Supporting Pleasure: Service Systems
The masturbation message
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.
Recognizing masturbation problems
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.
Implementing Supportive Environments
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 as 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.