“Underwear Rule” in Improving Sexual Abuse Prevention Attitudes among Parents of Intellectual Disabilities Adolescent

: Sexual abuse remains a prevalent issue among disabled individuals, particularly adolescents with intellectual disabilities. Parental lack of knowledge and negative attitudes towards sexual abuse contribute to its occurrence. This study aims to investigate the impact of “Underwear Rule” training on the attitudes of parents of adolescents with intellectual disabilities towards sexual abuse prevention. Employing a pre-experimental method with a one-group pretest-posttest design, the research involved 72 parents. The Wilcoxon test was utilized for analysis. The findings reveal a positive influence of “Underwear Rule” training on parents’ attitudes, enhancing their motivation to prevent sexual abuse in adolescents with intellectual disabilities. Collaboration among healthcare workers, educators, and parents is recommended to implement and integrate “Underwear Rule” training into daily activities, effectively preventing sexual abuse in this vulnerable population .


A. Introduction
Sexual abuse is defined as any sexual act committed by a person without the consent of the victim. 1 Sexual abuse refers to any unwanted sexual activity, where perpetrators use force, make threats, or take advantage of victims not able to give consent.It encompasses a range of behaviors, including but not limited to, rape, molestation, and any form of sexual violence or harassment. 2 The term can also extend to electronic-based sexual violence (EBSV), which includes online grooming, cyber harassment, and the non-consensual sharing of sexually explicit images or videos. 3Sexual violence is defined as forced sexual activity or contact based on coercion and threats.It can include behaviors such as hugging, kissing, touching, groping, and even forcing sexual relations under threat.More extreme behavior may involve manipulating a partner to have sex by administering drugs so their partner is willing to have sexual intercourse. 4exual abuse is a sexual act happens in the form of physical coercion, psychological coercion, disempowerment, and/or victim's inability to give consent or understand the act due to age, developmental constraints, or the influence of alcohol or drugs.
The prevalence of sexual abuse on adolescents with intellectual disability in the world ranges from 14-65. 5 Data shows that the number of sexual abuse on people with disability is 87 cases in 2020.Meanwhile, data from the Online Information System for the Protection of Women and Children (Simfoni PPA) recorded that there were 987 cases of violence against children with disabilities, of which 264 were boys and 764 were girls during 2021.Going __________ 1 Amylee Mailhot Amborski et al., "Sexual  even further, 591 people were the victims of sexual abuse, where the majority of the victims were teenagers (76.4%).Data from the Public Services of Women Empowerment, Child Protection, and Family Planning (Dinsos P3AKB) in Bondowoso mentions that there were 54 women who experienced sexual abuse in 2022, where 2 of them were people with intellectual disabilities. 6The violence data scale earlier shows the high rate of sexual abuse experienced by adolescents with intellectual disability, which can be caused by several factors.
The first factor is the individual factor, which is caused by the lack of the victim's education regarding consent and healthy sexuality. 7People with intellectual disability have less exposure to sexual education.This is probably because their parents, caregivers, and educators do not see them as a sexual being.The second factor comes from parents.Parents have a huge role in preventing sexual abuse because they can observe the potential for child sexual abuse and communicate well with children regarding sexual prevention. 8owever, research has shown that parents do not have the knowledge regarding the forms, risk factors, perpetrators, and influence of sexual abuse. 9arents of children with intellectual disability are reported to have poor attitude in the sexual abuse prevention, which can influence their ability in giving education regarding sexual abuse prevention and personal safety skills for young people.Therefore, intervention is needed to prevent sexual abuse that may occur against children with intellectual disability.One of the the interventions that can be done is "Underwear Rule" training."Underwear Rule" training is a simple way to protect children and teenagers from sexual abuse.The "Underwear Rule" teaches that a child should not be touched by other people on body parts that are usually covered by __________ underwear, and they should not touch other people on those areas either. 10his training also helps to explain to the children that their body belongs to them, that there are good secrets and bad secrets, as well as good touch and bad touch. 11"Underwear Rule" training also contains education regarding sexual abuse using interactive video which can increase people knowledge and attitudes in disease prevention and health care. 12"Underwear Rule" training is expected to be able to prevent sexual abuse on adolescents with intellectual disability with the focus of providing training to parents and adolescents with intellectual disability.
"Underwear Rule" training can increase individual knowledge regarding sexual abuse prevention. 13The "Underwear Rule", a program aimed at preventing early childhood sexual violence, has been proposed as a potential solution to the increasing cases of such abuse.The "Underwear Rule" teaching children about boundaries, has been critiqued for reinforcing gender stereotypes and sexual objectification. 14The campaign's focus on underwear as a symbol of personal space and privacy may also be influenced by the gendered social pressures and boundaries associated with underwear.Furthermore, the campaign's emphasis on the "right" type of underwear may inadvertently contribute to the construction of female identity. 15

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The recent studies state that providing health education on "Underwear Rule" to parents can improve their knowledge regarding child sexual abuse prevention. 16This is because the training activity provides information to individuals involved which in turn can increase their knowledge.Knowledge is one of the factors that determine attitude formation.Knowledgeable individuals will show more positive attitude towards sexual abuse prevention. 17However, a preliminary study at Sekolah Luar Biasa Negeri Cindogo conducted by researchers shows that parents still do not have positive knowledge and attitudes regarding sexual abuse.Parents also do not understand the forms of sexual abuse, the impact of sexual abuse and the risk factors for sexual abuse.Parents still don't know how to prevent sexual abuse; parents only monitor and accompany their children continuously without ever informing them about how to protect themselves from sexual violence.For this reason, training is needed for parents to provide information that can further improve attitudes towards preventing sexual abuse.However, there has been no research that discusses the effect of "Underwear Rule" training on attitudes toward preventing sexual abuse in parents with intellectual disabilities adolescents.Thus, the researcher of this research is interested to conduct research about the influence of "Underwear Rule" training on the sexual abuse prevention attitudes in parents of adolescents with intellectual disability.

B. Method
This research used a pre-experimental method with one group pretestposttest design.The population of this research were parents of adolescents with intellectual disability in Cindogo Special School, Badean Special School and Jember Special School.The research was conducted from 18 September to 7 October 2023.The number of students with intellectual disability in those schools is 102 students in the 2022/2023 academic year.Therefore, the population of this research was 102 parents of adolescents with intellectual disability.This research used purposive sampling to decide the research participants.All parents of adolescents with intellectual disability who met the inclusion were involved in this research.The inclusion criteria for this research were parents or guardians of adolescents with intellectual disability aged 10-21 years old, parents of guardians involved in the study from the beginning to the end, and parents or guardians who were willing to be the research respondents.Meanwhile, the exclusion criteria for this research were parents or guardians with communication barrier and illiteracy and parents or guardians with chronic disease.The sample of this research was 72 parents of adolescents with intellectual disability.
The measuring instrument of this training was the questionnaire about sexual abuse prevention attitudes that has been made and tested by the researcher.The reliability value of the questionnaire was 0.736.This questionnaire contains 10 items with likert scale which includes 3 indicators, i.e. know, care, and act.The first indicator is know, which means awareness and understanding regarding sexual violence and the risks faced by children with intellectual disabilities, which consists of 3 statements.The second parameter is care, namely sensitivity and empathy towards vulnerabilities of people with intellectual disabilities people and the importance of measures to prevent sexual violence with a total of 3 statement items.The third parameter is act (action), which is the existence of efforts made in order to avoid sexual violence which contains 4 statements.
This research was conducted 3 weeks.Before conducting training, the parents were recommended to fill the questionnaire to know their attitudes towards sexual abuse prevention before doing the training.The training activity was divided into 2 sessions.The first session was offline and the second was online.The offline session provided educational video about sexual abuse, discussion and lab practice for 8 hours using "Underwear Rule" training module made by the researcher as the guideline.Participants practice singing "Sentuhan boleh dan tidak boleh" and demonstrate how to prevent sexual violence with the "Underwear Rule" (PANTS).Parents who practice sexual violence prevention include P which is private are private, A means "Always remember that your body is yours", N which is "No" means "no", T means "Talk about secrets that upset you" and S means "Speak Up, someone can help."Parents also instil simple ways that parents can use to prevent sexual violence, such as not talking to or accepting gifts from strangers, children are required to always ask permission from their parents when going out, children are required to dress modestly and cover up, and so on.etc.The online session contained a 3-hour discussion regarding sexual abuse and its prevention.After the offline and online session were conducted, parents were asked to fill the questionnaire again to identify their attitudes towards sexual abuse prevention after they participated in the training.Then, the questionnaire that had been filled out by parents, was analyzed using SPSS 26.0.The Wilcoxon test was used to identify the difference in the mean score of attitudes to prevent sexual abuse in parents of adolescent with intellectual disability.

C. Result
The data of this reseach covers respondent's age, age of the adolescents with intellectual disability, mother's job, father's job, monthly income, highest level of education and the person living with the child.The description of the characteristics of respondents is shown in Table 1.Based on the Table 1, the average age of the respondents was 40 years old.The youngest adolescent with intellectual disability was 10 years old and the oldest was 20 years old.The average age of the adolescents with intellectual disability was 12 years old.Most of the mothers of adolescents with intellectual disability were housewives, with a total of 46 people (63.9%).Some of the fathers of adolescents with intellectual disability were self-employed, with a total of 36 people (50%).The income of most respondents was below Rp. 2,150,000 per-month, with a total of 40 people (55.6%).The respondents' latest education was mostly college, with a total of 20 people (27.8%).Meanwhile, the least was junior high school, with a total of 15 people (20%).The majority of the children lived with their nuclear family, with a total of 55 children (76.4%).
The sexual abuse prevention attitude values before and after intervention among parents of intellectual disability adolescents are presented in Table 2. Based on Table 2, the mean score of the sexual abuse prevention attitude of the respondents before being given intervention was 32.96 and after being given intervention was 35.13.The lowest score of sexual abuse prevention attitude before being given intervention was 15 and after being given intervention was 23.The highest score of sexual abuse prevention attitude variable before and after being given intervention was 40.The results of bivariate analysis using Wilcoxon test showed that there was a difference between the mean score of the sexual abuse prevention attitude in parents of adolescents with intellectual disability before and after participating in the "Underwear Rule" training, where the significance value obtained was 0.001 (p value = 0.000).From the results of this analysis, there was an influence of "Underwear Rule" training on attitudes towards preventing sexual violence in parents of adolescents with intellectual disabilities.

D. Discussion
The results of the research showed that before being given intervention, there were some respondents whose sexual abuse prevention attitude scores were below the median value.In line with this research, recent study also explained that most parents had unsupportive attitude towards child sexual abuse prevention. 18The first factor influencing parents' attitude towards sexual education is parents' gender, 19 where a mother has better attitude in sexual education due to the fact that a mother often serves as the primary caregivers and have a closer relationship with their children, allowing for a more open conversation about sexuality knowledge.The next factor is education level of the parents, where parents with high education level tend to be more aware of the importance of sex education and support its implementation in schools, which consist of various topics on sexual abuse prevention. 20 higher education are associated with good health literacy skills, which makes them show more positive attitudes. 21Education can also increase parents' confidence in their ability to protect children from sexual abuse so that parents will show a more proactive attitude. 22he third factor influencing parents' attitude towards sexual education is age, where older parents may tend to have more respect for traditional beliefs and values, causing them to prevent discussions about sexuality and sexual abuse prevention with their children. 23They may also feel uncomfortable or not ready to discuss this topic.On the other hand, younger parents may tend to be more open to discuss this kind of topic and may be more supportive of comprehensive sex education, including sexual abuse prevention.The fourth factor influencing parents' attitude towards sexual education are religion and belief. 24Parents who support traditional religious and cultural values and beliefs are more reluctant to discuss sexuality, including sexual abuse prevention with their children.Misunderstanding and misinterpretation towards religious teaching can also lead to the resistance of sex education which includes sexual abuse prevention topic. 25In addition, discussion about sex and its related topic is considered taboo in certain culture, which inhibits the open conversation about sexual abuse prevention.
The next factor is parents' occupation. 26Parents who work in healthcare or education sector may have more knowledge regarding the importance of sexual abuse prevention and more likely to discuss these topics with their children.They may also have more resources and accesses to educate their children regarding sexual abuse prevention. 27The sixth factor influencing parents' attitude towards sexual education is parents' income. 28Parents with higher income rate are generally more supportive and show more positive attitudes towards sexuality education in schools, including the topic of sexual abuse prevention. 29This may happen because parents with higher income have more accesses to resources and information about sexual abuse prevention. 31They may also have more time to spend with their children, allowing them to have more opportunity to discuss sexual abuse prevention.The factors elaborated earlier can influence parents' sexual abuse prevention attitude.The solution that can be offered to improve the attitudes of parents of adolescents with intellectual disability is sex education service that is in line with the culture, religion, and education level of the parents, so that information gained can be more applicable and easier to understand.These efforts include simplifying text, picture and video, and give additional support to understand healthcare information for individuals.
Before carrying out the training, parents thought that only male strangers could sexually abuse female victims.Parents also do not understand that children with disabilities experience stigma.Discrimination and exclusion from society due to ignorance and negative perceptions.Some perceptions about people with disabilities increase their vulnerability to overt sexuality.In one area, there is a myth of cleansing by exploiting women's virginity, which triggers sexual violence against women with disabilities.This myth states that having sexual relations with a woman with a disability can cure one of the diseases suffered by the perpetrator, one of which is HIV. 30The gender bias in __________ sexual abuse prevalence is a significant factor that contributes to the vulnerability of children with intellectual disabilities to such exploitation and sexual abuse.
The "Underwear Rule" training was conducted by the researcher to parents of adolescents with intellectual disability and showed an increase in the score of sexual abuse prevention attitude.This result is in line with a recent study, which mentioned that there was a score improvement in the attitudes toward risky sexual behavior after being given sexual education. 31According to attitude theory, education plays a significant role in building individual attitudes.Education can increase individual knowledge regarding healthcare information, leading to more positive beliefs and feelings and increasing motivation to engage in healthy behavior. 32Health education can also help individuals develop accurate perceptions about the risk experienced to inspire them to adopt healthier behavior. 33Education can improve attitudes toward preventing sexual abuse because education can equip a person with the knowledge, values, and support needed to make decisions about sexual behavior, thereby reducing the risk of sexual abuse occurring. 34Education can play a significant role in preventing sexual abuse.By teaching about reproductive health education and anti-violence education to parents, young men, and women, individuals can be better equipped to prevent and protect themselves from violent behavior, whether as victims or perpetrators. 35Giving education through "Underwear Rule" training will develop awareness and __________ accurate perception of the risks of sexual abuse on adolescents with intellectual disability so that parents' motivation to take a positive attitude towards the prevention of sexual abuse in adolescents with intellectual disability can be increased.

E. Conclusion
The results show that there is an influence of "Underwear Rule" training on sexual abuse prevention attitudes among parents with intellectual disability adolescents.A collaboration between healthcare workers, education workers, and parents is needed to do "Underwear Rule" training so that parents' and children's knowledge and attitudes toward sexual abuse prevention will increase.Increased knowledge and attitudes towards sexual abuse prevention will build sexual abuse prevention behavior, which can reduce the number of sexual abuses on adolescents with intellectual disability.It is hoped that future researchers will be able to continue research on parents' experiences in teaching the "Underwear Rule" as a form of preventing sexual violence in adolescents with intellectual disabilities.

Table 1
Characteristics of Parents with Intellectual Disabilitiy Adolescent