Journal of Learning Disabilities

http://jid.sagepub.com

Responding to Masturbation in Supporting Sexuality and Challenging Behaviour

in Services for People with Learning Disabilities: A Practice and Research
Overview
Paul Cambridge, Steven Carnaby and Michelle McCarthy
Journal of Learning Disabilities 2003; 7; 251
DOI: 10.1177/14690047030073005
The online version of this article can be found at:
http://jid.sagepub.com/cgi/content/abstract/7/3/251

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Responding to masturbation
in supporting sexuality and
challenging behaviour in
services for people with
learning disabilities
A practice and research overview
PAU L C A M B R I D G E

University of Kent at Canterbury, UK

STEVEN CARNABY

University of Kent at Canterbury, UK

M I C H E L L E M C C A RT H Y

Journal of
Learning Disabilities


London,Thousand Oaks
and New Delhi
() -

-():

University of Kent at Canterbury, UK

Abstract Masturbation is frequently referenced as a key issue for

supporting the sexuality of people with learning disabilities, yet
the subject has received little attention in the professional and
academic literature. This article provides an overview of
masturbation in relation to service responses and user support in
sexuality work in learning disability more widely, drawing in
evidence and experience from sex education, clinical work and
staff training. Issues such as gender, sexuality, culture and consent
are addressed and some of the commonly held myths and
assumptions about sexuality and masturbation are challenged. The
discussion and related suggestions are designed to be of value to
service managers and practitioners, particularly those involved in
sexuality work and one-to-one support.

challenging behaviour; masturbation; rights; sex

education; sexuality policy

Keywords

Introduction
There is a long discourse on the sexuality of people with learning disabilities and the development of protective and empowering support and education based on an increased awareness of sexual abuse and risks (e.g.
Brown and Thompson, ; Brown et al., ; McCarthy and Thompson,
) and the articulation of rights and education agendas (e.g. Brown,

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; Craft, ; ). The related research and practice debates have

focused on emerging themes including HIV and homosexuality (Cambridge, ; a); the sexuality of men (Cambridge and Mellan, ;
Thompson, ); capacity to consent and consent to touch (Brown and
Turk, ; Murphy and Clare, ); and the sexuality and sexual health
of women with learning disabilities (McCarthy, ; ), including
menstruation (Rogers, ) and the menopause (McCarthy, a).
These and related literatures in sexuality have shifted the agenda for sexuality in learning disability from one characterized by pathology and suppression to one centred on rights and empowerment, despite a continuing
recognition of the prevalence of sexual abuse.
Despite this paradigm shift, relatively little attention has been paid to
one of the commonest sexual behaviours, namely masturbation. This is
particularly surprising as it is also the most frequently referenced presenting issue for referral to sex education for men (much less frequently,
women) with learning disabilities (McCarthy, ) and repeatedly
surfaces in staff training and clinical work (Cambridge, b; Cambridge
and McCarthy, ). Concerns are seen to centre primarily on five key and
sometimes interrelated themes:
The person is considered to be unable to masturbate properly, usually
meaning that it is thought they are unable to reach orgasm/ejaculate.
The person does not know how to masturbate, usually meaning that they
have been observed rubbing their penis or vagina, generally through
their clothes, against people or objects.
The person is doing it too much, usually meaning that the duration or
frequency of the masturbation is such that staff consider that the person
is losing out on social opportunities at home or in the community.
The person is inappropriately masturbating, usually meaning that they
are masturbating in public or shared spaces in services, causing difficulties for staff or other service users.
The person is using inappropriate objects or means to help them masturbate, usually meaning that they are using objects not intended to aid
masturbation which could hurt them.
Commonly, staff relate explanations or hypotheses they have developed to
help them understand the behaviours they observe. An example is linking
unsuccessful masturbation with frustration, leading to challenging behaviour (e.g. Sheppard, ). Challenging behaviour may also be directly
linked to masturbation, such as inappropriate sexual behaviour, which may
include masturbation in a public place, self-stimulation through sexual
rubbing against another person or the inappropriate use of pornography

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to aid masturbation. Self-injury may be linked to the use of inappropriate

or dangerous objects by the person to aid sexual self-stimulation or masturbation. In such situations it may be hypothesized that their removal may
lead to aggression or other challenging behaviours. Complex causal
linkages may therefore be constructed between masturbation, as it presents
itself or is perceived to be a problem, and challenging behaviour, so it
remains important to ensure that masturbation and sexuality per se are not
pathologized in any debate.
Overlying such considerations are issues of gender and sexuality.
Masturbation is generally reported to be much more of an issue for men
with learning disabilities than for women (McCarthy, b). More widely
it has been observed that the sexuality of men with learning disabilities is
seen as relatively pathological, with a range of sexual behaviours such as
homosexuality having historically reinforced such perceptions owing to
homophobia (Cambridge, ; Cambridge and Mellan, ). Conversely, it has been observed that the sexuality and sexual experiences of
women with learning disabilities have remained relatively hidden
(McCarthy, ; McCarthy and Thompson, ). Lesbian sex, for
example, is virtually invisible in services for people with learning disabilities, particularly compared with the relative visibility of homosexuality
between men. Such observations are mirrored in relation to referrals to sex
education in services for people with learning disabilities (McCarthy, )
and discussions in staff training in sexuality and learning disability (Cambridge and McCarthy, ).
The remainder of this article examines these issues and offers interpretations and explanations for the commonly reported difficulties associated
with masturbation, with suggestions for supporting service users in
masturbation and supporting staff to respond effectively.

Why masturbation is often seen as a problem

One of the main explanations for this is that masturbation is a common
and frequently occurring sexual behaviour, regardless of intellectual ability.
It is therefore not surprising it is often visible in services for people with
learning disabilities and is consequently perceived to be a problem, regardless of related considerations such as the neglect of sex education, lack of
privacy in services themselves or failure to recognize differences in culture
or ethnicity (Baxter, ; Malhotra and Mellan, ; Senker, ). We
construct and organize social and physical space and support in services
for people with learning disabilities in ways where communal and collective spaces such as living rooms, bathrooms and toilets often merge along
the publicprivate continuum with shared or individual spaces such as

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bedrooms (Parkin, ) or in ways which are fundamentally ethnocentric.

By and large, private space and culturally appropriate space are at a
premium. In residential services someone may have their own bedroom,
but its use may be discouraged during the day, there may be no locks on
bedroom doors, and staff and other service users may not respect privacy.
This is why simple messages such as a right to privacy and respect and the
importance of gender in some intimate care interaction have received
prominence in some educational materials (e.g. Cambridge, ; Cambridge and Carnaby, a; McCarthy and Cambridge, ). Private spaces
in day services or services for people with profound and multiple learning
disabilities are even scarcer, and the only places available for someone to
masturbate may be the toilets, which may sometimes not even have private
cubicles or locks on doors.
In addition to the tendency to disrespect or disregard privacy in services
for people with learning disabilities, there is also a tendency to desexualize and to deindividualize people with learning disabilities (Carnaby, ;
). This can mean that ordinary sexual behaviours, when they do
surface, are interpreted as inappropriate. Masturbation, exposure of the
body and homosexual tendencies were, for example, crudely referenced as
behaviour problems on the Adaptive Behaviour Scale (Nihira et al., ,
referenced and discussed in Felce et al., ).

How best to respond

The first steps are to clarify and accurately describe the actual behaviour
and its social and physical context. Five key sets of questions can be asked
about the actual behaviour, evidence and context (McCarthy and
Thompson, ), the answers to which can be formulated into an agenda
for individual work:
What is the actual behaviour or form of sexual self-stimulation? For
example, is the person rubbing themselves against objects or touching
their vagina or penis directly?
How do staff respond to the behaviour, and are responses consistent? For
example, do some staff or staff responses seem to be more effective than
others?
Does the behaviour (masturbation) vary between places or settings? If
so, what factors might explain this variation?
Is there a daily or temporal pattern to the persons masturbation? If so,
what might this suggest? Are there times when this does not appear to
be a problem? If so, is there a ready explanation for this which might
help formulate an intervention?

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Is this is a new behaviour which has recently surfaced or been observed,

or has it been going on for some time? If it seems durable, what interventions have already been tried out and how successful have they been
in modifying the behaviour?
Depending on the individual situation or behaviour, more detailed questions may also be helpful to ask and seek to answer, for example:
For a woman, does she directly stimulate her clitoris, vagina or breasts,
and is this done above or beneath clothing?
Does she seem to achieve satisfaction, whether through orgasm or not?
For a man, does he get an erection, does he get his penis out and use
his hand, and does he ever ejaculate?
Answers will provide precision about describing different forms of selfstimulation and masturbation which may have only been loosely described
or labelled in the past and consequently aid the design and planning of
interventions.
For both women and men, a series of secondary questions are also
likely to prove useful, in particular:
Does there seem to be a particular stimulus or co-factor, for example a
particular place, contact with a particular person or association with a
particular care activity, such as changing a continence pad? If so, such
associations may need to be mapped and understood in more detail in
terms of their cause or function.
Is the masturbation part of a wider repertoire of attention seeking behaviours or other challenging behaviours such as self-injury? If there appear
to be links, then the underlying functions of the masturbation and other
challenging behaviours will need to be clearly articulated and understood.
Is there any suspicion or evidence that the person may have experienced
sexual abuse in the past or is currently at risk of sexual abuse or exploitation? If so, and especially for people with very limited verbal communication, touching their genital area may be their only way of
drawing attention to something having happened to that part of their
body.
Answers to these questions will help place the behaviour on a continuum
between sexual arousal, self-stimulation and masturbation, which will
inform the response. They will also help develop and test hypotheses about
the link between masturbation and other stimuli or challenging behaviours
or the function of the behaviour itself which may be more than selfstimulation. In some cases, it may be necessary to collect additional

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information to help decide on the function of the masturbation and clarify

the attribution if it is a challenging behaviour, for example using a simple
but widely recognized ABC (antecedent, behaviour, consequence)
approach to understanding setting conditions and triggers as part of behaviour analysis (e.g. Murphy, ).
In many cases it will also be important to check out some even more
basic but often overlooked possibilities, particularly in relation to situations
where the woman or man is considered to be unable to masturbate effectively. For example:
Does the person have a vaginal, penile or urinary tract infection?
Are there any signs of a skin irritation or condition, such as thrush or
eczema?
Could having an erection cause pain for the man, as with a very tight
foreskin?
Is the person on any form of medication which could reduce their ability
to masturbate or their libido, such as anti-psychotic medication?
Whilst we may not always be able to understand why a person behaves in
a certain way, if we accept the premise that the person will usually have a
reason for what they are doing, the challenge for carers and support
workers lies in working out the reason. The importance of such a response
has been clearly stated:
addressing inappropriate masturbation successfully relies on an understanding of what the behaviour communicates about that person, or what
purpose the inappropriate masturbation may be serving for them. If this
understanding is lacking, approaches tend to be oppressive and punitive.
(Walsh, , p. )

In trying to understand a persons sexual behaviour, staff need to be

encouraged to reflect on their own beliefs and values about sexuality. We
draw on a range of models and sources for this, including our cultural
backgrounds, subjective feelings (gut reactions), beliefs about how
common or uncommon a certain type of sexual behaviour is, our understanding of the law, and so on. The models of normality people hold can
be influential in determining our responses and staff need to be helped to
recognize that many of us make distinctions about what we think is
normal or abnormal on an instinctive and subconscious level, rather than
as a result of considered reflection.
Finding out more about a persons motivations and purposes will obviously require careful and respectful observation. Intimate and personal care
or help with washing or bathing can sometimes provide such opportunities
(Cambridge and Carnaby, a). If a person is able to discuss such

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matters, then private and respectful conversations can help. However, in

many cases if staff already consider someone is unable to masturbate effectively, then they are likely to hold similar information or observations to
support their concerns or will have collected evidence indirectly. It will
remain important to check such evidence at staff meetings or case reviews
in order to validate any assumptions or interpretations as a first step to
planning responses or deciding on what additional information may be
needed to inform any intervention. Considerations likely to surface from
such work include links with activities and levels of meaningful engagement. If people lack meaning in their lives they are more likely to engage
in self-involved behaviours which serve the purpose of relieving boredom
or frustration, than in interesting and enjoyable activities. Similarly, if they
have been denied structured sex education they are more likely not to have
been given clear messages about masturbation being a normal and enjoyable activity, either on your own or with a consenting partner, or about the
importance of privacy.

Policy and practice guidelines

Two caveats need to be referenced at this point in the discussion. The first
relates to the role of sexuality policies in services for people with learning
disabilities (Cambridge and McCarthy, ). Most such policies make a
point of referencing service users rights to information about sexuality,
and services responsibilities for providing sex education and support for
sexuality, including masturbation. The second concerns the ways individual
or group sex education work is organized.
Individual educational interventions need to be agreed and referenced
in the persons individual plan (Carnaby, ). This may need to involve
the multi-disciplinary or community team, care manager and service
manager, depending on supervision and line management arrangements
and the nature of outside support being provided for the service user. This
has obvious implications for an individuals confidentiality and rights to
privacy and these need to be weighed against the benefits of sharing such
sensitive information about an individual (Downs and Farrell, ). It will
also be important to identify the aims of the work, how these relate to the
teaching, how the teaching will be undertaken, who will conduct the work
and where it will take place. Similarly, group educational interventions,
such as womens or mens sex education groups, require careful planning,
supervision and management (Cambridge and McCarthy, ; McCarthy
and Thompson, ). In short, both forms of sex education require the
unambiguous allocation of worker led responsibility, within an individual
or service-level action plan and outcomes.

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Commonly reported problem areas

Attempts to masturbate during intimate or personal care are frequently
reported, especially in services for people with profound and multiple
learning disabilities, for whom a discourse on sexuality has been initiated
(Downs and Craft, ). Such situations may be the only time someone
has access to the sexual parts of their bodies (Cambridge and Carnaby,
a) and so are easily understandable, but they do raise particular adult
protection concerns (Cambridge and Carnaby, b). However, there are
a number of ways staff can respond, such as leaving someone in a safe and
comfortable place to allow them to explore their own bodies in private and
giving them a positive response verbally or through other forms of communication (Ware, ) that the behaviour is allowed and valued.
Where an individual is masturbating in a communal area and it is not
thought that they are doing it deliberately to offend others, the role of staff
would be to sensitively guide the person to his or her own private space
(usually a bedroom). If this behaviour occurs in a day service setting, then
strictly private space is unlikely to be available and the best option available (such as the toilets) may have to be used. Clearly, there are other
instances where consideration must be given to the possibility, or likelihood, that the person knows what they are doing is wrong and indeed that
they are doing it deliberately to offend others or gain attention. Good
guidance on working with men with learning disabilities with unacceptable and difficult sexual behaviours now exists (Thompson and Brown,
) and such materials can help formulate service responses.
If a man is deemed to be masturbating too much or ineffectively, it is
sometimes suggested that chemical responses using medication designed
to suppress the male sex drive (such as Androcur) will help the situation.
However, without the persons informed consent, which in the case of
someone with a profound or severe learning disability would be very
unlikely, then this is not a realistic or ethical option to consider. In addition
to the ethical problems, there is the question of effectiveness, as experience
suggests that men who take this medication may still experience sexual
feelings and attempt sexual activity (either alone or with a partner), but
are unable to reach orgasm. This can then exacerbate the problem it was
trying to solve. Rather, support staff need to be asking whether the individual concerned is having enough private time. For example, if appropriate and safe, is he being given time to relax alone in the bath or shower,
or have time to rest in bed when not actually sleeping, without wearing
pads or restrictive clothing?
Similar dilemmas occur, for example, with managing the risk to people
who use inappropriate or dangerous objects to masturbate. Vaginal or anal

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insertions of certain objects pose a clear risk and necessitate action on the
part of staff. There will clearly be a strong case in terms of risk management to protect the person by removing the dangerous object. However, in
terms of the persons rights and in interests of providing a supportive
response, there would also be a case for replacing the object with a safe
alternative, such as a specially designed sex aid or similarly shaped object.

Taking sex education forward

A range of possible educational responses for helping teach someone to
masturbate effectively or in an appropriate place can be considered
(McCarthy and Thompson, ):
talking to the person, using unambiguous terms
discussion using photographs or line drawings (for example Cambridge,
; McCarthy and Thompson, )
using a sex education video, where actors or puppets demonstrate
masturbation (for example FPANSW, : WLHPA, )
demonstrating on a model vagina or penis
directing them or taking them to an appropriate place when they start
to masturbate
introducing modification, such as lubrication or a sexual aid if an
inappropriate object is being used
physically directing a persons hand when they are trying to masturbate
(for example Shelton, ).
Two overriding principles are relevant here. The first is informed consent,
and the second is that the least intrusive methods should always be tried
first. The most important practical consideration will therefore be to tailor
the educational response to the persons cognitive capacity and known
sexual experience. Issues of consent for and the design and targeting of
educational interventions underline why it is important to have these
agreed in the person centred plan (Department of Health, ) and to
adhere to basic principles of consent (mirroring those developed for sexual
activity itself by Brown and Turk, , and others). These would need to
take account of the persons sexual experience and their understanding of
the planned intervention. However, consent can be more difficult to put
first when service responsibilities for care and the protection of vulnerable
adults (Department of Health, ), possible legal constraints (Gunn,
; ) or the risk of negligent practice or assault (Cambridge, a)
are part of decision making.
Some of the difficulties of matching resources to needs are reflected in

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the range of off-the-shelf educational resources available. For example,

videos which use puppets to demonstrate masturbation (WLHPA, )
are sometimes considered to create an additional conceptual barrier,
namely the difficulty of the person relating the puppet on the video to self.
Conversely, there may be a reluctance on the part of the educator to use
sexually explicit educational material or images (such as those on masturbation using actors in FPANSW, ), on the basis that the service user
might misinterpret these or simply because the educator finds using such
material difficult.
When considering options, concern within services often returns to
whether such interventions, if successful, will then lead to the person
spending too much time masturbating, as they may have learnt how to do
it well and effectively. Although there is little evidence that this happens in
reality, if such outcomes occur, then it will be necessary to revisit considerations of engagement in activities more widely.
Another important reference issue at this stage is often the practice and
adult protection boundary between education and what has been
euphemistically coined hands-on intervention. Providing information and
education in response to an assessed need is clearly the right thing to do,
but the question of how to do this effectively may present a challenge.
Whilst it might be rational to suggest, in a particular agreed case or situation, that staff should guide a persons hand, this is not the same as, for
example, placing a mans hand on his penis or a womans fingers on her
clitoris, and simulating masturbation for the person. The latter interventions will rarely or ever be appropriate, owing to confounding issues
of consent and experience on the part of the service user and the feelings,
motives and rights of staff. Indeed, these interventions are highly likely to
be defined as abusive under adult protection procedures. For similar
reasons intimate and personal care interventions are informed by considerations of consent to touch (Cambridge and Carnaby, b) where
hand over hand contact and indirect cues to consent such as body language
and non-verbal forms of communication are utilized. However, it also
needs to be recognized that there are often no absolute boundaries on
issues such as hands-on interventions (Shelton, ), a reality mirrored
in sexuality work more widely, where previously taboo issues such as
access to paid sex by men with learning disabilities have recently been discussed (Cambridge, b).
The cultural appropriateness of educational method, image or message
is also an important consideration. For example, it has been observed in
safer sex education that images which may be culturally appropriate to a
gay identified man may not be culturally appropriate to a man with
learning disabilities who has sex with men (Cambridge, ). Cultural

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appropriateness in relation to race and ethnicity has also been discussed in

relation to sexuality work and sex education in learning disability (Baxter,
; Malhotra and Mellan, ; Senker, ) and is also relevant to antioppressive practice more widely (Baxter et al., ; Karmi, ; Shah,
). However, it is worth noting that few, if any, of the major world
religions take a positive view of masturbation (Thomson, ). That is not
to say that there is no value in consulting specialist advisers on cultural
matters relating to the education of people with learning disabilities about
masturbation. Experience suggests that this may be very useful and sometimes a very pragmatic and helpful approach may be taken, but there may
also sometimes be conflicts with user rights as articulated in law or in sexuality policies.

Considerations for working with men with learning

disabilities
An issue which often emerges when undertaking sexuality work with more
able men with learning disabilities concerns the use of pornography, which
is often used as part of masturbation or an aid to masturbation. Difficult
political and practice arguments surround the use of pornography, such as
situations where the man may have bought this himself or been given it
by other men he has met (Cambridge and Mellan, ). Staff may object
to its presence in bedrooms and the man has responsibilities to use it
appropriately and in private. However, in situations where it is used in
shared spaces or for masturbation in non-private places, the man will need
to be given clear messages that this is unacceptable.
For more able men with learning disabilities who may be having sex
with men outside their service (Cambridge, ), it will be particularly
important to present consenting masturbation and mutual masturbation as
positive sexual behaviour in the context of safer sex education, counselling
about HIV or assertiveness work. Men with learning disabilities who
engage in masturbation in public sex environments will be less vulnerable
to exploitation or sexual abuse and more able to escape assault or arrest
than those engaging in other, more involved forms of sexual contact.
However, the reality of sexual encounters in such situations will often mean
that masturbation is the initial stage of a sequence of sexual behaviours
which may lead to very unsafe sex, and safer sex education will need to
acknowledge such connections and risks (Cambridge, ).
Masturbation is popularly considered to be almost a preoccupation for
adolescent boys in the general population and clearly the enormous
physical and hormonal changes that take place during this time in a young
persons life can lead to a very strong interest in masturbation and indeed

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other sexual activities, for girls as well as boys. Yet the needs and feelings
of adolescents with learning disabilities are often overlooked (Rowitz,
), despite the fact that they will largely be undergoing the same
physical changes, with the disadvantage of less formal and informal sources
of sex education and support than other young people.

Considerations for working with women with learning

disabilities
One of the main considerations for working with women with learning
disabilities on masturbation issues is how little we know about womens
experiences and their feelings and needs related to this sexual activity.
There are few avenues for women with learning disabilities to talk about
masturbation and, even when provided with respectful opportunities to do
so, most women with learning disabilities find it extremely difficult and
embarrassing (McCarthy, ). This is not surprising given the double
standards and strong social taboos which still exist for all women in talking
about the sexual pleasure they can give themselves (McNeil, ). This
issue is made more complex for women with learning disabilities given
the negative feelings and lack of pleasure and pride they often take in their
bodies (McCarthy, ).
However, if appropriate opportunities can be made to discuss masturbation (and experience suggests that for many women with learning disabilities, this will be need to be on an individual basis, owing to the
embarrassment factor in group settings), then there is much that could be
gained from it. If women with learning disabilities can be helped to understand that masturbation is normal and widely practised amongst most
women (Hite, ), then they may feel less embarrassed and negative
about their own experience of it. In turn, they may learn what kinds of
sexual touch they do and do not enjoy and this can only help in any subsequent sexual activity they have with a partner. As evidence suggests that
many women with learning disabilities do not get much, if any, pleasure
from the sexual activity they engage in (McCarthy, ), then this would
clearly be of benefit.

Concluding remarks
Masturbation is one of the commonest and potentially most harmless
forms of sexual behaviour, enjoyed by women and men alike, sometimes
solely, but more often as part of a wider sexual repertoire. Most people also
masturbate throughout the majority of their lives. Considering this reality,
services for people with learning disabilities have been slow to empower

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service users to enjoy masturbation and to support them to masturbate

effectively and in appropriate ways and places. This is sadly often reflected
in the responses of service users themselves to masturbation, reported from
individual and group sex education (Cambridge and McCarthy, ;
McCarthy and Thompson, ), where it attracts negative interpretations
and associations with guilt and shame.
This inheritance reflects decades of neglect in relation to sexuality,
rooted in a values system in which people with learning disabilities are
socially and culturally marginalized and economically excluded, and where
services are still largely segregated and fail to acknowledge the heterogeneity in the population of people with learning disabilities. Recent policy
initiatives (Department of Health, ) have stressed the importance of
individualized and person-centred services and of social inclusion, and
almost two decades on from the influential work of Craft () and Brown
() we are now in a service culture where adult protection policy
(Department of Health, ) and management and practice in sexuality
can move forward in more empowering as well as protecting ways. A
starting point is how we respond to masturbation in productive and
empowering ways.
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Correspondence should be addressed to:
PAU L C A M B R I D G E , Tizard

Centre, University of Kent at Canterbury, Canterbury, UK.

e-mail: [email protected].

Date accepted

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