The Role of the Ethicist in Sexual Enablement

By Kevin Reel, ethicist and OT working in Toronto. Canada


Sex and ethics. The pairing of those words together can inspire an infinite array of responses. Ethics is about what is ‘right’ and ‘wrong’. Sex is considered ‘right’ or ‘wrong’ for many reasons in different contexts. The question is which of these responses do we consider when it comes to deciding about the ethics of enabling sex?

For an ethicist who supports healthcare providers and their clients (in Canada we use the term ‘practicing healthcare ethicist’ to identify this type of role), the challenge is how to respect everyone’s response as far as is possible…and enable others to do so as well.

The trouble with sex is that it’s always so thoroughly wrapped up in morals – personal positions on matters to do with right and wrong. Like other moral ideas, these notions have been instilled in us from a very early age. Sex also intersects with extraordinarily intense emotions.

Layered with this is ethics – a broader set of ideas or norms that prevail across a community or society. Ethics frames what is ‘right’ and, along with the law, ethics considers what ought to be ‘rights’ within certain limits. Where sex is involved, ethics speaks to issues of autonomy, liberty, equality, freedom from harm and maximizing of benefits. It also speaks to respectful relationships, transparency, duties to others and recognition of public and private domains.

Exploring the preconceived ideas we hold, their roots in our personal moral values and the limits to which we can apply them is usually difficult and often uncomfortable work. But it is essential if we are to work in a way that is client-centred, and if we are to help clients live as they wish, as fully as they can. This is where ethics, and practicing healthcare ethicists, can be of some help.

Ethics and ethicists can be critical to thinking through the practice standards and guidelines and the organizational policies and procedures that guide the work of those who support people with disabilities to live their lives. No matter the practice context – inpatient or outpatient, acute or rehabilitation, school or work, shared residential or individual home based – dimension of sexuality and sexual expression can arise.

  • Should staff provide printed erotic material for someone who cannot easily obtain it on their own?
  • How should relationships in a shared residential context be addressed?
  • What differences would this present in a residential high school versus a university campus or a retirement home?
  • What if the individuals involved have physical limitations that require assistance to get naked and get close enough for intimacy?
  • Who then takes care of ‘the cuddle puddle’?
  • Are these considerations different when the ‘sex’ is part of a ‘relationship’ versus when it is expressly ‘recreational’?
  • How do we navigate a situation where there are cognitive limitations – when is consent valid?
  • Do we respond differently if it is happening in the midst of other ‘spousal’ contexts – if an individual is part of one relationship but engaging in another as well?
  • Does anything change if we know or suspect one someone is a paid sex worker visiting a client?
  • And what if we believe there is some sort of emotional or even physical harm arising from a sexual partnership?
  • Do our own responses carry any relevance? How much, to what extent?

The questions can be endless. So, too, can be the responses. Achieving consistent responses from all involved is an elusive ideal. To get close to this goal, decisions and actions must be based primarily on shared ethical (and legal) norms, rather than on personal moral and emotional reactions.

It may well be the case, at times, that those shared norms are actually too restrictive – and advocacy becomes an additional imperative. Think here of the ways in which some ‘norms’ have evolved in many societies over time – homosexuality has been removed form the list of psychiatric disorders, gender identity is seen very differently, paid sex work is still criminalized in some societies but not others.

Ethics and ethicists in practice can support the work of creating a just approach to enabling sexuality and sexual expression. This often begins with crafting policies and procedures that are grounded in respect for individual choice. Exploring personal values, clarifying the law and reviewing applicable professional standards can help with much of the unease that can be associated with involvement in the sex lives of others. From there, ongoing support and education can foster better understanding of the reasoning and rights underpinning what might still feel uncomfortable for some. Finally, facilitating communication among those involved can help highlight the shared goals and roles of those who may appear to have differing opinions.

Where people can manage to truly think through their own moral and emotional responses to issues of sexuality and sexual expression, it bodes well for their ability to engage with other ethical issues that prompt similarly intense reactions – such as the use of drugs and assisted dying. Becoming able to identify emotive responses and consider more rational and reasoned responses is a critical skill for providing person-centred support services, just as it is essential to creating a civil pluralist society.

A practicing healthcare ethicist1 typically helps people explore what they think is right and why, and how to work respectfully with others whose ideas of right and wrong might differ. In the realm of enabling sexually fulfilling lives, this can mean more person-centred practice and less moral distress.

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