexuality, stigma and perceived vulnerability and the perception of heterosexual bias were some of the barriers identified in several reviewed studies (Frank & Sandman, 2019; Lafferty et al., 2012; Mendes & Denari, 2023; Wolfe et al., 2019).

Communication challenges were significant (Dupras & Dionne, 2014; Kucuk et al., 2017; Miller et al., 2017). Parents struggled to establish effective communication with their children. Cognitive limitations and varying social competence levels make it hard for individuals with intellectual disability to understand abstract relationship concepts (Finlay et al., 2015; Heifetz et al., 2020; Kucuk et al., 2017; Lafferty et al., 2012; Miller et al., 2017), often requiring repeated explanations (Lafferty et al., 2012; Wolfe et al., 2019). Teachers found it challenging to assess comprehension and adjust teaching methods for mixed-ability students (Finlay et al., 2015; Povilaitiene & Radzeviciene, 2015). Therefore, parents and teachers often felt discomfort and reluctance to discuss complex relationship topics (Colarossi et al., 2023; Eyres et al., 2022; Frank & Sandman, 2019).

Schoolteachers commonly reported inconsistent educational practices, including insufficient guidelines, gaps in socio-sexuality curricula, and inconsistent implementation across schools (Laganovska & Kviese, 2021; Löfgren-Mårtenson, 2012; Povilaitiene & Radzeviciene, 2015; Wolfe et al., 2019). Parents similarly perceived a gap in structured sexuality education and noted minimal interaction with teachers on relationship-related topics (Laganovska & Kviese, 2021; Wolfe et al., 2019). Parents felt that limited social opportunities, including a lack of privacy, mobility issues, cultural expectations, exclusion from social activities and social isolation, prevented their adolescents from learning how to navigate friendships and relationships in practice (Dupras & Dionne, 2014; Retznik et al., 2021, 2022)

3.6.2. Enablers

Professional frontline staff, families, clinicians and teachers emphasised that accessible information and training facilitated relationship and consent education and requested further training on relevant legislation and resource development (Lafferty et al., 2012; Laganovska & Kviese, 2021; Mendes & Denari, 2023; Miller et al., 2017). Providers would like to have resources that are accessible, relevant, trusted, and appropriate to the developmental and diverse learning needs of adolescents with intellectual disability. They wanted resources that are interactive and multi-lingual (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Greene et al., 2024; Lafferty et al., 2012; Laganovska & Kviese, 2021; O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2022; Strnadová et al., 2022b; Wolfe et al., 2019), mixed training sessions for parents and children (Dupras & Dionne, 2014), individualised learning plans, visuals, role plays, and tailored storybooks (Kucuk et al., 2017; Strnadová et al., 2022b). Providers would like to be able to use a range of formats, such as books (Greene et al., 2024; Kucuk et al., 2017; Löfgren-Mårtenson, 2012; Povilaitiene & Radzeviciene, 2015), structured curriculum activities (Greene et al., 2024; Kucuk et al., 2017; Löfgren-Mårtenson, 2012; Povilaitiene & Radzeviciene, 2015), illustrations (Kucuk et al., 2017; Retznik et al., 2021), informational tools (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Mendes & Denari, 2023; Retznik et al., 2021), theatre performances (Löfgren-Mårtenson, 2012), videos (Eyres et al., 2022; Greene et al., 2024; Löfgren-Mårtenson, 2012; Wolfe et al., 2019) and visual aids (Eyres et al., 2022; Finlay et al., 2015; Greene et al., 2024; Löfgren-Mårtenson, 2012).

Some parents and teachers used engaging learning methods, including relatable content, interest-driven learning, repetitive learning methods, supportive small group discussions, persistent reinforcement strategies and proactive approaches to teaching about sexuality (Finlay et al., 2015; Frank & Sandman, 2019; Löfgren-Mårtenson, 2012). Creating supportive educational environments and inclusive social opportunities for social interaction was valued (Heifetz et al., 2020; Retznik et al., 2021, 2022). Some teachers involved external professionals, such as psychologists, to cover sensitive topics to avoid discomfort (Mendes & Denari, 2023). Special education teachers were more likely than other providers to seek professional development in sexual education and were aware of where to seek assistance (Laganovska & Kviese, 2021). Some studies used collaborative approaches, including community-based partnerships and support among schools, families, healthcare providers and disability professionals (Eyres et al., 2022; Greene et al., 2024; Miller et al., 2017; Retznik et al., 2021). Education was more effective when parents were strongly involved and provided insights on physical safety skills (Miller et al., 2017). Education and support groups for parents (Colarossi et al., 2023; Kucuk et al., 2017; Lafferty et al., 2012; Miller et al., 2017; O’Neill et al., 2016; Wolfe et al., 2019) and professional advice and support from paediatricians were recommended (O’Neill et al., 2016).

4. Discussion

This review identified several important findings. First, adolescents had a limited understanding of relationships and consent, but they wanted happy relationships and were interested in learning more about how to achieve them. Second, education content varied significantly by provider type, and each provider’s methods varied. Third, most providers generally felt confident covering basic topics but identified a need for improved communication methods and increased support and training in various areas of relationships and consent conversations. Finally, the recommendations for improvement included increased training, the use of engaging methods, active parental involvement, provider collaboration, and improved communication and customised resources.

Most of the studies we reviewed found that adolescents had a varied and patchy understanding of relationship topics (Finlay et al., 2015; Heifetz et al., 2020) such as awareness of relationship evolution (Heifetz et al., 2020; Löfgren-Mårtenson, 2012; Retznik et al., 2021, 2022), but their understanding of the complex dynamics of a relationship, including respect and the nuances of consent, was often limited (Mendes & Denari, 2023; Retznik et al., 2022; Strnadová et al., 2022b). Their understanding of sexual behaviours, emotional connections (Retznik et al., 2022), and regulations (Finlay et al., 2015) varied with inadequate practical strategies to manage emotions (Strnadová et al., 2022b). Awareness and skills regarding personal safety (Miller et al., 2017; Strnadová et al., 2022b), including internet safety (Finlay et al., 2015), were shallow and often influenced by misinformation from the media (Lafferty et al., 2012). Their understanding of relationships, gender roles, commitment and marriage was often traditional and heterosexually biased (Heifetz et al., 2020; Kucuk et al., 2017). These findings are not surprising in the context where the sexuality of adolescents with an intellectual disability is often overlooked, and their access to sexuality education and information is inadequate (Harden, 2014; Nelson et al., 2020). Our findings highlight the need to provide adolescents with social opportunities and appropriate media access (Heifetz et al., 2020).

Despite their limited understanding, many adolescents seemed optimistic about relationships and strongly desired accurate, evidence-based, and age-appropriate information (Finlay et al., 2015; Frank & Sandman, 2019; Lafferty et al., 2012). They sought foundational knowledge on building healthy and happy relationships (Frank & Sandman, 2019; Heifetz et al., 2020; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Povilaitiene & Radzeviciene, 2015; Retznik et al., 2021; Wolfe et al., 2019) and how to incorporate consent in relationship dynamics (Dupras & Dionne, 2014; Eyres et al., 2022; Greene et al., 2024; Kucuk et al., 2017; Laganovska & Kviese, 2021; Miller et al., 2017; Pryde & Jahoda, 2018; Strnadová et al., 2022b; Wolfe et al., 2019). Of specific interest to adolescents were skills for safety and well-being in relationships, including effective communication (Frank & Sandman, 2019; Retznik et al., 2022), decision-making (Greene et al., 2024), online safety (Heifetz et al., 2020; Strnadová et al., 2022b), emotional regulation and emotional intelligence (Lafferty et al., 2012; Povilaitiene & Radzeviciene, 2015; Strnadová et al., 2022b), navigating romantic and relationship challenges, including managing breakups (Retznik et al., 2022) and healthy relationship dynamics (Retznik et al., 2022). Their desire for relationships and interest in learning more about healthy relationships could help adolescents learn about their topics of interest (Brown et al., 2024). One major issue for many adolescents was a lack of a trusted adult in their lives to share concerns and receive information and advice, and, in their absence, adolescents had to resort to informal and external sources of information that often lacked depth and reliability (Löfgren-Mårtenson, 2012).

Education content varied significantly by provider type. Parents generally offered foundational, ethical, and practical aspects, emphasising safety, cultural values, and social norms. Parents’ education was often based on personal experiences and tended to be heterosexually biased and focused on long-term commitment. Some parents expressed scepticism about their children’s future relationships (Colarossi et al., 2023; Dupras & Dionne, 2014; Eyres et al., 2022; Frank & Sandman, 2019; Heifetz et al., 2020; Lafferty et al., 2012; O’Neill et al., 2016; Pryde & Jahoda, 2018; Retznik et al., 2021, 2022; Wolfe et al., 2019). Teachers provided more structured education, focusing on relationship concepts, social skills, communication, decision-making strategies, safe behaviours, anti-bullying, online safety, and peer pressure (Finlay et al., 2015; Greene et al., 2024; Lafferty et al., 2012; Laganovska & Kviese, 2021; Löfgren-Mårtenson, 2012; Mendes & Denari, 2023; Povilaitiene & Radzeviciene, 2015; Strnadová et al., 2022b; Wolfe et al., 2019). The level of detail and comfort in delivering education varied, but parents and teachers seemed to complement each other in this effort. Healthcare and disability providers focused on empowerment and safety skills for adolescents’ health and well-being, including negotiation skills and finding support, with reinforcement at home. Some healthcare providers emphasised legal and safety requirements over personal development, and it was unclear if they covered relationships, values, culture, and sexuality (Lafferty et al., 2012; Löfgren-Mårtenson, 2012). Some disability providers, however, used a social and tailored approach to address individual learning needs (Finlay et al., 2015).

Relationship and consent education was included in school curricula but was often inadequate and inconsistent (Dupras & Dionne, 2014). While some well-structured school programs existed (Greene et al., 2024; Strnadová et al., 2022b), they were not always tailored to the diverse learning needs of adolescents with intellectual disability (Laganovska & Kviese, 2021). There was a significant gap in formal education distinguishing between romantic relationships and friendships (Lafferty et al., 2012). Traditional views on gender roles, heterosexual relationships and marriage (Retznik et al., 2021) suggest a need for broader education on diverse sexualities and sexual rights. Previous studies also highlighted that existing education at schools and homes was inadequate, often conservative, negatively framed, and focused on heteronormativity messages, which can lead to social exclusion by preventing adolescents from experiencing their rights to sexuality (Rowe & Wright, 2017; Treacy et al., 2018; Waling et al., 2019). Similarly, most education from parents, carers and some health professionals focused on risk-based and protectionist approaches to education (Lafferty et al., 2012), which overlooked the positive aspects of relationships and sexuality. This aligns with previous studies suggesting that positive aspects of sexuality are generally underexplored, especially for adolescents with intellectual disability (Bosó Pérez et al., 2022; East & Orchard, 2014; Ford et al., 2019; Kågesten & van Reeuwijk, 2021; Mitchell et al., 2021). Some studies indicated that sexual health education provided to adolescents with an intellectual disability was limited to preventing abuse, vulnerability or pregnancy rather than sex-positive approaches to relationships and intimacy and recommended for disability-specific content with aspects of pleasure and desire (United Nations Educational Scientific and Cultural Organisation [UNESCO], 2015; Harden, 2014; Travers & Tincani, 2010; Wolfe et al., 2019; Frank & Sandman, 2019; Brown et al., 2024; Treacy et al., 2018). Future consent and relationships education could benefit from moving from a risk-based approach to one that promotes personal development and sexual well-being for adolescents with intellectual disability (Travers & Tincani, 2010).

In addition to education content, teaching methods differed among providers. Parents used reactive and sporadic approaches, often waiting for the adolescents to start the conversation (Lafferty et al., 2012; Pryde & Jahoda, 2018; Tricco et al., 2018), but recognised a need for clear, explicit conversation and enhanced support and resources for parents (Dupras & Dionne, 2014; Heifetz et al., 2020; Pryde & Jahoda, 2018; Retznik et al., 2021). School education was based on well-developed guidelines and pedagogical methods, including tiered and spiral curricula, individual learning plans (Finlay et al., 2015; Laganovska & Kviese, 2021; Strnadová et al., 2022b) and tailored programs. Some successful examples, such as the ‘Circles’ (Strnadová et al., 2022b) and ‘Ask Me First Choices’ (Greene et al., 2024) programs, deserved further implementation research. Healthcare providers and clinicians employed professional and scenarios-based teaching methods using vignettes and scenarios typically used in clinical education (Miller et al., 2017; Schuwirth & Van der Vleuten, 2003; Tseng et al., 2021).

Despite various techniques used, all providers indicated a lack of formal training, which was often a reason for a lack of confidence in providing relationship and consent education. Many teachers and family carers generally felt ill-equipped (Lafferty et al., 2012) but were aware of the challenges (Povilaitiene & Radzeviciene, 2015; Wolfe et al., 2019). Parents, especially mothers, seemed anxious discussing sensitive topics (Dupras & Dionne, 2014; Heifetz et al., 2020; O’Neill et al., 2016; Pryde & Jahoda, 2018) and provided education drawing from their personal experience and comfort levels, seeking more guidance and support. Teachers showed mixed feelings of empowerment and uncertainty (Eyres et al., 2022; Povilaitiene & Radzeviciene, 2015). Those using structured approaches demonstrated higher competence (Kucuk et al., 2017), while others highlighted varying confidence levels, particularly in emotional and relationship education. One of the challenges for teachers was difficulty assessing comprehension (Finlay et al., 2015; Laganovska & Kviese, 2021; Pryde & Jahoda, 2018) when working with nonverbal students (Strnadová et al., 2022b), indicating a need for extensive training. Clinicians did not explicitly express a lack of competence (Miller et al., 2017), as only two studies specifically addressed clinicians’ perspectives. These studies indicated that some clinicians and frontline staff jointly sought training in policy and practice related to legislation, parenting assessments, and resource development, supported by improved procedures for staff supervision and organisational policies (Lafferty et al., 2012).

Our review highlights numerous barriers to sexuality and consent education. Some barriers are common, such as inconsistent educational practices (Löfgren-Mårtenson, 2012; Povilaitiene & Radzeviciene, 2015; Wolfe et al., 2019), lack of training and support for providers (Finlay et al., 2015; Greene et al., 2024; Lafferty et al., 2012; Laganovska & Kviese, 2021; Mendes & Denari, 2023; Wolfe et al., 2019), and limited resources and materials (Colarossi et al., 2023; Eyres et al., 2022; Kucuk et al., 2017; Lafferty et al., 2012; O’Neill et al., 2016; Povilaitiene & Radzeviciene, 2015; Pryde & Jahoda, 2018; Strnadová et al., 2022b). Other barriers are specific to adolescents with intellectual disability, such as complexities of topics and content (Colarossi et al., 2023; Eyres et al., 2022; Finlay et al., 2015; Frank & Sandman, 2019; Mendes & Denari, 2023), lack of individualised and customised resources (Dupras & Dionne, 2014; Finlay et al., 2015), communication challenges (Dupras & Dionne, 2014; Finlay et al., 2015; Heifetz et al., 2020; Kucuk et al., 2017; Lafferty et al., 2012; Miller et al., 2017) and social isolation of adolescents with intellectual disability (Dupras & Dionne, 2014; Retznik et al., 2021, 2022). Further complicating this education are cultural and societal attitudes, which deprive adolescents with intellectual disability (as members of society) of the inherent human right to have healthy and satisfying relationships. Some parents and educators expressed fear of increasing sexual behaviour and avoided discussing relationship topics with adolescents (Laganovska & Kviese, 2021)—a finding that was reported in previous studies (Strnadová et al., 2022a; Treacy et al., 2018). Combined with assumptions that adolescents with intellectual disability are childlike and asexual, these negative provider views hinder comprehensive education (Strnadová et al., 2022a). We found mixed perspectives, as some parents doubted their adolescents’ future relationships. Parents believed that adolescents should be older before they start dating, compared to what the adolescents thought. A subset of parents felt that adolescents would never be ready for relationships (Retznik et al., 2021). Adolescents who discussed relationships with these parents were less likely to pursue dating. Instead, they tended to have levelled and positive views on relationships, seeing them as lifelong commitments focused on companionship (Heifetz et al., 2020). This suggests a need for providers to expand their awareness of current evidence and deliver evidence-based education.

Training and support were significant issues for many providers. Both parents and teachers reportedly encountered communication challenges when educating adolescents, often needing to repeatedly explain concepts multiple times and adjust their methods due to varying comprehension levels (Dupras & Dionne, 2014; Kucuk et al., 2017; Miller et al., 2017). They emphasised the need for ongoing training, support (Lafferty et al., 2012; Laganovska & Kviese, 2021; Mendes & Denari, 2023; Miller et al., 2017), and continuous monitoring to improve effectiveness (Finlay et al., 2015; Löfgren-Mårtenson, 2012), consistent with previous research (Strnadová et al., 2022a; Treacy et al., 2018). Using a social model of disability can help address these comprehension issues collaboratively (Finlay et al., 2015). Similarly, providers also highlighted the need for individualised resources tailored to the needs of adolescents with intellectual disability (Colarossi et al., 2023; Dupras & Dionne, 2014; Finlay et al., 2015; Pryde & Jahoda, 2018; Strnadová et al., 2022b), consistent with previous research (Michielsen & Brockschmidt, 2021; Treacy et al., 2018).

Finally, effective education is enabled by increased provider training (Lafferty et al., 2012; Laganovska & Kviese, 2021; Mendes & Denari, 2023; Miller et al., 2017), the use of engaging teaching methods (Finlay et al., 2015; Frank & Sandman, 2019; Löfgren-Mårtenson, 2012), active parental involvement (Kucuk et al., 2017; Miller et al., 2017; O’Neill et al., 2016; Wolfe et al., 2019) and collaboration between providers (Eyres et al., 2022; Greene et al., 2024; Retznik et al., 2021), including improved communication and individualised instruction (Eyres et al., 2022; Povilaitiene & Radzeviciene, 2015). Parents and teachers should collaborate to provide consistent relationship and consent education at home and school (Eyres et al., 2022). Proactive, structured approaches encouraging multidirectional communication and long-term reinforcement through collaborative relationships are essential (Dupras & Dionne, 2014; Eyres et al., 2022; Mendes & Denari, 2023; O’Neill et al., 2016; Povilaitiene & Radzeviciene, 2015). Self-determination is often overlooked in sexuality education for individuals with intellectual disability. Only a few teachers focused on autonomy and self-advocacy (Pryde & Jahoda, 2018; Strnadová et al., 2022b). There is a gap in linking sexual health with self-determination for adolescents with intellectual disability (Treacy et al., 2018). Understanding their sexual self-perceptions and environment can improve relationships and consent education, promoting sexual autonomy and well-being (Harden, 2014). There is a need for early investments and positive approaches regarding adolescent sexuality to promote sexual well-being over time (Bosó Pérez et al., 2022; Ford et al., 2019; Kågesten & van Reeuwijk, 2021; Mitchell et al., 2021).

This review is unique in addressing the critical need for effective relationships and consent education for adolescents with intellectual disability. It highlights gaps in knowledge and resources and takes a comprehensive approach to investigating the views of both the adolescents and their various care providers regarding relationship and consent education. Given recent changes in consent laws in New South Wales Australia and the mandatory integration of consent education into the national curriculum in Australia and other countries, this study is timely and essential. By increasing awareness about the varied needs and skills of adolescents with intellectual disability, this work aims to shift current paradigms around their sexuality and consent education.

This review assessed the content of education provided in schools, homes, and health, disability care, and support services by various providers, their competencies, and the barriers and enablers for implementing relationships and consent education. The recommendations highlight policy change and implementation support for relationship and consent education that meets the needs of adolescents with intellectual disability. These recommendations include addressing the limited research on adolescents with intellectual disabilities, the need for better access to CSE materials, and the development of tailored educational programs. This review examined the status of sexual and reproductive health rights and consent education among adolescents with intellectual disability and how these rights are upheld in various countries.

Strengths and Limitations of This Review

Our literature review has several limitations. We could only analyse published studies, which varied in sample size and provider groups, making it uncertain how well conclusions apply to all adolescents with intellectual disability. There is a lack of longitudinal data to assess the long-term impact of relationship and consent education. Additionally, the review may be biased towards certain cultural perspectives. Although it included studies from high- and middle-income countries, most were conducted in the USA, making it difficult to generalise findings globally. The heterogeneity of study designs, including qualitative, quantitative, and mixed methods, complicated comparisons. Most studies were qualitative, limiting the ability to quantify the problem. Additionally, few studies reported on healthcare and disability providers’ views, limiting the representation of these perspectives. The review did not assess publication bias or risk of bias.

5. Conclusions

Our review underscores the urgent need for effective relationships and consent education for adolescents with intellectual disability, highlighting significant gaps in knowledge among both adolescents and providers and emphasising the importance of targeted interventions and resources. Adolescents desire comprehensive, evidence-based education, but the quality varies by provider. Many educators and parents feel ill-equipped, leading to inconsistent, risk-focused education. Barriers include cultural attitudes, communication challenges, complex topics, social isolation, lack of training, and limited resources. To improve education, we advocate for tailored resources designed specifically for the education of adolescents with intellectual disability, the use of more engaging methods, increased training, and collaborative approaches between parents and teachers. A shift from risk-based education to promoting sexual well-being and autonomy is essential. We recommend prioritising comprehension and using a social model of disability in education. This includes collaborative curriculum planning, a co-design approach to resource development, and embedding self-determination, autonomy, and self-advocacy skills into a spiral curriculum to enhance personal development and sexual well-being for adolescents with intellectual disability. These recommendations also have broader implications for national education policies and legislation. Policymakers should ensure that comprehensive sexuality education for adolescents with intellectual disabilities is mandated and adequately resourced within national curricula. Legal frameworks should support inclusive education that promotes sexual rights, well-being, and autonomy for all students, with a specific focus on those with intellectual disabilities. Inclusive education incorporates standardised training programs, accessible resources, and frameworks for monitoring and evaluation.