In practice, where a sexual relationship involving a person who is believed to have an intellectual disability, a mental illness, or dementia, has begun or appears imminent, then families, carers and professionals should consider the following issues.
• Is there a major imbalance of power between the two persons (for example, is one physically frail or a subservient partner)? If so there is a much greater risk of an abusive relationship.
• Is the sexual relationship rewarding in itself, or is one person offering inducements to the other (such as cigarettes or car rides)? If one partner always gives tangible inducements to the other then there is a far greater risk of the relationship being abusive.
• If the relationship is heterosexual, do both partners understand (at least) that pregnancy can result from sexual intercourse?
• Where the relationship is heterosexual, do both know what contraception means and how to use methods of contraception?
• Do both partners understand that there is a risk of sexually transmitted diseases, particularly when the sexual activity includes oral or anal penetration, and know how to engage in safer sex?
• If pregnancy is a possibility, have both people been given adequate access to genetic counselling and have they been informed and understood issues relating to parenting (including the reality that fostering may be required)?
• Have both people been offered sex education?
In some cases, where the answer to any of these questions is 'No', then one or both persons may need counselling and/or further sex education, possibly with assertiveness training if the relationship appears exploitative. There are a number of sex education packages available for people with intellectual disabilities (Craft and Brown, 1994) and/or autism (Koller, 2000), including both slide and pictorial packages, many of which can be employed in either group or individual training (e.g. Kempton, 1988; Hingsburger, 1995; McCarthy and Thompson, 1998). Most of these would also be appropriate for other adults who may be more vulnerable than the general population.
It may be necessary to assess a person's understanding both before and after the training. Ideally this ought to be done in a standard way, using the same questions each time, to see what the person has gained from the training. There are a number of tests of sexual knowledge available for this kind of assessment, some of which include questions about social interaction issues (as well as sexual facts), and which have been designed specifically for a particular population (e.g. Fischer et al., 1973; Wish et al., 1979; Bender et al., 1983; McCabe, 1999). If the two people appear not to be able to understand or retain information from the sex education sessions, even though pictorial, signed and other forms of communication have been used, then consent may not be possible. Many carers, however, would still consider that the couple had a right to be sexual (Craft and Brown, 1994) if it appeared that they had a genuine affection for each other and there was no clear evidence of exploitation. In such circumstances it may be possible for carers to assist the couple in obtaining protection from any risk of pregnancy; however, limiting the risk of sexually transmitted diseases is much more problematic (practical guidance on this issue is given by McCarthy and Thompson, 1994). In the absence of apparent affection between the two people, some carers would argue that a sexual relationship should be discouraged if informed consent is not possible. This may mean that some people have less likelihood of establishing a sexual relationship (for example, people with autism are unlikely to display affectionate behaviour in a normal way). Meanwhile, Carson (1994) in the UK has argued that what is needed is a change in the law, creating a new offence of serious exploitation of a person with a 'mental disorder', as defined in Section 1 of the Mental Health Act 1983. This would provide some legal recourse for vulnerable persons (and might serve some protective role, through acting as a deterrent to potential abusers) but enable those with severe learning disabilities to engage in non-exploitative sexual relationships.
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