Supporting Pleasure: Facilitating masturbation for people receiving care services.
The politics surrounding facilitated masturbation for people with varied disabilities are contentious. While much research has been done to examine the effects of training, education, and interventions on problematic masturbation practices, little literature exists addressing the need to support positive masturbation skills. Further, literature addressing the adaptation of sexual aides for people with mobility and dexterity concerns exists only in the form of case studies. With the rise of support for sexual pleasure as a fundamental human right, more information needs to be made available about the potential for integrating current sexual aide technology with adaptive design technology. This article addresses some of the underlying concerns around pleasure as a human right, summarizes previous literature regarding masturbation problems, offers suggestions for changes that can be made in care systems to support pleasure and provides a very short overview of some current sex aides that could be adapted to facilitate masturbation for people with mobility and dexterity concerns.
Keywords: sexuality, sexual health, masturbation, physical disability, intellectual disability, education, sexual aides, human rights, sexual rights
In the 2007 publication, Sexual Health for the Millennium, The World Association for Sexual Health asserts, “Sexual health is more than just the absence of disease. The right to sexual pleasure should be universally recognized and promoted” . Further, they extend this ideal to specific groups that have historically received education and training focused on negative sexual rights, focusing on youth and people with disabilities. According to The Arc and the American Association on Intellectual and Developmental Disabilities, “People with intellectual disabilities and/or developmental disabilities (IDD), like all people, have inherent sexual rights. These rights and needs must be affirmed, defended, and respected . This article, informed by the above statements and many like it, continues under the assumption that sexual pleasure is a fundamental human right and an important facet of sexual health.
The sexuality of people with disabilities has been problematized and strictly regulated. From the use of compulsory sterilization during the eugenics movement in the United State and England to contemporary movements to keep people with profound impairments physically small and prevent sexual maturation, people with disabilities, particularly those with IDD have faced systematic societal oppression and degrading stereotypes regarding their sexuality [3, 4].
Beyond the overarching attitudes about sexuality, masturbation in particular seems to be a particularly difficult issue within care communities. Historically, problematic masturbation practices, such as masturbating in public or excessively, were treated using Electroconvulsive Shock Therapy (ECT). During the period of exposes and lawsuits brought about in the 1970s, the method changed from ECT to the use of lemon juice, sprayed onto the tongue, as a deterrent, citing that it was a more humane method of discouraging inappropriate masturbation . While general human rights informed policies no longer support the use of punishment as a behavioral modification technique, masturbation is discouraged in different ways, unofficial ways .
Research supports that masturbation is among one of the most accepted forms of sexual expression that people with disabilities engage in . This acceptance reaches broadly across all types of stakeholders; family, professional staff, specialized care providers, and frontline staff . However, most of the literature surrounding masturbation and people with disabilities focuses on stakeholder support or lack thereof of masturbatory practices and how to manage “problem” masturbation behaviors. There are few offerings relating to the actual mechanics of masturbatory behaviors of service users or offerings for frontline staff who want to learn the best ways to address masturbation in care settings.
For ease and continuity, a common lexicon must be established. In this article, the term service users will be used to refer to any people with physical, intellectual or developmental disabilities that require support from care agencies. This term is chosen specifically not only because it is broad enough to encompass the needs of many people who may need assistance in facilitating masturbation practices, but also to remind the reader and all who work in the care field that people who require assistance are, in fact, consumers and therefore have a say in what kind of service they pay for. In certain sections, a particular type of disability may be acknowledged by name, specifically when discussing aspects of education and training or mobility and dexterity concerns.
Masturbation will refer to autoerotic acts performed for sexual pleasure. This article does not address additional sexual activities that may also include masturbation with partners. To delineate the larger society from services users, the article will use typical or identify the category of person being discussed. Some examples of categories are family members, professional staff, etc.
Finally, the use of the terms appropriate and inappropriate will refer to actions that fall within the societal norms being discussed. Generally speaking, appropriate actions happen in the “right” place and at the “right” time as deemed by the greater community. Inappropriate actions are things that are potentially harmful to self or others and/or are illegal.
Several researchers have put forth work examining the beneficial aspects of masturbation in the typical population. DeWolfe and Livingston reported improved self-esteem, increased assertiveness, and improved social adjustment after successfully finding an adaptive masturbation system for a woman with cerebral palsy . Coleman has formed a statistical link between masturbation and orgasmic capacity, healthy sexual functioning, and satisfaction in relationships. Further, he connects the practice of masturbation to increased body comfort and self-esteem, as well as speculating that, by merit of increasing those factors, masturbation encourages greater ownership of the body and autonomy . As previous research investigating the abuse of service users has shown, increased bodily autonomy decreases the risk of sexual victimization .
The messages service users receive about masturbation come from many sources; religion, media, attitudes of stakeholders and peers. In the US, although many studies have shown that most adults participate in masturbatory activities, messages surrounding those acts are largely rooted in secrecy and shame . In an examination of masturbation scenes in contemporary North American movies, acts of masturbation were rarely shown as acts done solely for self-gratification, but rather were framed to take place in the absence of a partner . In these scenes, many of the actors were caught, furthering the notion that masturbation is shameful and embarrassing.
It has also been noted that most messages about masturbation are focused on masturbation as an orgasm oriented activity. When viewing masturbation as a task to be completed for the goal of orgasm, it stifles the ability for one to explore sensations and treat masturbation as a way for one to learn about their own sexual responses, likes, and dislikes . This also presents a problem for people who have sexual function concerns related to diagnoses, past trauma, or medications. The continual focus on orgasm as the goal of masturbation creates the potential for those who are unable to reach climax with feelings of inadequacy or as though they are broken. Beyond this, discussions about pleasure may be absent from current education and training .
Another message about masturbation that is particularly prevalent in care settings is the idea of appropriate masturbation practices that hinge primarily on one factor—privacy. Many care settings utilize what could be referred to as “privacy-lite.” The word itself is liberally used to describe things like closing a bathroom door or knocking before entering one’s bedroom. However, as a function of both care provisions and the culture that surrounds personal care work, privacy-lite is sometimes the standard. The bathroom door may be closed during personal care, but at any moment a staff member may enter. A staff member may knock on the door, but does not wait for an affirmative response before opening.
This is further complicated in situations where one may share a bedroom in a residential facility or group home. As masturbation is the sexual activity engaged in most often by service users, and the assessment has been made that for masturbation to be deemed appropriate it must happen in private , this would imply that the deficits in respect for privacy and autonomy make engaging in acceptable masturbatory practices difficult. Research has supported that masturbation is viewed, generally as the most permissible sexual expression for service users to engage in, by both stakeholders and society at large . However, to functionally support that belief, a higher standard for respecting privacy must be ensured.
Within the idea of appropriate and inappropriate masturbation practices lies the issue of identifying what acts are masturbatory. In the typical population, we recognize that not all genital touching is masturbatory. While it would seem logical that this is the case for service users as well, unfortunately genital touching is usually categorized as an act of masturbation and deemed inappropriate. Hingsburger outlines seven reasons that one may be touching their genitals that are not related to masturbation: physical discomfort (poorly fitting underpants, itchy skin), medical concerns (such as a UTI or rash), signaling a history of abuse, hygiene issues, allergies (to soaps or laundry detergents), attention seeking, and task avoidance . These alternative reasons for one to touch their genitals are fall into two categories, easily correctable and learned responses.
Sometimes, genital touching is masturbation, and if it falls under the category of inappropriate, it serves as an opportunity for learning rather than a punishable act. Often, as Gill points out, when someone is removed from a space for engaging in public masturbation, there is no explanation as to why . Hingsburger describes many of the issues surrounding inappropriate masturbation as learning or discrimination errors rather than as a problematic and intentional behavior . The issues that would signify problematic masturbation are cited by many sources as; when masturbation occurs in the wrong place or at the wrong time (public masturbation or discriminations errors), when there are hygienic concerns (such as semen left on clothing or objects), when the frequency of masturbation interferes with daily activities or causes physical harm to the individual, when orgasm cannot be attained and leads to frustration or behavioral outbursts, and when potentially harmful objects are used to masturbate [5, 11]. In light of the assertion that sexual pleasure is a right, how can stakeholders balance the desire to keep a service user safe with the mandate to support service users in the least restrictive environment?
There is not an answer to that question. Previous sections have discussed the need for staff members to facilitate privacy and the behaviors that indicate inappropriate masturbatory behaviors. Many of the concerns about problematic masturbation can be abated through education and support. However, regarding ability to attain orgasm and the use of harmful objects in masturbation practices, the need to create and respect privacy seems as though it would be at odds with the desire to prevent harm. Staff need to attend to patterns of behavior and medical patterns that may develop. For example, if a service user is assumed to be masturbating (in private) but exhibits more aggressive behavior or is easily frustrated afterwards, this might indicate a failure to reach a satisfactory sexual release (whether orgasm or not is achieved). Recurrent UTIs, genital soreness, or blood present on underpants could indicate issues within the mechanical practice of masturbation.
Both of the examples can be tricky, because, particularly in the highly medicalized, still institutional care setting, the first is indicative of a “behavioral” problem, and the second is likely to be fast tracked into a nursing or abuse framework. In many of his works, Hingsburger has made the point that all human behavior is a type of communication , and it is the responsibility of stakeholders, particularly frontline staff, to translate those behaviors into actionable improvement. Stakeholders need to constantly evaluate their practices to ensure both safety and rights are maintained. To complicate the matter further, there is no universal solution to individual issues. There are, however, some systemic changes that can occur. These generally align into institutional and administrative changes, attitudinal adjustments, and best practices for frontline workers.
Most changes that can be made to support pleasure in care settings, not to mention holistic sexuality and human rights awareness, are related to policy and training. Care agencies have policies regarding sexuality that elaborate beyond the boilerplate, “We affirm and support the right to sexual expression,” language, and include training requirements for frontline staff who may encounter sexuality related issues. Overall, training opportunities are lacking in availability and continuity. As Yool, et al. point out, since deinstitutionalization has restructured the way care is provided, services users interact with many different agencies in the course of their day, for example, home and day services, supported employment, and transportation . This is in no way meant to suggest that institutions were a better option for care, as history has spoken to the negative impacts of institutional living. It is meant to switch the onus for providing training onto agencies and state-level departments for providing training and ensuring consistency.
Yool, et al. suggest some steps agencies can take to put into place procedures that are supportive of both service users and frontline staff when it comes to managing interactions about sexuality. First, they recommend conducting a needs assessment to determine where the current blind spots are in the agency’s policy and training. Based on that assessment, the agency should put into place or update their policies that explicitly affirm sexual rights and outline expectations for frontline staff who encounter sexual situations. Finally, agencies need to train all current and new staff member on the policy, as well as provide some education regarding human sexuality and specific communication skills that are necessary to effectively support service users’ sexual rights.
This last step is particularly important because much research surrounding the attitudes and experiences of frontline staff has found staff to be unaware, unprepared, and anxious about dealing with sexuality related situation. In their survey, Yool, et al. found that none of the frontline staff that they interviewed were aware a policy existed . McConkey and Ryan found that half of the frontline workers in their research identified that increased opportunities for training and explicit policy would make them feel better equipped to handle issues around sexuality .
Further, McConkey and Ryan make an important point that merges the importance of policy and training as it regards to stakeholder attitudes surrounding the sexual expression of service users. If a policy doesn’t define attitudinal expectations for staff members, it leaves service users in limbo trying to determine and adjust to the personal beliefs and attitudes of each staff . While the ability to perform this sort of “code switching” speaks greatly to resilience skills and high interpersonal intelligence , it is unfair to create this anxiety provoking dynamic in someone’s home.
That said, a common echo throughout the halls of group homes is the frontline staff asking, “What about my human rights?” (personal observation). While it would be easy to make the argument that staff members are being paid to perform duties as needed and dictated by the service users, within the realm of sexuality, and specifically in regards to supporting healthy masturbation practices, no one benefits from forcing people with strong opposition or discomfort in supporting sexual practices, especially one as potentially intimate as facilitating masturbation. Mandating that frontline staff who are not comfortable or are opposed to facilitating masturbation is potentially harmful to the service user .
It is also worth noting that there are indicating demographic trends that seem to correlate in research with negative attitudes surrounding supporting sexuality. Frontline staff who are older, people who are devoutly religious, and those who may hold personal beliefs about members of the population (the specific information for this was provided from staff in a medium secure forensic institution that housed a number of service users who were either adjudicated or exhibited offending behaviors) [10, 12]. This is not to say that all people who fall into these demographics are uncomfortable or resistant to facilitating masturbation. Further research shows that all staff members who receive training about sexuality issues are more likely to handle sexuality related concerns and feel more confident in doing so, as well as having a higher likelihood of enlisting additional resources to help .
Above all, supportive attitudes from frontline staff are consistently cited s integral to the successful implementation of any sexuality intervention. The need for staff to recognize the inherent sexuality of all people [Craft, 1987 in 10] is of paramount importance when discussing the attitudinal requirements for all staff members. Providing education and support to frontline staff is a way to increase comfort with engaging in conversations and teachable moments around sexuality issues. With affirming attitudes and the corresponding awareness training at all levels of stakeholders, the benefits of actualizing sexual rights and pleasure will become part of the organizational culture in care systems.
Before describing techniques and suggestions for facilitating masturbation, it is important to place parameters on the discussion. Facilitating masturbation is not the same as masturbating a service user, standing by to observe, or providing intrusive assistance in the sex act itself. As said in the beginning, masturbation was being used to describe a solitary, autoerotic act. Having named the things that do not fall under the purview of facilitating masturbation, it is important to discuss some of the practices that do fall into this category. It is also important to note that the following suggestions would ideally involve someone with knowledge of human sexuality and a broad understanding of disability related concerns.
Many have written about the necessary steps to facilitate masturbation. The first step in the process of providing assistance is always to provide an assessment and accompany any action with an educational element. An important aspect of education surrounding masturbation is to build in follow continued reinforcement and use neutral reminders when a service user has made a discrimination error that leads to inappropriate masturbation .
In practice, experts agree that not only establishing, but respecting privacy is paramount in facilitating masturbation. This can take many forms: knocking on the bedroom door and waiting for a response before opening (and creating systems for people who do not speak to indicate an answer); allowing for a longer amount of time in the shower unattended; installing a dividing curtain in a shared room. [5, 11]. By delineating private spaces and times that are private, frontline staff can concretely assist a service user to avoid future discrimination errors. In this ongoing learning, however, it is important to also discuss contextually private zones and activities (e.g. one may disrobe in a doctor’s office, but it is not an appropriate place to masturbate; bathrooms that have stalls are regarded as public places, so, although one is engaging in a private activity by using the toilet, this is not a private place for masturbatory purposes) .
Assisting the service user to find stimulating sexual images or materials to assist in fantasy development is also important when facilitating masturbation [6, 11]. This can prove difficult for a number of reasons. Service users generally have limited income options, making the purchase of adult magazines difficult and can potentially be embarrassing for a service user. Pornographic videos are also difficult to access due to financial restrictions, and, although stimulating, they may not create realistic ideals or expectations about bodies or sex acts. Additionally, some service users may not read, so the easier to procure erotica may also be inaccessible. Finally, not all service users have internet access, and if they do, their computer may be located in a public area of the home. Finding ways to facilitate the acquisition of stimulating material requires some creativity and risk taking on the part of stakeholders.
A part of facilitating masturbation is to address the potentially harmful masturbatory practices. Because we have established the importance of creating privacy, this is where the need to be cognizant of behavior and health patterns is particularly important. Szollos and McCabe found that stakeholders, particularly frontline staff, overestimate the amount of sexual knowledge and skill that the service users they support have. For example, if staff assume a service user is going into to their room to masturbate, but is attempting to accomplish the task by striking their genitals because it causes sensation, staff members would not know this is the practice the person is engaging in and may only see signs of trauma to the genitals when assisting with personal care.
When facilitating masturbation it is important to gain an understanding of the current practices and mechanics being used. This is a particularly important time to enlist someone who is specifically trained to do this type of assessment and education. It is also important to remain neutral if a service user is engaging in a behavior that is potentially physically harmful that provides them pleasure. Staff should avoid the dichotomous language of good and bad  and neutrally reaffirm that masturbation is ok but that some aspects of how the person is performing masturbation are potentially harmful, furthering the option for replacement behaviors.
To offer a personal example from working in a group home, a male service user was inserting objects anally. The objects ranged from bars of soap to action figures to videogame controllers. There are a number of concerns in this situation; physical integrity of the anus and rectum, hygiene, the potential for one of those items to enter the rectum and require medical intervention. The substitute behavior suggested was to assist the service user to purchase a sexual aide designed for anal insertion, lube to make insertion easier (there was speculation that the soap was being used for that purpose), and education—for both him and the staff about the best ways to use, clean, and store the aide.
As shown in the above example, the use of commercial sexual aides can be a beneficial tool in facilitating masturbation. Unfortunately, not all masturbation facilitations requires a lone butt plug to solve the problem. Supporting the service user to find an enticing and functional sexual aide system requires knowledge about adaptive design and some niche knowledge about sexual aides. One of the things that is also important to know about in this aspect of facilitating masturbation is the chemical composition of sexual aides and safety measures that may need to be taken when using certain types of toys. This is particularly relevant for service users who may be on stipends or have limited incomes.
For people with mobility and dexterity concerns, an evaluation of physical capacity, as well as an examination of current adaptive aides are paramount in finding a solution to adapt masturbatory aides . For people who have sexual functioning concerns, this may involve a conversation surrounding what satisfactory masturbation looks like for them with their current state of sexual functioning [Pat Carney, Personal Communication].
In 1982, DeWolfe and Livingston identified the need for more mechanical sexual aides to be developed that foster independence and provide sexual gratification . Fortunately, in the past two decades many advances have been made in both the arenas of sexual aides and adaptive technology. Currently, there are a number of commercially available items that answer some mobility concerns by including remote controls. An entire genre of vibrators that respond to music exist. Ergonomics have started being taken into consideration in sexual aide design, as well as different textures, shapes, and sensations. There is even a new vibrator that can be controlled by a phone app from across the world.
In adaptive technology, Adaptive and Augmentative Communication devices have moved far beyond the image on a button that spits out a phrase recorded in someone else’s voice. Trigger switches can be made to accommodate almost any type of available movement. There is even some crossover in the two realms between slings, splints, and harnesses. With the use of the right sexual aides, frontline staff would generally be limited to set up of the device/positioning and clean up when the service user is done . This has been found by some care staff to be no more, if not less, intrusive than having to assist with bathroom related care [personal communication].
The following are products that have great potential for adaptation and/or represent novel concepts in sexual aides.*
The PULSE from Hot Octopuss  is a vibrator designed for the penis using the technology found in erectile dysfunction treatments. The aide has an oscillation plate that, when placed against the frenulum of a flaccid or erect penis will, according the website and many online reviewers, produce an orgasm. A benefit of the PULSE is that because it can be placed on a flaccid penis, the potential discomfort of having to apply a sexual aide mid-masturbation. The Pulse is designed to encase the penile shaft with flexible silicone wings, helping to keep the aide in place throughout masturbation. This is ideal for people with extremely limited mobility and those who lack the manual dexterity to masturbate manually.
The Minna Ola  is a slightly curved cylindrical vibrator that, rather than having a dial or buttons to control the intensity of the vibrations, uses an air filled, pressure sensitive pad to control speed. The vibrations could be used for clitoral or penile stimulation. There are two potential adaptations for the air pad function that would be beneficial for people with mobility issues. First, the aide could be used in conjunction with a splint to allow a user to use the pressure pad against the body (particularly for clitoral use, the pad could be pressed against the mons pubis). There is also potential, by merit of the pressure sensitivity, to use the Ola with a breath controlled switch.
OhMiBod  is a company that creates vibrators that connect to mp3 players and other sound sources via a 3.5 mm sound jack. Because of this capability, there is potential for a service user to connect the device with particularly stimulating songs (or potentially audiobooks) and have the vibrator act in combination with those other stimuli. The OhMiBod line of products could also to be connected to an existing AAC device, giving control of the sounds and sensations to the user.
There are many options for additionally adapted sexual aides. The ubiquitous Hitachi Magic Wand  comes with numerous attachments and may only require balancing on a pillow. Items like the LayaSpot  could be used in conjunction with a weighted blanked for vibratory sensation and pressure on the vulva. The La Palma, a hand harness from Spareparts , when used with a curved dildo or strapless strap-ons, like the Fun Factory Share  can be used for insertion by a service user who does not have the flexibility to reach the desired orifice with traditional aides.
The discussion around facilitating masturbation is the discussion about the right to pleasure. If we, the stakeholders and advocates, don’t discuss pleasure as a part of human rights and care provision, we reinforce stereotypes of services users as sub human and invalidate sexuality as an important part of all human identities. Mitch Tepper, who is consistently at the forefront of disability and sexuality activism and education, says, “When we do not include a discourse of pleasure we perpetuate our asexual and victimization status. We do nothing to alleviate what I see as endemic low sexual self-esteem among the many people with disabilities and illness who participate in my research or who come to me for help” . Service users are already singled out as ideal victims for abuse. It is our responsibility to help work against that notion by supporting increased bodily autonomy and self-esteem by facilitating the right to pleasure.
- The Author is not affiliated with any of the listed products or their parent companies and did not receive compensation for including them in this work.
- World Association for Sexual Health (2007). Sexual health for the millennium: A declaration and technical document. Minneapolis, Minnesota: World Association for Sexual Health. Retrieved 7/25/2014 from: www.europeansexology.com/files/WAS_2008.pdf
- Arc of the United States & American Association on Intellectual and Developmental Disabilities (2008). Position statement on sexuality. Retrieved 6/30/10 from http://www.aamr.org/content_154.cfm?navID=31.
- Taylor Gomez, M. (2012). The S words: Sexuality, sensuality, sexual expression and people with intellectual disability. Sexuality & Disability, 30(2), 237-245. doi:10.1007/s11195-011-9250-4
- McClelland, A. Flicker, S. et al. (2012). Seeking safer sexual spaces: Queer and trans young people labeled with intellectual disabilities and the paradoxical risks of restriction. Journal of Homosexuality. 59, 808-819.
- Gill, M. (2012) Sex can wait, masturbate: The politics of masturbation training. Sexualities, 15 (3/4), 472-493.
- DeWolfe, D.J. Livingston, C. A. (1982). Sexual therapy for a woman with cerebral palsy: A case analysis. The Journal of Sex Research, 18 (3), 253-263.
- Coleman, E. (2002). Masturbation as a means of achieving sexual health. Journal of Psychology & Human Sexuality, 14 (2/3), 5-16.
- Mahoney, A., & Poling, A. (2011). Sexual abuse prevention for people with severe developmental disabilities. Journal of Developmental & Physical Disabilities, 23(4), 369-376. doi:10.1007/s10882-011-9244-2
- Mandanikia, Y. Bartholomew, K. Cytrynbaum, J. B. Depiction of masturbation in North American movies. Canadian Journal of Human Sexuality 22(2), 2013, pp. 106–115; doi:10.3138/cjhs.2013.2052
- Yool, L., Langdon, P. E., & Garner, K. (2003). The attitudes of medium-secure unit staff toward the sexuality of adults with learning disabilities. Sexuality and Disability, 21(2), 137-150. doi:10.1023/A:1025499417787
- Hingsburger, D. (1994). Masturbation: A consultation for those who support individuals with developmental disabilities. Canadian Journal of Human Sexuality, 3 (3), 278-282
- McConkey, R. R., & Ryan, D. D. (2001). Experiences of staff in dealing with client sexuality in services for teenagers and adults with intellectual disability. Journal of Intellectual Disability Research, 45(1), 83-87.
- Gardner, H. (2006). Multiple Intelligences: New Horizons. New York: Basic Books.
- Szollos, A. A., & McCabe, M. P. (1995). The sexuality of people with mild intellectual disability: Perceptions of clients and caregivers. Australia & New Zealand Journal of Developmental Disabilities, 20(3), 205-222.
- Hot Octopuss PULSE. http://www.hotoctopuss.com/how-pulse-works/
- Minna Ola. http://www.minnalife.com/products/ola
- OhMiBod. http://www.ohmibod.com/
- Hitachi Magic Wand. http://magicwandoriginal.com/
- Fun Factory LayaSpot. https://www.funfactory.com/en/vibrators/layaspot/
- Spareparts La Palma. http://www.myspare.com/product/la-palma
- Fun Factory Share. https://us.funfactory.com/en/dildos/share/
- Tepper, M. (2000). Sexuality and disability: The missing discourse of pleasure. Sexuality and Disability, 18 (4), 283-290