Cognitive disability and sexuality

Sexuality is a key part of human nature#

People with cognitive disability experience the same range of sexual thoughts, attitudes, feelings, desires, fantasies and activities as anyone else. To understand and enjoy their sexuality, everyone needs adequate information and support from a young age.

Sexuality has psychological, biological and social aspects, and is shaped by individual values and attitudes. A person’s sexuality develops throughout childhood and adolescence and is a key part of their identity. The way each person understands and interprets their sexuality varies widely and often changes over time. A sense of self-worth and respect for oneself and others are important in developing a positive sexuality.

Most people with cognitive disability can have rewarding personal relationships. Some may need extra support to develop relationships, explore and express their sexuality, and access services. Like everyone else, adults with cognitive disability are entitled to privacy and choice, within the law, regarding their sexuality and sexual activity.

Sexuality education#

A person’s sexuality education comes from many sources, including parents and carers, school, friends and society. People with cognitive disability also need sexuality education that is delivered in a way they can understand. Parents and carers benefit from having access to the information they need to support a child with the particular challenges they may face.

Some adults with cognitive disability received adequate sexuality education at school, while others missed out. Those who received it may need follow-up information suited to their level of ability and literacy. For those who missed out, it is important to start at the beginning, no matter how old they are.

Good sexuality education for people with cognitive disability:

• teaches them that people with disability can have fulfilling sex lives
• covers age-appropriate issues that may be linked to their particular disability
• explains social rules, such as the difference between private and public behavior

Social opportunities and relationships#

Mixing with other people of all sexes, sexualities and genders — socially, at school or at work — helps build confidence and social skills. Some people with cognitive disability have fewer opportunities to form social and sexual relationships, for reasons that can include:

• a lack of privacy or being dependent on others for daily living
• a lack of confidence about their appearance and abilities
• less knowledge of how to negotiate relationships and express their sexuality
• a limited social circle and little social experience
• carers who wrongly see them as childlike, asexual, or as people whose sexuality must be feared and controlled

A person with cognitive disability may need additional support to explore sexuality and relationships. This is especially relevant for people with high support needs — for example, those who live with their parents or in supported housing, or who need help with communication or personal care. People in these situations may want sexual relationships but, wrongly, may not be permitted to have them, or may lack the privacy they need. Restrictions at home can sometimes lead people into unsafe or illegal situations.

Sexual sensation, function and body image#

Cognitive disability may be caused by a genetic condition, difficulties during childbirth, an illness or an accident. Sometimes a person with cognitive disability may be less able to enjoy sex. This can be due to the disability itself or its physical or emotional effects, a physical injury, prescribed medication, ageing, or psychological conditions such as depression. Anyone experiencing problems with sexual sensation or function can talk to a doctor, sex therapist or support group for advice.

Society often presents a narrow view of how people should look. A person with cognitive disability may feel less worthy of a healthy sexual relationship because they do not match this idealized image. Talking with a counselor, or with others who have overcome body image concerns, can help.

Appropriate sexual behavior#

Sometimes a person with cognitive disability may behave in a sexual way that is not appropriate to the situation. This is more likely when the person lacks more suitable sexual outlets, such as masturbation in private, or has not had comprehensive education about the social rules and legal issues around sexual behavior. Appropriate relationships, sexuality education, behavioral support and, where needed, referral for further training are usually far better ways of addressing these issues than punishment or restriction.

Some people with cognitive disability have been given the message that any sexual expression is unacceptable. This may need to be addressed before the person can learn more acceptable behaviors. Sexuality should not be suppressed simply because of a cognitive disability.

Contraception#

All individuals, including those with disability, have the right to make their own informed choices about contraception. To do this, people need accurate, accessible information about reproduction, the purpose of contraception and the options available. Some people with cognitive disability find it difficult to access contraception and other sexual health services, especially if they cannot be open with family or carers about their sexual activity.

The choices available may be limited for a number of reasons:

• current medication may not be suitable for use with some hormonal methods
• the contraceptive injection (depot medroxyprogesterone acetate) and the contraceptive implant may cause unpredictable bleeding that some people find hard to manage
• inserting a contraceptive implant or an intrauterine device can be difficult, though it can sometimes be done while sedated or under anesthetic
• some people have difficulty remembering to take a daily pill — this can sometimes be managed with supervised use
• some people may find it hard to negotiate the use of condoms

Emergency contraception, sometimes called the morning-after pill, can prevent pregnancy after unprotected sex — for example if a pill is missed, a condom breaks, or a person is sexually assaulted. In many places it is available from pharmacists without a prescription. It should be taken as soon as possible, ideally within 24 hours of sex. It can be taken up to 120 hours (5 days) afterwards, but the longer the wait, the less likely it is to work.

Reproductive rights#

Everyone is entitled to access support and counseling about reproductive choices, including termination of pregnancy. Many places have laws designed to protect people with impaired capacity from sexual exploitation. These laws are sometimes wrongly understood to mean that it is illegal for a person with cognitive disability to have sex, which can make families and support organizations wary of supporting sexual relationships. While the question of giving informed consent to sexual activity may sometimes be more complex for people with cognitive disability, they still have the same right to consensual sexual relationships as anyone else.

Sterilization without a person’s consent generally requires legal authorization, such as from a court or tribunal, unless it is part of surgery to treat a medical condition and is a last resort. An adult with cognitive disability who has the capacity to make the decision can choose to be sterilized; if they lack that capacity, the decision must be referred to the appropriate legal authority. For more information about consent to medical procedures, contact a relevant legal or advocacy service.

Genetic services, pregnancy and parenthood#

Some people with cognitive disability who are pregnant or considering having a child may want to use genetic services, which can offer diagnosis, screening and testing, counseling, education and information on managing conditions that run in families. These services help people make the best decisions for themselves and their children.

Some conditions are associated with lower fertility, but many people with cognitive disability are as fertile as the general population, and many want to have children. Their family or carers may oppose this, making it harder for a couple to plan for pregnancy and parenting and to access the services they need.

Many people with cognitive disability can be loving partners and parents, maintain strong relationships and care for a child. Like many other groups — such as very young parents — they usually need some additional support.

Sexual health#

People with cognitive disability should have the same access to preventive health measures as anyone else:

• Condoms should be used to prevent sexually transmissible infections (STIs). The person may need accurate education about STIs and condoms, including the chance to practice putting condoms on correctly.
• Nearly everyone with a uterus and ovaries can learn menstrual hygiene and about their menstrual cycle.
• People with a cervix who are or have been sexually active should have regular cervical screening to help prevent cervical cancer. If someone finds screening difficult, a cervical screening service can advise on options.
• Immunization programs, including the HPV (human papillomavirus) vaccine, help prevent virus strains linked to cervical cancer. A doctor can give more information.
• People with breasts should be breast aware, and those over 50 should consider regular mammograms for early detection of breast cancer.
• People with testicles should understand the importance of seeing a doctor if they notice a lump or anything unusual.

When providing care to people with cognitive disability, doctors and other health professionals should take account of the individual’s particular disability and circumstances. For example, some people find a gynecological examination or a cervical screen overwhelming. Informed consent should be obtained before such procedures, except in a medical emergency. A prior consultation, where the clinician explains the procedure and shows any instruments, can help ease the person’s concerns.

Safety from abuse and exploitation#

All people, including those with cognitive disability, have the right to enjoy relationships and sexuality without being abused or exploited. Unfortunately, people with disability experience all forms of abuse at much higher rates than people without disability. Reasons for this include:

• not knowing they have the right to decide what happens to their body, especially when used to others attending to their physical needs
• being raised in situations where they are used to being told what to do, and so going along with an abuser’s requests or demands
• inadequate education about where and when it is acceptable to be touched
• difficulty resisting, protesting against or stopping abusive behavior
• consenting to initial sexual activity but not to what follows, which amounts to abuse

As in the wider population, assaults against people with cognitive disability are most often committed by someone they know, such as a family member, carer, colleague or housemate. These assaults are also less likely to be reported, because some people find it hard to communicate what happened, may have limited knowledge of how to report it, or may not be believed. Some people wrongly assume the effect of an assault is less serious for a person with disability. Any sexual assault is a very serious matter and should be referred to police and sexual assault support services.

Carers can help by modeling assertive behavior, making referrals for further training or support, and teaching the basics of protective behaviors:

• Every person has the right to say what happens to their body.
• Everyone has the right to feel safe. There are laws that protect a person’s right to live without being harmed or exploited.
• Many people can be trusted, but some cannot.
• Some types of behavior are appropriate for yourself and others, and some are not.
• You can communicate assertively and say “no” to unwanted behavior.
• It is okay to change your mind about sexual activity even after agreeing — consent is reversible.
• There are people who can help if you are being abused or exploited in any way.

Key points#

• Sexuality is a key part of human nature, and people with cognitive disability experience the same range of feelings and desires as anyone else.
• A person’s sexuality develops throughout childhood and adolescence and is a key part of their identity.
• A sense of self-worth and respect for self and others are important in developing a positive sexuality.
• For those who missed out on sexuality education, it is important to start at the beginning, no matter how old they are.
• Sexuality should not be suppressed simply because of a person’s cognitive disability.

Where to get help#