PERSONS WITH INTELLECTUAL DISABILITY: SEXUAL BEHAVIOUR, 
KNOWLEDGE AND ASSERTIVENESS
 1*
 2
, Daniela TAMAŠ 3
 3
, Vesela MILANKOV
3
1
University of Novi Sad, Faculty of Medicine, Department of Psychology, Hajduk Veljkova 3, 21000 Novi Sad, Serbia
2
Institution for Mentally Disabled adult Persons “Otthon”, Stara Moravica, Serbia
3
University of Novi Sad, Faculty of Medicine, Department of Special Education and Rehabilitation,  
Hajduk Veljkova 3, 21000 Novi Sad, Serbia
Received: Feb 7, 2020
Accepted: Jan 29, 2021 
 *Corresponding author: Tel. + 381 60 3660 388; E-mail: nina.brkic-jovanovic@mf.uns.ac.rs
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82
 ABSTRACT
Keywords: 
sexuality, intellectual 
disability, knowledge 
of sexuality, sexual 
assertiveness
 spolnost, intelektualna 
ovira, znanje o 
spolnosti, spolna 
asertivnost
Background: Persons with ID most often have incomplete, contradictory and imprecise knowledge of sexuality 
 and are often discouraged from and sanctioned for trying to sexually express themselves. Sexual abuse due to low 
sexual assertiveness is also common.
Aim: The principal aim of this study was to establish the presence or absence of sexual activity in adults with ID 
residing in institutional housing, as well as the level and structure of their knowledge of sexuality, their sexual 
assertiveness and preparedness to react in a sexually dangerous situation.
Methods: The sample consisted of 100 participants with ID residing in institutional housing. The instruments used 
included the General Sexual Knowledge Questionnaire, What-if test and Hulbert index of sexual assertiveness. 
 Results: The results showed that 82% of the participants are sexually active. Most participants admitted to 
 knowledge of pregnancy, contraception and sexually transmitted diseases was very low. Female participants and 
those that reported having sexual intercourse had more sexual knowledge and were also more sexually assertive.
Conclusion: Knowledge of sexuality and sexual assertiveness of persons with ID residing in institutional housing 
is very low. Additional information on sexuality is necessary, as well as support in learning to express their own 
desires and to deal with unwanted sexual activity.
 asertivnosti.
 ki prebivajo v institucionalnih ustanovah, ter raven in strukturo njihovega znanja o spolnosti, njihovo spolno 
 multiplo regresijsko analizo.
 Osebe z intelektualno oviro, ki prebivajo v institucionalnih ustanovah, imajo zelo nizko raven znanja o 
 © Nacionalni inštitut za javno zdravje, Slovenija. 

*Corresponding author: Tel. + 381 60 3660 388; E-mail: nina.brkic-jovanovic@mf.uns.ac.rs
1 INTRODUCTION
1.1 Sexuality of persons with ID
 subtle and complex thoughts and emotions of others, and 
are consequently unable to express their own thoughts and 
 their own sexuality and how to express it appropriately, 
studies show that persons with ID do have sexual needs 
 limitations of persons with ID in intellectual functioning 
and adaptive behaviour are manifested in poor conceptual, 
social and practical adaptive skills, and consequently 
in sexual behaviours (4). Slower memory processes, 
 development, poorer deduction and generalization 
capabilities all stem from the aforementioned limitations, 
 of learned information, in managing novel situations, 
in self-care, communication and social skills (5). These 
characteristics make engaging in sexual interactions more 
challenging for persons with ID (6). 
Pedersen and Harakopos conducted a study that 
 persons with ID residing in institutional housing, and their 
results showed sexual expression was present in 80% of the 
participants (7). Stereotypes and prejudices concerning 
this segment of the population still persist in the wider 
community, as well as among professionals and parents of 
persons with ID, especially when it comes to expressing 
sexuality (8). Another problem is the lack of information 
provided to persons with ID concerning their bodies and 
sexuality (9), their frequent discouragement and even 
punishment for trying to express themselves sexually (10), 
as well as sexual victimization (11).
1.2 Knowledge of sexuality in persons with ID
Persons with ID most often have inadequate, contradictory 
and imprecise knowledge of sexuality and sexual 
 especially genitals (12). Some studies indicate that persons 
with ID differentiate male and female genitalia, and can 
tell a person’s gender and gender differences, while others 
speak to the contrary (13, 14).
Persons residing in institutional housing were shown to 
be better informed on sexual intercourse, appropriate 
behaviour on a date, contraception and birth control 
compared to persons living in families, who on their part 
had more knowledge of sexually transmitted diseases, 
risky sexual behaviour and intimacy (15).
Frawly and Wilson concluded that young people with ID 
often know the most facts about sexuality but do not 
 knowledge of sexuality leads to subsequent problems in 
sexual behaviour (17, 18). 
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83
 relationships and making free-will decisions on starting 
and maintaining them (19). Persons with ID are not well 
informed on sexuality, although their interest in sexual 
life is high. Moreover. the sources of information used by 
members of the typical population are mostly inadequate 
for persons with ID, and this all leads to the development 
of socially unacceptable sexual behaviour, susceptibility to 
sexual abuse and other risks, such as sexually transmitted 
diseases or unwanted pregnancy (20). 
The results of a study in Serbia showed the negative attitudes 
and low level of knowledge in the general population with 
regard to the sexuality of persons with disabilities, and 
point to the need for educating parents and professionals 
on this subject (8). Although there are programs of sexual 
education in Serbia which contribute to the improvement 
of knowledge of sexuality in the general population (21), 
these programs are not adapted to persons with ID.
1.3 Sexual abuse of persons with ID
Persons with ID are often victims of covert psychological 
violence, and may seemingly voluntarily consent to sexual 
intercourse after being lured into it various promises. 
Studies have also found multiple factors that determine the 
sexuality of persons with ID, namely: lack of information 
 communication skills, low self-respect and lack of positive 
sexual experiences and models. Furthermore, the sexuality 
of persons with ID is also determined by an inability to 
distinguish between consenting and nonconsenting 
 public, and safe from risky behaviors as well as appropriate 
from inappropriate sexual encounters (22). Along with 
being constantly dependent on others and unable to stand 
up for themselves, the above-mentioned factors contribute 
to higher levels of victimization of persons with ID where 
sexual abuse is concerned. In addition to individual factors 
of increased risk for sexual abuse, factors associated with 
the perception of the risk of sexual abuse and those that 
concern the possibility of reporting on the actual abuse, 
 Studies show concerning results that point to sexual abuse 
of people with ID (23), indicating that most are victims 
of sexual assault at least once in their lives, with the 
perpetrators most often being persons that are close to 
them (24). Wissink and associates found a three- to four-
fold greater likelihood that a person with ID will fall victim 
to abuse compared to the typical population (25).
As mentioned above, various factors make persons with ID 
more susceptible to sexual abuse, with studies emphasizing 
poor self-defence due to physical/motor limitations, 
inability to assess potentially dangerous situations due to 

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299 residents. Data were collected in the period of May/
June 2018. 
The sample consisted of 100 participants with ID, 54% 
female and 46% male. The age range was 23 to 63 years. 
The average age for the entire sample was 47.64 years 
(SD=9.66). When observed by age category the majority of 
participants belonged to the over 50 years of age category. 
When answering the question where they lived prior to 
moving into this residential facility, the majority stated 
that they came from their family of origin (80%), while 
the remaining participants came from other residential 
facilities or foster families. As to their marital status, 81% 
of participants stated that they had never been married; 
46% of participants indicated that they currently have 
a partner. Of the entire sample, 24% stated they had 
children, with most having only one child. Out of the total 
of 100 participants, 82% reported being sexually active. 
2.2 Instruments
• For the purpose of this study information on the degree 
of intellectual impairment was obtained by access to 
 • For assessment of knowledge of sexuality, we used the 
General Sexual Knowledge Questionnaire (33) which was 
linguistically and grammatically adjusted to the Serbian 
language. This general questionnaire is divided into six 
sections, with 63 questions in total. The questionnaire 
allows sexual knowledge to be scored in total as 
 areas of sexual knowledge: Physiology (33 items), 
Sexual intercourse (10 items), Pregnancy (8 items), 
Contraception (5 items), Sexually transmitted diseases 
(8 items) and Sexual orientation and gender identity (3 
items). In our study this instrument was shown to have 
good test-retest reliability (r=0.86) and good internal 
consistency (Cronbach alpha >0.80). Factor analysis 
yielded six factors along with the possibility to calculate 
the total result. 
• The next instrument used for study purposes was the 
What-if-situations-test that consists of 29 questions 
(33). The test was developed with the aim of preventing 
sexual abuse and assesses participants’ behaviour in 
risky situations. Eleven questions are created in a way 
that the participant is asked to differentiate between 
acceptable and inacceptable situations. Seventeen 
further questions refer to actions that should be taken 
in particular situations, and one question pertains to 
naming intimate body parts. The internal consistency 
 • To assess sexual assertiveness, we used the 25-item 
Hulbert index of sexual assertiveness (30, 31). The items 
are based on self-assessment of cognitive, emotional 
cognitive impairment, lack of knowledge of sexuality and 
interpersonal relationships, lack of education on abuse and 
on adequate self-defence strategies, and a lack of sexual 
assertiveness (26). 
1.4 Sexual assertiveness
 
to develop assertive behaviour in a sexual context (27). 
 sexual assertiveness represents an ability to initiate sexual 
intercourse and to decline unwanted sexual contact, and 
a capability to protect oneself from unwanted pregnancy 
and sexually transmitted diseases (28). Santos-Iglesias and 
 the sexual assertiveness and sexual life of a person (29). 
Hulbert included initiating a sexual act and talking to one’s 
partner about potential sexual problems in the notion of 
sexual assertiveness (30). Sexual assertiveness is also 
associated with the use of birth control, especially condoms. 
Insisting on the use of condoms is directly associated with 
higher levels of sexual assertiveness (31). Studies on sexual 
assertiveness in persons with ID are rare, and in this context 
assertiveness is only used with the purpose of protection 
against sexual violence, so that a person could defend 
themselves against unwanted sexual intercourse (32). 
1.5 The present study
 
activity of persons with ID residing in institutional housing, 
as well as their level and structure of knowledge with 
regard to sexuality, sexual assertiveness and preparedness 
to react in sexually dangerous situations. The second aim is 
to assess the role of certain demographic variables in the 
prediction of sexual knowledge and sexual assertiveness. 
2 METHOD
The study was conducted in the residential facility 
“Otthon” in Stara Moravica, Serbia. Currently 299 persons 
with moderate and severe ID reside in this facility. 
Questionnaires were completed individually, in the form 
of interviews: the examiner asked questions and wrote 
down the participants’ answers. If necessary, the examiner 
provided additional explanations to the participant. 
2.1 Sample 
The study only included participants who signed a written 
consent or had a written consent signed by their guardians. 
Apart from that, the inclusion criteria encompassed: a 
diagnosis of moderate intellectual disability (information 
 each potential participant) and good command of the 
Serbian language. These criteria were met by 100 of the 

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85
and behavioural aspects of expressing sexual needs. 
Answers are given on a Likert-type scale, with 13 items 
scored from 0 to 4, with 0 having the highest value and 
4 the lowest, while the remaining 12 items are reverse-
scored (from 4 to 0). This questionnaire had excellent 
 2.3 Data analysis
Data entry and analysis was performed using the program 
package SPSS 20.0. We used descriptive statistics to analyse 
the obtained results and show the sample structure on 
relevant variables. 
 
regression analysis were used as methods of comparative 
statistics. In all the tests we performed the threshold of 
 3 RESULTS
Table 1 shows the average scores on scales used in this study. 
The performed analysis indicates that the distribution 
of results on all three questionnaires corresponds to the 
normal distribution (for total scores). The results show an 
extremely low level of knowledge of sexuality, both when 
the total score is observed and the scores on individual 
sections. Participants obtained very low scores on the test 
of sexual assertiveness and on the What-if test as well.
In order to establish if there is a connection between 
the scores on tests of sexual knowledge (General Sexual 
Knowledge Questionnaire and What-if test) and scores on 
sexual assertiveness (Hulbert index of sexual assertiveness) 
 (Table 2). With regard to the correlations among these 
 correlation, between the score obtained on the What-if test 
and score on the General Sexual Knowledge Questionnaire. 
The correlation was of moderate intensity and in the 
 knowledge of sexuality a person has, the better they are 
able to deal with “problem” situations regarding sexuality. 
None of the remaining correlations between the variables 
 indicates that sexual assertiveness is a skill independent of 
knowledge and formal education with regard to sexuality 
and reproductive health.
General sexual knowledge questionnaire 
    Physiology pictures
    Physiology questions
    Sexual Intercourse/Sex/Masturbation
    Pregnancy 
    Contraception
    Sexually transmitted diseases
    Sexuality
 Hulbert index of sexual assertivness 
General Sexual 
Knowledge 
Questionnaire
 Hulbert index of  
sexual assertiveness
Table 1.
Table 2.
Average scores and basic characteristics of the distribution. 
 .226
-.488
-.389
-.415
1.43
-.026
1.50
1.20
.875
-.032
13.63
4.68
1.72
2.50
2.95
2.58
0.28
4.68
5.54
5.82
74
16
17
9
16
10
12
2
37
64
.986
-.725
.930
.286
1.29
1.14
1.36
-1.45
.474
.014
33.63
5.88
3.92
4.70
2.19
1.72
0.94
5.88
19.88
48.80
14
10
0
1
1
0
0
0
7
33
1 
 
.360**
.187
.360** 
 
1
-.191
.187 
 
-.191
1
Domains No of studies
Hulbert index 
of  sexual 
assertiveness 
test General Sexual 
Knowledge 
Questionnaire
max AS SD Sk Ku min
In order to determine the proportion of variance of sexual 
knowledge (General Sexual Knowledge Questionnaire and 
What-if test) that can be explained by the variance of 
 variables, we performed a series of multiple regression 
analyses. The set of predictors included the following 
variables – gender, age, time spent in the institution and 
sexual activity. Criterion variables were total scores on the 
following tests: General Sexual Knowledge Questionnaire, 

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86
What-if test and Hulbert index of sexual assertiveness. 
 deviations from the expected normal distribution, linearity, 
multicollinearity and homoscedascity.  
 time spent in the institution and sexual activity for general 
knowledge of sexuality. The model was statistically 
 the General Sexual Knowledge Questionnaire explained by 
the predictor variables was 22.4%.  The variables Gender 
 individual contributions to the prediction (Table 3). Both 
correlations were positive, but the variable pertaining to 
having sexual intercourses had a slightly higher individual 
 and those having sexual intercourses scored higher on the 
General Sexual Knowledge Questionnaire. 
 of success on the What-if test F(4, 95)=4.832, p=0.001. 
 percentage of variance on the What-if test explained by the 
set of predictor variables was 16.9%. The variables Gender 
 to the prediction. Both correlations were positive, but the 
variable Age had a slightly higher individual contribution 
 older age scored higher on the What-if test. 
The predictive model of sexual assertiveness was also 
 variance of the Hulbert index of sexual assertiveness 
explained by the predictor variables was 13.7%. Only 
the variable/question Are you having sexual intercourse? 
 prediction. The correlation was negative and of moderate 
 practiced sex had a lower total score on the Hulbert index 
of sexual assertiveness. 
Gender
Age
Time spent in the institution
Are you having sexual intercourses?
Table 3. Partial contributions to the prediction of sexual knowledge and assertiveness.
.261**
.360**
-.165
.008
-.076
.050
.112
-.317**
.348**
.070
.006
.243**
 General Sexual Knowledge 
Questionnaire
 Index of sexual 
assertiveness 4 DISCUSSION
The results indicate that most persons with ID who 
participated in the study were sexually active. At the time 
the study was conducted 54% of participants claimed to 
have a sexual partner, while 46% reported the contrary. 
A total of 82% of participants reported having sexual 
experiences, while 18% had never been involved in sexual 
 have sexual needs and the capacity to engage in sexual 
behaviour. Gil-Liario and colleagues (2) obtained similar 
results, and their study showed that 84% of participants 
had previously had sexual intercourse with another person, 
with a greater proportion of women in this category (2). 
The General Sexual Knowledge Questionnaire consists 
of six sections on which our participants had rather 
heterogeneous results. The best results were obtained in 
the section of Physiology, which examines the respondents’ 
 identifying and naming external body parts; there was, 
however, a problem with identifying internal organs, such 
as the ovaries, uterus and testicles. 
In their own study, Isler and colleagues also obtained 
results that indicate that respondents with ID had 
 In Kijak’s study, 90% of participants answered questions 
on female and male bodies accurately (1). In our study all 
participants (100%) answered questions that asked them 
to identify external body parts (head, arm, leg, stomach, 
and chest) correctly, but had poorer results when it came 
to identifying internal body parts (testicles, ovaries, and 
vagina). It was our hypothesis that educational programs 
dealing with internal body parts and elements of sexual 
health, which require a certain level of abstraction in 
order to be fully understood, need to be better adapted 
to persons with ID.
Persons with ID often request education and support from 
peers, supervisors and other professionals in the domain 
of sexuality (35). In our study the participants scored low 
in the domain of knowledge of sexual intercourse, which 
should be especially addressed in educational programs. In 
a study conducted by Edmondson, respondents answered 
70% of questions on body parts and sexual intercourse 

correctly (36). However, in more recent studies (34, 37) 
participants scored much lower on questions concerning 
Sexual intercourse.
Our participants displayed rather poor knowledge of 
Pregnancy, Contraception and Sexually transmitted 
diseases. Lockhart also reached a conclusion that persons 
with ID have substantial knowledge of body parts and on 
intimate behaviour (holding hands or kissing), while their 
knowledge of pregnancy and childbirth is very poor (38). 
 persons with ID in institutional housing can cause a lack 
of information and skill in the domain of sexuality, but 
with appropriate education and good social support, 
people with ID are capable of improving both their sexual 
knowledge and behaviour.
Eastegate and colleagues (39) found their study participants’ 
knowledge of sexuality varied from extremely basic, 
without understanding the concept of sexual intercourse, 
to rather complex, including understanding the process of 
 as their primary source of information, while older ones 
stated that they did not even realize you could talk about 
these issues at school. Other sources of information listed 
by persons with ID included books, talking to their mothers 
 mostly unable to protect themselves from unwanted sexual 
experiences. In our study, most participants admitted to 
sometimes having sexual intercourse against their wishes 
 with results obtained by Eastegate and colleagues (39). 
We can look for causes for this behaviour in the domain 
of individual characteristics, factors associated with the 
perception of the risk of SA and factors linked to the 
possibility of reporting on the abuse actually taking place 
(2, 22). It is also important to consider housing conditions 
and the lack of independence of persons in institutional 
housing. This subject requires further investigation. 
The What-if test was created with the purpose of preventing 
sexual abuse. Our participants were shown to be mostly 
aware of basic risk situations and that they could ask for 
help if they ever found themselves in them. However, 
their strategies for dealing with potentially dangerous 
situations were far from adequate. We presume that the 
support and education offered to persons with ID do not 
include role-playing situations, and that the information 
the participants acquire in such education is not applicable 
to real-life situations. The results of the study conducted 
by Lee and Tang indicate that persons with ID are able 
to differentiate between appropriate and inappropriate 
situations, but they are far less successful when it comes 
to reporting the latter and asking for help (40), which is in 
accordance with the results of our study.
We tried to ascertain which groups of participants, 
with regard to sexual activity and socio-demographic 
parameters, have lower knowledge of sexuality, low 
sexual assertiveness and are the least prepared to 
prevent sexual abuse. We found female participants and 
those having sexual intercourse to score higher on the 
General Sexual Knowledge Questionnaire. Within our 
sample group there were women who had carried one or 
more pregnancies to term. During their pregnancies they 
had experiences and communication with health-care 
workers and other professionals which allowed them to 
widen their knowledge of sexuality. Moreover, women 
who reside in institutions are educated on self-care in 
the context of menstruation and contraception, which 
can all be predictors of the observed gender differences. 
 knowledge of sexuality (40), while the effect of age was 
found by other research (42). However, age did not turn 
 The literature available to us does not explain if the 
previous sexual experience of persons with ID correlates 
with their level of knowledge of sexuality. Michie and 
colleagues (43) conducted a study which showed that 
individuals with ID who had commited a sex-related crime 
knew more on sexuality compared to non-offenders. We 
can hypothesize that the reason for this lies in the fact that 
 which are not available to other persons with ID (43).  
Lambrick and Glaser (44) reported numerous examples 
of people with ID who, despite their impairment, have 
highly developed social skills and are completely able to 
understand problems associated with sexuality. Presumably 
these persons obtain their information via television shows 
or by talking to family and friends (44). The results of our 
study show sexual activity to be predictive of higher levels 
of knowledge of sexuality, i.e. study participants who 
are sexually active have more knowledge about sexuality 
compared to those without sexual experiences. Moreover, 
the sexually active participants score higher on the 
Hulbert index of sexual assertiveness, whereas no socio-
demographic variable makes any difference in the sexual 
assertiveness of persons with ID in the current study. When 
we observe the results obtained from the What-if test that 
are indicative of how prepared persons with ID are to 
prevent sexual abuse, we can see that older women are 
the most prepared. 
Taking into account the results of these earlier studies as 
well as our own, we can create an educational program 
 authors have done (45). All the authors in the literature 
we examined agree that there are many potential adverse 
consequences of poor knowledge about sexuality among 
persons with ID. Incomplete or inadequate knowledge can 
increase the risk of sexual abuse, sexually transmitted 
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diseases and unwanted pregnancy (46). Most participants 
in our study demonstrated a low level of knowledge of 
sexuality and similar issues, which is very important for 
future practice since most of the participants are currently 
involved in the process of deinstitutionalization, which will 
bring new challenges in the years to come. 
Several limitations of the present study need to be 
acknowledged. First, the participants were recruited from 
a single housing institution for adults with ID, which limits 
the generalizability of results. Second, the sample included 
only participants with moderate ID. The participants were 
also assisted by examiners in answering the questions, 
which is a possible confounding factor we attempted to 
control as much as possible. However, we must consider the 
 in understanding questions and verbalizing answers, and 
this may have impacted the results. 
5 CONCLUSION
With adequate support persons with ID can learn how to 
react in order to prevent high risk situations that involve 
sexuality. It is thus crucial to teach them to recognize 
potential abuse, give them information on how to react 
in such situations and who to report them to. All the 
results of this study are very important to us, especially 
information regarding the groups of participants that 
have the least knowledge and assertiveness, so that these 
individuals can be included in future programs that will 
be created for persons with ID. Adequate sexual education 
 the actual situations and experiences of individuals with 
ID. Such programs are highly relevant for the process of (re)
habilitation, as well as for encouraging the independence 
and social participation of people with ID.
CONFLICTS OF INTEREST
 in relation to this work. 
FUNDING
 ETHICAL APPROVAL
All the procedures performed in studies involving human 
participants were in accordance with the ethical standards 
of the institutional and national research committee. The 
ethical approval number of the Faculty of Medicine at the 
University of Novi Sad for the current study is 01-39/59/1. 
REFERENCES
1. Kijak R. The sexuality of adults with intellectual disability in Poland. 
Sex Disabil. 2013;31:109-23. doi: 10.1007/s11195-013-9294-8.
2. Gil-Llario MD, Morell-Mengual V, Ballester-Arnal R, Díaz-Rodríguez I. 
The experience of sexuality in adults with intellectual disability. J 
Intellect Disabil Res. 2018;62:72-80. doi: 10.1111/jir.12455.
3. Anker-Hansen C, Skovdahl K, McCormack B, Tønnessen S. The third 
person in the room: the needs of care partners of older people in home 
care services - a systematic review from a person-centred perspective. 
J Clin Nurs. 2018;27:e1309-26. doi: 10.1111/jocn.14205.
4. Tomaszewski B, Fidler D, Talapatra D, Riley K. Adaptive behaviour, 
executive function and employment in adults with Down syndrome. J 
Intellect Disabil Res. 2018;62:41-52. doi: 10.1111/jir.12450.
5. Perkins EA, Small BJ. Aspects of cognitive functioning in adults with 
intellectual disabilities. J Policy Pract Intellect Disabil. 2006;3:181-94.  
doi: 10.1111/j.1741-1130.2006.00078.x.
6. Dukes E, McGuire BE. Enhancing capacity to make sexuality-related 
decisions in people with an intellectual disability. J Intellect Disabil 
Res. 2009;53:727-34. doi: 10.1111/j.1365-2788.2009.01186.x.
7. Haracopos D, Pedersen L. Sexuality and autism: Danish report. Accessed 
July 30th, 2019 at: https://www.autismuk.com/autism/sexuality-and-
autism/sexuality-and-autism-danish-report/. 
8. Tamas D, Brkic Jovanovic N, Rajic M, Bugarski Ignjatovic V, Peric 
Prkosovacki B. Professionals, parents and the general public: attitudes 
towards the sexuality of persons with intellectual disability. Sex 
Disabil. 2019;37:245-58. doi:  10.1007/s11195-018-09555-2.
9. Treacy AC, Taylor SS, Abernathy TV. Sexual health education for 
individuals with disabilities: a call to action. Am J Sex Educ. 2018;13:65-
93. doi: 10.1080/15546128.2017.1399492.
10. Brown M, McCann E. The views and experiences of families and direct 
care support workers regarding the expression of sexuality by adults 
with intellectual disabilities: a narrative review of the international 
research evidence. Res Dev Disabil. 2019;90:80-91. doi: 10.1016/j.
ridd.2019.04.012. 
11. Fraser-Barbour EF, Crocker R, Walker R. Barriers and facilitators in 
supporting people with intellectual disability to report sexual violence: 
perspectives of Australian disability and mainstream support providers. 
J Adult Protect. 2018;20:5-16. doi: 10.1108/JAP-08-2017-0031.
12. with mental disabilities. Sex Disabil. 2007;25:93-109. doi: 10.1007/
s11195-007-9046-8.
13. Talbot TJ, Langdon PE. A revised sexual knowledge assessment tool 
for people with intellectual disabilities: is sexual knowledge related to 
sexual offending behaviour? J Intellect Disabil Res. 2006;50:523-31. doi: 
10.1111/j.1365-2788.2006.00801.x.
14. Galea J, Butler J, Iacono T, Leighton D. The assessment of sexual 
knowledge in people with intellectual disability. J Intellect Dev Disabil. 
2004;29:350-65. doi: 10.1080/13668250400014517.
15. Garbutt R, Boycott-Garnett R, Tattersall J, Dunn J. Talking about sex 
and relationships: the views of young people with learning disabilities. 
Project report. Leeds: Change, 2010.
16. Frawley P, Wilson NJ. Young people with intellectual disability talking 
 84. doi: 10.1007/s11195-016-9460-x.
17. Borawska-Charko M, Rohleder P, Finlay WML. The sexual health 
knowledge of people with intellectual disabilities: a review. Sex Res 
Social Policy. 2017;14:393-409. doi: 10.1007/s13178-016-0267-4.
18. Blasingame GD. Risk assessment of adolescents with intellectual 
disabilities who exhibit sexual behavior problems or sexual 
offending behavior. J Child Sex Abus. 2018;27:955-71. doi: 
10.1080/10538712.2018.1452324. 
19. Naaldenberg J, Kuijken N, van Dooren K, van Schrojenstein Lantman de 
Valk H. Topics, methods and challenges in health promotion for people 
with intellectual disabilities: a structured review of literature. Res Dev 
Disabil. 2013;34:4534-45. doi: 10.1016/j.ridd.2013.09.029.
10.2478/sjph-2021-0013 Zdr Varst. 2021;60(2):82-89
88

10.2478/sjph-2021-0013 Zdr Varst. 2021;60(2):82-89
89
20. Servais L. Sexual health care in persons with intellectual disabilities. 
Ment Retard Dev Disabil Res Rev. 2006;12:48-56. doi: 10.1002/
mrdd.20093.
21. Kapamadzija A, Vejnovic T, Vukelic J, Kopitovic V, Bjelica A. Sexual 
knowledge, attitudes and practice of adolescents in northern 
Serbia - are we making any progress? Follow-up study 2000-2008. J 
Reproduktionsmed Endokrinol. 2010;7:106-11.
22. Wissink IB, van Vugt E, Moonen X, Stams GJ, Hendriks J. Sexual abuse 
involving children with an intellectual disability (ID): a narrative 
review. Res Dev Disabil. 2015;36:20-35. doi: 10.1016/j.ridd.2014.09.007.
23. Stone M. Preventing sexual violence against people with disabilities: 
empowerment self-defense, risk reduction education, and 
organizational change. In: Orchowski LM, Gidycz CA, editors. Sexual 
assault risk reduction and resistance: theory, research, and practice. 
London: Academic Press, 2018:353-78.
24. Corbett A, Cottis T, Lloyd E. The survival and development of a 
traumatized clinic for psychotherapy for people with intellectual 
disabilities. In: Hopper E. Trauma and organizations. Routledge: Taylor 
& Francis Group, 2018:111-26. 
25. Wissink IB, van Vugt ES, Smits IAM, Moonen XMH, Stams GJJM. Reports 
of sexual abuse of children in state care: a comparison between 
children with and without intellectual disability. J Intellect Dev Disabil. 
2018;43:152-63. doi: 10.3109/13668250.2016.1269881.
26. 29th, 2019 at: https://www.rutgers.international/sites/rutgersorg/
 27. Santos-Iglesias P, Vallejo-Medina P, Sierra JC. Equivalence and standard 
scores of the Hurlbert index of sexual assertiveness across Spanish 
men and women. Anales Psicologia. 2014;30:232-7. doi: 10.6018/
analesps.30.1.143321.
28. Morokoff PJ, Quina K, Harlow LL, Whitmire L, Grimley DM, Gibson PR, 
et al. Sexual Assertiveness Scale (SAS) for women: development and 
validation. J Pers Soc Psychol. 1997;73:790-804. doi: 10.1037//0022-
3514.73.4.790.
29. Santos-Iglesias P, Sierra J, Vallejo-Medina P. Propiedades psicométricas 
de la versión Española de la Sexual Assertiveness Scale (SAS). Anales 
Psicología. 2011;27:17-26. 
30. Hulbert DF. Hurlbert index of sexual assertiveness. In: Fisher TD, 
Davis CM, Yarber WL, Davis SL, editors. Handbook of sexuality-related 
measures. 3rd ed. New York: Taylor & Francis Group, 2011:62.
31. Loshek E, Terrell HK. The development of the sexual assertiveness 
questionnaire (SAQ): a comprehensive measure of sexual 
assertiveness for woman. J Sex Res. 2015;52:1017-27. doi: 
10.1080/00224499.2014.944970.
32. Schaafsma D, Kok G, Stoffelen JM, Curfs LM. Identifying effective 
methods for teaching sex education to individuals with intellectual 
disabilities: a systematic review. J Sex Res. 2015;52:412-32. doi: 
10.1080/00224499.2014.919373.
33. Nemerofsky AG. The What-if-situations-test. In: Fisher TD, Davis CM, 
Yarber WL, Davis SL, editors. Handbook of sexuality-related measures. 
3rd ed. New York: Taylor & Francis Group, 2011.
34. Isler A, Tas F, Beytut D, Conk Z. Sexuality in adolescents with intellectual 
disabilities. Sex Disabil. 2009;27:27-34. doi: 10.1007/s11195-009-9107-2.
35. Wickström M, Larsson M, Höglund B. How can sexual and reproductive 
health and rights be enhanced for young people with intellectual 
disability? – focus group interviews with staff in Sweden. Reprod 
Health. 2020;17:1-10. doi: 10.1186/s12978-020-00928-5.
36. Edmonson B, McCombs K, Wish J. What retarded adults believe about 
 37. Jahoda A, Pownall J. Sexual understanding, sources of information 
and social networks; the reports of young people with intellectual 
disabilities and their non-disabled peers. J Intellect Disabil Res. 
2014;58:430-41. doi: 10.1111/jir.12040.
38. Lockhart K, Guerin S, Shanahan S, Coyle K. Expanding the test of 
counterfeit deviance: are sexual knowledge, experience and needs 
a factor in the sexualised challenging behaviour of adults with 
intellectual disability? Res Dev Disabil. 2010;31:117-30. doi: 10.1016/j.
ridd.2009.08.003. 
39. Eastgate G, Van Driel ML, Lennox N, Sheermeyer E. Women with 
intellectual disabilities: a study of sexuality, sexual abuse and 
protection skills. Aust Fam Physician. 2011;40:226-30.
40. Tang CS, Lee YK. Knowledge on sexual abuse and self-protection skills: 
a study on female Chinese adolescents with mild mental retardation. 
Child Abuse Negl. 1999;23:269-79. doi: 10.1016/s0145-2134(98)00124-0.
41. Siebelink EM, de Jong MD, Taal E, Roelvink L. Sexuality and people 
with intellectual disabilities: assessment of knowledge, attitudes, 
experiences, and needs. Ment Retard. 2006;44:283-94. doi: 
10.1352/0047-6765(2006)44[283:SAPWID]2.0.CO;2.
42. Healy E, McGuire BE, Evans DS, Carley N. Sexuality and personal 
relationships for people with an intellectual disability. Part I: service-
user perspectives. J Intellect Disabil Res. 2009;53:905-12. doi: 
10.1111/j.1365-2788.2009.01203.x.
43. Michie AM, Lindsay WR, Martin V, Grieveo A. A test of counterfeit 
deviance: a comparison of sexual knowledge in groups of sex offenders 
with intellectual disability and controls. Sex Abuse. 2006;18:271-8. doi: 
10.1177/107906320601800305.
44. Lambrick F, Glaser W. Sex offenders with an intellectual disability. Sex 
Abuse. 2004;16:381-92. doi: 10.1177/107906320401600409.
45. Kim YR. Personal safety programs for children with intellectual 
disabilities. Educ Train Autism Dev Disabil. 2010;45:312-9.
46. Mechlind LC. Thirty year review of safety skill instruction for persons 
with intellectual disabilities. Educ Train Dev Disabil. 2008;43:311-23.