376: Principles of supporting individuals with a learning disability regarding sexuality and sexual health (LD 307)

Individuals can be supported to keep safe sexually by being provided with relevant information and education. This can include guidance on safe sex, contraception, appropriate sexual behaviour and what is lawful and unlawful. It is also paramount to teach individuals that nobody has the right to touch their genitals or any other part of their body without consent. Building up a trusting professional relationship with an individual and installing a core value of ‘no secrets’ and talking openly about sexual subjects can be very useful in preventing sexual abuse, as can explaining the importance of gentleness in intimacy. In some cases, specialist assistance may be needed from other health and social care professionals such as psychologists and social workers.

In addition, it is paramount to remember that an individual with learning disabilities has the same rights as everybody else in their sexual expression and has the freedom to make their own choices providing it is lawful and there is not a safeguarding issue (a copy of my company’s Safeguarding Policy has been attached to this document as evidence).

There are several ways that an individual can express themselves sexually. Of course, having sexual intercourse is the most obvious but other intimate actions such as kissing, hugging and stroking can also be methods of sexual expression. There is also the use of sex aids and legal pornogography, masturbation and the way an individual dresses (including their underwear) can be a form of sexual expression.

It is important for a support worker to be able to support an individual in their sexual expression and respect the choices that they make without judgement, whilst also providing guidance on what is lawful and socially acceptable. This could mean dealing with sensitive subjects and doing things that some people may find uncomfortable with (for example, supporting an individual to buy products from an adult store).

The development of a meaningful relationship is often important to the development of an individual’s sexuality because it allows them to develop intimacy and share experiences with another person without sexual intercourse.

As the relationship between the individuals develops there will be opportunities for them to learn about each other and their likes and dislikes, including their sexual preferences. It will also allow them to try out new things with each other and develop closeness, understanding and empathy.

It is important that a support workers own values, belief systems and experiences do not influence the support they provide for individuals with learning disability. All individuals beliefs and choices should be respected whether you agree with them or not. For example, I do not believe in a God, however I have worked with clients that are deeply religious and I respect that. I don’t force my own opinions on others although I’m happy to discuss them if asked. I’ve also worked with clients that are racist and even though I have great difficulty understanding why people can be bigoted I do not let it affect my work (however I may formally explain to the individual that their views are discriminatory and not socially acceptable). I am addicted to cigarettes and I worked with a client who hated the smell of tobacco so I had to respect this and refrain from smoking when I was on shift with him so he didn’t become upset.

Some people with learning disability can become frustrated and stressed if they interact with people that do not their share their views about topics they feel strongly about, so in most cases, it is best not to get into a debate about it. In addition,some individuals are easily influenced by the views of others.

Legislation relating to sexuality and sexual health includes:

• The Equality Act & Human Rights Act – Individuals should not be discriminated against because of disability and should be free to make the same choices as anybody else, including those relating to sexuality
• The Mental Capacity Act – Until proven otherwise, an individual should be considered capable of the capacity to make their own choices
• Sexual Offences Act – Outlines what is considered a sexual offence
• Genital Mutilation Act – makes genital mutilation unlawful
• Abortion Act – legislation regarding abortions

Legislation sets out what is lawful and unlawful as well as making it clear that everyone has the basic freedom of free choice. However, in practice, it can be confusing for people with learning disabilities to understand what is legal and what is appropriate behaviour, so it is up to support workers and other health and social care professionals to provide information, education and guidance in this regard.

There are a few local services that exist to support sexual health for individuals in addition to local GP surgeries. There is a Sexual Health Clinic in Nuneaton that offers contraception, emergency contraception, pregnancy testing, chlamydia screening and general advice and information about sexual health. They also offer C-Cards, which allow the holders to get free condoms (although this is only available to young people). There is a Contraceptive Service, which provides contraception and pregnancy testing. Finally, there is also a GUM clinic at the hospital which offers full STI testing.

Like all other facets of an individual’s health, sexual health should be assessed and planned. Information about sexual health should be readily available to individuals and it should be in a form that they can understand.

Support plans should be put in place to provide the necessary information. This should be done in alliance with other health and social care professionals such as doctors, psychologists and care workers.

The Department of Health provides a Health Action Plan for all individuals with learning disabilities. Two copies are made; one for the individual and the other for their GP. They can be obtained by asking a doctor or nurse and are filled in jointly by the individual and a health professional. As well as containing information about eating healthily and exercise there will also me information about sexual health as it pertains to the individual.

Plans can include doing research about sexual health, going to workshops or classes or obtaining information from a health professional.

There are several sexual health issues that only affect one gender or affect genders differently. It is important for individuals to understand the sexual issues that affect their own bodies but it is also important to understand the issues of the opposite gender.

Females experience the menstrual cycle each month and in later life will experience the menopause. Many contraceptives affect only a female’s body such as the pill, injection, diaphragm and implants whereas condoms fit on a male’s penis.

Males experience erections and can suffer from impotence and premature ejaculation. During puberty, many males will have wet dreams.

Both males and females will usually masturbate at some point in their lives, however the technique is different between genders. Likewise, both genders experience orgasms but the feeling is different for the different sexes.

Sex drive can peak and trough during the lives of both men and women although females are more likely to experience a much-reduced sex drive when they hit menopause.

Sexual health is a state of physical, mental, social and emotional well-being related to sexuality. This not only means the absence of sexually transmitted diseases but also having mutually beneficial relationships with both partners respecting one another, physical intimacy and safe sexual experiences free from coercion, discrimination and violence.

An individual’s sexual health and well-being can contribute to their overall health and well-being because they will be happier and have increased self-esteem and self-confidence. They will not suffer from sexual frustration and having somebody to talk to often relieves stress. And, of course, being in a strong relationship provides emotional stability to an individual’s life.

Mental capacity can have a direct influence on sexual development, sexual experience, sexual expression and sexual health, however it should be remembered that under the Mental Capacity Act all individuals should be treated as being able to make their own decisions until it is shown that they are not able to do so.

Having said that, the Sexual Offences Act states that a person can only consent to sexual relations if they have the mental capacity to make that choice and that they only have the capacity if they understand the nature of the act and the reasonably foreseeable consequences.

Therefore it is essential that support workers and other health and social care professionals provide individuals with the education and information they need to make informed decisions. This can include topics such as sex education, an openness to talking frankly about sexual subjects and the importance of protection.

Mental capacity can influence sexual development if an individual can not understand sexually mature behaviours and attitudes. It can affect sexual experience if an individual is unable to comprehend the possible after-effects of unprotected sex. It can affect sexual expression if the individual can not understand what is socially acceptable. And it can affect sexual health if an individual is unable to understand the health risks of sexual intercourse.

However, in all these cases, mental capacity should not be confused with a lack of education.

Socio-cultural factors that can influence an individual’s sexual development are manifold. During childhood, ideas, views and opinions relating to sexuality will be learned from immediate family. This can include topics such as gender roles, contraception, sex before marriage or promiscuity. Children will be heavily influenced by what they see in the family home. Habitual norms will also influence a child’s sexuality such as marriage, single-parent families, cohabitation and same-sex partnerships.

As a child gets older, their sexual development will be influenced by groups outside of the family home such as friends, teachers and the media. Individuals that go to same-sex schools may have difficulty mixing with the opposite gender in later life and individuals that are ‘sheltered’ by their loved ones may not have the opportunities to grow sexually. The media may present ideas about sexuality that lead to stereotypes.

Religion can also play an important part in sexual development as the ethical and moral codes of many religions have strong views about promiscuity, sex before marriage and homosexuality. This can lead to an individual having conflicting views about sexuality.

Individuals with learning disabilities in particular may have reduced chances of normal sexual development as they may be excluded from sex education and taught that sex is a taboo in an effort by their loved ones to ‘protect’ them despite it being obviously discriminatory.

In genetics, the sex chromosomes determine whether an individual is male or female. An individual will get an X-chromosome from their mother and a second X-chromosome from their father if they are a female (XX). Males get an X-chromosome from their mother and a Y-chromosome from their father (XY). Therefore, sexual development is based on genes.

Variations on chromosomes can lead to variations in the sexual development and sexual expression of an individual. For example, if a male has an extra X-chromosome (XXY) they will have biological features resembling a female and if a male has an extra Y-chromosome (XYY) they will be taller and often have a learning disability. There are other genetic conditions that do not affect an individual’s sexual development but are the cause of a learning disabilities that make it difficult for them to have the cognitive and emotional structure to manage their sexual expression and sexual health in socially acceptable ways. Fragile X syndrome is an example of this.

From birth, babies can experience sexual pleasure from touching their genitals and males can have erections. By around age 2, infants will know their own gender and understand the difference between male and female genetalia. As they get older they will become more curious about sexual subjects.

Pre-adolescence usually occurs between ages 8 and 12 and children will become more self-conscious about their bodies. They will also experience some changes to their bodies including the growth of pubic hair, larger testicles in males and breast buds in female. They will become more interested in sexual subjects and may masturbate although the thought of sexual intercourse is often an unpleasant one.

During the teenage years, children experience puberty as their bodies mature in adulthood and their primary and secondary sexual characteristics develop. Females will experience menstruation and masturbation for both genders will be common. Teenagers will also become more interested in forming romantic and sexual relations.

During adulthood, most people will have a desire for intimate and sexual relations and may wish to have children.

At around age 50, women will experience the menopause, indicating the end of their ability to have children. This may also reduce their sexual desire. Men may also have a reduced desire for sexual relations and may find it more difficult to maintain an erection although they may still be able to father children.

Sexuality is the capacity for sexual feelings. Sexual health is a state of physical, emotional, mental and social well-being with regards sexuality. Sexual orientation is the gender to which an individual is attracted to. Sexual expression is the expression and experience of sexuality.