Decisions about sexual consent for people with cognitive disabilities must be person-centred and balanced, according to new research.

In order to achieve the ideal outcome, the person must be involved in the process of personalising these approaches, and both they and their family/carers should be taught about the importance of sexual consent.

Promoting choice and protecting from harm

The research, which is published in the Interactive Journal of Medical Research, set out to look at how sexual consent ability was determined, managed, and enhanced in people with cognitive disabilities, by conducting a systematic literature review.

The review included 47 articles featuring assessment practices, legal case studies, and clinical standards for managing sexual consent capacity in people with cognitive disabilities.

The researchers hoped by conducting the review, they would be able to better understand the recurring themes influencing the design and implementation of approaches to consent.

As people with cognitive disabilities have a greater risk of being sexually abused, the authors note that while it is important they have the right to exercise choice over their sexuality, there must also be policies and practices in place to protect them from harm.

Making informed decisions

By analysing the literature, the study’s authors found three key factors that had the potential to improve a cognitively disabled person’s ability to make informed decisions about sexual consent. These were education, attitude and advanced directive approaches.

Education

The research revealed a pattern in the reports explaining how education could improve the sexual decision-making ability of people living with cognitive disabilities. The pattern starts by mentioning the three legal criteria of consent components (knowledge, understanding, and voluntariness), followed by a defined set of basic skill checks to determine whether such people could address these components.

The basic skill checks included:

  • Knowledge of body parts and sexual relationships and acts.
  • Knowledge of consequences from sexual relationships.
  • Understanding of appropriate sexual behaviour and context for it.
  • Understanding of the voluntary nature of a sexual relationship.
  • Ability to recognise abusive situations.
  • Ability to be assertive in such situations to reject unwanted advances.

In addition to people with cognitive disabilities, it was encouraged for families and staff working with people with learning disabilities to receive education to better identify the difference between healthy and unhealthy sexual behaviours and how to resolve such situations accordingly.

Attitude

Some articles in the literature review argued for both disability and feminist rights movements to overcome negative attitudes within communities, as these attitudes impact on how people with cognitive disabilities are perceived.

The authors note that “the sexuality of a person with cognitive disabilities is potentially influenced by critical factors beyond just sex drive and instinct: it has learned behaviour characteristics, influenced by social contexts, affecting how people express themselves.”

To counter negative cultural attitudes, such as rape culture, the literature suggests that lifelong sexuality education and policy changes are implemented, which address both internal and external factors.

While a person with cognitive disabilities could be incapable of understanding consent capacity, the literature suggests educational interventions may allow the person to reach capacity and make their own informed decisions.

Addressing negative staff and family attitudes was also noted as an important step towards gaining greater independence. Family and carers should be taught about sexual expression in people with cognitive disabilities, making necessary environmental changes to ensure privacy, and tracking the person’s sexuality with recurrent assessments.

Advanced Directives

A person’s ability to consent to sex can change over time, varying across situations in terms of capacity and sexual preference. Unless legal exceptions have been established, it is illegal for consent to be given by someone else.

Advanced directives can therefore be used in situations where a person wishes to uphold their core values and beliefs when resolving decisions involving sexual relationships, such as preserving the sexual preferences of a person living with a cognitive disability.

Advanced directives are contingency plans that allow people to consent to specific sexual acts ahead of time or grant decision-making power to a substitute decision maker (SDM) for an applicable future context. The plan involves the person, who is legally capable of providing sexual consent at the time (the past self) to set up a contingency for a period when their sexual decision-making ability may become compromised (the future self).

The authors note: “Advance directives are not promises that could lead to the promiser being locked in servitude” and they are not about “owing a commitment”, rather “a person’s advance directive merely states that such an encounter be allowed if they token consent.”

A balanced approach

Ultimately, the authors of the review conclude that approaches to sexual consent work best when they are person-centred. That is, the wishes of the person with a cognitive disability are understood and they themselves are involved in the process of personalising the approaches used to facilitate healthy intimate relationships.

The person-centred approach needs to be flexible to accommodate the specific needs of each individual, promote their dignity and autonomy, and uncover potential contexts that could identify risks associated with sexual expression.

Approaches to sexual consent therefore need to be balanced, so that they promote the desires of the person while protecting them from harm. As the authors explain:

“It is important for the attitudes of those involved in this process to be balanced; otherwise, the sexual rights of such assessed people could be moved either in favour or against them.”