Following catastrophic injury, one area of a person’s life which is often not addressed is sexual issues. Sex is often seen as a private matter and raising this with clients can be seen as controversial. We find ourselves avoiding any questions pertaining to someone’s ability to engage in sexual issues or how to address these issues due to fear of embarrassing the client, family members or even ourselves. But we have a duty to raise and address issues relating to sexual needs for our clients.
Anna Freud famously wrote that “sex is something you do, sexuality is something you are”. Sexual intercourse includes physical, sexual, emotional and spiritual aspects and depending on who you ask, the answer to “what is sex” can differ. It might include: romance, holding hands, intimacy, kissing, massage, passion, foreplay, phone sex, or writing love letters.
Raising sex as a topic with our clients or their loved ones can be challenging due to their own, and societies, pre-existing beliefs about a person who has disabilities and sex. This can prevent a person’s talking about or engaging in sexual activities. Why should we address sexual issues with our clients?
Common Myths About People who have Disabilities and Sex:
- People with disabilities and chronic illnesses are not sexual
- People with disabilities and chronic illnesses are not desirable
- People with disabilities are a bad choice for romantic partners
- People with disabilities are not sexually adventurous
- People with disabilities and chronic conditions can’t have “real” sex
- If you have a disability you are too ill to have sex
At Case Management Services, we work with clients with a range of disabilities including those with traumatic brain injury and spinal cord injury. These clients can be left with complex care needs, and/or cognitive and physical impairment. However, the type of disability a person has should not preclude them from having their sexual needs addressed. The challenges our clients face when it comes to sex include physical barriers; reduced ability to communicate one’s sexual needs; loss of sexual identity and altered body image; reduced confidence and self-esteem; social norms; others’ views / beliefs.
Capacity and Safeguarding
A key area that we have to consider in all of this is a person’s capacity to consent to sexual activity, safeguarding and their right to a sexual relationship. We have to consider protection vulnerable adults against consequences of potentially harmful and exploitative relationships whilst protecting the rights of every adult to enjoy intimate and private relationships.
Key Issues to Consider in Terms of Capacity
- Current level behavioural presentation and specific areas of concern
- Potential risk factors:
- mental health status – psychology/psychiatry ref?
- drug/alcohol intake
- cognitive impairment – neuropsych ref?
- domestic and social status
- Relationship status and history
- Potential safeguarding concerns:
What is the role of the Case Manager when dealing with sexual matters with our clients?
As case managers we can support our clients by considering capacity / welfare / human rights; introducing the topic of sexual matters; providing information about sex and disabilities; referring to appropriate specialist / therapists; and arranging funding for equipment such as specialist equipment, surgery / other services such as talking therapies.
Helpful resources include:
- Accessing sexual services – http://enhancetheuk.org/enhance/sex-and-disability/
- Relationships and sex – http://disabilityhorizons.com/category/relationships-and-sex/
- Sexual Health and Disability Alliance – http://shada.org.uk/wp2/
- Assisting clients to have sexual intercourse – https://www.youtube.com/watch?v=-SgqGEX_DOw
- Enhance UK is a charity which deal primarily with challenging beliefs about sexual issues and disability and supporting people including the client / carers / partner in exploring sex and finding ways to enable a person to be recognised as a sexual being.
- M Kaufman, F Odette & C Silverberg (2016) The Ultimate Guide to Sex and Disability: For All of Us Who Live with Disabilities, Chronic Pain, and Illness. Simon & Schuster
- Kroll, K. & Levy Klein, E. (1992). Enabling Romance: A guide to love, sex, and relationships for people with disabilities (and the people who care about them). Publisher: No limits Communication
- Neistadt, M. (1986). Sexuality counseling for adults with disabilities: A module for an occupational therapy curriculum. AJOT, 40, 542-545.
OT & Case Manager