Attitudes to Sexuality Abuse and Protection

Historically, especially in the early 1900s, there was a great deal of concern in the UK, the USA and elsewhere about the reproduction of a number of groups, including people with intellectual disabilities or a mental illness, who were deemed to be 'unfit' (Barker, 1983; Showalter, 1985, p. 110; Fennell, 1996). Reflecting this concern, 'patients' in psychiatric and 'mental handicap' hospitals were very strongly discouraged from having sexual relationships (although illicit and abusive sexual activities were far from unknown). For example, wards were segregated by gender and no contraceptive or sexual advice was offered, even in long-stay hospitals. The advent of the normalisation movement (Nirje, 1980; Wolfensberger, 1980, 1983; Emerson, 1992) and the rights movement (Rioux, 1997; Shakespeare, 2000; Cook, 2000), with its associated legislation (e.g. Daw, 2000) radically changed views about the opportunities which should be offered to people with disabilities and/or mental health needs, providing a new emphasis on age-appropriate and culturally normative experiences. For people with intellectual disabilities, there was a recognition that sex education should be offered (Craft and Craft, 1983; Murphy et al., 1983; McCarthy, 1999, pp. 61-67) and, increasingly, there was a move to more ordinary living conditions in the community (Mansell and Ericsson, 1996). Similar deinstitutionalisation took place in regard to people with a diagnosed mental illness and hospitals themselves became less prohibitive about sexual matters: most wards began to contain men and women (though this has resulted in concerns about sexually abusive behaviour by men—see below).

In most jurisdictions, despite this evidence of attitudes opposing the expression of sexuality for marginalised groups, there was a legal presumption of capacity to consent to sexual relationships, so that everyone above the age of consent (with very few exceptions) was considered competent to consent to sexual activity. Most countries had laws to protect people from unwanted sexual encounters, though, and there were often added protections for those who were regarded as unable to consent (such as for men and women with severe intellectual disabilities in England and Wales; for the relevant law, see Gunn, 1996). Nevertheless, the law normally only concerned itself with situations where it was reported that a person did not or could not consent. Where consent appeared to have been given, the law did not usually seem concerned with the reason why consent was given, enabling people to consent to sex for all sorts of reasons including sexual gratification, affection, duty, money, physical closeness, physical comfort or fear. As a result, in cases where a man or woman had consented to sexual activities for a small gift, such as a cigarette, there could usually be no prosecution, even though others may have felt that he or she had been exploited.

People with intellectual disabilities, physical disabilities, a mental illness, or dementia are all thought to be at increased risk of sexual exploitation and/or sexual abuse because of their social and/or cognitive disadvantages (Sobsey, 1994; Brown et al., 1995; Williams and Keating, 1999; Glendenning, 1999; Nosek et al., 2001). Nevertheless, discussions about capacity to consent to sexual relationships normally only occur in relation to people with intellectual disabilities and these debates tend to be about the degree of sexual knowledge required to indicate capacity.

For all vulnerable groups, however, there has been a rising concern about how to provide them with protection, without wishing to remove their right to consenting sexual relationships. It has been suggested (e.g. Copperman and Burrowes, 1992) that mixed gender wards in psychiatric hospitals place women with mental illness or other mental health problems at risk of sexual abuse and that single sex provision should routinely be available (a similar argument might be made for women with intellectual disabilities or dementia living in hospital or community services). In addition, local policy guidelines on personal and sexual relationships and adult protection procedures have been drawn up by and for staff in residential and day care facilities for vulnerable people (Booth and Booth, 1992; Brown and Stein, 1998). Most ofthe guidelines assert that such persons have the same right to consenting sexual expression as other people but that they also have a right to be protected from abuse and exploitation. The majority of guidelines are then mainly concerned with procedures to be followed when abuse comes to light; they tend to provide no guidance on what constitutes consent.

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