Cognitive Disability and Sexuality

People with cognitive disability can express their sexuality in satisfying ways. The attitudes and support of other people are essential in helping people of all abilities to have healthy personal and sexual relationships.

Sexual abuse or exploitation is always wrong and should be treated as a very serious matter.

Sexuality is a key part of human nature. People with cognitive disability (including intellectual disability, Autism Spectrum Disorder and Acquired Brain Injury) experience the same range of sexual thoughts, attitudes, feelings, desires, fantasies and activities as anyone else. To understand and enjoy sexuality, everyone needs adequate information and support from a young age.

Sexuality has psychological, biological and social aspects, and is influenced 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 significantly, and often changes over time. Healthy self-esteem and respect for self and others are important factors in developing positive sexuality.

Most people with cognitive disability can have rewarding personal relationships. However, some may need additional support to develop relationships, explore and express their sexuality, and access sexual health information and services.

In Victoria, all people aged 16 years and over, including those with disability, are entitled to privacy and choice, within the law, regarding their sexuality and sexual activity.

A child’s sexuality education comes from a range of sources, including their parents, teachers and friends. People with cognitive disability also require sexuality education that:

• teaches them that people with disability can have fulfilling sex lives
• covers age-appropriate sexual issues that may be associated with their particular disability
• explains social rules, such as telling the difference between private and public behaviours
• is delivered in a way that a person with cognitive disability can understand.

It is important for parents to have access to the information they need to support their child in dealing with particular challenges they may face.

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

There are many different types of disability. Some cognitive disabilities may be caused by a genetic (inherited) condition, difficulties that occurred during childbirth, an illness or an accident.

Sometimes, a person with cognitive disability may be less able to enjoy sex, which may be due to:

• the disability itself or its physical or emotional consequences
• a physical injury
• prescribed medication
• ageing
• psychological illnesses, including depression.

A person with cognitive disability who is experiencing problems with sexual sensation or function can talk to a doctor, sex therapist or support group for suggestions on how to overcome these challenges.

Sometimes, a person with cognitive disability may exhibit inappropriate sexual behaviour, such as public masturbation, or soliciting sex from minors or in public. This is more likely to occur when the person lacks more appropriate sexual outlets, or has not been provided with appropriate education about the complicated social etiquette and legal issues around sexual behaviour and relationships.

Sometimes, police may charge the person with a sexual offence. The person may also be restricted in unreasonable ways, such as a man being prescribed medication by a doctor to suppress androgens (male hormones). However, appropriate education and behavioural training are, in most cases, better ways of addressing issues such as these.

Unfortunately, some people with cognitive disability may have received the message that any sexual expression is unacceptable. This may need to be addressed before the person can learn more acceptable behaviours.

All women and men, including those with cognitive disability, have the right to make their own informed choices about which method of contraception they use. To make these choices, people need adequate, accurate and accessible information about reproduction, the purpose of contraception and their contraceptive options.

Some people with cognitive disability may find it difficult to access contraception and other sexual health products and services, especially if they cannot be open with their family or carers about their sexual activity.

The contraceptive choices available to a person with cognitive disability may be limited for a number of reasons, including:

• Certain medication can interfere with oral contraception, the contraceptive vaginal ring, the contraceptive implant or emergency contraception (EC, also known as ‘the morning after pill’).
• The contraceptive injection (depot medroxyprogesterone acetate, known as Depo-Provera) and contraceptive implant (Implanon NXT) may cause unpredictable bleeding that can be difficult for some women with a cognitive disability to manage.
• There can be difficulties with insertion of the contraceptive implant or an intrauterine device, which can be overcome by having the procedure while sedated or under anaesthetic.
• Some women have difficulty remembering to take tablets such as the contraceptive pill regularly. This can be overcome by supervised use.
• Some people with cognitive disability may have difficulty negotiating the use of condoms.

It is important to remember that EC can prevent pregnancy after having unprotected sex, for example, if a pill is missed, a condom breaks, or a woman is sexually assaulted. Action should be taken as soon as possible, ideally within 24 hours of having sex but can be taken up to 5 days after sex.

It is legal in Victoria for any woman to seek to terminate a pregnancy. All people are entitled to access support and counselling about issues relating to abortion.

Most Australian states and territories, including Victoria, have laws designed to protect people with ‘impaired capacity’ from sexual exploitation. However, people sometimes misunderstand these laws to mean that it is illegal for a person with cognitive disability to have sex. This may make families and support organisations wary of supporting sexual relationships.

While the question of understanding and 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 others in the community.

The law states that a court or tribunal authority is needed before a person can be lawfully sterilised, unless the sterilisation is associated with surgery to treat a medical condition or disease, and that sterilisation is the last resort. An adult with cognitive disability can choose to be sterilised if they have the capacity to make the decision. If they lack the capacity to make this decision, it must be referred to a tribunal authority.

For more information about forced sterilisation and consent to medical procedures, contact the Office of the Public Advocate or Victorian Civil Administrative Tribunal.

Some people with cognitive disability who are pregnant or are considering having a child may want to use genetic services such as diagnosis, screening and testing, counselling, education, clinical research and information on the management of individuals and families with a history of particular health conditions. Access to services such as these will help people to make the best decisions for themselves and their children.

Some people with cognitive disability, such as men and women with Down syndrome, have lower fertility, but many others are as fertile as the general community. Many people with cognitive disability want to have children. However, their own family or carers may oppose this, making it difficult for the couple to plan for pregnancy and parenting, and to access the necessary services for themselves and their baby.

Many people with cognitive disability can be loving partners and parents, maintain strong relationships and care for a child. Parents with cognitive disability usually need additional support, as do many other groups in our community, such as parents who are very young or who are experiencing mental health issues.

People with cognitive disability should have the same choice regarding preventive health measures for sexually transmissible infections (STIs) and other conditions as people without disability, including:

• Condoms should be used to prevent the transmission of STIs. The person with disability may need to be provided with appropriate and accurate education about STIs and condoms, including the opportunity to practise how to put condoms on correctly.
• Nearly all women with cognitive disability can learn menstrual hygiene, just like any other woman. A woman’s menstrual cycle should not be suppressed just because of her cognitive disability.
• Women who are or have been sexually active should have a regular Pap test to help prevent cervical cancer. If a woman with cognitive disability has difficulty with Pap tests, she can contact PapScreen Victoria.
• People with disability should participate in immunisation programs, including the HPV (human papillomavirus) vaccine and immunisation program, which helps prevent cervical cancer.
• Women need to understand the importance of being aware of how their breasts normally look and feel and should be encouraged to see a doctor if they notice anything unusual.
• Women aged over 50 years need to consider having a mammogram for the early detection of breast cancer. A doctor can provide more information about this.
• Men need to understand the importance of seeing a doctor if they notice a lump or anything unusual with their testicles.

When providing health services to people with cognitive disability, doctors and other healthcare professionals need to take into account the particular disability and circumstances of their client. For example, some women with cognitive disability can find a gynaecological examination or procedure such as a Pap test, overwhelming. It is important for people with cognitive disability to provide informed consent before these procedures are carried out, unless in the case of medical emergency.

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

Reasons for this include:

• inadequate sexuality education on where and when it is acceptable to be touched by other people
• inability to resist, protest against or stop abusive behaviour from happening
• not knowing that a person has the right to decide what happens to their body, especially if they are used to other people constantly attending to their physical needs
• being raised in situations where they are used to being told what to do and therefore going along with requests or demands made by an abuser
• agreeing to engage in sexual activity to fulfil unsatisfied cravings for attention, affection or rewards
• consenting to initial sexual activity, but not to sexual activity that follows, which amounts to abuse.

Just as in the wider population, assaults against people with disability are more likely to be perpetrated by somebody they know, such as a family member, carer, work colleague or someone they live with. Research also shows that sexual assaults on people with disability are less likely to be reported.

Reasons for this include:

• Some people with disability find it difficult to communicate with others.
• A person may tell someone of the assault, but that person may not understand them.
• A person may have limited knowledge or ability to report what happened to them.
• Some people wrongly think the effect of sexual assault on a person with disability is not as serious as an assault on someone without disability.
• A person may not be believed.

Any sexual assault is a very serious matter and should be referred to police and sexual assault support agencies.

The carers of a person with cognitive disability can help by modelling assertive behaviour, making referrals if the person needs further training or support, and explaining the basics of protective behaviours, including:

• 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 safely without being harmed or exploited.
• There are many people who can be trusted, but also some who cannot be trusted.
• Some types of behaviour are appropriate for yourself and others, but some types are not.
• You can communicate assertively and say ‘no’ to unwanted behaviour.
• It is okay to change your mind about sexual behaviour or activity, even if you have already agreed to something.
• There are people who can help if you are being abused or exploited in any way.

Cognitive Disability Referral & Secondary Consultations (Professional Advice)

When individualised counselling for sexualised behaviours of concern is deemed not appropriate, Sexual Health Victoria offers a single session to parents, carers and/or professionals to discuss the situation and offer advice and resources to manage behaviours.

Group Education for Individuals with a Cognitive Disability

Sexual Health Victoria conducts tailor-made, age and developmentally appropriate group education to increase the knowledge and awareness of RSH and relationship issues for people living with cognitive impairment.

• Your local doctor (GP)
• Better Health Channel
• Yooralla
• Centre Against Sexual Assault (CASA)
• National Sexual Assault, Domestic and Family Violence Counselling Service
• Office of the Public Advocate Advice Service
• Victorian Civil Administrative Tribunal