The View on the Sexual Education of People with Autism in Modern Greek Society

Sexual education is not part of any formal educational program in Greece and there exist rare researches so far. People with autism have the right to grow up and be treated with respect and dignity in their adult lives and have the right of knowledge in order to be able to control their feelings and have proper social behavior. The purpose of the present study was to investigate the views of parents of children with or without autism in the sexual education of autistic children in school age. The target population was parents of children with autism and of children with typical development at school age, attending educational structures of the Greek state (school age for children with autism in Greece is from 6 to 22 years). The factors examined included the place of residence, the educational level, the profession and the gender of the parents and their views on the sexual education of children with autism. The results showed that older parents of children with or without autism were more progressive about the sexual education of children with autism. Also, the higher educational level of parents was related to greater acceptance of sexual education of children with autism. In conclusion, both groups of parents believe that sex education will help young people with autism make good sexual decisions and develop healthy interpersonal relationships.


Introduction
Limiting the problem Autism spectrum disorders (ASD) affect one in 68 children in the United States (Centers for Disease Control and Prevention 2014). While early detection and intervention can improve cognitive, social, and communicative functioning [1,39], core symptoms typically persist into adolescence and adulthood [9].
Considerable research has focused on promoting independence and optimizing the quality of life for adolescents and young adults with ASD [13,16]. Unfortunately, the areas of sexual development and sexuality of people and especially young people with ASD have been largely neglected [2,4,25]. In part, the absence of relevant research may occur due to conservative views of society that people with autism do not have sexual needs and do not develop sexual relations [17,24,26]. As a result, the parents of children with autism and professionals may think that youth with ASD lack interest in sexual relationships [2,16]. However, recent research indicates that individuals with ASD desire and pursue sexual relationships and engage in a variety of sexual behaviors typical of most people [41,45].
Parents of children and of teenagers of typical development recognized as the primary sexuality educators and parent-child communication about sex issues is an ongoing, bidirectional process beginning early in life and continuing into early adulthood [11,35]. Also, parents consider being necessary for their children to have formal sex education in school mainly under the need for restriction on unwanted pregnancies and the prevention of sexually transmitted diseases [36,39].
Parents of children or of the adolescences with autism, particularly concern about sexual development and behavior of their children [8]. Many of the parents are uncertain on how and when to cover sexuality-related issues with their child and what sexuality-related topics they should include [32,33]. They have feelings of fear and anxiety, which are mainly focussed on the supposed inappropriate behavior of their child [8,21]. As a result, parents of youth with ASD delay or avoid covering important sexuality-related topics, leaving their child to learn about those issues from various, possibly less credible, sources. Indeed, at least one study with ASD youth found that they have learned about most sexuality topics by themselves or from peers, rather than from their parents [4,5,30]. It is possible, parents' underestimation and unawareness to inform their adolescents about sexual issues arises from the broader view of society that people with autism do not have sexual interests and needs [38].

Journal of Autism
Research into the sexual education of young people with autism is not extensive [23,31]. Even more limited are the studies about parents' views for the sexual education of children with ASD. A short number of studies show that the personal characteristics of parents such as age, educational level [19] socio-economic situation [40] and religion [39] influenced their attitudes towards the sexual education of their children with autism. The results show that young parents with a high level of education and high socioeconomic status have a positive attitude towards the sexual education of children with autism [9]. Religion affects the attitude of the parents and it seems that usually the followers of religion adopt the belief that sexual concerns are inappropriate to discuss and much further to include them as a part in formal education [9]. In addition, a large number of studies do not include the views of the general population [3]. It would be interesting to identify if those factors also affect attitudes of parents of children with typical development and whether they consider that sex education is as important for young with autism, as they consider that it is for young with typical development [25]. The views of parents of general development children reflect the overall, general attitude of society towards sexual education and sexual rights of people with autism [15,33]. Only a few references to sexuality compared to the general population [9,12] showed that children with autism are particularly in need of appropriate sex education as well as their peers without autism, in order to be protected from sexual exploitation and abuse [39,41]. So, it is difficult to decide if the general population is tolerant toward sexual education of young people with autism [14,15]. The positive view of parents and society, in general, can be a very important element in developing appropriate educational policy and training to sex education programs for children or youth with autism [45].

Objectives of the survey
The aim of the present research is to investigate the views of parents of children with and without autism on the influence of demographic characteristics, place of residence, gender, age, education, degree of participation in the sexual education of their children, the formation of views with regard to the sexual education of children with autism.

Assumptions
1. Parents of children with or without autism consider that young people with autism should receive sexual education at school 2. The parents' age, place of residence and profession correlates to the view of the sexual education of children with autism. 3. The higher the educational level of the parents of children with autism, the higher believe that their children should receive sexual education.

Participants
Participants were total 614 and from them, 308 had children with autism from 6 to 23 years old and 306 had children with typical development from 6 to 18 years old. Children and young people with autism attended educational structures in general or special education, according to the Greek law for the education of children with special needs [1].

Data collection tool
In order to be able to collect data for the present research, a specific questionnaire invented which consisted of 3 parts (1st) Demographic features of the parents outlining their social profile as age, marital status, occupation, educational level and place of residence (2nd) Parents' views on sexual education for young people with autism about their concern on sexual education of young people in general [10,17,21,28], if they are willing to take the responsibility to talk to their children about sex education or if they prefer someone else to do so [5][6][7] and (3rd) Parents participation in the implementation of sexual education as the most appropriate age at which sexual intercourse begins educating young people with autism [34,36] which is the most appropriate person to undertake sexual education of young people with autism [44] the purpose and content of sexual education programs [43,44] in what ways can parents teach sexual education [13,38], the characteristics that parents need to have to teach children with autism [6,43] points to emphasize sexual education [1,35] the different way that each family faces the issues sexual education [39,41] the issues of sexual education that the same parents consider more important to teach [27,33] whether they consider puberty the most appropriate age to talk about sexual education for their children [28,41] the reasons why there is no sexual education for young people with autism in Greece [3]. The questions are of the Likert type [18,22,29] in which the respondent is asked to declare the degree of agreement or disagreement on a five-point graded scale (1=totally disagree, 2=disagree, 3=neither disagree nor agree, 4=agree and 5=totally agree) or there were five options from which respondents should choose one, or Yes/ No options.

Results
A total of 614 people participated in the present study. 306 of them were parents of children with autism, of whom 116 (37.9%) were men and 190 (62.1%) were women and their age ranged from 28-58 years. 308 were parents of children with typical development of whom 137 (44.5%) were men and 171 were women (55.5%) and their age ranged from 28-64 years.
doi: 10.7243/2054-992X-6-2 The mean age of the sample for both groups was 42.3 years.
Regarding the place of residence, 109 (36%) parents of children with autism lived in urban areas, 123 (40%) lived in rural and 74 (24%) lived in suburban areas. Most of the parents of children with typical development 220 (71%) lived in urban areas, 40 (13%) of them lived in suburban and 48 (16%) lived in rural areas ( Table 2).
Regarding parental support in the sexual education of    In order to develop Parental Typology of their views on the sexual education of young people with autism, the Hierarchical Analysis was performed in clusters. It revealed 3 clusters/ types of parents (S1, S2, and S3) based on the degree of progressive views they expressed about the sexual education of young people with autism. In the first cluster (S1) were 169 (28%) parents, in the second cluster (S2) was 86 (14%) of them and in the third cluster (S3) were more numerous 359 (59%) of parents. We tested the correlation between the three types of parents and gender, age, educational level, place of residence and marital status. Statistically significant correlations were found between parent type (S1, S2, S3), educational level and their age. In particular, S2 and S3 clusters included parents with a higher level of education than parents in cluster S1 (Graph 2).
The χ2 statistical check showed that there is a statistically significant correlation between the parent and their educational level (χ2=16,166, β=6, p=0,014, Cramer's V=0,115). The variance analysis showed that the age of the parents did not differ significantly between the three types (F (2,610)=4,773, p=0,009). More specifically, the cluster-type S3 includes slightly younger parents in relation to the cluster S2. Parents' views on the sexual education of young people with autism in relation to their age have shown the following: Means followed by a different letter differ statistically significantly from a significance level of α=0.05 according to the LSD criteria ( Table 5).

Discussion
The purpose of the present study was to investigate the views of parents of children with or without autism about the sexual education of children with autism.
The results showed that all parents, regardless they have children with or without autism are positive regarding the sexual education of children with autism. The results consist of some researches which show that nowadays parents in general, believe that all youth people need sex education, regardless children are of typical development or experience difficulties such as mental disabilities or autism [44,45]. According to their opinion, sex education will help young people to develop responsible behavior and respect for their mental and physical health and protection. In the present research, parents recognize the need for sexual education of children with autism probably in order to minimize the likelihood of offending behavior and sexual abuse and to provide the teenagers or adults with ASD with the necessary training in order to experience healthy sexuality as typical adolescents and adults do. The result is according to unpublished researches conducted by the University of Queensland in Australia that found that in 1982 only 38% of parents believed that their child with ASD could have sexual relationships, but in 1991 the percentage rose significantly and reached 85% of parents [37]. Unfortunately, there is little research in the field and future research should investigate thoroughly that issue.
Also, the results showed that the beliefs of parents of children with and without autism are related to their age and educational level. The results are consistent with studies that have shown that the personal characteristics of parents such as age, educational level, and socioeconomic status influence the attitude toward the sexual education of children with autism [42,44]. In the present study, older parents have progressive attitudes about the sexual education of young people with autism. The result may occur due to the fact that older parents have older children and they experienced many difficulties bringing up their children and recognized    the benefits of sexual education for the quality of life for the individual with autism and for their family, in general. Hence, rendering in the absence of longitudinal studies, it is unclear whether that progressiveness demonstrated by younger age parents arises from a historical shift in their views or occurs because younger parents are more likely to have younger children, and so they did not have to deal with the sexuality of their children. The parents' educational level related to the parents' positive attitudes. Specifically, parents with higher education level had more progressive views on sex education than parents with lower educational level. Results are consistent with previous research that found that the higher the parents' educational level, the more progressive views on sexual education they had [41,42].
In the present research, the views of parents are not related to the place of residence. The results seem to be in contrast with previous research [15,16] reported that parents' attitudes towards people with autism, related to the place of residence and residents of rural areas expressed more traditional views than those living in urban environments [33,43]. One reason that the place of residence is not an essential factor in the views on the sexuality of young people with ASD may arise of the fuller information from a variety of media in every part of the country. Possibly, the general population adopted the views on equal rights of people with disabilities [37,42]. The results need to be confirmed by future research.
Also, it should be mentioned that the country in which research is taking place is considered as another very important determinant that may influence the views on sexual education of young people with or without autism because of the cultural particularities and the traditions of every country [3,20]. Possibly, in modern and progressive societies, residents are positive about the sexual education of young people with or without autism, in contrast to conservative societies where citizens are negative about sex education of young people, regardless of the presence of serious disabilities or not.

Conclusions
The present research shows that parents of children with or without autism have more progressive views than they did in the past and they believe that young people with autism should get formal sex education. The educational level of the parents related to the positive attitudes according to sex education of people with autism. Parents with higher educational level seemed to have more modern views about the sexual education of people with autism than parents with a lower educational level did. Also, the positive attitudes toward sex education of people with autism may occur from the fact that sexual issues are discussed more often than in the past, possibly in response to the pressure of sexually transmitted diseases. Furthermore, this study shows that the parents of children with or without autism are willing to recognize the important role of sex education for the development of people with disabilities. Also, sexuality education for youth with ASD is essential in order to promote sexual health and prevent negative sexual health outcomes (e.g., unwanted pregnancy, HIV/AIDS or inappropriate sexual behaviors) [33,34]. Nevertheless, the importance of providing quality and individualized sex education is substantial because individuals with ASD have unique needs that may not be addressed in sexuality education programs designed for young people of typical development [1,7,40].

Competing interests
The author declares that he has no competing interests.