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Judith Davies
Dalhousie University

Copyright © 1996,
Judith Davies. All rights reserved.

Table of Contents

Chapter I

A Canadian Perspective

Canadian sexuality educators have used the definition proposed by the World Health Organization (WHO) and Lanfeldt and Porter to assert that sexuality is an integral part of the personality of everyone: man, woman and child. It is a basic need and aspect of being human that cannot be separated from other aspects of life.... Sexuality influences thoughts, feelings, actions and interactions and thereby our mental and physical health. Since health is a fundamental human right, so must sexual health also be a human right. (cited in Health Canada, 1994, p. 7)

This holistic approach encompasses the physical, emotional, intellectual, and social dimensions of sex and gender. Sexuality includes a persons' entire sense of self as male or female and is reflected in her or his personality, behaviour, and relationships with others. How people feel about this aspect of themselves affects their self-esteem and thereby influences all aspects of their lives, including whether or not they reach their full potential as human beings. Healthy sexuality is critical for human happiness and fulfillment.

The need for comprehensive and accessible sexual health education is clearly stated in the "Canadian Guidelines for Sexual Health Education" (Health Canada, 1994). These guidelines declare that healthy sexuality is a basic human right and that sexual health education should be available to all Canadians. The guidelines suggest that the goals of sexual health education include (a) positive outcomes such as self-esteem, respect for self and others, non-exploitive sexual satisfaction, rewarding human relationships, and the joy of desired parenthood and (b) the avoidance of negative outcomes such as unwanted pregnancy, sexually transmitted disease, sexual coercion, and sexual disfunction.

All Canadian provinces have school curricula that address sexual health and sexually transmitted diseases (STDs), including AIDS. Nevertheless, teen-pregnancy, sexual abuse, sexual harassment, and sexual assault are still prevalent. The Canadian guidelines urge schools to continue to improve existing sexual health education programs and to develop new approaches that address these issues. They encourage educators to go beyond simple dissemination of facts to provide educational experiences that help young people (a) develop the motivation and personal insight that is necessary to act on information provided, (b) acquire the skills needed to maintain and enhance sexual health, and (c) create an environment that is conducive to sexual health.

The "Canadian Guidelines for Sexual Health Education" (Health Canada, 1994) include the following philosophical themes specifically related to people with disabilities:

  • In terms of access and content, effective sexual health education does not discriminate against race, gender, sexual orientation, religion, ethno-cultural background, or disability.
  • In addition, effective sexual health education provides, within the domain of its subject matter, accurate information that counters misunderstanding and reduces discrimination based upon race, gender, sexual orientation, religion, ethno-cultural background, or disability.
  • Effective sexual health education recognizes and responds to the specific sexual health educational needs of particular groups, such as senior adults, people who are physically or developmentally disabled, children and adults who have experienced sexual abuse, isolated populations, Aboriginal peoples, immigrants, gay and lesbian youth, and street youth. (p. 8)

It is in the spirit of these philosophical principles that this project has been undertaken. My objectives in this project are to: (a) provide resources to parents that will encourage and assist them to facilitate their children's development and understanding of sexuality, (b) provide sexuality information and materials to children and teens with visual impairments in a format that they can use, and (c) collect and house these resources in the main and toy libraries at the Atlantic Provinces Special Education Authority (APSEA). This literature review forms the basis for "The Parents' Guide"(see Appendix A of this project). This guide describes the specific sexual health information needs of children and teens with visual impairments. It also outlines the developmental tasks related to sexuality that should be achieved by children at various stages and offers suggestions to ensure that these tasks are achieved.

The Need for Specific Programs for Children with Visual Impairments

Impediments to Learning

Society has been slow to acknowledge the need for sexuality education of the disabled (Neff, 1982). Beliefs that persons with disabilities are asexual, fear of awakening unsatisfyable aspirations, and concern that individuals with disabilities will be unable to cope with their sexuality has led parents and educators to withhold the information disabled people need in order to cope with their sexuality (Baugh, 1984; Neff, 1982). Today, a growing number of educators recognize the right of all persons to be fully informed sexual beings. The needs of children with visual impairments for comprehensive sexuality education are similar to those of their sighted peers. However, their needs go beyond those of sighted children and are different from the needs of individuals with other handicapping conditions.

In my work with children attending the APSEA Resource Center, I have noted that many children who are visually impaired have significant gaps and delays in their understanding of both the social and physical aspects of sexuality. Low self-esteem, poor social skills, difficulties in interpersonal relationships, as well as naivety about sexual anatomy and functions are often apparent. Conversations with parents and with visually impaired adults have further convinced me that more needs to be done to meet the sexual health education needs of these children. Teachers of sexual health, personal development and relationships, and family studies are often unsure of their ability to meet the needs of students with visual impairments in the regular classroom. Itinerant teachers (vision specialists who serve children with visual impairments in integrated settings) frequently request suggestions and resources to assist parents, classroom teachers, and themselves in dealing with this topic.

The writings of many professionals in the field of visual impairment express a need for better sexuality education for this group (Elonen and Zarensteyn, 1975; Foulke and Uhlde, 1974; Holmes, 1975; Inana, 1978; Neff, 1975; Scholl, 1974; Torbett, 1975; & van'T Hooft and Heslinga, 1975). A study conducted by Welboume, Lifchitz, Selvin, and Green (1983) included both sighted women and women who were visually impaired. They found that the women who were visually impaired obtained significantly lower sex knowledge scores and obtained their information about sexual matters at a later age than did the women with sight. When asked for their recommendations for sex education, these women requested more accurate information and more discussion. They wanted to receive this information from parents and teachers rather than from agencies, friends, and books. They felt that their learning was impeded by over-protective and negative attitudes of parents and professionals and by a lack of non-visual teaching methods and materials.

Meeting the Needs

Because sexuality education begins at birth and becomes a lifelong process, parents play a vital and inevitable role in this aspect of their children's development. Parents of sighted children often express concerns about the sexuality education of their children. These concerns are compounded for those whose children have a visual impairment. The subject, "sexuality" cannot be confined to a school-based curriculum, although classroom-based programs are a very important part of children's learning about sexual matters. It is necessary to go beyond the classroom to fully address the needs of children with visual impairments. It is important to begin early to address the needs of very young children in an attempt to avoid the gaps and delays that lead to misconceptions and hinder further growth.

The sexual development of children with visual impairments follows the same pattern as that of sighted children. The development of understanding of sexuality, however, may be affected by lack of sight. Vision plays a major role in concept development and children with visual impairments may require assistance to fully develop and understand their sexuality. Young people who are visually impaired do not have the same access to sexuality information as do their sighted peers. They cannot learn incidentally through observation and because of societal taboos against touching, they are denied their most efficient learning modality. Intervention strategies are required to ensure that these children learn about sexual anatomy and function, develop positive attitudes toward their sexuality, as well as gain the skills they require to form and maintain satisfactory relationships.

Every child is unique. It is not possible to make generalizations that will apply to all children who are visually impaired. Scholl (1974) reminded us, "children react in their . individual ways--ways that reflect their experiences and opportunities" (p. 208). Blindness may be partial or complete, congenital (from birth) or adventitious (acquired either suddenly by trauma or gradually over time), and it may be accompanied by other impairments that are related to the visual condition. The effects of a visual impairment tend to be more apparent when the age of onset is earlier, when the degree of impairment is greater and when other handicapping conditions are present (Scholl, 1974). Not all of the comments and suggestions offered in the parent guide will apply to all children who are visually impaired. Those who know the child best (usually the parents) should decide the most appropriate educational modifications for the needs of their particular child.

Chapter II

The Effect of Visual Impairment on the Development of Sexuality

Early Development of Self-Concept

Children are sexual beings from the moment of birth and sexuality education begins at this point. Infants receive messages about who they are from the ways they are held, touched, fed, changed, and spoken to. Hicks (1980) tells us that earliest relationships (particularly that formed with the primary care-giver who is usually the mother) profoundly affect the pattern of future relationships. When the Infants needs are met in loving and consistent ways, a sense of trust is developed. Babies who are blind, however, may receive negative messages as their parents struggle to cope with their feelings of grief and the realities of their child's impairment. These messages affect both the child's self-image and ability to relate to others.

Gillman and Gordon (1973) suggest that there are no specific deviations in gender identity and gender roles that can be ascribed to congenitally blind children. It is their belief that in the absence of vision, language serves as the major source of information. for the development of gender identity and related role behaviours. In a commentary on Gillman and Gordons work, Freedman (1973) agreed that for most children who are visually impaired this is true, but that roughly one fourth to one third of these children present with a syndrome not unlike infantile autism. He attributes this maldevelopment to impaired early mother-infant relations. In the absence of vision, the infant is less able to induce maternal responses through eye-contact and smiling, thus early bonding may be thwarted. In yet another commentary on the study done by Gillman and Gordon, Prescott (1973) suggests that the somatosensory system (near receptors) rather than vision and hearing (distance receptors) has the primary role in the development of emotional, social, and sexual behaviours. Somatosensory deprivation during formative periods results in avoidance and aversion to body contact and touching. Inadequate bonding due to lack of eye contact, delays in smiling, or to parental grieving may lead to decreased touching, cuddling, and handling of the blind infant, inhibiting psychosocial -sexual development.

It is essential that families receive appropriate help and support from the moment the child's disability is discovered. Parents need to understand the importance of the bonding process and can be shown ways to interact effectively with their blind infant so that behavioral and developmental abnormalities are prevented. Lisa Dom (1993) describes some promising research conducted with blind infants that found that these babies do send signals although they differ from those sent by sighted infants. She suggests that parents be helped to interpret these signals, thus mitigating some of the negative effects on bonding. Hicks (1980) assures us that children with visual impairments brought up in a warm, caring and accepting family atmosphere can develop the normal ability to relate positively to others.

As children grow, they continue to receive messages about themselves from significant others. The ways that children are encouraged to play, the clothes they are given to wear, the chores they are expected to perform, the behaviours in which they are encouraged to engage, the kinds of touching they receive and are allowed to give, and the compliments and reprimands they receive send messages to children about their sexuality. When children receive messages of a positive nature, they develop positive self-concepts, they feel good about themselves and their sexuality, and they exhibit high self-esteem. When the messages they receive are negative, self-esteem suffers.

Without adequate visual information, the development of self-concept is hindered. It is difficult to form an accurate body image when one cannot see in a mirror. Many children who are visually impaired do not understand how their bodies compare with those of others and may believe that they are less attractive than their sighted peers. Corn (1988) recommends providing children who have low vision with a magnifying mirror to allow them to study their own facial features to form a more realistic view of their appearance. Children with little or no vision require verbal and tactual feedback that will enable them to realistically appraise how they "look" to others.

Mangold (1982) tells us that because children with visual impairments are unable to see the mistakes and less than perfect performance of others, they often view sighted children as super human. Because perfection is impossible to achieve, many become discouraged, devalue their own achievements, or in extreme cases, refuse to try at all. It is important that children with visual impairments learn that all people make mistakes and are clumsy at times. Parents can do this by gently pointing out when they themselves and others have erred (Mangold, 1982). Children need help in developing a realistic appraisal of their abilities. It is also possible for parents and teachers to over-praise certain abilities so that the child develops an unrealistic sense of self, one that will be deflated during adolescence or early adulthood (Scholl, 1974).

Children need to feel competent and in control of certain aspects of their lives. Many parents struggle with their desire to protect their child from harm and their desire to see their child develop competence. Parents and teachers may have low expectations for children who are visually impaired. They may do more difficult tasks for them, continue to assist with tasks already mastered, and make decisions for children after the children are ready to make those decisions for themselves. Over-protection of children, teaches them to become passive and helpless and seriously undermine their development and ability to make sound, independent decisions and choices. Personal competency and the ability to make choices leads to a sense of control and empowerment. Even very young children should be encouraged to make choices that are within their ability. Age appropriate skills of independence must be developed if children are to perceive themselves as competent. Self-esteem suffers if they believe themselves to be less able than their peers. This lack of self-esteem becomes devastating in the teen years when peer pressure is so strong.

Gender-Role Socialization

Gender-role socialization is influenced by families, peer groups, and the school system throughout childhood and adolescence (Allgeier & Allgeier, 1991). Traditionally, North American males have been expected to be active, aggressive, athletic, and unemotional, while females have been expected to be passive, nurturant, yielding, emotional, and gentle. Today, women, as well as some men challenge many of these stereotypes. Parents and teachers need to be aware of their influence on the way children come to think about themselves and their expectations for their future roles in society. Children who are visually impaired seem to receive, through verbal feedback, the same stereotypic messages that sighted children are bombarded with every day in books, magazine advertisements, movies, and television. The limitations society imposes on both sexes may leave these children no freer than their sighted friends to pursue interests and to develop healthy gender roles.

Sex-role stereotypes affect the ways that teens who are visually impaired are perceived by their peers and, consequently, by themselves. The Canada Health Attitudes and Behaviour Survey found that teen-aged girls ranked consistently lower in self-esteem than their male peers across the country (King, Robertson, & Warren, 1985). In her book, School girls- Young Women, Self-esteem, and the Confidence Gap, Peggy Orenstein (1994), describes in graphic detail the influences of home, school, and society on the development of female self- esteem as well as the differences in the manner in which boys and girls are socialized. Young women who are visually impaired, face the dual stigma of being blind and female. Young men, on the other hand must compete with society's stereotype of the strong, independent, and dominant male. For both genders, sex-role stereotypes can cause significant difficulty in the establishment and maintenance of a positive self-concept that is essential for high self-esteem. There is a strong link between self-esteem and the capacity to make positive choices and decisions. The ability to make sound decisions becomes critical in adolescence when increased independence and exposure to potentially harmful situations become inevitable.

Access to Information

One of the greatest barriers to the development of sexual understanding in children with visual impairments is limited access to information. It is not unusual for the psychosocial-sexual development of children with visual impairments to lag behind that of their sighted age-mates (Baugh, 1984). This is not a reflection of mental deficiency, Lack of vision seriously undermines children's ability to gather information about sexuality. They cannot learn incidentally through visual observation as do sighted children. This results in limited knowledge of gender roles, fashion, male-female attractiveness factors and relationship behaviours, toileting practices, various body shapes and sizes, pregnancy changes, and other developmental changes throughout the life cycle (Neff, 1983; Schuster, 1986). They do not see displays of affection or the reactions of others to those displays that allow them to form conclusions about what is or is not acceptable in our society. The concept of privacy is difficult for children who are visually impaired. They need to learn which behaviours are considered private, what degree of privacy is appropriate for various behaviours, and what constitutes a private place. The young man who expresses his affection for his date in front of her parents is not likely to get a second opportunity!

Children with visual impairments do not have the same access to the television programs, movies, books, and magazines of explicit sexual nature that are readily available to their sighted peers. Parents and teachers are often uncomfortable reading sexually explicit material aloud. They may be hesitant to use the sexual language necessary to describe the sexual "action" on the screen and may, in fact, be relieved that the child cannot observe activities they find difficult to explain (Neff, 1983).

Neff (1983) also explains that many parents fear telling children "too much," "too soon." They wait for their children to ask questions as an indication of readiness. Without visual stimulation, children may not be inspired to ask questions about sexuality until long after they should have the information. Parents need reassurance that children are not harmed by too much early sexual information; that they simply disregard information they are not ready for and retain the rest. Parents of children with visual impairments need to learn creative and natural ways to ensure that their children have the sexually related information they need at each stage of development. They need to understand the importance of this aspect of their children's education and the consequences of its neglect upon their overall development. Neff (1983) suggests that when children do not receive sexual information until they are older, the concepts are less readily understood. She believes that misconceptions are not easily discarded when new information is presented and that the facts simply add to the child's confusion.

When sexuality information is withheld from children, the effects are far-reaching. The risk of sexual abuse and exploitation increases (Elonen & Zwarensteyn, 1975; Pava, 1994). Psychological damage may result from experiencing a sexual event such as the onset of menses or nocturnal emissions without adequate preparation (Neff, 1982). Also, children may harbour feelings of fear or guilt about sexual feelings they do not understand.

It is a paradox that the means by which children with visual impairments learn best (through the sense of touch) is a cultural taboo in North American society. Neff (1982) and Schuster (1986) express concern that parents may not be at ease allowing young children to explore their own bodies or those of parents and siblings even in natural settings such as bathing, dressing, and changing a baby. Yet, how else can children with visual impairments learn about their own bodies and those of others? Torbett (1975), assures us that tactual exploration by a blind child is no more sexually stimulating than is visual observation by the sighted. Schuster (1986) stresses that this exploration should happen while children are young and still in the data-gathering stage, before sexual-social overtones impart other messages to the contact.

Social Skills

Friendships are essential for normal development. Interactions with peers allow children to develop and refine skills that are important for social development and acceptance by their peers (Kekelis, 1992). Unfortunately, children with visual impairments tend to fall below the median in acceptability as playmates in elementary school. Those sighted youngsters who seek out the company of blind children tend to fall below the social median themselves (Kent, 1983). Obviously, the fewer social contacts children have, the fewer opportunities they will have to develop the social skills they need to ensure these contacts. In sighted children, these skills develop largely through observation and imitation. Many researchers recommend teaching social skills to children with visual impairments to help them form the friendships so vital to their development (Zell Sacks, Kekelis & Gaylord-Ross, 1992).

Children with visual impairments often turn to adults, whom they may perceive to be kinder toward them, to fill their need for friendship. This affiliation with adults may further isolate them from their peers. As children grow older, they tend to become more loyal to their peer group, suspicious of adults and of the motives of children who choose to spend time with adults. Too much intervention by adults may be detrimental to the development of friendships with peers. MacCuspie (1992) stresses that adults do, however, have an important role in ensuring that the social environment of children who are visually impaired is one that "promotes the positive acceptance of differences and eradicates the stigma of being different" (P. 100).

Social interactions become a prime concern in the adolescent years and teens typically have little tolerance for those who lack basic social skills (Mangold, 1982). Children with visual impairments face many challenges to effective social interactions. In addition to their inability to learn appropriate behaviour through observation and imitation, they must overcome many difficulties in communication. Feelings are expressed both verbally and nonverbally. Facial expressions and eye behaviours, gestures, body movement, and postures are used as well as words and voice quality, to let others know how we think and feel. Often misunderstandings result, as without visual cues it is more difficult to accurately interpret the messages and emotions of others. Sighted people are uncomfortable when they do not receive the non-verbal messages they expect or when they receive non-verbal messages that do not match the verbal messages they are hearing. People tend to avoid uncomfortable situations and the result may be avoidance of the person who is visually impaired.

Children with visual impairments should learn to send appropriate non-verbal messages. Understanding that they may be missing the non-verbal messages sent by others will alert them to the need to ask for clarification of these missed messages. These skills can be taught through modelling and role play activities. It is important to let children who are visually impaired know when they are sending inappropriate or confusing messages in day-today situations and it is also necessary to explain to them the effect their behaviour has upon the receiver of these messages (Mangold,1982). Effective communication is essential for the formation of meaningful and enduring relationships, including sexual ones.

Children with visual impairments may be prone to repetitive motor behaviours, such as rocking, head rolling, and eye rubbing. Negative reactions to these stereotypic behaviours can lead to teasing and social segregation. These behaviours are thought to be the result of restricted movement and physical activity, social deprivation, lack of ability to imitate and lack of stimulation (Heubner,1986). Once established, they are difficult to extinguish. Heubner (1986) recommends the reduction of stereotypic behaviours through early intervention that provides adequate sensory stimulation, movement and social skills, physical activities, and exposure to a variety of environments. Success is more likely when the extinction is paired with a compensatory, socially acceptable behaviour. Parents and teachers must be sensitive to the child's needs, self-concept, and self-esteem when attempting to modify these behaviours. An open and honest approach as to the negative effect of these behaviours will spare the child from misunderstandings and grief in social situations,

Conformity is highly valued in adolescence. Blindness makes it very difficult to conform to adolescent norms. Corn (1988) stresses the importance of being "aware of the uniform." Unless teenagers are aware of and conform to the appropriate code of dress for teens in their locality, acceptance is unlikely. Many teenagers who are visually impaired depend upon their mothers to choose their clothing. If mothers taste in clothes is too conservative, they will stand out further from their peer group. As well, grooming and the use of make-tip, scent, and other beauty aids must be taught. This will permit adolescents with visual impairments to choose whether or not to use such artifacts as well as help them to understand the reaction of others to the misuse of these aids (Heubner, 1986).

Relationships

Social contact with members of the opposite sex is important for social, psychological, and emotional development of teenagers who are visually impaired and their sighted peers (Heubner, 1986). The presence of stereotypic behaviours and the lack of appropriate

Heubner, IS communication and social skills will interfere with acceptance as potential dating partners. In addition, children with visual impairments may encounter negative attitudes toward visual impairment and disability. These attitudes may include beliefs that disabled people are not sexual and should not be dating. Children who are visually impaired need opportunities to discuss these prejudices and their possible effect. The ability to deal with the questions and concerns of dating partners and their parents in assertive and appropriate ways is an important task for these youngsters (Heubner, 1986).

One young woman attending APSEA-RCVI lamented the fact that "sighted guys don't often ask blind girls for a date." Her classmates readily agreed that this was true. They felt that peer pressure deterred sighted boys from dating girls who were visually impaired. The date is often seen as a status symbol, especially in the early stages of dating. Young men, often unsure of themselves and influenced by peer pressure, may be unwilling to date a girl whose social status is uncertain (Kent, 1983). Concern over theirability to adequately partner a girl without vision is a further deterrent. Young men who are visually impaired may also experience problems dating sighted girls, but perhaps to a lesser extent. Women in our society still tend to be the more nurturing sex (although men are beginning to close the gap) and they may be less hesitant to accept dates from men who are visually impaired.

The inability to visually scan the scene limits choices of potential dating partners. Subdued lighting common in many of the places teens tend to gather greatly diminishes the ability to see for those individuals who have limited but useable vision. These teens are dependent upon the information they receive from their friends about who is present and might be interesting to meet. Heubner (1986) explains that many flirting behaviours are visual. Eye gaze, facial gestures, and body postures signal when one person is interested in meeting another. Although teens who are visually impaired can learn to flirt, it will not be possible for them to receive these cues from others. They must depend upon verbal communication and the information they receive from friends. Learning to ask for that information begins with an awareness that such messages are, in fact, being sent.

Heubner (1986) points out that independent mobility skills are critical to the success of any date. Young people who are visually impaired need to be well organized to deal with the many logistical problems involved in planning a date. Young men, in particular, bemoan their inability to obtain a driver's licence. Alternatives to the family car must be found, not only for transportation, but for the privacy it affords. Double-dating is one solution, with the couple who have not provided the car paying for gas. Parents can be sensitive to their teen's need for privacy by making the family den or recreation room available for entertaining. Young women need independent mobility skills in order to feel confident in dating situations. Knowledge of what activities constitute an acceptable date will help increase the comfort level for both young men and young women. Books about teens and dating experiences as well as discussions about dating will help these youngsters feel more assured of their ability to request and accept dates.

Heubner (1986) suggests that young people who are visually impaired should be encouraged to pursue desired relationships in appropriately assertive ways. The feminist movement has had an effect on dating practices and it is now acceptable for both males and females to initiate a date. Young women can, and should be encouraged to extend invitations to young men in whom they have an interest. Young men may also need encouragement to pursue desired relationships assertively. The current trend toward group dating may very well increase the opportunities that teens with visual impairments will have to date and interact with their peers. Teens today often go to movies, dances, and sports events in groups that may or may not include "couples" and almost always includes several unattached members.

Personal Safety

Because children with visual impairments may be more passive and reluctant to protect themselves, they are often vulnerable to sexual trauma and exploitation (Elonen & Zwarensteyn, 1975). It is common for sighted persons to perceive those who are visually impaired as helpless, increasing the likelihood of exposure to sexual harassment, molestation, and abuse. It is important that children who are visually impaired understand what constitutes sexual abuse in order to protect themselves. Assertiveness training will be valuable for many young people who are visually impaired. Knowledge of their personal rights and development of assertiveness skills necessary to secure those rights is essential (Loumiet & Levack, 1994).

Children with visual impairments receive a great deal of touching not experienced by sighted children (Loumiet & Levack, 1994). In our efforts to "show" them their world, we often use more touching than would be necessary for the sighted child. This touching is usually positive and helpful in nature but it may result in children becoming desensitized to their feelings about touch. This may cause them to be more vulnerable to negative or abusive touch. From a very early age, children should be told that it is okay for them to say "no" to any touching that is uncomfortable or that they do not want. Adults need to respect the child's right to refuse. Children should be given opportunities to practice how to recognize and respond assertively to inappropriate touch. Parents should discuss with children circumstances in which it may be necessary for someone to touch their private body parts, such as during medical examinations or when helping with personal hygiene.

Chapter III

The Effect of Visual Impairment on Physical Aspects of Sexuality

Gender Identity

Neff (1982) stresses that the establishment of gender identity is critical to healthy sexuality and sense of self. It is one aspect of self-concept and it affects self-esteem. Gender identity results mainly from spontaneous visual input in sighted children, largely through comparison between family members and playmates. Children can generally apply the correct gender label to themselves by the time they are two and a half years old, but awareness of gender differences develops later and varies from one child to another and from one culture to another. This variation in awareness is due at least partially to the opportunities children have to observe males and females (Allgeier & Allgeier, 1991). The child who is visually impaired is obviously at a disadvantage and may require direct and explicit instruction in gender differences.

Gender cues such as hairstyles, clothing, adornments, and even names are vague in our society; difficult even for sighted children to sort out. The obvious differences lie in the genitalia and their function in the reproductive process. Neff (1982) recommends that parents help children who are visually impaired conceptualize gender differences and similarities in natural settings within the family environment through use of tactual experiences paired with verbal explanation. Her suggestions include: bathing or showering with siblings and parents, changing babies or helping younger siblings dress, dressing anatomically approximate dolls ingender appropriate clothing, and sharing pregnancy changes and breast-feeding with mother or a family friend. Teach-A-Bodies have anatomically correct models of grandmother, grandfather, adult male and female, child, toddler, and baby available for purchase. Exploration of sculptures in museums or art galleries or store mannequins can help the child form concepts of body differences. Breeding pets is another way to stimulate discussion of reproductive processes. Sorting the family laundry provides the opportunity to discuss sexspecific articles of clothing, differences in textures, decorative and functional features, and sizes.

Sexual Language

The establishment of an appropriate sexual vocabulary is an important developmental task of childhood. Failure to provide labels for sexual parts of the body sends the subtle message that these parts are not to be mentioned or are somehow unacceptable. Parents are encouraged to use proper terms for sexual anatomy (Foukle and Ulde,1975; Heubner, 1986; & Neff, 1982). It is as easy for the child to learn correct terminology as it is to learn "cute" names for the genitals and bodily functions. Children who use such terms will find it difficult to communicate meaningfully with others and may be subjected to ridicule by their more sophisticated peers. Neff recommends that sexual anatomy be taught naturally along with other body parts in order to convey the message of acceptability. Childhood games that label body parts can as easily include "penis" or "vulva" as "arms" and "toes." Children can be helped to make models of clay or other materials. They can also be helped to trace their own bodies on large sheets of paper. Bold markers or tactile representations and braille can be used to fill in and label the details (Neff, 1982; Schuster, 1986).

Masturbation

Masturbation concerns many parents. It is important that they receive assurance that this is a normal activity in all children. Children with visual impairments are often more isolated from their environment, are less mobile, and may turn to their bodies for stimulation (Neff, 1982). Ensuring that these children have ample opportunity to be involved in the world around them will usually decrease the need or desire to masturbate. Expression of shock or disgust or reprimands about masturbation that are too stem may leave children with feelings of guilt, shame, anxiety and emotional difficulties. Parents are encouraged to acknowledge the pleasurable feelings the child is experiencing. As children mature, they can be taught that although these activities are acceptable and pleasurable in private, they are not appropriate in public. This is a good opportunity to teach about public and private places (Neff, 1982; Schuster, 1986).

Anatomical Differences

Explanations given about anatomical differences must be explicit in order to avoid misconceptions. During a lesson on puberty, when one young man asked what breasts were, his classmate was quick to inform him that they were "things that come out of a woman's stomach." The lesson was quickly revised to include a discussion about the location of the stomach as well as breasts. Young women are often under the misconception that the urethra and the vagina are a single opening. These gaps in understanding may be difficult to identify. Scholl (1974) cautions that children who are visually impaired are often able to give verbal descriptions without any real understanding of the concepts involved. This capacity, known as verbalism, is encouraged by over-reliance on verbal descriptions in communication of concepts to children with visual impairments.

The ideal method of instruction for children with visual impairments includes the use of real objects whenever possible. Models are somewhat less useful and verbal descriptions alone should be used as a last resort. Verbal instruction, in combination with real objects and models allows for optimum learning to occur (Scholl, 1974). As children grow older, tactile methods with live models become socially inappropriate or legally unacceptable. Menstruation, sexual intercourse, and the birth process can be explained using dolls such as the Judith Franing anatomically correct rag dolls, which include a pregnant female. Excellent tactually lifelike anatomical models of the reproductive organs are available from Jim Jackson and Company, although the cost makes them prohibitive for most families. These models provide excellent tactual detail of both internal and external reproductive organs. The models available include a female reproductive system in cross-section, including uterus with embryos in four stages of development; a male reproductive system in cross-section; a flaccid penis; an erect penis; and a female pelvic model (menstruating uterus optional). Medical models have been suggested, but they are usually made from rigid plastic and tend to be visually oriented. Likewise, stereo-photocopies (raised line) of anatomical diagrams have been used in classroom settings. Many students, especially those who are congenitally blind, report gaining little understanding from this teaching method.

When explaining menstruation, real sanitary pads and tampons should be used with the models. Actual condoms, birth control pills, and other contraceptive devices should be used to explain birth control. It is important that young people who are visually impaired understand that many symptoms of STD's are visual. Non-visual symptoms, high risk behaviours, safersex practices (including abstinence), and where to go for diagnosis or treatment need to be explicitly taught.

Many visual conditions are the result of difficulties during pregnancy. Rubella, toxoplasmosis, some STD's, cerebral palsy, premature and problematic births, and a number of hereditary conditions may result in blindness or visual impairment. Young people who are visually impaired need to understand the nature and cause of their particular form of blindness. If their condition is hereditary in nature, genetic counselling is required. The decision to parent must be an informed one.

Welboume et al (1983) confirm previous reports that there is a relationship between visual impairment and the onset of puberty. Young women who are totally blind, with no light perception, seem to reach menarche an average of one year earlier than girls with light perception or sighted girls. It seems that the production of melatonin, a hormone of the pineal gland, is stimulated by light entering through the eyes. This hormone is thought to inhibit gonad activity. Its absence, then, would allow more rapid sexual development. Parents should be aware of the potential earlier development of girls who are blind, so that they will be prepared for this event. Research indicates that children are not harmed by early sexual knowledge. However, experiencing a sexual event such as the onset of menses without adequate explanation and preparation can be very damaging.

Chapter IV

Conclusion

Many articles about sexuality and visual impairment were published in the late 70's and early 80's, when sexuality education was very much in the spotlight. These articles stress the need for sexuality education for "blind children," offer suggestions for the implementation of "sex education programs," point out the implications of visual impairment on the development of sexual understanding, and suggest strategies to be used. Studies done at this time usually involved young adults who were educated in residential schools and curricula were developed for use in these settings (Elonen & Zarensteyn, 1975; Foulke & Uhde, 1974; Holmes, 1975; Inana, 1978; Neff, 1975; Scholl, 1974; Torbett, 1975; van'T Hooft & Heslinga, 1975). In 1983, The Journal of Visual Impairment and Blindness devoted an entire issue to the experience of blind women that included problems of gender, adolescence, and sexual development ( Elder, 1983; Kent, 1983; Mangold & Mangold, 1983; Neff, 1983; Welbourne et al, 1983; & Zell Sacks, 1983 ). The women quoted were educated in the 1970's, often in residential settings. Some of this information is not relevant to today's youth with visual impairments who are educated primarily in public school environments.

The advent of HIV/AIDS has brought about the recognition that significant changes are necessary in the type of information that young people require today. A current curriculum that makes reference to HIV/AIDS prevention is Independent Living: A Curriculum with Adaptations for Students with Visual Impairments (Loumiet & Levack, 1994). This curriculum, produced by the Texas School for the Blind and Visually Impaired, contains sections on personal and social as well as physical aspects of sexuality. It suggests appropriate goals and skills for children at various stages of development, offers strategies for teaching, and includes resources to be used. It relies heavily on the writings of earlier authors for its theoretical background.

Parents play a critical role in the sexuality education of their children (Neff, 1982; Schuster, 1986). The common concerns expressed by many parents about how to address topics associated with sexuality education are further complicated by the effects of visual impairments "The Parents' Guide" has been written to increase awareness of and to help parents meet the special sexuality education needs of their children. The guide offers suggestions for strategies to be used at various stages of children's development. Reference to the resource materials available at APSEA is included.

The need to make sexuality information available in a format accessible to children and teens with visual impairments has been clearly identified. Resources at the APSEA Library have been expanded to include books related to sexuality education for children and teens with visual impairments and their parents. Pamphlets, tapes, and videos on different aspects of sexuality are also available. These materials are provided in accessible formats of large print, braille, twin-vision (braille overlays on print book pages), and audio-taped format. The APSEA Toy Library lends anatomically approximate baby girl and baby boy dolls with gender appropriate clothing. When paired with the parent guide, these resources will enable children with visual impairments to fully develop and understand their sexuality.

Bibliography

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Curricula

Dupont, H. (1979). Transitions: A program to help students through the difficult passage from childhood to middle adolescence. Circle Pines, Minnesota: American Guidance Service.

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O'Day, B. (1983). Preventing sexual abuse of persons with disabilities: A curriculum for hearing impaired. physically disabled, blind and mentally retarded students. Santa Cruz, CA: Network Publications.

Vernon, A. (1989). Thinking, feeling, behaving: An emotional education curriculum for adolescents -grades 7-12. Champaign, IL: Research.

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Anatomically Correct Models and Dolls

Discovery Dolls c/o Monique Felder, 167-44 145th Ave., Springfield Gardens, NY 11434,(718) 712-2057: models for sex education

Effie Dolls - Mrs. Judith Franing, 4812 48th Ave., Moline, IL 61265, (309) 764-3048: child size and anatomically correct rag dolls

Jim Jackson and Company, 33 Richdale Ave., Cambridge, MA 02140, (617) 864-9063: reproductive anatomy models

Louise Kool & Galt, 91 Armstrong Ave., Georgetown, Ont., L7G4Sl, 1-800-668-4302: anatomically correct dolls and gender specific clothing

Teach-A-Bodies, 2544 Boyd Street, Ft. Worth, TX 76109, (817) 923-2380: models for sex education