Social workers’ perceptions of intimate relationships of people with intellectual disabilities in residential settings

Abstract

Summary

People with intellectual disabilities still struggle to enjoy intimate and sexual relationships. Social workers have a potentially key role in realizing the intimate and sexual rights of people with intellectual disabilities, particularly in residential settings. However, we still know relatively little about the meaning social workers attribute to such relationships. The present study addresses this lacuna by examining the perceptions and practices of 15 Israeli social workers in residential settings.

Findings

Drawing on thematic analysis of semi-structured interviews, two key themes are identified: (1) Intimate relationships as a human need, and (2) Intimacy with a question mark. Combined, these themes depict an ambivalent position toward residents’ intimate and sexual relationships.

Applications

The study's findings highlight the need to incorporate intimacy and sexuality within social work education, with a particular focus on people with intellectual disabilities and positive aspects of intimacy and sexuality. From a policy perspective, the findings urge state and professional authorities to develop national guidelines on realizing intimate rights.

Introduction

Historically, intimacy and sexuality have been complex issues for people with intellectual disabilities. For the sake of society or for their own perceived interests, various policies and professional interventions have deprived them of their intimate and sexual rights (McConnell & Phelan, 2022; Shakespeare, 2000). In recent decades, however, motivated mainly by the disability rights discourse, these practices and their underlying perceptions have been increasingly challenged. Instead, disability rights scholars and activists advocate for the rights of all individuals to explore and realize intimacy and sexuality as well as to receive proper support in that regard (Arstein-Kerslake, 2015; Martino & Campbell, 2019).

This call for supporting people with intellectual disabilities in realizing their intimate and sexual rights is consistent with studies showing that when given the opportunity, people with intellectual disabilities express sexual desires as well as the wish to experience (more) intimate relationships and love (e.g., Fulford & Cobigo, 2018; Healy et al., 2009; Whittle & Butler, 2018). This right-based paradigm is also supported by the numerous studies demonstrating how expressing such wishes and desires is crucial in fulfilling people's needs for company and affection, in promoting their well-being and happiness, and in making “the difference between a life lived with vitality and enjoyment and one of relative loneliness” (Ledger et al., 2014, p. 135).

Despite the growing impact of the disability rights discourse, people with intellectual disabilities still struggle to enjoy intimate and sexual relationships (Whittle & Butler, 2018). Importantly, recent studies have consistently shown that their limited enjoyment of intimate and sexual life is due largely to a range of structural barriers, particularly among those living in residential settings (Black & Kammes, 2019; Chin, 2018; English et al., 2018). They have also demonstrated that with the growing acceptance of disability rights discourse, the repression of sexuality and intimacy largely involves subtle, indirect barriers, rather than direct prohibition of these rights. These include lack of privacy; limited exposure to sex education, reliable knowledge, and social networks and media; intensive scrutiny and protectiveness by families, professionals, and guardians; limited material sources; and living in highly segregated, institutional or quasi-institutional settings (Fulford & Cobigo, 2018; Gomez, 2012).

Social workers employed in residential settings are key players in this context, as they are able and authorized to tackle some of these barriers. Their potentially crucial role in tackling these restrictive barriers is grounded firstly in the core values and practices of the profession. In particular, the profession's strengths-based orientation, its focus on an ecological and holistic view of human needs, its aspiration to promote individual and social well-being, and its commitment to social justice and change (Krumer-Nevo, 2020; Lundy, 2011; Saleebey, 1996; Weiss-Gal, 2008), make social workers well-positioned to promote and advocate for intimate and sexual rights of clients with intellectual disabilities (Dodd, 2020; Turner, 2021).

The potentially emancipatory role of social workers is also grounded in their professional mandate (Oliver & Sapey, 2018). Social workers are often responsible for providing individual, familial, or group counseling, in which issues of sexuality and intimacy can be discussed. As case managers, they are also responsible for helping the residents and their families consume social services, including sex therapy and education. Often, they also have professional authority over the direct staff and life in the residential setting in general. As such, they have at least some power to shape the organizational culture and policy regarding sexual issues. Moreover, as the profession strives to influence macro aspects of life, social workers can be key agents in changing state policies and public perceptions (Bigby & Frawley, 2018; Jagannathan & Reddy, 2020).

Against this backdrop, it is surprising to find that the literature is rather silent on this issue. Only few empirical works have focused on how social workers, especially in residential settings, perceive their service users’ intimate and sexual lives. These studies indicate that social workers often fell short in fulfilling their emancipatory potential in supporting people with intellectual disabilities (Kulick & Rydström, 2015; Turner & Crane, 2016). First and most generally, the social work literature and curriculum overlook sexual-related issues, rendering workers ill-prepared to address these issues in their clients’ lives. The situation is even more severe when it comes to people with disabilities, as the intersection of sexuality and disability is all but absent in the social work curriculum (Ballan, 2008). Moreover, studies also show that when sexuality is addressed in education or practice, it is often from a risk-averse standpoint, with a particular focus on the negative, pathological aspects of sexuality (Dodd, 2020; Lee et al., 2018).

Drawing on semi-structured interviews, the current article extends the limited literature by seeking a better understanding of how Israeli social workers perceive the sexual and intimate relationships of people with intellectual disabilities living in residential settings. Our findings stress the ambivalent position of these workers as they constantly move from recognizing the needs and rights of residents for intimacy and sexuality in principle to questioning them in practice. In particular, our findings show that this gap is evident with regard to three key aspects: desire, consent, and risk.

Method

Participants

The participants in this study were licensed social workers employed in two types of residential settings for people with intellectual disabilities: protected housing and hostels. The former are small group homes housing six to eight residents, and the latter are large group homes with 12–34 residents. Besides size, these two types differ in their level of supervision, community inclusion, and residents’ autonomy and choice, with hostels being a more restrictive, standardized, impersonal environment. However, as in other countries, protected housing settings are also often organized according to an institutional mindset, with relatively low levels of choice, autonomy, privacy, and person-centered support (Holler et al., 2020).

Participants were recruited using convenient sampling, by contacting setting providers directly, and indirectly via professional networks. Efforts were made to recruit social workers employed in a variety of geographical areas and with different sociocultural backgrounds. The snowball technique was employed to recruit additional participants. In total, 15 workers (13 women) participated in this study (M_age= 31.66, SD = 6.59, range = 25–51). Of these, one worked in a hostel, five in protected housing, and nine in both. Two self-identified as orthodox Muslims, four as orthodox Jews, two as traditional Jews, seven as secular Jews, and one as an atheist. Eight of them had an MSW, and four reported having participated in some kind of formal training on intimate relationships and sexuality. All participants stated that the residents in their work settings were diagnosed with mild to moderate intellectual disabilities.

Data collection

After providing informed consent, the participants were interviewed in a place of their choosing. In the interviews, conducted in Hebrew by the second author, the participants were asked to elaborate on the meaning they associated with intimate and sexual relationships among their residents, the ways these relationships were experienced in practice, the barriers faced by residents, and the way the interviewees perceived their professional role, practices, and dilemmas. Participants were prompted to describe concrete cases and events. The interviews lasted 60–90 min and were audiotaped and transcribed, with identifying information removed. Approval for this study was obtained from the Ethics Committee of [masked for review].

Data analysis

Data were analyzed thematically (Braun & Clarke, 2006). The coding process was implemented using the MAXQDA software and included several iterative phases: breaking data into discrete units of meaning; open coding; constant comparison of codes, and aggregating them into themes and subthemes. Following this iterative process, several master topics were yielded, chief among them being the perceptions of social workers towards intimacy and sexual relationships.

Trustworthiness

To enhance the trustworthiness of our findings, their presentation is accompanied by selected interview excerpts, using pseudonyms. These quotes have been translated at the manuscript writing stage by a professional, with all translations approved by the authors. Finally, authors held peer debriefings throughout the analysis stages to ensure consistency and verify that all themes and subthemes follow a coherent pattern (Nowell et al., 2017).

Findings

Our analysis highlights social workers’ ambivalent position towards intimate and sexual relationships of people with intellectual disabilities in residential settings. Two key themes reflect this inner conflict: (1) Intimate relationships as a human need; and (2) Intimacy with a question mark.

“It seems like a basic and very natural need”: intimate relationships as a human need

All interviews began with a broad question about what comes to mind when thinking about intimate relationships among people with intellectual disabilities. In most cases, social workers tended to start their answer by pointing out that intimate relationships were often one of the key goals of their residents. Many also emphasized intimacy as a universal human need, shared by people with or without disabilities, and some even viewed it as a human right. Often, social workers justified such support for intimate relationships by referring to their own experiences and needs:

The main thing that comes to mind is that everyone wants a relationship, I’m thinking that it's true for all of us, them too. […] like everyone else, they want the closeness, the warmth and love, beyond the love of parents and friends […]. It seems like a basic and very natural need (Yael, F, 29).

During the interviews, participants suggested several positive aspects and benefits of intimate relationships. These included mutual assistance and support, a sense of meaning, and the feeling of being cared for by someone. Furthermore, the participants’ descriptions sometimes referred to behaviors that signaled to them, in their daily practice, that they were witnessing a valuable, healthy relationship. These include small gestures made by the partners, non-sexual physical contact such as giving hands, and generally taking care of the partner.

[…] also helps his partner go to places. I gathered that there were times she wet her bed, he would simply remove all the linens, throw them in the laundry, and help her shower and get dressed. Where can you find that? (Dana, F, 37)

Some participants also stressed how their perceptions of resident intimacy changed in time, and how they gradually came to recognize and accept this aspect of the residents’ lives. In some cases, this perceptual change also included a redefinition of intimate partnership, as well as thoughts about how it can and should be realized, despite what sometimes appeared to be odd or non-standard relationship patterns.

I think that what I learned the most as time went by is that a relationship can take lots of shapes and shades. The things I imagine and think about may not necessarily represent reality, how things should be and seem. I think that with time, I also learned to allow things that looked weird to me, or that I didn't understand the meaning of the relationship […]. As long as I saw that it did both of them good, then it was their thing (Tehila, F, 29).

Many of the participants also felt strongly that enabling relationships and sexuality was part of their professional role:

I think that my goal is to enable them to have quality of life, well-being. As much as possible and as safely as possible […]. It's not that the family entrusted them to us so that we would take care of food, drinks, lodging … It's beyond that. I think that had it been only food, drinking, lodging and basic stuff, there would be no [need for] social workers (Naomi, F, 30).

The accounts also reveal a number of practices that social workers use, including holding social nights, having personal conversations with residents, referring residents to professional counseling, creating personal plans, training staff, and formulating organizational procedures. The participants’ descriptions of these practices clearly indicate that the issue is highly relevant to their role, and that they address it on a daily basis. Moreover, when they are overworked and cannot find the time to deal with it, they experience disappointment and frustration.

Finally, some of the social workers were critical of the various barriers preventing the residents from experiencing intimacy and sexuality, from the very nature of their institutionalized setting to perceptions of direct staff and family members. Some even raised criticism as to their own role in regulating and preventing residents from having and consummating relationships: “Whereas we have the right to have a relationship, they are required to prove that they do. They don’t have the right to a relationship like we would like to think and tell ourselves” (Tal, M, 37). This final point leads us to the second theme—the doubts social workers have regarding the appropriateness of resident intimacy

“But it doesn’t go any further …”: intimacy with a question mark

A deeper look into the interview transcripts reveals that beyond general statements of support, social workers are ambivalent about the issue. While expressing their recognition of the residents’ need and support for their rights to intimate and sexual relationships, all participants have constantly pointed to the complexity of the issue. Analyzing this complexity, as reflected in the various anecdotes and stories shared by participants, revealed three key underlying assumptions, all of which place a question mark on residents’ needs and rights to intimacy and sexuality.

“When it comes to the sexual part, they don’t seem to get aroused”: lack of desire

Many participants expressed the presupposition that residents often lacked any real desire for intimate relationships. In fact, while few of them did find that all of their residents had such a desire, most of them viewed some or even most of their clients as lacking it. These social workers constantly and rigidly differentiated between residents believed to have as opposed to lack such desire, particularly with regard to actual sexual intercourse.

[…] and we have many members who have no [such] interest at all, so I don’t need to talk about it. For some residents this is not an issue, and that doesn’t mean they don’t have friends, but when it comes to the sexual part, they don’t seem to become aroused. […] Some guys are simply too low-functioning, and sometimes it's not all that relevant, or it simply doesn’t interest them (Noa, F, 29).

As implied by the last quote, this belief was often based on the silence of service users. Service users believed not to have had previous experience with intimacy or sexuality, or those who did not express any direct request for support in that area, were often assumed to lack the need and desire in the first place. In many senses, it seemed as though residents were often assumed to be asexual unless proven otherwise.

This belief was deeply grounded in the resident's perceived cognitive ability. People identified as having severe cognitive impairment and low functioning were more likely to be seen as lacking the desire for intimate and sexual relationships. In some cases, they were seen as having sexual desire, but this was usually framed as a basic instinct, which could be satisfied by masturbation, with no need for a meaningful, intimate interaction with another person. Conversely, in some other cases, those with identified as low functioning were also perceived as having “pure,” almost childlike intimate relationships, again, without any mature sexual desire or expression.

Importantly, in talking about their residents’ lack of intimate and sexual desire, social workers tended to overlook their broader, restrictive context. The absence of private spaces, the strict rules, and the staff's and family members’ anxiety about sexual expressions were all factors within this context. While some social workers did acknowledge this context and its detrimental effect on the ability to realize sexual and intimate rights, they seldom incorporated it in their framing and understanding of the residents’ perceived lack of desire. Instead, they tended to view that “lack” as inherent to their clients and indicative of their impairment. An illustrative example for such individual emphasis could be found among those social workers who worked in both hostels and protected housing. Often, these workers described hostel residents as having lower needs for meaningful intimacy, and tended to explain this by referring to their perceived lower levels of cognitive functioning, rather than in terms of their past and current restrictive environments:

In the [protected] apartments, they have lots of sexual relations. If you talk to [name], the social worker there, she’ll probably tell you. The level of the residents there is much higher … Definitely, you bet, wow, threesomes … It's hot in there! [Name] often consults with me on how much to allow it to them, how much to intervene. This issue is highly … we [in the hostels] don’t really have it. It's a question we don’t often have to deal with, because in our place, they’re very far from it (Yael, F, 29).

“Maybe she didn’t really”: consent

Another key question mark refers to residents’ consent. During the interviews, participants shared numerous cases of relationships formed in residential settings, and questioned the authenticity of the consent provided by either partner or both. In these cases, despite having expressed their agreement, the participants wondered whether this reflected true consent. These repeated descriptions indicated that the issue of consent was very high on the social workers’ minds, and sometimes continued to bother them even long after the relationship had begun:

Her level of understanding is very low, and so is her level of communication. It could be that inside me, I told myself that she says she wants it, but I kinda had a little doubt that maybe she didn’t really, and [maybe] she didn’t really know she had a choice. But maybe it's also just all in my head. She also really loves him very much. The question is whether to get his attention she … These are like some dilemmas I have within me (Yael, F, 29).

As illustrated by Yael's words, wondering about residents’ “real” wishes was also highly related to the perceived level of their cognitive functioning, and in particular, their ability to communicate verbally. People with significant cognitive impairment, and especially those unable to communicate verbally, were perceived as having difficulty providing real consent.

Relatedly, some residents were also perceived as lacking knowledge of what a true relationship entailed. Social workers judged these residents based on their own idea of a good and healthy relationship. Here, a particular focus was on the need for such a relationship to be monogamous and distinct from other types of human contact. Participants often perceived their clients as failing to meet these standards, and here too their perceived level of functioning played a role.

They hear that this one is her boyfriend, and the other is that one's boyfriend, but they don’t understand the difference between that and just friendship. What makes it special? And then it gets to the point where someone is somebody's boyfriend, but can also tell many other girls [sic] that he wants to be their boyfriend, to give them a hug and kiss them, because there they don’t have that loyalty thing so much … Perhaps it's simply lack of understanding of the real need for a relationship … Whether it's something they’ve heard about and this made them want it, or it's something truly internal that they want a boyfriend (Michal, F, 27).

As participants questioned their clients’ authentic consent, they often cast doubt on their underlying motivations, considering their sexual conduct an attempt to please others, such as their family members or partners. In many of these cases, especially when marriage was discussed, the participants perceived the residents’ expressions of intimacy as status-driven or as resulting mainly from imitating other people, from their surroundings, or from the media.

“So long as it did not significantly damage others and themselves”: risky relationships

The risk was often around the corner. Throughout the interviews, social workers shared stories and anecdotes that highlight another important presumption: intimacy and sexuality come with a cost, which is often high. In many interviews, in fact, right after the participants referred to the need and right for realizing intimacy and sexuality, they quickly qualified their enlightened statement by describing a case where this meant danger. Sometimes, entitlement and endangerment were discussed in the very same sentence. This tight linkage seemed to express the profound inner doubts raised by this issue among social workers:

Interviewer: When you hear the words “relationships of people with intellectual disabilities,” what goes on in your mind?

I think it's very positive […]. My aspiration is for them to live a life that's as normal as possible, and my role here is to help them together with the existing support systems or to create systems of support and risk management. Everything has to be judiciously managed. Of course, I won’t place a male resident who's constantly eager to please with a female resident I know is very sexual and dominant […] in the same room with a resident I know is incapable of protecting himself. I mean, there's a kind of complexity here, but it's something that's very essential (Talia, F, 25).

The participants’ main concern, as evident in previous quotes, was with sex-related exploitation and abuse. This concern was strongest when referring to sexual relations that were not part of a committed relationship, and more so when occurring outside the residential setting. This type of sexual contact was predefined as dangerous and requiring supervision and prevention. However, the fear of sexual exploitation and abuse was very much present even when discussing committed and even long-term relationships within the setting.

Importantly, in many cases, that risk was not obvious, as in the case of deliberate abuse and lack of consent. Rather, the situation was more ambiguous, involving cases where one party was seen as less interested in the sexual aspects of the relationship, or where one party was exclusively interested in sex, or where one party tried to ingratiate the other or did not say no for various reasons. These gaps between the parties signaled to the social workers that these were risk situations to be feared and even avoided, again, even without deliberate intent to abuse. Moreover, the fact that sexual behavior took place in a private space, and sometimes even outside the residential setting (mainly in the family home or in the partner's place) meant that the social workers were preoccupied by wondering and fearing what could be happening behind that closed door. In some interviews, it even seemed that every type of sexual behavior was potentially abusive or exploitative:

There's another couple … The young woman's functioning level is higher than the man's […] they really love each other […]. In terms of contact, they need boundaries. […] he needs boundaries in this matter and she's also very sexual. She has been sexually abused in the past […]. She keeps seeking out boys [sic]. I worked very strongly about it with her, that if you have a boyfriend then only he is your boyfriend and you can’t be with other boys. […] I let them hold hands, say, and even kiss him on the cheek, but we won’t let them be alone in a room because we don’t know where this would lead (Omer, F, 30).

Besides sex-related risks, social workers feared a variety of other risk situations, including verbal and physical violence, as well as emotional and financial exploitation. Many of these risk scenarios depicted unilateral acts that are relatively common in “normal” relationships, such as buying gifts, cleaning the partner's room, or attitudes such as being possessive and domineering.

They’ve been together for a long time […]. She's very domineering, he's wrapped around her little finger, and he loves her very much. I often felt that she was kinda flirting with other residents coming in, while he is very infatuated with her. He comes over twice a week, pampers her, buys her stuff, invests in her, downloads songs to her MP (Tehila, F, 29).

Importantly, as seen in the above quotes, the fear of abuse and exploitation often did not reflect traditional gender roles. Instead, the participants often described women as the offenders and men as the victims. This gender blurring was mainly fueled by the perception that what mattered in a relationship, and what made it prone to exploitation and abuse, was the partners’ level of functioning, or more precisely their compatibility. When one of the partners was perceived as having lower functioning, he or she was seen to be at risk.

The dilemma of how to address these risks, including how to strike the balance between rights versus safeguarding, was highly present in the social workers’ professional life. They often discussed it among themselves or with colleagues and managers. Many found this deliberation difficult and stressful. They felt that a great deal of responsibility lay on their shoulders and that the line between endangerment and entitlement was extremely blurry. In the above case, described by Tehila, after trying to teach her resident that a relationship should be mutual, she realized at some point that “he's doing her a great service in the sense that he was with her for many years already, he's the most highly present person in her life. We are replaced every few years, and he's been with her for years, and that's something I can’t take away from her, nor from him” (Tehila, F, 29).

In some cases, social workers decided to permit and even support the relationship, while in many others they eventually decided to restrict it. But whatever they decided, the basic premise was nearly always that social workers and other staff members had the authority and responsibility to decide on this issue, and that this decision could also include steps to terminate the relationship. Another assumption was the belief that this decision should be made on the basis of the “best interest” principle, even when it contradicts the residents’ own will.

Once there's a will, I’ll do everything to try to make it work. I can’t promise I will. If it's dangerous […]. There are all kinds of stories in other hostels about things that happened […]. I can’t promise I’ll do anything just because the will is there, it needs to be backed up. I need to make sure it's OK, involve the guardian, whoever's necessary … (Talia, F, 25).

As implied by this quote, the participants often feared not only for the safety of their clients, but also for their own professional liability. This fear was closely related to the lack of a clear policy, on the national or organizational level, regarding whether and how to allow people with intellectual disabilities in residential settings to have intimate or sexual relationships, and on how to determine the authenticity of one party's consent. Some participants said that there was an incongruity between enlightened statements by managers, academicians, and policymakers and the realities on the ground, which they found particularly difficult to reconcile given their lack of appropriate training and supervision:

Any kind of guidance, or preferably dedicated training. […] to allow contact, but only with the guardians’ approval? For example. Never to allow no matter what? […] they tell us direct them as much as you can towards independence, permanent relationships and children. On the other hand, it's a far cry from what's really going on. […] Everybody wants to cover their back, nobody wants anything to happen, so we don’t really let them (Michal, F, 27).

Discussion

In recent years, there is growing recognition of the rights of people with intellectual disabilities to reap the benefits of their intimate and sexual rights (Addlakha et al., 2017). Our participant's accounts attest to this recognition, as the findings show that Israeli social workers working in residential settings for people with intellectual disabilities acknowledge the residents’ need and right to intimacy, and consider facilitating their realization as part of their role.

However, our findings also join recent studies in showing how professionals struggle to translate this abstract recognition into practice (e.g., Guenoun et al., 2022). Looking at intellectually disabled youths, Löfgren-Mårtenson (2004) describes these professionals as “an ‘in the middle’ generation,” exposed on one hand to new reforms and discourses that, but on the other hand struggling to apply them in their practice, thereby becoming become the “new obstacles or institutional walls” (p. 206). Our findings show that this “in the middle” generation also reflects the position of current social workers.

In our case, social workers’ accounts reveal their reservations about issues of desire, consent, and risk. Given other, structural barriers, as well as the key role of social workers in residents’ institutional life, this ambivalent position places the latter in a different kind of risk—that of failing to experience meaningful, healthy intimacy and sexuality. Whether in finding a partner, going out on dates, or securing private spaces, residents rely on staff support to benefit from this experience. The social workers’ ambivalence, therefore, undermines their ability to be the residents’ allies in promoting their intimate citizenship (Plummer, 2003).

A useful way of conceptualizing this ambivalence is the notion of “conditional sexuality” (Rushbrooke et al., 2014; Wilson et al., 2011), which highlights that often, sexuality among people with intellectual disabilities is contingent upon various extraneous factors. According to Wilson et al., direct caregivers recognize that their clients “have sexual rights […] but that these rights are realised only up to a point” (p. 285). According to Rushbrooke et al. (2014), while caregivers believe they should support the realization of sexuality, they also believe they should step into a position of control when they feel their clients are not resilient, knowledgeable, and capable enough to manage their sexuality.

Gill (2015) referred to this attitude as “sexual ableism”: perceptions and practices, often unintended or well meant, which restrict people's intimacy and sexuality based on their perceived ability. Indeed, cutting across our findings was the linkage between residents’ desire, consent and perceived risk and their perceived intellectual disability. Those considered severely disabled were also deemed lacking in true desire for intimacy and sexuality, incompetent of “real” consent, and highly vulnerable when realizing intimacy and sexuality.

Crucially, the consequent denial of residents’ rights to intimacy and sexuality is often subtle, indirect, and hard to identify. A prime example in our findings is the tendency to question the authenticity of residents’ consent. As this view rightly assumes, sexuality for people with intellectual disabilities is indeed largely socially constructed. However, having a social-led desire does not imply that it is unreal or even exceptional. In fact, according to social scripting theory (Simon & Gagnon, 2003), the sexual behaviors of all humans follow scripts affected by sociocultural norms. Rejecting a biological, reductionist understanding of sexuality, this theory argues that sexual expression is always realized in a dynamic, sociocultural context. In this sense, being motivated by the expectations of their environment does not make these residents exceptional but rather perfectly normal.

Conversely, we should also recognize that the sexual scripts of people with intellectual disabilities are indeed drawn heavily, perhaps more than others, on their immediate surroundings, and on prevailing norms of what sexual life looks like. However, this should in no way affect the perceived authenticity of their consent. The way to enable them to adopt their own, authentic script should not involve regulation, but rather support, experience, and learning (Turner & Crane, 2016). While in some cases, our participants have followed these enabling practices, this has not always been the norm.

Note that respecting residents’ consent and supporting them with developing their own, authentic script, does not mean that ensuring residents’ consent is not of ethical and professional importance. In fact, one of the duties of social workers is to make sure that residents realize their autonomy and that their choices are not shaped by undue influence. However, in doing so, social workers need to be cautious not to conflate their residents’ perceived cognitive and communicative functioning with their right to consent to sex and intimacy (Arstein-Kerslake, 2015). Similarly, they need to consciously avoid demanding higher, unrealistic standards of consent from service users, such as consent completely independent of any social influence or context.

Another subtle, indirect way of questioning the residents’ desires and rights to intimacy was equating their silence on this issue with a lack of desire. Here too the notion of sexual scripts is useful. While we should respect people's rights to asexuality, there is no ground to presume that it is more prevalent or even predominant among people with intellectual disabilities, as some of our participants seem to believe. This perception of “inherent” asexuality tends to ignore the context in which it is constructed: restrictive spaces that make it difficult for people to express their sexuality, negative attitudes that mark such expression as problematic if not outright dangerous, and limited opportunities to discuss or have sex. All these minimize the resources that residents can draw from on while constructing their own sexual scripts (Björnsdóttir & Stefánsdóttir, 2020). Paradoxically, however, while our participants identify the role of society in shaping residents’ desire for intimacy and sexuality, they seldom recognize its role in shaping their lack of such desire.

The risk was another key and related element in social workers’ reservations, as they tended to view the residents’ sexuality as a source for abuse and exploitation, causing them to intervene in and even prohibit certain relationships. Indeed, as repeatedly demonstrated (Byrne, 2018; Tomsa et al., 2021) people with intellectual disabilities, and in particular, those living in residential settings, are more likely to experience abuse and exploitation than are people without disabilities. However, this association between intellectual disability and various risks should be approached with great care. For one, this vulnerability is not necessarily or exclusively due to the residents’ perceived (in)abilities. Such individualistic conceptualization of risk not only masks the social context of exploitation or abuse, but is often counterproductive in failing to protect residents from harm (Onstot, 2019). Using an ecological model of sexual violence, Hollomotz (2011) argues that by focusing on the inherent vulnerability of people with intellectual disabilities and restricting their sexual agency, supposedly for their best interests, “may disable individuals from becoming competent social and sexual actors and from accessing information and services that have the potential to reduce sexual ‘vulnerability’” (p. 1).

Emphasizing the potential risk embedded in intimacy and sexuality also overlooks their vital role in people's life. Many studies have shown their positive effects, including for people with intellectual disabilities: from health and reduced stress to happiness and well-being (Neuman & Reiter, 2017; Pietromonaco & Collins, 2017). Thus, viewing the intimacy and sexuality of people with intellectual disabilities mainly through the prism of risk while overlooking its positive aspects runs the risk of denying them all these enriching experiences.

Limitations and implications for research and policy

The study is not without its limitations. First, while efforts have been made to recruit participants from diverse backgrounds and group homes, our convenience sample cannot be considered representative of the Israeli social workers population. Relatedly, the study is focused on social workers employed in group homes. It is reasonable to assume that those working in more segregated settings may hold different views around issues of intimacy and sexuality. Future studies should examine that population as well.

Before moving to discuss the implications, our findings should be understood against the backdrop of the broader social context. As in many welfare states (Ballan, 2008), social workers in Israel are provided with few opportunities to learn and develop intimacy-related practices (Lavie-Ajayi, 2022). When such opportunities are available, they are usually risk-led and couched in terms of the individual-medical perspective of disability. Positive sexuality, rights-based understanding of intimacy and sexuality, and social perspective of disability more generally are still largely absent from their curriculum. These practitioners also work in a policy vacuum, in which the state, the profession, and the organizations they work with rarely guide them on how to support residents’ intimate rights. When a policy is presented, it is often implicit and prone to ambivalence and contradictions, resulting in practice in denial of intimate citizenship.

Our findings hold important implications. First, social work education, including in-service training, need to incorporate intimacy and sexuality with particular, but not exclusive focus on people with intellectual disabilities. Further, in developing curricula for social workers emphasis should be given to providing safe spaces where students and practitioners can openly explore dilemmas and tensions, including those related to consent and risk, and critically discuss their views and values on intimacy and sexuality. Emphasis should also be placed on the positive aspects of intimacy and sexuality. Recent advancements in the profession, including writings on positive sexuality, sexual well-being, and rights (e.g., Dodd, 2020; Giertsen et al., 2021) will be instrumental in informing these efforts. Relatedly, these efforts should be informed by disability rights and social perspectives of disability, as well as their connections and relevance to other critical social work perspectives (e.g., anti-oppressive, radical and structural frameworks; e.g., Slayter et al., 2022). Finally, from a policy perspective, state and professional authorities should develop national guidelines on realizing intimate citizenship, so that social workers are not left alone with their conflicts and doubts. Importantly, such an enabling intimacy policy should not restrict itself to professionals’ attitudes and practices, but also tackle the broad social context, particularly the institutional regime in which they and their service users are situated.