Reproductive and Sexual Health Education in Students with Intellectual Disabilities: A Systematic Review

This research feeds a systematic review research that aims to find learning methods used by teachers in learning Reproductive Health Education and Sexual in students with intellectual dis- abilities. Eight articles published between 2013 and 2021 were used in the study. The results of the study describe in learning Reproductive and Sexual Health Education can use training methods and role-playing with learning materials are awareness and prevention of sexual crimes, hy- giene, and self-care, escape and recovery from sexual crimes experienced. The conclusion that can be drawn based on this study is the methods used in learning Reproductive and Sexual Health Education are training and role-playing, but teachers must learn the curriculum, norms, and rules, as well as plan the learning programs to be carried out.

Intellectual disability itself is a person who has deficiencies in cognitive function and adaptive behavior (Hallahan et al., 2020). Nevertheless, children with intellectual disabilities continue to experience growth and development into adulthood in the form of the process of maturing reproductive organs (puberty) in adolescence (Farakhiyah et al., 2018). Adolescents with intellectual disabilities begin to show a desire to date, have questions about puberty, sexual activity, masturbate, and perform inappropriate behavior (Maia et al., 2015). Other behaviors that appear in adolescents with intellectual disabilities, both female and male, include seducing, holding hands, embracing the shoulders or waist, hugging, kissing the opposite sex, teenage boys who hold the breasts of their female friends, holding their own or friends' genitals, and masturbating in inappropriate places (Fauziah, 2017;Sari & Warsiti, 2017;Utami & Warsiti, 2015).
It occurs due to a lack of cognitive ability, especially in the aspect of self-management, while the physical remains were growing but not balanced with the power of control that exists in the self (Farakhiyah et al., 2018;Roswita & Primastuti, 2019). For example, the case of a 16-year-old intellectually disabled girl from Paluta, North Sumatra who was a victim of sexual abuse until she became pregnant (Rangkuti, 2020). Another case is an 18-year-old intellectually disabled girl in Lampung who was incestuous by her own father and brothers (Batubara, 2019).
The causes of these cases include a lack of knowledge, information, lack of access to existing services, the enforcement of rights in the form of policies regarding all aspects related to reproduction and sexuality of intellectually disabled adolescents, and attention in terms of health care providers (Frohmader & Ortoleva, 2014;Greenwood & Wilkinson, 2013;Katalinić et al., 2012;Kelrey, 2020 One of the steps that can be done to overcome the problems that concern Reproductive and Sexual Health in adolescents with intellectual disabilities is to provide knowledge through education and skills training in formal education. The knowledge and skills provided in the formal education bench are provided through self-building subjects. Arianti (2012) reproductive and sexual health education materials taught in this learning are about reproductive health rights, reproductive organ care, nutrition that must be consumed, and ways to control sexual desire. Kelrey & Hidayati (2019) provide an overview of Reproductive and Sexual Health Education in adolescents with intellectual disabilities that its implementation still needs to be improved, and this is due to the lack of role of parents, teachers, curriculum, and health workers. Some teachers and parents of intellectually disabled adolescents consider reproductive and sexual material to be unworthy of discussion and considered taboo (Tjasmini, 2014).
Adolescents with intellectual disabilities who are given knowledge of reproductive health and sexual behavior then their knowledge and skills will increase (Helda, 2017;McCann et al., 2019;Nurbaya & Qasim, 2018;Sarwinanti & Frintika, 2021;Yuliyanik, 2021). Wynkoop et al. (2018) in his research, revealed that Reproductive and Sexual Health Education for intellectual disabilities is beneficial when viewed by people around him and individuals with intellectual disabilities themselves. But these studies, it has only shown that the provision of Reproductive and Sexual Health Education can increase the knowledge of adolescents with intellectual disabilities and has not pro-vided an explanation of alternative methods that can be used. Therefore, researchers want to review the delivery of reproductive and sexual health education learning in adolescents with intellectual disabilities.
Specifically, this research's question is: "What learning methods do teachers use in learning Reproductive and Sexual Health Education in adolescents with intellectual disabilities?".

II. Method
This study is a systematic review with search strategies using Sage Journals, ProQuest, and EBSCO. The selection of this database is because the database publishes many articles and can be accessed for free through the eresource of the National Library of the Republic of Indonesia. The database accessed through the e-resource of the National Library of the Republic of Indonesia was selected so that anyone could participate in accessing the articles used in this study.
The eligibility criteria are research articles published between 2010-2021 and are limited to the type of intellectual disability with no accompanying disability. Researchers used Boolean search by using the keywords "AND", "OR", and quotation marks ("). The keywords used in this study are "sex education" OR "reproductive education" OR "reproductive health education" AND "intellectual disability" OR "mental disability" OR "mental disabilities" OR "mental retardation".
The inclusion criteria used in this research are, 1) articles focusing on the population of school-age children both at primary and higher education age (6-22 years), 2) school-age children in question are children with intellectual disabilities 3) articles describing sexual education at the formal education level, 4) are not limited to specific studies.
The exclusion criteria used in the research are the results of research focusing on children with multiple disabilities, intellectual disabilities who are beyond school age (less than 6 years of age and/or over 22 years), research published longer than 2010, and that research using languages other than English.
The data obtained in each research is the teacher (Chappell et al., 2018;Hartwig & McMullen, 2021;Löfgren-Mårtenson & Ouis, 2019;Nelson et al., 2020;Povilaitienė & Radzevičienė, 2013), principal and deputy principal (Chappell et al., 2018), parents (Povilaitienė & Radzevičienė, 2013;Sravanti & Arul, 2021), and secondary data (Matin et al., 2021). A complete overview of the characteristics of the study is presented in Table 1. The preparation of the findings in each research will be prepared following the steps of planning self-protection units proposed by Hartwig & McMullen (2021). This is done so that the information conveyed is arranged systematically and has a basis for a good order.

C. Consent and Permissions
The implementation of Reproductive and Sexual Health Education for some parties becomes taboo, so it is important for educators to get approval from relevant parties such as parents/guardians, school boards, principals, and counsellors before holding the education (Hartwig & McMullen, 2021;Löfgren-Mårtenson & Ouis, 2019;Nelson et al., 2020). This is important because there are families who hold the value that the information contained in Reproductive and Sexual Health Education is inappropriate to be conveyed to students with intellectual disabilities and considers that the topics contained in this education are not important to be conveyed (Nelson et al., 2020).
Multicultural schools must consider more differences, because in multicultural schools, there are diverse cultural backgrounds owned by their students. The school, especially teachers, can communicate with parents/assistants, as well as provide understanding to students with intellectual disabilities about differences in treatment related to Reproductive and Sexual Health Education that may occur (Löfgren-Mårtenson & Ouis, 2019).

D. Meet the Student Character
Although in a class, all students in it are students with intellectual disabilities, this does not make their abilities and experience of Reproductive and Sexual Health Education the same (Matin et al., 2021;Nelson et al., 2020). Nelson et al. (2020) describe with a parable, "Five students, Five abilities, Five balls in the air". This means that every student has different abilities, knowledge, and experience.
These differences include gender, social class in society, ethnicity, biological age, knowledge, and experience of reproduction and sexuality (Chappell et al., 2018;Löfgren-Mårtenson & Ouis, 2019;Matin et al., 2021;Nelson et al., 2020;Povilaitienė & Radzevičienė, 2013) describe that usually female students are shy but have a huge interest in understanding the body and physical changes they experience, while male students are more open and confident when talking about topics of reproduction and sexuality. Low socioeconomic status becomes a distinct obstacle in the implementation of Reproductive and Sexual Health Education (Nelson et al., 2020). Ethnic differences will cause differences in culture, norms, and values that they embrace, for example, students who are of Islamic background but are in other countries/religious environments (Löfgren-Mårtenson & Ouis, 2019). Students who have reached a certain biological age will experience changes in their physical, so that the delivery of education is adjusted to their conditions and needs (Sravanti & Arul, 2021). Some students have rich knowledge and experience. This is an influence of technological advances (internet) and social experiences outside of school and home (Chappell et al., 2018;Nelson et al., 2020). These differences need to be known by the teacher so that the teacher can choose strategies, modify, and use appropriate learning support so that students are motivated to learn (Hartwig & McMullen, 2021).

E. Program Planning
Planning of reproductive and sexual health education program is done by studying the applicable curriculum (Löfgren-Mårtenson & Ouis, 2019), determining the norms and rules when learning is done (Nelson et al., 2020), determine the content to be included (Hartwig & McMullen, 2021;Sravanti & Arul, 2021), and determine who will be involved in providing education (Löfgren-Mårtenson & Ouis, 2019). In addition, the breadth and depth of content also needs to be considered because some students may not be time to be given the same broad content as other students (Sravanti & Arul, 2021). (2019) reveals that what needs to be considered in the curriculum is whether Reproductive and Sexual Health Education stands alone as a subject or is integrated into other subjects. From the same source, it is explained that if Reproductive and Sexual Health Education is integrated into other subjects, then teachers should feel comfortable talking about reproductive and sexuality issues and should be able to include the material.

2) Creating Norms and Rules
Norms and rules are important to create because they can minimize feelings of shame and taboos on content that is a natural thing to talk about in Reproductive and Sexual Health Education, both shame and taboos experienced by students and teachers (Nelson et al., 2020). Furthermore, Nelson, et al also mentioned that these norms and rules could limit the change that comes out of the context of learning and inappropriate speech.

3) Defining Content
Sravanti & Arul (2021) stated that there are five contents included in Reproductive and Sexual Health Education, namely understanding human body parts, hygiene and self-care, privacy, social skills and feeling handling, and security. Hartwig & McMullen (2021) adds the act of escape and recovery and group's understanding of body parts and privacy into the content of preventive measures. So, if the grouping of actions is done based on the opinion of Hartwig & McMullen, there are four contents, namely the cultivation of awareness, preventive measures, escape, and recovery.

a) Awareness and Prevention
The essence of this content is to provide knowledge about the name of body parts that are personal and foster awareness about actions to the body that are good and bad (Hartwig & McMullen, 2021). Teaching the name and function of personal body parts can make students know themselves better and feel comfortable with their bodies (Sravanti & Arul, 2021). The same source mentions that the presence of this content, it can prevent students from learning from unreliable sources, so it is important for teachers to discuss it. But keep in mind that conveying any personal body part should avoid using names other than scientific names, such as "penis" called "bird". This knowledge can be conveyed by discussing, telling stories, watching videos, using pictures, dolls, and stake boards (Frawley & O'Shea, 2020;Hartwig & McMullen, 2021;Sravanti & Arul, 2021).
Further knowledge is personal space/privacy (maintaining a safe distance and inappropriate behavior) and good and bad touches (Hartwig & McMullen, 2021;Sravanti & Arul, 2021). Hartwig & McMullen discusses "privacy" as a space that has certain limitations regarding situations that are still classified as safe and situations that are potentially a threat to students with intellectual disabilities. This knowledge aims to make students have an understand when they are in a dangerous situation. Hartwig & McMullen also gives an idea of how to align it, namely by doing activities that allow two students to stand close together and get used to students to say, "You're too close, please get out of my personal space". Sravanti & Jayendra discusses "privacy" as inappropriate personal behavior in public spaces, for example, masturbation and changing clothes. This knowledge can be provided using flash cards.
The next piece of content is about good/bad touches. This good/bad touch is not only when a personal part of the body is touched by an undue person, but also when the student is instructed to touch the property of another person (Hartwig & McMullen, 2021). Sravanti &Jayendra refers to this as "Security", not only about good /bad touch but also about knowing the type of person who can be trusted / untrustworthy and the skill in rejecting. Rejecting skills are related to social, interpersonal, body language, saying "please", "sorry", "no", "thank you", tone modulation, and different types of emotions. This knowledge and skills can be imparted with flash cards (describing dangerous situations related to sexual crimes, facial expressions, postures required) and role-playing (Hartwig & McMullen, 2021;Sravanti & Arul, 2021).

b) Cleanliness and Self-Care
Sravanti & Arul (2021)) explained that this content aims to be able to provide skills in helping and caring for themselves so that students can be independent in the present and future, as well as to prevent infections that may occur due to a lack of awareness regarding personal hygiene. Skills taught include hand hygiene, brushing, bathing skills, and toilet use, and menstruation. Based on the same source explained that the delivery of this content can use a visual schedule by including -using the student's favorite character that describes a series of steps of an activity. This series of steps can be placed on the bathroom door or any other place that corresponds to the activity depicted. Sravanti &Jayendra also explained that evening is a great time to train students at home by parents/caregivers rather than done in the morning during rush hour. In this context, students need to also be taught self-protective skills to help themselves in unexpected situations (Hartwig & McMullen, 2021). Further explained the skills that need to be given, among others, dexterity movements and noise-making tools/skills. Agility movements can be kick movements, block movements, and proper self-release techniques. Hartwig & McMullen urges students to be given knowledge and understanding so as not to hurt themselves or others who are innocent. While the noise making tool can be a whistle, or if there is no whistle, then students can shout or kick things around it.

d) Recovery
The content in this content is in the form of concepts of seeking and finding immediate and appropriate help to report attacks that occur to them and to prevent attacks that may occur in the future (Hartwig & McMullen, 2021). Hartwig &McMullen further explains to introduce to students anyone who is entrusted by the school (such as teacher, principal, school counselor, etc.) to be a trustworthy person and will accompany if a crime/sexual assault occurs, then shows how and process to report cases of sexual crimes committed to the authorities (police, KPAI, Komnas HAM, etc.), this reporting serves so that the perpetrator is acted on and students get recovery services from professionals. Also tell students that if students experience sexual crimes, then students should not shower and do not change clothes first because it can eliminate evidence.
The findings of this review can provide an overview of the methods and materials/content that can be used to provide learning of Reproductive and Sexual Health Education for students with intellectual disabilities, namely by using training methods and role-playing ( (Hartwig & McMullen, 2021;Sravanti & Arul, 2021). This is in line with the opinion of Schaafsma et al. (2015) that methods such as role -playing and training are very beneficial to improving skills in students with intellectual disabilities. But with, this method alone is not enough, a method used can be said to be an effective and can be a reliable method if use of the method there is a description presented in detail about the specific purpose, material, measurement of the effectiveness of the material listed, and the results of research (Schaafsma et al., 2014). Unfortunately, in the research used only one study that measures the effectiveness of the material and the results of research, even making improvements and adding material that is deemed necessary to be in accordance with the issues and developments of the era, namely research conducted by Frawley & O'Shea (2020).
The implementation of special education in Indonesia is carried out based on the law and the curriculum regulated in the Peraturan Direktur Jenderal Pendidikan Dasar dan Menengah No 10/D/KR/2017 about Curriculum Structure, Basic Core-Competency Competencies, and Curriculum Implementation Guidelines 2013 Special Education, this is in accordance with the opinion of Löfgren-Mårtenson & Ouis (2019). From the same source, it is also revealed that the implementation of education needs to be integrated with other subjects, because the education in the curriculum does not stand alone. Similarly expressed by Aziz (2014) that the implementation of Reproductive and Sexual Health Education is integrated with appropriate subjects and has to do with religious education, sports education, and special programs. Knowledge about legal protection in the event of a sexual crime is knowledge that should not be missed because most the students with intellectual disabilities are not aware of any legal protection for victims of sexual crimes Aziz (2014). The form of legal knowledge provided can use a method like the one Hartwig & McMullen (2021) put forward.

F. Limitations
There are some limitations to his study. Only three databases that researchers use, the search and filtering process is also limited to the research found and determined by the author. This certainly affects the diversity of research content that can be used to enrich the results of this research. In addition, it can cause differences in method criteria or other important aspects of this study."

IV. Conclusion
The learning methods used by teachers in learning Reproductive and Sexual Health Education for adolescent students with intellectual disabilities include role-playing and training. But before using these methods, teachers need to study the applicable curriculum, make norms and rules during learning, and carry out planning of reproductive and sexual health education learning programs that are appropriate for students with intellectual disabilities.