DOCUMENT 12 FOI 25/26-1343

NDIA Research Paper: Sexual Activity Supports

Purpose of paper: This research paper has been developed to provide guidance on;

• Definitions and terminology used for various sexual activity supports
• Evidence around expected experience, training and qualifications of service providers
• Domestic and International policy and/or guidelines relevant to delivering sexual activity supports to people with a disability
• Existing disability sexual activity supports
• Information relating frequency of sexual activity in the community and benefits (physical or mental) of sex or sexuality
• Sexuality and disability
• Viewpoint of advocacy groups

Date 10/07/2020

Requester Karyn redacted: s22(1)(a)(ii)-irrelevant material (Director, Technical Advisory Branch)

Researchers Jane redacted: s22(1)(a)(ii)-irrelevant material Research Team Leader Technical Advisory Branch

Craig redacted: s22(1)(a)(ii)-irrelevant material Tactical Research Advisor Technical Advisory Branch - Administrative Appeals Tribunal

Lizzie redacted: s22(1)(a)(ii)-irrelevant material Senior Research Officer, NDIA Research Service Research and Evaluation Branch

Ivana redacted: s22(1)(a)(ii)-irrelevant material Senior Research Officer, Evidence Service Research and Evaluation Branch

Cleared by Karyn redacted: s22(1)(a)(ii)-irrelevant material

Contents

World Health Organisation definitions of sexual health …………………………………………………………………. 5 Sexual health …………………………………………………………………………………………………………………………… 5 Sex …………………………………………………………………………………………………………………………………………. 5 Sexuality ………………………………………………………………………………………………………………………………. 5 Sexual rights ……………………………………………………………………………………………………………………………. 5 Disability Specific Terminology, Definitions and Services ……………………………………………………….. 6 Training and Qualifications ………………………………………………………………………………………………………….. 8 Sexual Assistant……………………………………………………………………………………………………………………….. 8 Training and Certification Overview ……………………………………………………………………………………. 8 Voluntary non-profit relationship ………………………………………………………………………………………………. 8 Sex Surrogate/Surrogate Partner ……………………………………………………………………………………. 8 Training and Certification Overview ……………………………………………………………………………………. 9 Australia ……………………………………………………………………………………………………………………………… 9 Sex Worker ……………………………………………………………………………………………………………………………… 9 Training and Certification Overview ……………………………………………………………………………………. 9 Outcomes/Objectives …………………………………………………………………………………………………………. 10 Evaluation …………………………………………………………………………………………………………………………. 10 Sexual Advisors ……………………………………………………………………………………………………………………… 10 Sexual Facilitators ………………………………………………………………………………………………………………….. 10 Sex Therapist and Sex Educator ……………………………………………………………………………………. 11 Training and Certification Overview ……………………………………………………………………………………. 11 Policy and Guidelines on Sexual Activity Supports – Domestic and International ……………………. 14 Northcott Sexuality and Relationship Policy ……………………………………………………………………… 14 Level of support …………………………………………………………………………………………………………………. 15 Expectations ………………………………………………………………………………………………………………………. 15 NSW Government, Family and Community Services Guidelines on Sexuality and Relationships ………. 15 Education ………………………………………………………………………………………………………………… 16 Respecting diversity ………………………………………………………………………………………………….. 16 Providing opportunity ………………………………………………………………………………………………….. 16 Sex workers (based on previous NSW legislation) ……………………………………………………….. 17 Sex Aids …………………………………………………………………………………………………………………………….. 17 Specialised sexuality education for people with a disability …………………………………………………….. 17 Hard copy and online disability related resources ……………………………………………………….. 19 International models of sexual activity supports ……………………………………………………………………… 19 Overview of disability policy – The Netherlands ……………………………………………………………………… 20 Framework for Disability Support ……………………………………………………………………………………. 20

Sexuality Support Context …………………………………………………………………………………………………… 20 Overview of disability policy – Sweden …………………………………………………………………………………….. 21 Framework for Disability Support …………………………………………………………………………………………. 21 Sexuality Support Context …………………………………………………………………………………………………… 22 Assistive Technology, Allied Health and Medical Professional Sexual Activity Supports …………….. 22 Assistive Technology ………………………………………………………………………………………………………………. 22 Continence ………………………………………………………………………………………………………………………… 24 Nursing …………………………………………………………………………………………………………………………………. 25 Physiotherapy ……………………………………………………………………………………………………………………….. 25 Occupational Therapy …………………………………………………………………………………………………………….. 26 Remediation: ……………………………………………………………………………………………………………………… 26 Modification: ……………………………………………………………………………………………………………………… 26 Talk Therapy ………………………………………………………………………………………………………………… 27 Sex Therapy ………………………………………………………………………………………………………………… 27 Sexuality Education/Counselling ……………………………………………………………………………………. 27 Psychology ………………………………………………………………………………………………………………… 27 Mainstream Medical Support Options ……………………………………………………………………………………. 27 General Practitioner (GP) ………………………………………………………………………………………………….. 27 Medication support ……………………………………………………………………………………………………………….. 28 Erectile Dysfunction ………………………………………………………………………………………………….. 28 Inappropriate sexual behaviours ……………………………………………………………………………………. 29 Sexual Activity of Australians ………………………………………………………………………………………………….. 29 First times ……………………………………………………………………………………………………………………………… 29 Sexual Practices ………………………………………………………………………………………………………………… 29 Masturbation ………………………………………………………………………………………………………………… 29 At the most recent sexual encounter ……………………………………………………………………………………. 30 In the past year ………………………………………………………………………………………………………………… 30 Homosexual experience and recent homosexual encounters ………………………………………………….. 30 Sexual relationships and satisfaction ……………………………………………………………………………………. 30 Sex and satisfaction ……………………………………………………………………………………………………………. 30 Attitudes ………………………………………………………………………………………………………………… 30 Sexual Coercion ………………………………………………………………………………………………………………… 30 Paying for sex ………………………………………………………………………………………………………………………… 30 Benefits of sex ………………………………………………………………………………………………………………………….. 30 Sexuality and disability ……………………………………………………………………………………………………………… 31 Sex Workers who provide services to clients with disability in NSW………………………………………… 32 Reasons why some sex workers would not provide their service to PWD …………………………… 33 Number of PWD client’s serviced by the sex workers ……………………………………………………….. 33

Gender ………………………………………………………………………………………………………………………………. 33 Identifying the range of disabilities / impairments that clients presented with ……………………………… 33 Frequency of client visits ………………………………………………………………………………………………………… 34 Location of work place ……………………………………………………………………………………………………………. 34 Sexual services provided to clients with disability ………………………………………………………………. 35 Challenges and barriers in sex workers communicating with PWD …………………………………………. 36 Prevalence of sexual abuse and psychological impact among individuals with an intellectual disability ……………………………………………………………………………………………………………………………………………….. 37 Risk factors for sexual abuse ………………………………………………………………………………………………….. 37 Psychological effects of sexual abuse ……………………………………………………………………… 37 Position of Advocacy Groups in Australia ……………………………………………………………………………………… 1 Appendix ……………………………………………………………………………………………………………………………………. 1 Appendix A – Search Strategy ………………………………………………………………………………………………….. 1 Appendix B – List of disabilities and impairments of PWD who have sought a sex worker in NSW …….. 1 Appendix C – Third party difficutlies identifed by sex workers in NSW …………………………………………… 1 Appendix D – Position statements from advocacy groups ……………………………………………………….. 2 Appendix E – Informed consent, culture and linguist diversity ………………………………………………………. 6 References …………………………………………………………………………………………………………………………………. 8

World Health Organisation definitions of sexual health

The World Health Organisation (WHO) has developed working definitions of key terms relating to sexual health [1]. These terms are used extensively throughout this document and are provided for reference.

Sexual health

According to the current working definition, sexual health is:

“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” [2]

Sex

Sex refers to the biological characteristics that define humans as female or male. While these sets of biological characteristics are not mutually exclusive, as there are individuals who possess both, they tend to differentiate humans as males and females. In general use in many languages, the term sex is often used to mean “sexual activity”, but for technical purposes in the context of sexuality and sexual health discussions, the above definition is preferred.

Sexuality

Sexual health cannot be defined, understood or made operational without a broad consideration of sexuality, which underlies important behaviours and outcomes related to sexual health. The working definition of sexuality is:

“…a central aspect of being human throughout life encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.” [2]

Sexual rights

There is a growing consensus that sexual health cannot be achieved and maintained without respect for, and protection of, certain human rights. The working definition of sexual rights given below is a contribution to the continuing dialogue on human rights related to sexual health.

“The fulfilment of sexual health is tied to the extent to which human rights are respected, protected and fulfilled.” Sexual rights embrace certain human rights that are already recognized in international and regional human rights documents and other consensus documents and in national laws. Rights critical to the realization of sexual health include:

• the rights to equality and non-discrimination
• the right to be free from torture or to cruel, inhumane or degrading treatment or punishment
• the right to privacy
• the rights to the highest attainable standard of health (including sexual health) and social security

• the right to marry and to found a family and enter into marriage with the free and full consent of the intending spouses, and to equality in and at the dissolution of marriage
• the right to decide the number and spacing of one’s children
• the rights to information, as well as education
• the rights to freedom of opinion and expression, and
• the right to an effective remedy for violations of fundamental rights.

Disability Specific Terminology, Definitions and Services

The search strategy utilised to identify evidence can be found in Appendix A.

Table 1 provides a list of professionals who provide disability specific sexual activity supports. This includes their roles, definition, services provided and the country of origin.

Table 2 provides a comparison of services provided by each identified provider.

Table 3 is a comprehensive list of organisations that provide sexual activity support to PWD.

Table 1

(Sexualbegleiter)

8. Sex therapist/ Psychosexual therapist

(not disability specific profession)

Sex therapists provide a specialized form of professional counselling that focuses on addressing the sexual concerns, sexual functioning and sexual expression of human beings.

The Society of Australian Sexologists uses the term Psychosexual Therapist for accredited members who must meet stringent educational standard.

Therapeutic counselling (talk therapy) may be provided within specialist areas in the field including sexual development over the lifespan (child, adolescent and ageing sexuality), sexual relationships, sexual behaviour and activity, sexual identity and orientation, and also with groups (cultures, people with disability, adolescents, sex in older age).

The International Society for Sexual Medicine and Society of Australian Sexologists clearly state that sex therapy does not involve physical contact or sexual activity among clients and therapists.

Definitions/services provided by Lisa Torney (National Chairperson – Society of Australian Sexologists)

Table 2

Table 3.

• Teach staff about disability and sexual abuse. • Teach staff about disability and sexuality – Responsibilities and liabilities. • Facilitate processes on how to create a policy for sexuality. • Give courses for couples with disabilities – Learning how to act in a relationship. • Teach and advise people with a disability. | Denmark | https://www.seksualvejlederforeningen.dk/in-english/ |

• Provide guidance in sexuality – for singles and couples.

Includes Introductory meeting (in which PWD discusses possibilities, limitations and sexual wishes) and, if desired, a one hour Visit (tailored to person’s needs and wants). If help is needed getting in and out of bed, getting out and getting dressed, the SAR asks the PWD to arrange this. | Netherlands | https://www.stichtingsar.nl/English/index.html | | 17 | Love Giver | An Italian committee created to promote sexual assistance in Italy | Italy | www.lovegiver.it | | 18 | The Federation of Youth with Mobility Impairments | “A Secret Known by Everyone” was a project to challenge negative attitudes to sexual facilitation | Sweden | N/A |

Training and Qualifications

Sexual Assistant

Training and Certification Overview

The training program for sexual assistants was originally developed in Switzerland. Although training programs vary from one country to another, they are generally similar to the program delivered in Switzerland [7, 21, 22].

To be accepted into a training program candidates must undergo a rigorous selection process to ensure the purity of their intentions (professionalism) and their ability to practice this profession. Candidates must be:

• At least 30 years old
• Have a stable relationship status
• Give evidence of the necessary human qualities (e.g., active listening skills, good knowledge of their own personal limitations, excellent sense of touch, being comfortable with their own sexuality, balanced personality)

Candidates must then submit an application including:

• A letter of motivation
• Résumé
• Proof of employment
• Criminal record check
• Proof of payment of the registration fees

They are then contacted by telephone, after which they have an interview with a sex educator and an individual with experiential knowledge related to disabilities. Finally, the selection process ends with the administration of a questionnaire covering the candidates’ knowledge of sexuality in people with disabilities, the people close to them, their education and profession, their knowledge of disabilities in general, their health, and their expectations regarding the training.

The training program takes 1-year (300 hours) and covers the following topics:

• Specific knowledge of different disabilities
• Legal knowledge
• Sexuality and sexology related to disabilities
• Knowledge of and initiation into bodily approaches (body language and eroticism)
• Institutional contexts and the role of accompanying persons, and ethics

At the end of the program, the new sexual assistants are sometimes supervised by an experienced worker, while at other times peer support groups are set up for supervision. Since the profession of sexual assistant is a difficult one, this kind of follow-up makes it possible to ensure that a new sexual assistant is maintaining his/ her mental health.

Voluntary non-profit relationship

We are unable to locate any qualification/training criteria.

Sex Surrogate/Surrogate Partner

The International Professional Surrogates Association (IPSA) [23] provides training and accreditation to become a professional surrogate partner. The profession follows a code of ethics, however, it is

not a regulated profession. In the USA, sex surrogacy falls within a legal grey area. There is no law against providing the service, but there are no laws that stipulate that it is ok. The use of sex surrogates is relatively uncommon. The IPSA website lists only 22 certified surrogate partners globally.

Training and Certification Overview

• No specific academic degrees or courses are required as prerequisite to IPSA’s Professional Surrogate Partner training program.
• Emotional maturity developed via a combination of life experiences and academic exposure is essential (unclear how this is assessed).
• IPSA offers a 100-hour didactic course which is considered the ‘first phase’ at a cost of $2,000 (USD) and covers:
  • Intimacy and Human Sexuality
  • Sex Therapy (Clinical Sexology) (in this section reference is made to “working with the differently-abled”)
  • Surrogate Partner Therapy
  • Professional Issues
• Following successful completion of ‘phase one’ applicants are recommended for Internship. This includes;
  • Working with real clients under the supervision of experienced therapists (normally the clients primary therapist) and a surrogate partner mentor
  • The internship continues until the IPSA training staff are satisfied the intern is ready to continue as a professional surrogate partner. This is based on periodic progress evaluations made by mentors (*unclear what needs to be achieved, appears to be subjective assessment)
• Certification and Full-membership to IPSA requires:
  • Letter of interest and intent
  • Description of training (length of training, certificates, IPSA trainees must complete a list of training dates and mentors)
  • Personal evolution essay
  • Two letters of recommendation
• To maintain certification, members must engage in continuing education, “honour the letter and spirit” of the IPSA Code of Ethics, and undergo periodic peer review.
• Membership in IPSA must be maintained on an annual basis to retain IPSA certification status. If membership in IPSA lapses, certification will also lapse.

Australia

Currently within Australia, there is no governing or educational criteria for working as a sex surrogate, and sex surrogacy is a term that can be used interchangeably for sex workers who have experience or training in disability, sex therapy or other relevant field [24].
https://www.goodvibesclinic.com.au/sex-surrogacy

Sex Worker

Training and Certification Overview

There are no minimum training or qualification requirements for sex workers in Australia.

The not-for-profit organisation, Touching Base provides Professional Disability Awareness Training [25] for sex workers. Lack of specific awareness or training for sex workers providing services to clients with a disability was a major reason for the development of the course.

To be eligible sex workers must have been providing sex services for a minimum of 3 months.

Goals of the course include:

• Progress the concept of professional training being made available to sex workers and sex industry staff who wish to gain greater awareness and skills in working with clients who have a range of special needs
• Assist sex workers and sex industry staff to challenge myths and prejudices they or their workplace may have regarding clients with disability
• Inform participants of the diverse sexuality of people with disability
• Educate participants on how discrimination may create barriers for people with disability to access the sexual lifestyles of their choice – including accessing sex workers and sex services premises
• Inform on better practice for providing accessible services to people with disability
• Inform on how to arrange services through a third party (personal care attendant, family member or friend of client, etc)

Outcomes/Objectives

• Participants will gain knowledge and skills on how to increase the accessibility of their services/premises to people with disability
• Participants will gain skills in working with clients with various disabilities – including mobility and communication impairments
• Increased awareness and skills on a range of Occupational, Health and Safety issues
• Increased awareness of the sexual rights of people with disability
• Increased recognition of the rights of sex workers to have access to courses for professional development
• Sex workers and people with disability will be empowered through their vital collaboration in the development and presentation of this training programme
• Increase of the numbers of sex workers available for referrals through the Touching Base database of sex workers who have completed the Professional Disability Awareness Training (PDAT)
• Increased networking and support for sex workers who see clients with disability

Evaluation

On completion of the training programme sex workers will receive a Certificate of Attendance from Touching Base Inc. Certificates are available to participants in their working and/or personal names, allowing sex workers to safeguard their anonymity.

Sexual Advisors

We are unable to locate any qualification/training criteria.

Sexual Facilitators

We were unable to locate any qualification/training criteria for sexual facilitators. The literature suggests that ‘personal assistants’ or ‘nurses’ could act as a sexual facilitators [12, 13, 19 20]. In

Sweden, ‘personal assistants’ (similar to disability support worker in Australia) often work alone in the service user’s home; there are no formal requirements for education or training; they rarely receive formal supervision or meet with colleagues to discuss their work during work hours; the work is highly individualized; there is an absence of regulatory body/professional [12].

The role of a sexual facilitator does not exist in Australia [26]. The book Sexual Citizenship and Disability: Understanding Sexual Support in Policy, Practice and Theory [26] provides interviews with a representative from Touching Base to question the use of the term/service in their Sexuality and Relationships Policy. Their response to this was;

“We’ve often spoken about this new role – a facilitated sexual assistant – you know, probably perfectly suited for a lot of sex workers who are wanting to retire. And quite frankly, if I was providing services to a client and they needed positioning, if I know that person was an ex-sex worker, then, you know, you just don’t care, you feel more [at ease]. … The recognition of the different roles that sex workers can play is really understated.” [Chapter 6, Pg 26.]

Furthermore, a representative from People with a Disability Australia was also interviewed and asked about the possibility of creating the role of a facilitated sexual assistant.

“A particular type of disability support worker, rather than a sex worker, who would be involved in that whole kind of continuum of activities that didn’t include having sex with the person. … but all of the stuff about, you know, accessing pornography, positioning, putting on condoms, etcetera … It was this sort of concept about whether the disability support worker industry would find that palatable to have this kind of new role, but it was really just describing a role that some support workers were very comfortable with and were doing, and just kind of acknowledging that, giving it a framework, so that they were supported, and that there were particular sort of skills or competencies, and safeguards, and accountabilities.” [Chapter 6, pg. 27]

Sex Therapist and Sex Educator

Training and Certification Overview

In Australia, sex therapy is not regulated yet by the government. This means untrained and inexperienced people can call themselves sex therapists.

The Society of Australian Sexologists Ltd (SAS) is Australia’s leading peak body for the regulation and accreditation of psychosexual therapy and sexuality education. SAS has therefore developed a system of accreditation [27] to ensure the public is protected with trained, qualified and experienced therapists and educators providing professional psychosexual therapy and sexuality education in Australia. Table 4 provides the criteria for becoming a clinical and provisional psychosexual therapist.

Table 4.

Minimum of 1000 client-contact hours, with a minimum of 80 supervision hours; consisting of a minimum of 50 hours individual supervision, with a maximum of 20 hours group supervision and a maximum of 10 hours of peer supervision.

All hours except the first 200 hours MUST be sex therapy oriented.

Proof of registration with approved professional association

AHPRA (those that are not appropriate for registration as a psychosexual therapist include dentistry, podiatry, chiropractic, optometry, osteopathy and pharmacy)

Psychotherapy and Counselling Federation of Australia

Australian Association of Social Workers

Australian Association of Social Workers

International Applicants: Applicants from countries other than Australia seeking accreditation as a Psychosexual Therapist will need to meet this criterion as appropriate to their national registration standards. Proof of registration with the respective professional body will need to be supplied

Proof of professional indemnity

Proof of National police check (and/or working with children’s check where appropriate)

Sexological Education

Minimum of 216 hours is required covering the following content areas:

• Overview of the discipline of sexology (including historical and contemporary approaches to psychosexual therapy and sexuality research)
• Socio-Cultural Aspects of Sex, Sexuality, and Gender (including sexual and gender diversity/identity, spirituality/religion, ethnicity/race, ability, sexual subcultures)
• Sexual Function and Dysfunction (including diagnosis, testing/assessment, intervention)
• Sexual and reproductive anatomy and physiology (including models of sexual response cycles)
• Developmental sexuality across the lifespan
• Knowledge of sexually transmitted infections and safer sex practices
• Knowledge of atypical sexual behaviours (including rape and sexual assault, paraphilias, and fetishes)
• Familiarity of current research in psychosexual therapeutic and sexuality-related (broad) research

Attitudes and Values Training Experience

A minimum of 12 hours is required in:

A Society of Australian Sexologists Ltd. approved Attitudes and Values training experience (e.g. SAR); consisting of a process oriented exploration of the applicant’s own feelings, attitudes, values, and beliefs regarding human sexuality and sexual behaviour.

Such training is not to be construed as personal psychotherapy or as an academic experience in which the primary emphasis is on cognitive information.

The applicant will submit a one page comprehensive statement of his/her professional philosophy and goals of psychosexual therapy including how the SAR affected that philosophy. | | Provisional Psychotherapist | Supervision and Client Hours

A minimum of 200 client-contact hours with a minimum of 50 supervision hours; consisting of a minimum of 30 hours individual supervision with maximum 20 hours group supervision. The supervisor needs to be approved by Society of Australian Sexologists Ltd.

Proof of Registration with Approved Professional Association

Same as for Clinical Psychotherapist

Proof of Professional Indemnity Insurance

Same as for Clinical Psychotherapist

Sexological Education

Same as for Clinical Psychotherapist

Attitudes and Values Training Experience

Apart from sexological education, sexuality educators have specific training in education, teaching and assessment and provide education in a variety of areas including schools and community organisations. Table 5 provides the requirements for membership to the SAS.

Table 5.

A minimum of 216 training/teaching hours in sexuality or a cognisant area

A minimum of 24 hours mentorship by SAS clinical sexuality educator or SAS approved (by Accreditation Committee) mentor

These must be formal training hours and not adjunct to another role or therapy

Training and Education Provision

Minimum Certificate IV Training and Assessment (or equivalent, or RPL), or

Diploma/Advanced Diploma/Bachelor/Graduate Certificate/Graduate Diploma and Masters in a cognate area (Education, teaching, training)

Proof of Professional Indemnity Insurance

Proof of National Police Check (and/or Working with Children’s Check where appropriate)

Sexological Education

A minimum of 216 hours (or RPL equivalent) is required covering the following content areas:

• Overview of the discipline of sexology (including historical and contemporary approaches to psychosexual therapy and sexuality research)
• Socio-Cultural Aspects of Sex, Sexuality, and Gender (including sexual and gender diversity/identity, spirituality/religion, ethnicity/race, ability, sexual subcultures)
• Sexual Function and Dysfunction (including diagnosis, testing/assessment, intervention)
• Sexual and reproductive anatomy and physiology (including models of sexual response cycles)
• Developmental sexuality across the lifespan
• Knowledge of sexually transmitted infections and safer sex practices
• Knowledge of atypical sexual behaviours (including rape and sexual assault, paraphilias, and fetishes)
• Familiarity of current research in psychosexual therapeutic and sexuality-related (broad) research.

Attitudes and Values Training Experience

A minimum of 12 hours is required in:

A Society of Australian Sexologists Ltd. approved Attitudes and Values training experience (e.g. SAR); consisting of a process oriented exploration of the applicant’s own feelings, attitudes, values, and beliefs regarding human sexuality and sexual behaviour.

Such training is not to be construed as personal psychotherapy or as an academic experience in which the primary emphasis is on cognitive information.

A minimum of 72 training/teaching hours in sexuality or a cognisant area.

These must be formal training hours and not adjunct to another role or therapy

Training and Education Provision

Same as for Clinical Sexuality Educator

Proof of Professional Indemnity Insurance

Same as for Clinical Sexuality Educator

Sexological Education

Same as for Clinical Sexuality Educator

Attitudes and Values Training Experience

Same as for Clinical Sexuality Educator |

Policy and Guidelines on Sexual Activity Supports – Domestic and International

The media and various academic writings refer to sexual activity supports (i.e. sex workers) being provided as part of Government funding arrangements for PWD. Attempts were made to contact various domestic compensation schemes such as Department of Veterans Affairs, Transport Accident Commission, WorkSafe and iCare to identify any public facing documents which outline policy or guidelines as to what is covered, however, we were unsuccessful in obtaining any guidance. The following section will summarise the resources which describe different funding arrangements and potentially packages of support both overseas and domestically.

Northcott Sexuality and Relationship Policy

The NSW not-for-profit organisation Northcott has developed a policy [28] to assist PWD who require assistance with exploring sexuality and creating positive relationships.

This policy states that support will be provided if:

Under NSW Crimes Act 1900, the person/s is over 16 – unless assessed as not having the capacity to consent or if one of the person’s holds a supervisory role under care.

• In NSW to have capacity to consent the person needs to understand the nature of a sexual act and understand the difference between sexual touch and non-sexual touch.
• If there is uncertainty about the person’s capacity to consent to sexual activity a team approach including staff who know the person well, psychologists and a medical practitioner can be adopted. It is not the role of an individual staff member to decide if a person has capacity to consent.
• In NSW it is an offence for any person to sexuality engage another person under his or her special care who is aged 16 or 17 years. That supervisory role would include teachers, religious leaders, support staff etc.

• All people involved consent to the sexual act. This consent does not need to be communicated verbally
• All people involved have been offered sexual health information, for example, advice on contraception and safe sex
• A private and safe space for the sexual act has been agreed
• A safe space for staff has been agreed. Note: Staff should never be in the same room or waiting at the door, they should be in a completely separate room
• A minimum of two staff must work together for this process to ensure staff and person/’s safety. This does not apply for masturbation, one staff member can set up or give the person/s the sex aids or toys they require to independently masturbate
• Staff have had Manual Handling training for people that need Medium Level help

Level of support

• Low Level – Access to space only.
• Medium Level – The person/s need support to undress and be positioned in location e.g. on bed, set up correct aids and equipment. They can have sex or masturbate without physical help e.g. positioning during sex.
• High level – The person/s need physical help during sex or masturbation and putting on/insertion of contraception. At this level a sex worker or sex facilitator is required. Refer to Page 6 for more information on Guidelines for staff supporting people to a Sex Worker

Expectations

Support workers can help the person/s with a disability to:

• Get to/onto the place that they would like to have sex on (e.g. transfer the person/s on the bed referring to standard Manual Handling procedures)
• Undress
• Set up/give the person/s the sex aids, sex toys or contraception they need (e.g. hand the person/s a dam, put vibrating underwear on a person – must be off when staff are in the room)

Support workers cannot help the person/s with a disability to:

• Position them sexually (Transfers must refer to standard Manual Handling procedures)
• Help with penetration of any opening (e.g. put a penis inside an anus)
• Physically assist with masturbation (e.g. physically guide someone’s hand to masturbate)
• Be in the room during the sexual act
• Put on/insert contraception or sex toys that need to be inserted (e.g. put a condom on a person’s penis or insert a dildo into a vagina)

NSW Government, Family and Community Services Guidelines on Sexuality and Relationships

The following section is based on the NSW Government, Family and Community Services: Ageing, Disability and Home Care guidelines [29] on sexuality and relationships.

The Sexuality and Relationship Guidelines are written for any person who is supporting a PWD to explore and express their sexuality. The Guidelines are intended to provide direction about the roles and responsibilities of all supporters to enhance opportunities for people while exercising their duty of care to avoid harm. The guidelines focus particularly on the importance of providing access to information and education to people, and decreasing their vulnerability to abuse and exploitation.

Education

Workers who support PWD have a role to inform and educate people about their rights in relation to sexuality and relationships. A skilled workforce is needed to achieve this, and requires the full support of service providers to offer opportunities for the professional development of their workers in the area of sexuality and developing relationships. Negative myths and stereotypes about disability and sexuality contribute to contribute to the lack of sexuality education provided to people with disability.

In a service environment supporters must be able to:

• Assist people to understand sex and relationships, and help them to address their reproductive and sexual health needs
• Assist people to understand gender identify, sexual identity, sexual orientations, informed consent and self-advocacy skills
• Understand their responsibilities to the person and the limitations and boundaries related to their role
• Identify what sexual behaviours are legal and illegal, and to fulfil their obligations to support the person and respond appropriately.

For example, Family Planning NSW, Family Planning Victoria and other states run regular courses on sexuality for service providers, support workers and health professionals to build their skills in providing education and support to people with disability.

Respecting diversity

Supporters should be educated to inform people that they have a gender identity, that is, they identify as being a man, a woman or transgender. People can have different gender identities and should be supported to understand that it is possible and acceptable to identify as being the opposite gender to the sex they were born. Education also informs people that they have a sexual identity which is about how they identify and feel about themselves, in relation to their sexual orientation and who they are attracted to. People can have different sexual orientations and should be supported to understand that it is possible and acceptable to be attracted to the opposite sex, the same sex or both.

Providing opportunity

It is with the scope of a support worker to enable PWD to form friendships. Finding friends can be harder for people who need support to undertake activities of daily living or who have mobility and communication difficulties. They require thoughtful and sensitive support to overcome barriers to developing social networks.

Sexual and non-sexual relationships help in the development of social skills. Skill building could include:

• Increasing lifestyle opportunities to form relationships that are equal and balanced for both people
• Building capacity to recognise and interpret non-verbal cues and unwanted behaviour, and to give or withhold consent based on an understanding of the behaviour
• Providing opportunities to make choices and communicating these choices in a variety of life areas, including who they want to spend time with
• Learning conversation and communication styles, for example, taking turns, being part of a group conversation, maintaining comfortable physical distance between people and acceptable touching of other people.

In relation to sexual activity, support workers should consider;

• Promoting opportunities for sexual activity to happen
• Providing privacy to make phone calls or have space for sexual activity
• Be supported to access items such as condoms and lubrication

Sex workers (based on previous NSW legislation)

In a service environment, support workers have an active, legal and legitimate role to support people to access a sex worker. This may include contacting an organisation for information about sex workers, or driving the person to see the sex worker. Touching Base Inc is one organisation that people with disability can contact for access to information about sex services and providers.

It is recognised that “Engaging a sex worker is one of a range of available options to satisfy the sexual needs of a person, but should not be the first strategy for meeting a person’s need for intimacy. Nor is it an appropriate strategy to satisfy a person’s identified need for developing friendships” [p.19].

Sex Aids

Support workers cannot be expected to provide physical assistance with masturbation and sexual positioning. Visual aids and resources are available from recognised organisations, and supporters may assist people to contact suppliers for advice if they want more information. Further information on sex aids will be provided in the assistive technology section.

Specialised sexuality education for people with a disability

All young people need access to and can find benefit from sexual health information. However, programs delivered to people with a disability need to be modified in order to allow for information to be understood and learned in a way that is meaningful to them.

A child’s sexuality education comes from a range of sources, including their parents, teachers and friends. Sexual health education is delivered in Australian schools, however, no specific mention is made relating to sexual health and relationships education in the Disability Standards for Education 2005. In addition to general sexual health education, people with cognitive disability also require 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.

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.

One-on-one education programs can be accessed through external agencies or not-for-profit organisations. These are delivered by experienced disability and community educators.

For example, Family Planning Victoria delivers the following courses which are designed specifically for those with a cognitive disability:

• Safer Sex: Contraception and Sexually Transmitted Infections
• Consent and the law
• Anatomy and conception
• Sex and Sexual decision making

• Dating and respectful relationships

A report from Sexual Health and Family Planning Australia lists additional ‘Good Practice Programs’ which deliver sexual health and education programs (Table 6).

Table 6.

Hard copy and online disability related resources

Family Planning NSW has a wide range of online and hard copy resources developed for PWD and their supporters. All resources are available for loan from the Disability Resource Collection. The Disability Resource Collection covers puberty, health and hygiene, self-protection skills, social skills and relationships, sex and relationships, pregnancy and parenting and sex work produced by Family Planning NSW, as well as resources sourced from across the world. A membership fee applies for borrowing from this collection.

International models of sexual activity supports

A number of countries have been identified as having set up Government sanctioned funding arrangements to assist with paid sexual services for people with disability. Most notably are the Netherlands and Denmark. While reports about the Netherlands indicate that state funded sexual assistance has been provided for over 30 years [30], it has not been possible to find further information about either country or their subsidies for people with disability.

Media headlines appeared to have sensationalised the concept of PWD paying for sexual services. In reality, these countries may have implemented person-centred policy approaches, allowing people to choose to pay for whatever services they wanted.

The article by Ward (2014) [31] referring to the Netherlands reports that there is no direct “sex grant” per se, the benefits citizens with disabilities receive can be spent however they like. Some reports indicate that they can use these benefits to access sex services 12 times a year, but information on the specifics is elusive.

News articles by the Telegraph and Life Site News claim that in Denmark social services pay for sex workers up to twice a month for disabled men, and that in the town of Aarhus residents can visit a brothel or have a sex worker visit their home and be reimbursed up to £300.

The peer reviewed article by Mannino (2017) [4] provides an brief description of how the type and frequency of services are provided. “The way in which this service is given is determined case by case, after a series of meetings, which involve these subjects: the person with disability, the sex worker and a psychologist. The team of specialists will establish with the client the number of

sessions of the sexual assistance, which must not exceed twelve (per year). Physical contact between the client and the sexual assistant can take place only after the fifth session contact. Regardless of the type of performance required, the encounters between the client and the sexual assistant will be 1 h each in duration.”

Overview of disability policy – The Netherlands

This overview has been taken from the book Sexual Citizenship and Disability Understanding Sexual Support in Policy, Practice and Theory (Chapter 5) [26].

The Netherlands has developed comprehensive and state-funded work around sexuality, and there is the existence of some disability-specific ‘sex care’ organisations.

The discourse around the commercial prostitution industry is paradoxical. It is a legalised system but still stigmatised. Its legalised status may be one reason for the relatively easy development of sex care organisations, but at the same time the stigma around traditional sex work leads the sex care actors to wanting to distance themselves from it, while sex workers feel denigrated.

Framework for Disability Support

The Long-Term Care Act (2014) along with the Social Support Act (2015), and Health Insurance Act (2006) (Zorgverzekeringswet, Zvw) make up the framework for care and support provision for adults with ‘permanent disabilities and chronic conditions’

The Social Support Act aims to promote independence and participation through personalisation and ‘less complex support’ and is provide d by municipalities. The Netherlands still has the highest expenditure for long-term care in the EU and the OECD, one reason being the provision of institutional living and support arrangements rather than independent/community ones. This has also affected disabled people’s general participation in society [32]. Furthermore, the complexity of the newly developed support scheme has led to blind spots for people who have ‘cross domain needs’ due to input from different levels of authority [33].

Developments in the care system “need to be understood against the background of a new liberal and responsibilisation approach to health care under the new model of ‘Positive Health’. This research based concept has been adopted by the Government along with a new framework for health policy which includes collaboration in a network of governmental and corporate organisations. Positive Health conceptualises health as ‘the ability to adapt and to self-manage, in the face of social, physical and emotional challenges’ [34] (p. 1).

The Positive Health approach has been criticised by rehabilitation sexologist Egbert Kruijver (2018) [35] for not including aspects of neither disability nor sexual health. Kruijver contrasts the model with the WHO’s newly updated approach to sexual health promotion which incorporates aspects relating to policy, culture, social norms and inequalities. He concludes that for marginalised populations it may not be possible to ‘take control if you do not have equal opportunities’ [35] (p. 31).

Sexuality Support Context

As concerns sexuality in disability policy and legislation, the only place where such issues are mentioned is in a sub-section of the Social Support Act: ‘violence in the provision of a facility’.

It is stated that: sexual penetration of the body or fornication with a client, as well as physical and mental violence against a client, by a professional person or by another client with whom the client is staying … is illegal. (Article 1.1.1, point 18). In other words, although the protection from sexual violence and abuse is very important, there are no mentions of how to support disabled people in the positive sides of sexual life.

In June 2019 the Central Appeals Board ruled that municipalities are not obliged under the Social Support Act to pay for sexual services because sex is not seen as part of so-called ‘daily living activities’ such as eating, toileting, showering, sports and hobbies. Furthermore, the Board stated that the requested support is neither aimed at self-reliance and participation in society, nor are his ‘sexual limitations’ restrictions on self-reliance or participation as referred to in the Social Support Act. This judgement ended a lawsuit of a disabled man in the village Peel en Maas against his municipality [36].

Overview of disability policy – Sweden

This overview has been taken from the book Sexual Citizenship and Disability Understanding Sexual Support in Policy, Practice and Theory (Chapter 3) [26]. The author explored disabled people’s experiences of sexual facilitation within the context of personal assistance services in Sweden, as well as personal assistants’, managers’ and policy stakeholders’ perspectives. She suggests that disability and sexuality is largely a neglected issue:

• There are currently no laws, policies or guidelines that regulate sexual facilitation in Sweden.
• Neither has the broader disability movement advocated for sexual rights in general nor the right to sexual support in particular [26, p. 68].

Framework for Disability Support

In Sweden, the main disability policy is the Act concerning support and service for persons with certain functional impairments. (SFS 1993:387), (LSS). Among the ten available services, personal assistance is the most popular and most debated. The LSS law aims for personal assistance to make it possible for service users ‘to live as normal a life as possible’, ‘under good living conditions’ and on the same terms as non-disabled citizens.

To be eligible, applicants must prove that they have ‘profound and lasting disabilities’, which fall within specified categories and that cause them to require assistance in fulfilment of their ‘basic needs’ for a minimum of 20 hours per week. Basic needs mean help such as managing hygiene and meals, dressing and undressing, and communicating with others. Eligible service users can also apply for assistance with ‘personal needs’, for example household duties, leisure activities and assistance at work or with studies – in order to ‘counter isolation and passivity’.

Disability rights organisations worked closely together with governmental bodies to develop the personal assistance scheme. They championed the Independent Living (IL) ideology, visible in the law’s guiding principles: autonomy, integrity and self-determination for service users. The aim of the ideology was to empower service users to direct their own individualised home-based services.

The Swedish Penal Code (SFS 1962:700), which makes it illegal to purchase sexual services, further complicates issues around sexual facilitation. Since personal assistance services are funded by the state or the municipality, some fear that sexual facilitation could be interpreted as an indirect purchase of sexual services [10]. Even though such fear is unfounded, the Swedish anti prostitution/ sex work discourse has a strong influence in interpreting and handling sexual situations. The

background to this discourse lies in the process of criminalising the demand for prostitution, as advocated by the women’s movement and social workers. Their understanding is based on a view of prostitution constituting gender-based violence in a patriarchal society where women can never consent to selling sex [37].

Sexuality Support Context

Sexual facilitation is an unregulated issue in Swedish personal assistance services. It is therefore up for negotiation among service users and personal assistants, or for managers to provide instructions. No policies, regulations or other types of advisory materials exist concerning sexual facilitation issued by national authorities [26, p. 71].

Among all concerned parties there is insecurity in how sexual needs and sexual facilitation should be conceptualised and handled in practice [26, p. 92]. Sweden ratified the Convention on the Rights of Persons with Disabilities (CRPD) in 2008, however, implementation has not been a priority. Concerning sexuality and disability specifically, neither the Swedish Agency for Participation nor the Public Health Agency of Sweden have included disabled people’s sexuality or sexual health in recent reports.

In a policy submission to a governmental inquiry on increasing equality and efficacy in accessing aids, one of the main points argued is the right to sexuality and sexual health. While the inquiry suggests that the right to aids should include those needed for sexuality, the Agency argues that they should not be regarded as aids for ‘recreational purposes’ but for ‘daily life’.

When it comes to sexual facilitation, neither the LSS law nor the preparatory works mention anything related to sexuality. The National Board of Health and Welfare, an agency under the Ministry of Health and Social Affairs responsible for guidelines and regulations, does not mention sexuality in their regulation about knowledge requirements for those working in disability services (SOSFS 2014:2) [26, p 71].

Assistive Technology, Allied Health and Medical Professional Sexual Activity Supports

Assistive Technology

The majority of assistive technology (AT) described in this section have been taken from “Pleasure ABLE – Sexual Device Manual for Persons with Disabilities” [38] and “The MA+ Guide: A Guide to more Accessible Sexuality-Related Assistive Technology” [39] Many of these devices are commonly used by people without a disability. Below is a description of potential AT devices. Table 7 lists the suitability of devices based on physical/functional categories.

Wahl Massager: Total body massager that is ergonomically designed with a long handle.

Universal Cuff: Leather cuff with elastic strap can hold a variety of objects including sexual devices such as dildos and vibrators. Adjustable for hand size and has a plastic extender available for self/partner penetration.

Hitachi Magic Wand: an AC-powered wand vibrator. It was originally manufactured for relieving tension and relaxing sore muscles, but is most famous for its use as a sex toy.

Fleshlight: Realistic penetration device. Made with Real Feel Superskin, also known as cyberskin (non-allergenic, no latex, no silicone). Easy to grip with one or two hands

Butt seriously: silicone anal dildo + vibrator can be used by men or women

MHP tongue vibrator: attaches to your tongue or any other body part with one of the elastic silicone bands provided

Finger vibrator: Finger vibrators allow users to turn their fingers (or toes…or anything else they may fit onto) into a vibrator, without the need to continually hold onto it.

Fukuoko 5 Finger Massage glove: Waterproof stretch fabric glove, with small vibrating units at the tip of each finger

The Strapper: Leather harness for dildo, worn around pelvis to use with a partner

Aslan Men’s harness: Leather harness for dildo, designed specifically for men. Pouch safely and comfortably allows room for genitals.

Thigh rider: Leather harness for dildo, worn around thigh to use with a partner.

Furniture harness: Nylon harnesses to hold dildos; can be attached to anything from chairs and beds to a washer or dryer.

Intimate rider: Designed by a person with C6-7 quadriplegia to facilitate positions for sexual activities and to aid with thrusting and sexual movement. A small seat glides on precision bearings to produce a natural, fluid motion. Movement occurs with minimal upper body motion

Body bouncer: Steel frame, soft rubber seat. Slight flexing of thighs will cause bouncing movement.

Liberator shapes: Soft-core foam positioning pillows that can be used in a variety of ways during sexual activities. Wedge, ramp, and rocking pillows are available.

Love bumpers: Soft-core foam positioning pillows that can be used in a variety of ways during sexual activities. Iceberg Love Bumpers are pillows with openings to accommodate Vibrators.

Thigh sling: This sling fits around the neck (padded neck brace) and has adjustable leg straps (padded loops) that hold thighs in an elevated and open position for easy contact.

Vibrating underwear: Commonly, a bullet vibrator is placed within the underwear and a remote is used to turn on and change settings.

Hands free kit: Designed to enable “hands free” vibrator stimulation to assist persons with spinal cord injuries. Includes metal grab bar (and hardware to attach to wall), the ‘Lean On Me link’, and a two-speed Homedics plug-in massager.

Suction based toys: Suction based toys are available in two types and allow hands free use for solo or couple play. Suction based vibrators are designed for external use. Suction based dildos are available in both vibrating and non-vibrating styles and designed for penetration by both males and female. Some suction toys are one piece, with the suction cup built in to the bottom of the toy.

Others are two-piece, with a detachable double sided suction cup allowing use with a range of toys. Suction based toys may be fastened to the floor, wall or smooth furniture

Table 7

Continence

Purpose designed bed protection is available that stays and feels warm and dry, even when handling large amounts of fluid.

Liberator Fascinator Throe (Liberator): A moisture proof blanket which is microfiber or plush on one side and satin on the other. The blanket is machine washable and has a moisture barrier contained within.

Connie Mate Bedpad: Bed pads consisting of a soft polyester top layer, highly absorbent core and a breathable PUL waterproof backing. They are available with or without tuck-ins and are designed to keep the skin feeling dry. Able to absorb 2L of fluid over an 8hr period.

Nursing

A recent systematic review [40] investigating the factors that influence nurses’ provision of sexual health care of patients has found that nurses have a key role in teaching patients about sexual health care. However, it is evident that sexual healthcare information is not widely addressed by nurses. This is due to a lack of knowledge, attitudes and beliefs, and perceived barriers such as scope of practice, responsibility, lack of time and privacy). It has been concluded that professional societies should publish guidelines and white papers on expectations for nursing programmes as well as practicing nurses and clinicians.

The role that nurses can play in acknowledging and facilitating the sexual needs of PWD within a holistic framework are listed below in Table 8 [19].

Table 8.

Physiotherapy

Physiotherapists are trained to provide treatment to restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities of patients suffering from injuries or disease.

Despite the holistic intention of physiotherapy, sexual health has historically received insufficient attention by physiotherapists. There are several areas where physiotherapists can assist in improving sexual health [41, 42]:

• Increasing physical activity to improve general health and physical capacity
  • Promoting greater involvement in active leisure time pursuits, including physical exercise, decreases feelings of pain and fatigue, and may indirectly improve a person’s sexual health

• Increase the choice of possible positions for sexual intercourse by increasing joint mobility and muscle strength, and patients’ knowledge of their own physical abilities
• Pelvic floor rehabilitation for patients with gynaecological and urological problems, erectile dysfunction and premature ejaculation
  • Utilise a range of treatment tools, including manual therapy, therapeutic exercise, biofeedback, electrical stimulation and heat/cold modalities. Present literature on the efficacy of such techniques on the treatment of sexual dysfunction in both men and women reveals that physiotherapists are integral members of the healthcare team involved in the improvement of sexual health.

Occupational Therapy

The American Occupational Therapy Practice Framework: Domain and Process, 2nd Edition [43] lists sexual activity as an activity of daily living (ADL). As such, sexual activity falls under the scope of practice of occupational therapists and should be included as part of a routine evaluation of clients, and address this area in occupational therapy interventions.

Occupational therapy is seen as a safe place for addressing sexuality, allowing the client to express fears and concerns, and offering assistance with problem solving. Empathy, sensitivity, and openness are necessary aspects of the therapeutic relationship, the foundation of occupational therapy, and are used in addressing sexuality. Partners are often included in occupational therapy interventions to achieve goals of mutual concern, such as sexual expression and satisfaction.

The following are types of interventions offered by occupational therapy practitioners [44, 45].

Remediation:

This is the first approach to take if possible. It consists of restoring skills, such as range of motion to make more positions available, increasing endurance for longer sessions of sexual activity, or increasing strength to be able to support a partner, effective communication, and social engagement, as part of meeting sexual needs. For example, a person with multiple sclerosis is likely going to need energy conservation strategies. A person with cerebral palsy may need alternate positioning suggestions. A person with a spinal cord injury may need to use a vibrator for masturbation when previously they were able to do so by hand.

Treatment methods can also be cognitive and relate to health promotion – like providing education on contraceptive use for teenagers with intellectual disability, sexual abuse prevention training for children who have trouble communicating, stress relieving activities or working on relationship/social skills for adults with mental illness.

A behavioural approach is also applicable. Many individuals with autism or other social disorders often exhibit challenging behaviours during puberty such as public masturbation, unwanted touching of others, or inappropriate conversations. Social Stories can be a great resource for teaching appropriate behaviour, and paired with healthy outlets to explore this part of their lives, these teens may stop maladaptive behaviours entirely.

Modification:

This approach consists of changing the environment or routine to allow for sexual activity. Examples include resting prior to sexual activity for those with poor endurance; placing pillows under stiff or painful joints or preceding sexual activity with a warm bath; learning new positions to compensate for amputated limbs, using positions that incorporate weight bearing to compensate for tremors or compensating for decreased sensation with the use of sex toys.

Intensive therapy is outside the scope of usual OT practice, and includes referral to or intervention by specialized clinicians including but not limited to the areas of: sexual medicine, gynecology, urology, psychology, etc.

Talk Therapy

Sex Therapy

Definition, qualification and services provided by a sex therapist have been provided above. In relation to PWD, a sex therapist may:

• Discuss things like attitudes towards sex
• Provide sexual education or practical advice, or
• Recommend activities that can help people achieve their sexual goals that are otherwise not possible due to their disability.

Sexuality Education/Counselling

Sexuality educators apart from sexological education have specific training in education, teaching and assessment and provide education in a variety of areas including schools and community organisations.

For example, Family Planning NSW and Family Planning Victoria delivers best practice education and training in reproductive and sexual health for PWD.

Not-for-profit organisations such as Sexuality Education Counselling and Consultancy Agency (SECCA) also provide specialist counselling services in the area of human relationships and sexuality to people who have a disability, their family and significant carers. Counsellors have extensive experience in both sexuality and disability issues. Counselling is conducted on a one-to-one basis, allowing for tailor-made sessions specifically to suit the needs, age and ability of the individual.

Psychology

Various clinical psychologists specialise in sexual psychology and have advanced training in this area which sets them apart from sex therapists. They can help to learn what drives sexual problems in addition to helping:

• Understand your diagnosis
• Manage depression and anxiety
• Manage anger
• Work on your emotional wellbeing
• Understand and communicate your feelings
• Express your needs and wants
• Recognise emotions in others
• Increase your confidence
• Learn how to manage stress
• Help you learn and remember information
• Develop social skills
• Build relationships
• Improve your quality of life

Mainstream Medical Support Options

General Practitioner (GP)

Attending to sexual health is a core part of general practice in Australia and is relevant to patients across the lifecycle [46]. General practice management of sexual health covers physical, emotional, mental and social wellbeing in relation to sexuality, and not merely the absence of disease, dysfunction or infirmity.

Sexual and reproductive health presentations are common in Australian general practice. According to the Bettering the Evaluation and Care of Health (BEACH) activity data, out of every 100 patient encounters in general practice, 4.7 were for issues regarding the female genital system, 3.0 were for pregnancy and family planning issues, 2.8 were urological, and 1.2 for the male genital system [46]. This does not include encounters for relationship counselling or other sexual health concerns.

The Royal Australian College of General Practitioners (RACGP) require GP’s to be “competent and comfortable discussing sex with a wide range of people including those of different ages, gender (male, female, transgender or intersex), sexual preference, culturally and linguistically diverse backgrounds, and people with disabilities [46].”

People with physical disabilities have higher rates of female sexual dysfunction, erectile dysfunction (ED), and low desire [47-49]. In some cases these may be due solely to medical conditions; in others, psychological distress may contribute as well. GP’s can assist with maximizing sexual physiology and reducing the medical issues that often interfere with sexual interest and activities e.g. medications, pain, bladder and bowel continence, autonomic dysreflexia, and spasm. Other physicians (urologist, gynecologist, neurologist, etc) may also have valuable expertise. These physicians can refer clients to other health care professionals as needed [47-49].

Medication support

Medications commonly used to treat secondary conditions like depression, heart disease, and chronic pain among PWD have known sexual side effects [50]. If sexual dysfunction is associated with specific medications, it may be practical for the consulting GP or specialist to consider alternative medications [50].

Other medications that can affect sexual function are beta blockers, thiazides and anti-androgens. Alternatives to beta blockers and thiazides are plenty, including calcium channel blockers and angiotensin converting enzyme inhibitors, which do not carry the same risk to sexual function as the aforementioned medications [51].

If a patient has significant pain associated with their disability, they should be encouraged to use analgesics approximately 30 minutes before sexual activity. These can include nonsteroidal anti-inflammatory medications, acetaminophen, or opioids. If there are limitations from positioning, a muscle relaxant, such as baclofen, cyclobenzaprine, and methocarmamol, can assist with lower extremity spasticity [51].

Erectile Dysfunction

WorkSafe [53] and TAC [54] both have policy for the provision of medication to treat erectile dysfunction.

TAC: Erectile dysfunction medication in oral or injectable form, up to a maximum of 8 intermittent use tablets or injections per month, or low dosage daily use tablets.

WorkSafe: The quantity of erectile dysfunction medication that the Agent can pay for is restricted to the reasonable costs of:

• a maximum of eight intermittent use tablets or injections per month, or
• low dosage daily use tablets (where the medication is indicated for low dose daily use) in circumstances where clinically justified and where written clinical rationale is provided by the appropriate prescribing medical practitioner, as outlined in this policy

Who can prescribe erectile dysfunction medication?

The diagnosis and initial prescription of erectile dysfunction medication must be made:

• by a medical specialist such as a Urologist, Endocrinologist, Rehabilitation Physician or Neurologist where the cause of the erectile dysfunction is physical, e.g. urological, neurological, hormonal or vascular damage
• by a Psychiatrist where the cause of the erectile dysfunction is psychogenic, or
• by the treating medical practitioner or a medical specialist where the cause of the erectile dysfunction is considered to be a direct side-effect of medication used to treat another work-related injury or illness. In these cases, payment for medications for erectile dysfunction will be limited to the period of time the causative medication is required.

Inappropriate sexual behaviours

When educational and behavioural interventions have failed to reduce inappropriate sexual behaviours, pharmacological intervention can be used [52]. A review of the literature on pharmacological treatments for such behaviors especially in children and youth with ASD showed the interventions to be effective, however, only single case studies were included meaning the results have limited generalisability. The medications prescribed included;

• Leuprolide (injectable)
• Estrogen (oral)
• Mirtazapine (oral)
• Propranolol (oral)

The use of Androgen depleting drugs (cyproterone acetate, medroxyprogesterone acetate and luteinising hormone releasing hormone agonists) and psychotropic drugs (serotonin specific reuptake inhibitors and antipsychotics) are two major categories of medications used in the treatment of inappropriate sexual behaviours for people who have committed serious sexual offences [52]. Most trials indicated beneficial effects including reduction in sexually deviant fantasies and behaviours, however, few included people with intellectual disability [52].

Sexual Activity of Australians

The Australian Study of Health and Relationships is conducted once a decade and gives a snapshot of the sexual health and wellbeing of the Australian population. Between October 2012 and November 2013 20,094 men and women aged 16-69 were interviewed. Key findings from the published literature [55-60] are summarised below.

First times

• Approximately 50% of people had intercourse for the first time between the ages of 15 and 17
• Men (39%) were more likely than women (19%) to have first intercourse with a casual partner
• 88% of men and 86% of women have experienced oral sex

Sexual Practices

Masturbation

• 72% of men and 42% of women had masturbated in the past year

• Men who masturbated did so more often (6 times in past 4 weeks) than women (3 times in past 4 weeks)

At the most recent sexual encounter

• 73% had sex with a live in partner, 17% with a regular partner who they didn’t live with and 8% with a casual partner

In the past year

• 63% of men and 20% of women looked at pornography (print, film or online)
• 15% of men and 21% of women had used a sex toy such as a vibrator or dildo

Homosexual experience and recent homosexual encounters

• Women were significantly more likely than men to report lifetime same-sex experience (13.5% vs 6.5%, P < 0.001).
• Among people who reported same-sex experience, the median number of same-sex partners was four for men and one for women and the mean was 63.1 for men and 3.7 for women

Sexual relationships and satisfaction

Sex and satisfaction

• On average, people in regular relationships had sex about 1.4 time a week in the past 4 weeks
• Most people said they would ideally like to have sex about 2-4 times a week

Attitudes

• Most Australians have positive attitudes toward premarital sex, abortion and homosexual behaviour
• Over the last decade there has been a shift towards less tolerance of sex outside a committed relationship

Sexual Coercion

• 4% of men and 22% of women had ever been forced or frightened into doing something sexual that they didn’t want to do: 2% of men and 12% of women reported that this happened before they turned 17

Paying for sex

• Among men, 16.7% had ever paid for sex; only 0.3% of women had done this (P < 0.001)
  • In the year before being interviewed, 2.3% of men had paid for sex (rates are similar to surveys performed in Britain)
  • No relationship between states where sex work is legal
• Very few people reported that they had ever been paid to have sex with someone: 1.3% of men and 1.0% of women (P = 0.27).

Benefits of sex

“Sexuality is an integral part of human life. It carries the awesome potential to create new life. It can foster intimacy and bonding as well as shared pleasure in our relationships. It fulfils a number of personal and social needs, and we value the sexual part of our being for the pleasures and benefits it affords us…. Sexual health is inextricably bound to both physical and mental health” [61, p. 1].

Historically, there has been the presumption that the only health-relevant aspect of sexuality concerns its potential for risk. Study into the morbidity and mortality of HIV and STD’s is extensive. In comparison, we know very little about the health benefits of regular, satisfying sexual activity (beyond simple replacement of the species). More recently, researchers have shifted the focus and are attempting to determine the potential health benefits of regular, positive sexual functioning [62].

Large-scale observational research emphatically suggests that individuals who engage in regular sexual activity have better health [63]. Early studies found greater longevity among men with more frequent sexual activity. Among women, greater enjoyment of sexual activity predicted longevity [64, 65].

More recently, two large studies with long follow-up periods have yielded even more compelling evidence for the health-promoting qualities of sexual behaviour. Men who reported a greater frequency of orgasm at baseline had a lower all-cause mortality over the 10-year follow-up [66]. Chen, Tsend, Wu, Lee, and Chen [67] reported findings from a 14-year prospective study of Taiwanese individuals over the age of 65. Being sexually active at baseline was negatively associated with all-cause mortality over the next 14 years for both men and women.

The following positive outcomes have also been attributed to sexual activity:

• Protective effect on cardiovascular health, especially in women [68].
  • Lower risk of cardiac events later in life
  • Women who expressed sexual satisfaction had lower blood pressure
• Increased effectiveness of the immune system
  • People who had frequent sex (1-2 times per week) had more immunoglobin A (IgA) in their system than others [69].
• Reducing prostate cancer
  • Those who ejaculated more than 21 times per month had a lower risk of prostate cancer than men who only ejaculated 4–7 times per month [70].
• Relieving stress and improving sleep
  • Expressions of intimacy, whether sexual or not, helped to bring cortisol levels in both males and female back within normal range [71].
  • Sexual activity has hormonal benefits for sleep
• Sexual health is a highly important aspect of quality of life and wellbeing [71].

Sexuality and disability

The lived experience of PWD in relation to their sexual lives has not been well documented in Australia. Johnson et al. [73] are of the opinion that the failure to take account of how this group of people see their lives has led to the continuation of stereotypical views of people with intellectual disabilities and their sexuality. Sexual activity statistics of people with a disability are rare. However, research among those with a disability has indicated that being able to express one’s sexuality is an important dimension in the construction of a good life [11, 74, 75]. A survey in England reported that most people with a mild/moderate intellectual disability have had sexual intercourse by the age of 19/20 (slightly higher than the Australian average) and were more likely to have unsafe sex [76].

An investigation into the frequency and satisfaction of sexual activity of PWD has shown that’

• Women with physical disabilities have significantly more positive feelings about their sexuality and significantly more frequent mutual sexual experiences than their male counterparts
• Frequency of oral sex and nude cuddling were significant predictors of sexual satisfaction in men
• Frequency of deep kissing predicted sexual satisfaction in women

Unfortunately, these results don’t assist with making comparison to the general community/able bodied population.

A review of the social and empirical evidence on disability and (a)sexuality, conducted in 2001 [77], highlighted that people with disabilities tend to face disproportionate levels of difficulty in leading fulfilling sexual lives compared to people without disabilities, despite possessing the same sexual needs and desires. The review identified that people with disabilities tend to encounter several barriers when expressing their sexuality and accessing sexual and reproductive healthcare, located at the individual (e.g. poor body image), societal (e.g. negative attitudes), and structural (e.g. inaccessible environments) levels.

A more recent review [78] of the sexuality issues and voices of adults with intellectual disabilities identified 5 themes regarding the experiences, perceptions and needs of individuals regarding the expression of their sexuality. These include;

1. Autonomy v’s risk of harm a. The balance and tensions between protection from harm within a relationship, autonomy, and the right to make independent decisions regarding relationships
2. Knowledge and sexuality a. The need for education regarding sexuality and relationships
3. Relationships and intimacy a. A wish and desire for relationships and for some, this may be sexual; for others, there was a desire for intimacy and friendship
4. Self-determination and taking control a. Some men and women with intellectual disabilities want to have, and be able to talk about, loving relationships; they seek passion, romance and intimacy. They want influence over forming and maintaining intimate personal relationships
5. Encouragement and supports a. Central to the expression of their sexuality, both men and women with intellectual disabilities want to know that they are being listened to and their wishes and needs are regarded and respected

Sex Workers who provide services to clients with disability in NSW

In 2016, Rachel Wotton carried out a substantial study of sex workers who provide services to clients with disability in New South Wales, Australia [79]. Her research is an exploratory study with the aim to identify the nature and extent of such activities to produce empirical data to support anecdotal evidence and recent emerging research in this field.

The research method was an exploratory online survey of sex workers. Ages ranged from 21 to 61 years, with 65 respondents being 55 female, 9 male and one transgender sex worker. They were asked to share their experiences of providing services to clients with disability. This included:

• The frequency, type and range of services provided,
• Location of service delivery and how clients made contact.
• Third party assistance and the identification of any barriers or challenges faced by sex workers.

Reasons why some sex workers would not provide their service to PWD

Seven survey participants suggested they did not provide services to PWD for the reasons such as ‘never been asked/approached by a client with a disability (n = 5), ‘never had any training’ (n = 1), ‘brothel/parlour/premises I work in is not disability accessible’ (n = 1) or ‘would feel uncomfortable seeing clients with a disability’ (n = 1).

Number of PWD client’s serviced by the sex workers

Out of the 57 survey participants who gave absolute numbers, the total number of clients seen ranged between 1,301 and 1,535. This is because a few respondents answered with approximations such as 160-250 or 20-30. Other responses including no idea - it’s only a few a year, approx. 2 - 3 per month, don’t know and many.

As this has never been asked to a cohort of sex workers before there is no way to currently determine if these figures are representative but it challenges the notion that clients with disability never seek the services of sex workers in NSW or that it is a rare occurrence.

Gender

From all respondents:

• 100% identified as having male clients with disability
• Seven (11.29%) had provided services to female clients, and
• Three (4.84%) had prior bookings with clients with disability who are transgender.

Identifying the range of disabilities / impairments that clients presented with

Participants were asked to identify the specific name or type of disability/s their clients had presented with. Answers were derived from 50 respondents with a wide range of disabilities mentioned spanning both physical and cognitive disabilities, as well as acquired and congenital disabilities as detailed in the list below in order of frequency.

In assessing the results:

• The researcher noted that over a third of the nominated disabilities had a degree of cognitive impairment (See Appendix B for a list of disabilities). The research suggesting that this is important to acknowledge and identify specifically due to the ongoing discourse around the ability for people living with an intellectual disability to give informed consent, which prompted Touching Base Inc. to produce educational booklets aimed at this cohort.
• It is anticipated that further research in this area could include an analysis of how and why the client with disability decided to see a sex worker and what support and educational tools were utilised to reach such a decision. These findings also substantiate that there is no specific ‘type’ of person with disability who has sought the services of a sex worker.

• Given that people with disability are constantly experiencing stigma and discriminatory attitudes, it appears that there is substantial acceptance of the diversity of clients to whom sex workers are more than willing to provide services. Consequently, this data can be used to support further discussions within the disability sector about peoples’ sexual expression, no matter what their disability may be.

Frequency of client visits

• Out of the 62 respondents 90% had seen their clients with disability more than once suggesting that their clients were satisfied with their services and chose to return regularly to the same sex worker.
• Participants were asked to identify how often your clients with a disability come back to visit. The responses are in the table below with the most common response was only when they can afford to see me.
• The paper suggests that the frequency of bookings is consistent with previous research done in Australia about clients in general [80]

Location of work place

The research also aimed to identify where the service delivery took place. Results are in the table below. The paper notes that:

• The results indicated that at least some clients with disability in NSW had an awareness of the range of options available to them.
• The increased accessibility of communication devices such as computers, tablets and mobile phones has allowed the internet to enrich the lives of some people with disability by becoming less reliant on others for information and options available to them.

Sexual services provided to clients with disability

Results regarding the types of sexual services provided to PWD are in the table below. The paper noted that:

• The range of services paid for by clients with disability reflect the broad range of desires and sexual activity enjoyed by the general population within Australia. These include both physical and emotional services as reflected by the additional comments pertaining to personal intimacy, cuddling and conversation and company.
• These also reflect current empirical literature where the sex workers interviewed clearly identified that, alongside sexual activities, services offered to clients included many therapeutic and emotional dimensions.

Challenges and barriers in sex workers communicating with PWD

Common barriers were ‘the client wanted me to lower my price’ (n = 18, 60%), ‘my workplace was not suitably accessible – so had to see them somewhere else (n = 14, 46.67%), ‘I couldn’t understand the client on the phone’ (n = 13, 43.33%), ‘they kept changing the time of the appointment’ (n = 11, 36.67%), ‘they rang everyday’ (n = 10, 33.33%), ‘other’ (n = 9, 30%), ‘I had to borrow equipment (ie ramp) to make workplace accessible (n = 2, 6.67%) and ‘management won’t make specific appointment times for my client to see me (n = 2, 6.67%).

The nine responses that were given in the ‘other’ option were:

• service had unrealistic low price expectations
• carer won’t take them
• Couldn’t talk to client directly on the phone
• my limited sign language, a parlour receptionist being cruel

• client asked to speak to me directly
• difficulty negotiating through the disability
• A time when both carer & client were free.
• very worried about access prior to 1st apt
• Carers’, parents’ values/judgements, other apts

See Appendix C for ‘Third party difficulties’

Prevalence of sexual abuse and psychological impact among individuals with an intellectual disability

A recent narrative review [81] investigated the prevalence of sexual abuse among individuals with an intellectual disability, well-known risk factors and the psychological effects of sexual abuse.

The findings confirmed that children and adults with an intellectual disability are at a higher risk of sexual abuse than nondisabled peers. Despite the heterogeneity of included studies, prevalence rates are between 14% and 32% for children with an intellectual disability [82] and 7% and 34% for adults with an intellectual disability [83, 84]. Table 9 displays the results of 8 studies which investigated prevalence of abuse.

A global review [85] of violence against women with disabilities found that women with disability, regardless of age, ethnicity, sexual orientation or class are subjected to double the rate of exploitation, violence and abuse, including domestic and family violence as experienced by women without disability. More than a quarter of rape cases reported by females are perpetrated against women with disability [86].

Risk factors for sexual abuse

Attempts have been made to highlight the risk factors that may increase the likelihood of sexual abuse occurring [81]. These include;

1. Being a woman or younger child
2. Having a disability that severely impacts activities of daily living
3. Increased language difficulties
4. Lack of sexual education. Briggs (2006) [87] reported that 20% of children in their study thought that sex between an adult and a child was “OK” or did not know. a. This suggests that those with an intellectual disability have difficulties distinguishing between appropriate and non-appropriate touching

Psychological effects of sexual abuse

Individuals with an intellectual disability who have experienced sexual abuse have a similar range of psychological disturbances as the general population, especially regarding depressive and traumatic symptoms. Included studies rely on informant accounts of the effect of trauma rather than firsthand accounts of the abuse. Table 10 summaries the results of studies included in the narrative review by Byrne [81]

Table 9.

Table 10.

Position of Advocacy Groups in Australia

It appears that there is overwhelming community support for the NDIS to support funding for sexual activity and the development of a comprehensive sexual activity supports policy.

No oppositional statements could be found from religious groups

One oppositional statement could be found from a feminist advocacy group

It appears that there are two prominent Australian disability groups leading and advocating for policy changes in sexual activity supports. Disabled People’s Organisations Australia is an alliance of four national peak organisations made up of, led and governed by people with disability. The alliance members are People with Disability Australia (PWDA), Women With Disabilities Australia (WWDA), National Ethnic Disability Alliance (NEDA) and First Peoples Disability Network (Australia) (FPDN). Touching Base Inc developed out of the need to assist people with disability and sex workers to connect with each other, focusing on access, discrimination, human rights and legal issues and attitudinal barriers

See Appendix D for the joint position statement from Disabled People’s Organisations Australia and Touching Base Inc, Family Planning NSW and Project Respect.

Appendix

Appendix A – Search Strategy

Search string “sex therapy” OR “sex assistan*” OR “sex work” OR “Sex* surrogacy” OR “sex* advisor*” OR “Sex* facilitation” OR “prostitut*” OR “surrogate partner”

AND

disabil* OR “people with disabil*” OR pwd OR “disabled people” OR disabilit* OR “people with disabilit*” OR PWD

Limiters Keywords found in Title and Abstract

Type of publication: peer reviewed article

Year of publication: 2005-present

Language: English

Databases: CINHAL, PsycInfo, Cochrane, Medline, Scopus and ProQuest: Consumer Health Database Health & Medical Collection; Healthcare Administration Database; Nursing & Allied Health Database; Psychology Database; Public Health Database; Social Science Database; Sociology Database (1985 - current); International Bibliography of the Social Sciences (IBSS) (1951 - current)

Number of references: Database search 115

Hand search 17

Included 23

Data extraction Data was extracted for Author/s, Year, Terminology/role, Services (role), Education, Organisation, Type of service (organisation), Country/ies and Webpage

Appendix B – List of disabilities and impairments of PWD who have sought a sex worker in NSW

Paraplegia/quadriplegia (28), Schizophrenia/Bipolar (27), Cerebral Palsy (25), Deafness / hearing impaired (17) Multiple Sclerosis (13) Blindness (10) Autism / Asperger’s (9) Amputees (9) Anxiety disorders (8) Parkinson’s (7) Acquired Brain Injury (6) Obsessive compulsive disorder (4) Depression (4) Use of colostomy bags (4) Spinal cord injuries (4) Down syndrome (4) Post Traumatic Stress Disorder (3) Stroke survivor (3) Morbid obesity (3) Degenerative disorders of the spine (including spina bifida, severe scoliosis) (3) Wheelchair bound (3) Severe burns (3) HIV (3) Intellectually disabled (2) Muscular Dystrophy (2) Mute (2) Physical disabilities / birth deformities (2) Tourette’s (2) Polio (2) Agoraphobia (1) Haemocromotosis (1) Psoriasis (1) Born with no limbs (1) Diabetes (1) Heart Disease (1) Frail aged (1) ADHD (1) Bone disorder (1) Prostate cancer survivor (1) Liver cancer (1) Elephantitis (1) Epilepsy (1) Degenerative disorder of the feet (1)

Answer Choices Responses

Appendix C – Third party difficutlies identifed by sex workers in NSW

Third party difficulties

•  The values and judgements imparted by carers and other third parties can negatively impede
  upon the enjoyment level of a booking and can create further barriers for the person with
     disability wanting subsequent bookings with a sex worker. This situation places sex workers in a
    precarious position between respecting their client’s wishes of privacy and their own right to be
   paid for the range of services they provide.

•  A large proportion of respondents spoke about how carers would not take the client to their
   appointment, with others reflective upon the lack of privacy given to the sex worker and their
     client including mentioning that the carers entered room/knocked/talked through door

•  The worst example of crossing professional and ethical boundaries was exemplified by one
   respondent’s statement that the carer [was] overprotective but wanted to touch me also. These
    kind of actions are extremely inappropriate and unethical and can be ameliorated by the
   development of supportive organisational policy and procedure guidelines to clearly
  communicate the rights and responsibilities of staff.

•  The creation of clear communication pathways between the disability and sex worker
   communities will also strengthen the confidence of sex workers to know that they can speak up
  and report such incidences without fear of reprisal, possibly where the client is denied future
    access to the sex worker or the organisation / carer refuses to coordinate other clients to see
     this sex worker.

Appendix D – Position statements from advocacy groups

Joint Position Statement: A call for a rights-based framework for sexuality in the NDIS (2019) A joint position statement in 2019 from Disabled People’s Organisations Australia and Touching Base Inc. [3] and endorsed by 45 community advocacy groups and organisations, emanates from concerns that: • The NDIS need to develop a clear and comprehensive sexuality policy for NDIS participants that encompasses and supports individual sexual needs and goals at all life and development stages.

An NDIS policy should encompass and support the types and range of professional support some people with disability may need to use to express their sexuality, and to have the opportunity for fulfilling sexual experiences in life.

The NDIS policy should include a broad range of goals an NDIS participant may seek to include in their NDIS plan. These goals might include:

•   Appropriate disability-inclusive sexuality and relationships education;
•   Information and resources to support individual learning needs;
•   Support for dating and social sexual engagements;
•   Access to adaptive sex toys;
•   Access to sex therapy or
•   Utilising sexual services from sex workers.

The benefits of sexual expression for people with disability The position statement suggests that the benefits of sexual expression for people with disability: Fulfil sexual needs and goals can positively contribute to the overall quality of life and self-esteem for individuals

Meets a range of other emotional, psychological, physical and social needs.

That some people with disability are in need of specific support to learn about their sexuality and sexual capacity after a significant injury, illness or sexual assault

Increase their experience, knowledge and acceptance about changes in their own bodies and abilities

Gain confidence and social skills to enjoy a positive sexuality.

Professional Services The position statement suggests that: The professional services of a wide range of educators, including allied health professionals and sex therapists, can play an integral role in supporting an individual’s capacity to develop life skills necessary to engage in healthy and consenting sexual and romantic relationships.

Sex workers who can and do provide mutually consenting physical contact. While accessing services of sex workers may not be for everyone, this option should not be denied nor dismissed on the basis of disability, or the moral beliefs of third parties.

Sex workers, especially within Australia, have already been recognised as being able to provide professional sexual services for a wide range of people with disability. Their skill-set can complement

sex education and sex therapy and allow an individual to practice, experience and enjoy a range of activities in a safe and supportive environment. (Statement quotes: Wotton, R. (2016), Sex workers who provide services to clients with disability in New South Wales, Australia. University of Sydney, Sydney, Australia, retrieved from: https://ses.library.usyd.edu.au/bitstream/2123/16875/1/Wotton_RW_thesis.pdf)

Giving people with disability the right to exercise choice and control over the supports they need to achieve the goals they’ve identified is the primary objective the community expects the NDIS to deliver on.

Community Support The position statement is supported by the following advocacy groups and organisations wanting “the NDIA to develop a comprehensive sexuality policy to allow for all levels of sexual education and support to be provided, according to our individual needs and goals”. ACON (NSW) ACT Council of Social Service Advocacy for Inclusion AIDS Action Council of the ACT Australian Centre for Disability Law Australian Federation of AIDS Organisations Australian Society of Sex Educators, Researchers and Therapists NSW Family Advocacy Family Planning NSW Migrant Women’s Lobby Group (SA) Multicultural Disability Advocacy Association of NSW National Council of Single Mothers and their Children Inc. National LGBTI Health Alliance Northcott Northern Territory AIDS and Hepatitis Council NSW Council of Intellectual Disability People with Disabilities WA Physical Disability Council of NSW Public Health Association of Australia Queensland Advocacy Inc. Queensland AIDS Council Queensland Voice for Mental Health Inc. Respect Inc. (QLD) Scarlett Alliance, Australian Sex Workers Association Self Advocacy Sydney Inc. Sex Work, Education, Advocacy & Rights Western Australia Sex Workers Outreach Program, Northern Territory Sex Workers Outreach Project Inc. (NSW) Sex Workers Reference Group, Northern Territory Sexual Health and Family Planning ACT Inc. SHINE SA SHQ and People First Program (WA) SIN (SA) Society of Australian Sexologists Tasmanian Council on AIDS, Hepatitis and Related Diseases Thorne Harbour Health (VIC) True Relationships & Reproductive Health (QLD)

Vixen Collective (Victoria’s peer only sex worker organisation) WA AIDS Council WA Council of Social Service Women in Adult and Vocational Education Women with Disabilities ACT Women’s Electoral Lobby Inc. Australia Working It Out (TAS) YWCA Australia

Family Planning NSW

Family Planning NSW is the state’s leading provider of reproductive and sexual health services. The organisation has been delivering targeted services to people with disability and those who support them for over 35 years, including health promotion, education and training. Family Planning NSW is also a registered provider under the National Disability Insurance Scheme (NDIS), and provide services under the following NDIS support areas: • Specialised assessment of skills, abilities and needs • Therapeutic supports

In April 2019 Family Planning NSW made a submission to the Joint Standing Committee on the National Disability Insurance Scheme [8] regarding ‘General issues around the implementation and performance of the NDIS’. Their recommendations are detailed below. The submission reiterates issues raised in their August 2017 submission [9] to the Committee regarding ‘Transitional arrangements for the NDIS’, where many of the issues they raised have been resolved.

Recommendations Family Planning NSW recommends that: Mechanisms be introduced to allow more responsive changes to plans so that participants’ sexuality support needs can be met in a timely fashion.

Sexuality support requirements be considered as a standard inclusion for all participant plans, including puberty support for children and adolescents.

The NDIS website and associated materials provide clearer guidance about the kinds of services that can be obtained as part of sexuality support, in the form of an NDIA policy or procedure document.

Adequate funding be provided for professional learning of NDIA representatives, including in the areas of sexuality and relationships.

Opposition to NDIS funding Sexual Services

Project Respect

Project Respect is a “non-profit, feminist, community-based organisation”. They operate a support and referral service for “women trafficked for sexual exploitation and women in the sex industry”. They assist women one-on-one, create a safe community and advocate for women’s rights. They believe the sex industry is deeply gendered, and that the majority of people in the industry are female, and the majority of clients are male. As a feminist organisation, they “believe that gender based inequality exists, and that the sex industry strengthens and reinforces this inequality”. [4] Position Statement: Accessing sexual services through the NDIS Project Respect produced a position statement [5] in 2019 with asserting following key points:

The National Disability Insurance Agency (NDIA) has made an official statement that it ‘does not cover sexual services, sexual therapy or sex workers in a participant’s NDIS plan. We believe the NDIA has made the right decision not to ‘fund sexual services’ as part of the NDIS.

This position paper aims to unpack the arguments for including sexual services on the NDIS and argues against this inclusion.

We need to acknowledge that this is a deeply gendered issue. Hiding beneath gender neutral language proponents are fighting for the rights of mostly men with disability to access sexual services provided by mostly women.

When proponents argue for sexual services to be included on the NDIS because it is an essential need and a human right, they are arguing for men’s needs and rights. The belief that men have a right to sex is based on regressive gender roles and entrenched ideas of masculinity and male sexual entitlement which have been recognised as major drivers of violence against women.

Another unstated assumption proponents of including sexual services on the NDIS make is that men with disability all, or mostly all, want sexual services in the first place. This stems from the belief that men “need” sex and assumes that all or mostly all men with a disability want to participate in commercial sexual encounters.

There are concerns that some men with disability who may not be able to give meaningful consent will have sexual services decided for them as part of their NDIS plan.

It may be difficult for the woman providing the commercial sexual service to negotiate what is being consented to. This raises obvious concerns for men with disability being assumed to want to participate in commercial sex when they may not want that service.

In concluding their statement Project Respect asserts:

We believe the NDIA has made the right decision not to ‘fund sexual services’ as part of the NDIS.

We urge the government to instead provide information and programs about rights and health in sex and relationships for PWD, as many disability advocates have recommended.

We have argued that sexual services are not an essential service, a necessity or a human right and therefore should not be included on the NDIS.

The ideas that underpin the arguments for commercial sex to be included on the NDIS are based on male sexual entitlement, which contributes to a culture of sexism and violence against women already prevalent in Australia.

Men’s perceived needs are privileged above women’s human rights, as seen in the very different ways women with disability are treated, and though the complete lack of concern for the women in the sex industry expected to provide these services.

We argue against men’s right to buy sexual access to women on the grounds of women’s human rights and gender equality. This includes men with disability.

Appendix E – Informed consent, culture and linguist diversity

Informed consent means that the person understands what they are consenting to, and is able to make informed decisions. Supporters have a role to create opportunities that increase a person’s decision making skills and confidence. This can be done by improving communication systems, supporting the person to understand the decision making process, and providing opportunities to practice making decisions. People have the legal right to consent to having sexual relations in Australia if they: • Are 16 years of age (for males and females, and whether heterosexual or homosexual) in ACT, NSW, NT, QLD, VIC and WA, and 17 years of age in TAS and SA.

Four areas of knowledge are required in order to give consent: understanding of what the physical act(s) involve, their meaning, society’s laws and cultural norms, and possible consequences [88]. According to theoretical and practical understandings of consent, those key elements include:

•   transparency about what is being proposed (not being tricked or fooled);
•   that all parties possess similar cultural knowledge about standards of behaviour;
•   that all parties are similarly aware of possible consequences, such as pregnancy or disease;
•   having respect for agreement or disagreement without repercussion; and
•   that consent is freely given, and that all parties have the legal competence to freely give
   consent (being in possession of decision-making capacity and unaffected by intoxication)

Anyone providing support to a person with cognitive impairment has a duty of care to ensure that the person with cognitive impairment: • Has the capacity to give consent to sexual activity • Has freely consented to sexual activity with another person • Understands what that consent means for them and the other person.

There are many other situations where the person’s consent is required, for example: • Using a contraceptive and the method • Having a pap test • Choosing whether to have a date with a person.

A Capacity Toolkit exists which acts as a guide to assessing a person’s capacity to make legal, medical, financial and personal decisions. The Capacity Toolkit was created in response to requests from lawyers, medical professionals, health workers, carers and advocates who required more information about capacity, some general capacity principles and guidelines on assessing a person’s capacity to make decisions.

Culture Sexual expression may be viewed differently within cultural groups. Before starting conversations about sexuality, supporters and others should first learn what topics and behaviours are sensitive for discussion in other cultures. Aboriginal and Torres Strait Islander people Sensitivity to cultural norms is important in discussions about sexuality and relationships with Aboriginal and Torres Strait Islander people. While the person’s right to make decisions about their own life must be upheld, the following culturally sensitive matters are fundamental for consideration when supporting Aboriginal or Torres Strait Islander people to explore and express their sexuality:

• Recognise that acknowledging the person’s culture is a way of acknowledging and valuing the person’s identity • Acknowledge the history of difficult relationships between governments and Aboriginal people • Recognise family, kinship and friend relationships and the person’s connection to community and the land • Determine who in the family or community should be approached for discussions about sexuality and relationships • Ask the person or family if they wish to choose who would provide sexual health services, Aboriginal or mainstream providers.

Sexual issues are personal and sensitive and discussion with some people is taboo. The person and family or carers should be consulted to learn what sexual matters are sensitive. Identify the family member or carer to speak to about matters of sexuality and relationships, and record the information in the person’s records. Understanding cultural sensitivity includes understanding the person’s individual history, experiences and choices. A high degree of sensitivity is required to support the person and family with a history of sexual abuse. Sexual health can be a private matter and is often discussed within gender groups. Shame can be a barrier to people accessing health services and being tested for sexually transmissible infections. People face other barriers such as location of services and issues of confidentiality, especially in small remote communities, and willingness to access health services to discuss sexual health matters.

Cultural and Linguistic Diversity People may still retain their values, beliefs and experiences, even when they no longer live in the culture where they learned them. The person and family’s behaviour, attitudes, preferences and decisions about sexuality and relationships, are influenced by culture and religious practices. The person and family or carer’s cultural and religious beliefs about sexuality and relationships should be understood before starting a conversation with the person about exploring and expressing their sexuality. Demonstrate respect and sensitivity to their culture by considering: • The person and the family or carer’s perspective on sexuality and relationships • The person and the family or carer’s views about Western sexuality and relationship practices • The role of spiritual and religious beliefs and practices in sexual development • How the person and the family or carer communicate, for instance, through an interpreter • The person’s own role in problem solving and decision making.

It is important to acknowledge that some people may choose to adopt practices, values and attitudes that are different from those of their parents or family. Supporters need to be aware of this and provide support according to the person’s wishes.

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