Prevalence and sequelae of self-reported and other-reported sexual abuse in adults with intellectual disability

Sexual Offenders With Intellectual Disabilities: An Exploratory Comparison Study in an Incarcerated U.S. Sample

Research indicates that individuals with intellectual disabilities (ID) are overrepresented among sexual offenders, and that those with ID might differ from those without ID in terms of the etiology of offending behavior. Despite this, few studies have explored ID using incarcerated U.S. samples. The present study sought to identify relevant characteristics of this population by comparing individuals with and without ID who are incarcerated in the U.S. for sexual offenses. Archival records for 3,066 participants were used to determine demographic, historical, and offense-related characteristics. Participants with ID, including those with borderline ID, comprised 19.1% of the sample and displayed elevated rates of adverse childhood experiences and psychopathology. Contrary to previous research, participants with ID were no more likely to offend against children than those without ID. These findings help to elucidate the etiology of offending behavior among those with ID and inform on potential targets for intervention.

A call for trauma-informed dental care for individuals with intellectual disabilities

People with intellectual disabilities are at increased risk of dental anxiety and poor oral health. In addition, people with intellectual disabilities are at increased risk of potentially traumatic experiences, such as violence and sexual abuse, and appear to be more vulnerable to developing trauma-related disorders following such experiences. While psychological trauma is associated with poor oral health and dental anxiety in the general population, the potential link between dental anxiety, poor oral health and psychological trauma is yet to be explored in people with intellectual disabilities. In this conceptual paper, we provide an overview of recent findings concerning the relationships between oral health and intellectual disabilities, psychological trauma and intellectual disabilities, as well as between psychological trauma and oral health, and discuss the relevance of these findings related to dental care for people with intellectual disabilities. We conclude that psychological trauma is likely to contribute to dental anxiety and poor oral health also in people with intellectual disabilities. Implications include an urgent need for research exploring how trauma affects oral health and experiences of dental care for people with intellectual disabilities, as well as the importance of individualized and trauma-informed dental care for these individuals.

Sexual experiences and knowledge of people with moderate intellectual disability

BACKGROUND

This study addresses the sexuality of people with moderate intellectual disabilities (PMID), a topic that has been little studied. Understanding romantic and sexual experiences is highly relevant for reducing stigma and prejudice related to their sexuality. Additionally, comprehending the level of sexual knowledge of PMID contributes to the development of preventive and sexual health education programmes tailored for this group. Our aim is to explore the sexual history (relationships, sexual behaviour, condom use and sexual abuse), sex education received and the level of sexual knowledge of PMID.

METHOD

The total of 142 PMID completed questionnaires about sexual knowledge and experiences, and their support staff provided additional information. Data were analysed using chi-square test (χ2) and descriptive statistical analysis.

RESULTS

Masturbation was the most common sexual behaviour (75.7%), especially among men (χ2 = 5.81, P < 0.05). Sexual intercourse was rare, and only 30.5% reported using condoms. Women reported a higher prevalence of self-reported sexual abuse (27.3% vs. 6% in men). The study also highlighted misconceptions about sexual intercourse risks and contraceptive methods.

CONCLUSION

The results suggest that PMID need sexual education to ensure healthy sexual experiences and prevent risky behaviour.

Analysis of the Effectiveness of an Affective-Sexual Education Program for Adults with Intellectual Disabilities

In recent years, the number of programs to improve sex education for people with intellectual disabilities has increased. However, in most cases, these programs do not provide any evidence of their impact. In the present study we analyzed the effectiveness of the SALUDIVERSEX affective-sexual education program for people with intellectual disabilities using a controlled trial design. 246 individuals from eastern Spain completed a battery of questionnaires before and after the intervention. Multilevel statistical analyses showed that the risk of experiencing sexual abuse had significantly decreased and knowledge about sexuality significantly increased among those who received the intervention compared to those who did not. The evaluation of the professionals who worked daily with the participants agreed on how knowledge about sexuality and intimacy increased and concerns about sexuality decreased among those in the intervention group. The SALUDIVERSEX program is a powerful educational strategy to promote better sexual health and quality of life for people with intellectual disabilities.

SALUDIVERSEX: A quality of life and sexual health intervention for adults with mild intellectual disabilities

Individuals with intellectual disabilities need an affective and sexual education adapted to their characteristics. There are few interventions that meet these objectives and offer empirical evidence of their efficacy. To respond to the limitations of existing interventions, an evidence-based affective-sexual educational intervention for adults with a mild degree of intellectual disability is proposed: SALUDIVERSEX. Participants will be randomly assigned to an intervention group that will receive the SALUDIVERSEX program or to a waiting list group. The intervention will be implemented by educators of occupational centers after a thorough training phase. Our main hypothesis is that the SALUDIVERSEX program will improve the sexual health and quality of life, through the joint action built into three components: the acquisition of basic information, the development of skills and strategies and the achievement of healthy attitudes towards the experience and expression of sexuality. The results of this approach could have important implications for optimizing the quality of life and self-determination of individuals with Intellectual disability by contributing to the development of healthy sexuality.

Characteristics and Prevalence of Lifetime Sexual Victimization Among a Sample of Men and Women with Intellectual Disabilities

This study examines the prevalence and characteristics of sexual victimization experiences suffered by people with intellectual disabilities (ID). The sample consisted of 260 adults with an ID diagnosis (154 men and 106 women), ranging in age from 20 to 71 years (M = 41.69, SD = 12.05). The results showed that 35% of the sample had been sexually victimized at some point in their life. Being a woman, being declared legally incapable, and having comorbid mental health diagnoses were the most relevant characteristics of sexual victims with ID. Fondling was the most reported victimization, and rape showed the greatest gender differences, with a higher risk for women with ID of being raped compared to their male counterparts (odds ratio = 4.28, p < .05). The offender was generally a known male adult, and the percentage of incidents reported to the authorities was very low (7.4%). The psychological consequences of abuse were general distress, anxiety, and depressive symptomatology. Intervention and prevention programs targeting this population, as well as the training of professionals and caregivers, are essential to deal with sexual victimization and to protect and ensure the quality of life of people with ID.

Sex Education for Students with an Intellectual Disability: Teachers’ Experiences and Perspectives

Background: Sex education assists students in the development of a healthy sexual identity and relationships. However, students with an intellectual disability tend to receive less holistic sex education as compared to students without a disability. In this inclusive study, we explored the perspectives of 10 high school teachers through interviews and focus groups on how students with an intellectual disability are informed about sexual relationships and prepared for their future life living with as much autonomy as possible, including living with a partner and becoming parents. Method: The interviews and focus groups were analysed using the inductive content analysis. Results: Data analysis revealed three themes: (a) sex education; (b) self-determination and self-advocacy skills; and (c) teachers’ concerns. Conclusions: Several recommendations are discussed. These include incorporating sexuality education-related goals in an Individualised Learning Plan (ILP); teachers adopting a rights-based approach and focusing on students’ self-determination, agency, and rights regarding sex education; and providing schools with necessary resources to teach sex education.

External sources promoting resilience in adults with intellectual disabilities: A systematic literature review

BACKGROUND

Persons with an intellectual disability are at increased risk of experiencing adversities. The current study aims at providing an overview of the research on how resilience in adults with intellectual disabilities, in the face of adversity, is supported by sources in their social network.

METHOD

A literature review was conducted in the databases Psycinfo and Web of Science. To evaluate the quality of the included studies, the Mixed Method Appraisal Tool (MMAT) was used.

RESULTS

The themes: "positive emotions," "network acceptance," "sense of coherence" and "network support," were identified as sources of resilience in the social network of the adults with intellectual disabilities.

CONCLUSION

The current review showed that research addressing sources of resilience among persons with intellectual disabilities is scarce. In this first overview, four sources of resilience in the social network of people with intellectual disabilities were identified that interact and possibly strengthen each other.

Lifetime Victimization and Poly-Victimization in a Sample of Adults With Intellectual Disabilities

People with intellectual disabilities appear to be more vulnerable to victimization. However, few studies have assessed victimization in these groups and those that do exist are highly heterogeneous and tend to focus only on specific forms of violence. This study attempts to shed light on the phenomenon of victimization among adults with intellectual disabilities by assessing victimization and poly-victimization throughout their life course. The sample consisted of 260 adults (154 men and 106 women) with an intellectual disability diagnosis, recruited from the Catalan Federation for People with Intellectual Disabilities (DINCAT) in Spain. They ranged in age from 20 to 71 years (M = 41.69, SD = 12.05). Victimization experiences were assessed by means of an adaptation of the retrospective version of the Juvenile Victimization Questionnaire (JVQ). The results showed that 96.9% of the participants had suffered some kind of victimization throughout their lives. With respect to the types of victimization, the most frequent were common victimization (87.7%), witnessing and indirect victimization (67.3%), victimization by caregivers (59.2%), sexual victimization (35%), and electronic victimization (23.5%). Women and early adults tended to experience higher rates of victimization. The poly-victimized group experienced 13 or more incidents of victimization throughout their lives. This study highlights the elevated rates of lifetime victimization among people with intellectual disabilities. It adds to previous evidence that special protection programs are required to address this issue and emphasizes the need for prevention and intervention measures in this particularly vulnerable group.

Effectiveness of pre-employment independent life education program designed for young adults with intellectual disability

It is important to provide the independent life support individuals with intellectual disabilities need in preparing for employment. The primary purpose of this study was to investigate the effectiveness of the Pre-Employment Independent Life Education Program (PILEP) design based on the needs to inform and support young adults. The research model is a pre-test post-test control group design. Thirty young adults with intellectual disabilities participated in the study. Also, included within the scope of the social validity study were the opinions of the participants and stakeholders in the PILEP. The PILEP consists of three modules: (1) Personal Care and Hygiene, (2) Preparation to Community Life and (3) Health and Safety. A mixed ANOVA (2x3) with two factors was performed to investigate the effectiveness of the PILEP. The results showed that PILEP was effective regarding the knowledge and skills of young adults. A significant difference (p < .05; η² = 0.94) was found between the experimental group and control group with large effect size. In the social validity study, the opinions of the participants, their parents, employer, job teacher and lead waiter were interviewed. The opinions on the content, presentation, and implementation with multimedia design of the PILEP were positive.

A scoping review of measurement of violence against women and disability

INTRODUCTION

Existing evidence indicates that prevalence of violence against women with disability is elevated compared to women without disability. We conducted a scoping review with a focus on measurement to assess the forms of measurement and study design utilized to explore the intersection of violence against women with disabilities, and to identify strengths and limitations in current approaches to measuring violence against women with disabilities. This scoping review is designed to inform current debates and discussions regarding how to generate evidence concerning violence against women with disabilities.

METHODS AND RESULTS

We conducted systematic searches of the following databases: PubMed, PsycINFO, Embase, CINAHL, PILOTS, ERIC, Social Work Abstracts, International Bibliography of the Social Sciences, Social Services Abstracts, ProQuest Criminal Justice, and Dissertations & Theses Global, and conducted structured searches of national statistics and surveys and grey literature available on-line. We identified 174 manuscripts or reports for inclusion. n = 113 manuscripts or reports utilized acts-specific measurement of violence. In terms of measurement of disability, we found that amongst the included manuscripts and reports, n = 75 utilized measures of functioning limitations (n = 20 of these were Washington Group questions), n = 15 utilized a single question approach and n = 67 defined participants in the research as having a disability based on a diagnosis or self-report of a health condition or impairment.

DISCUSSION

This scoping review provides a comprehensive overview of measurement of violence against women with disabilities and measurement of violence within disability-focused research. We identified several important gaps in the evidence, including lack of sex and disability disaggregation, limited evidence concerning adaptation of data collection methods to ensure accessibility of research activities for women with disabilities, and limited evidence concerning differential relationships between types of disability and violence exposure. This scoping review provides directions for sub-analyses of the included studies and further research to address gaps in evidence.

Sexual Health in Spanish People with Intellectual Disability: the Impact of the Lockdown due to COVID-19

INTRODUCTION

The lockdown due to COVID-19 affected the sexual health of the people with intellectual disabilities by differentially modifying the frequency and characteristics of people's sexual activity depending on whether or not they lived with a partner during this period. The aim of this study was to analyze the extent to which the sexual behavior of people with intellectual disabilities (with and without a partner) was affected during the lockdown.

METHODS

The sample consisted of 73 people with intellectual disabilities between 21 and 63 years old (M = 39.63; SD = 10.11). The variables analyzed were the physical, social, and technological environment during the lockdown, sexual appetite, sexual behavior, online sexual activity, and sexual abuse. The data were collected between the months of May and June of 2020.

RESULTS

The lockdown increased the sexual appetite of a third of the sample (38%), especially the youngest participants. Sexual activity focused on autoeroticism and online behavior, particularly sending nude images of oneself (88%) and viewing pornography (83.6%). Rates of sexual abuse during this period were relatively high (6.8%).

CONCLUSIONS

The sexual activity of people with ID was important during the lockdown, and they had to adapt to the circumstances of isolation in a similar way to the general population. Technological improvements in terms of devices and connection quality at home allowed their sexual behavior to be reoriented, opening the door to new risks for the sexual health of people with ID.

POLICY IMPLICATIONS

Cybersex and the increase in sexual abuse due to confinement are aspects that should be included in programs to improve the sexual health of this group.

Prevalence of adult sexual abuse in men with mental illness: Bayesian meta-analysis

BACKGROUND

Sexual abuse is a broad category of traumatic experiences that includes rape and any unwanted sexual contact with a body part or foreign object, whether penetrative, oral or otherwise. Although patients with mental illness have a higher risk of becoming victims of sexual abuse in adulthood, few studies investigate the proportion of male victims in this population. Their underrepresentation in research is a barrier to understanding the negative outcomes associated with sexual abuse in men.

AIMS

We estimated the prevalence of recent (past year) and adulthood sexual abuse perpetrated by any perpetrator and separately by intimate partners in males diagnosed with a mental illness.

METHOD

To model the prevalences and heterogeneity arising from reports, we used Bayesian multilevel models. Prevalences were estimated for mixed-diagnosis, substance misuse, intellectual disability and post-traumatic stress disorder samples, and studies reporting specifically on intimate partner violence. This review was registered through PROSPERO (CRD42020169299).

RESULTS

Estimated adult sexual abuse was 5.3% (95% Credibility Interval 1.6-12.8%) for past-year abuse and 14.1% (95% Credibility Interval 7.3-22.4%) for abuse in adulthood. There was considerable heterogeneity of prevalence between studies and diagnosis groups.

CONCLUSIONS

Our analyses show that the prevalence of sexual abuse of males diagnosed with a mental illness was much higher than for men in the general population. This has important implications regarding the proportion of undetected or untreated sexually abused men in clinical practice.

Sexual abuse of people with intellectual disabilities in residential settings: a 3-year analysis of incidents reported to the Dutch Health and Youth Care Inspectorate

OBJECTIVES

To explore characteristics of sexual abuse within residential settings for people with an intellectual disability and to map out measures undertaken and improvement plans made by healthcare organisations after sexual abuse.

DESIGN

Descriptive analysis of reports about sexual violence against persons with an intellectual disability submitted to the Dutch Health and Youth Care Inspectorate by healthcare organisations.

SETTING

Residential settings for people with an intellectual disability in The Netherlands.

SELECTION

186 incident reports submitted to the Inspectorate between January 2017 and December 2019 were included.

RESULTS

125 incident reports concerned sexual abuse by fellow clients and 61 reports concerned sexual abuse by professionals. Client perpetrators were predominantly male whereas almost 30% of the abusing professionals were female. The majority of the perpetrating professionals were unlicensed professionals. Clients who committed sexual abuse were mostly relocated to another residential setting. Most healthcare organisations invested in education and training for employees instead of improving the sexual education programme for clients after an incident of sexual abuse. If there was a strong suspicion of sexual abuse by a professional, resignation followed in most cases. In just two cases, the perpetrating professional was reported to a warning registry.

CONCLUSIONS

A small amount of the perpetrating professionals held a licensed profession, which makes it challenging to address this form of sexual abuse through healthcare regulation. It raises the question why warning registries are not engaged more often after alleged sexual abuse. Constantly relocating abusing clients might endanger the (sexual) safety of clients in these new environments. Previous literature suggests that adequate sexual education regarding social skills and sexual behaviour is very effective for the majority of clients who commit sexual abuse. Healthcare organisations could take up a more prominent role in this to ensure safety for their own clients and for clients residing elsewhere.

Validation of the educational technology "abuse no more" for young people with intellectual disabilities

The implementation of educational actions, including sexual violence prevention, aimed to promoting the sexual rights of young individuals with intellectual disabilities, can be characterized as a huge challenge in the services that assist this population. This article aims to validate, with expert judges, educational technology aimed at sexual abuse prevention among young individuals with ID. This is a content and display validation study, performed with 25 judges. The information was collected through a questionnaire, considering the domains: objective, relevance, structure and presentation. The quantitative data were analyzed using the Content Validation Index (CVI) and a cutoff point of 0,80 was adopted, while qualitative data were submitted to thematic content analysis. An educational technology "Abuse no more: learning to protect yourself", was subsidized by Vigotsky's theoretical framework and consists of a set of materials, including a storybook and support resources (dolls, booklet and explanatory video). This technology was validated by the judges, with a total CVI of 0,99, obtaining a CVI >0,95 in all items and domains. The judges highlighted the relevant and innovative nature of the technology, offering suggestions for its improvement.

Syndrome-Related Risk Factors for Sexual Abuse: The Example of Prader-Willi Syndrome

Many genetic disorders associated with intellectual disability are characterized by unique behavioral phenotypes which may have serious psychological consequences such as increasing the risk for sexual abuse (SA). Prader-Willi Syndrome (PWS), a severe neurogenetic syndrome with uncontrollable hyperphagia and high threshold for pain, is an excellent example of this issue. The absence of reports on SA in PWS highlights the lack of awareness to the topic. Our aim was to report on SA in individuals with PWS, describe its unique characteristics, and offer recommendations for its prevention. Caregivers of all individuals with genetically confirmed PWS living in the only two residential facilities designated for PWS in Israel were interviewed for a history of sexual behavior and abuse, and medical data were collected from their files. SA was reported in a quarter of the sample. In most of the cases (78%), food reward was used by the perpetrators to attract their victims. Age at SA ranged from 11 to 29 years. Most of the individuals did not disclose the event and some continued to initiate inappropriate sexual activity to obtain food. Characteristics unique to PWS, such as food-seeking behaviors and high threshold for pain, likely contribute to the risk for SA. These findings suggest that syndrome-specific programs for SA prevention should be considered for individuals with any genetic syndrome with behavioral problems that may increase SA risk.

Prevalence of Sexual Abuse in Adults with Intellectual Disability: Systematic Review and Meta-Analysis

This study presents the results of a systematic review on the prevalence of sexual abuse experienced in adulthood by individuals with intellectual disability. An electronic and manual search of academic journals was performed on four databases via EBSCO Host: Academic Search Complete, PsycINFO, Medline, CINAHL Full-Text. In addition, PubMed, ProQuest, and Web of Science (core collection) were searched. After an initial selection of 1037 documents, 25 articles remained for quantitative synthesis. The combined prevalence of sexual abuse in adults with intellectual disability was 32.9% (95% CI: 22.7–43.0) and sensitivity analysis revealed that the prevalence was not outweighed by a single study. Overall, the United Kingdom had the highest prevalence (r = 34.1%), and the USA had the lowest (r = 15.2%). The overall prevalence in females was lower (r = 31.8%) than that in males (r = 39.9%). Subgroup analyses revealed that prevalence of sexual abuse was higher in institutionalized individuals. The most prevalent profile of abuser is of a peer with intellectual disability. Prevalence increases from mild to severe levels of intellectual disability and decreases in profound levels. It is also more prevalent when the informant is the individual with intellectual disability than when someone else reports abuse. In sum, one in three adults with intellectual disability suffers sexual abuse in adulthood. Special attention should be paid for early detection and intervention in high risk situations.

Development and psychometric properties of an instrument for the Assessment of Sexual Behaviour and Knowledge of people with Intellectual Disability

BACKGROUND

This paper presents psychometric properties of an instrument for the Assessment of Sexual Behaviour and Knowledge of people with Intellectual Disability (ASBKID), other-reported by professionals who are in daily contact with them.

METHODS AND PROCEDURES

Assessments of 236 individuals with intellectual disability were obtained from 100 professionals.

RESULTS

Confirmatory factor analysis revealed a four-factor structure: concern about the user's inappropriate or uninhibited sexual behaviour; perception of the user's knowledge about privacy and social norms; perception of the user's knowledge about sexuality; and concerns about the user's sexuality. A multi-group CFA was also conducted in men and women, confirming the adequacy of this four-factor structure by gender. The reliability of the factors ranged from 0.74 to 0.92.

CONCLUSIONS

The psychometric results obtained support the use of the ASBKID as a valid and reliable measure for the assessment of sexual behaviour and knowledge in both men and women with intellectual disability.

Development and Psychometric Properties of the Detection of Sexual Abuse Risk Screening Scale (DSARss)

People with intellectual disability (ID) are more vulnerable to being victims of sexual abuse (SA) because, in most cases, they are not able to detect the warning signs that abuse could occur. However, there is a lack of appropriate assessment tools to determine their vulnerability. To address this limitation, the current study tests the psychometric properties of the Detection of Sexual Abuse Risk Screening Scale (DSARss), a new scale developed to assess the ability of individuals with mild or moderate ID to detect the risk of SA. In all, 246 individuals with mild or moderate ID (55.3% males) completed the DSARss, along with other scales assessing related dimensions (e.g., psychopathological symptoms, quality of live). Exploratory factor analysis (EFA) yielded a four-factor structure explaining 65.34% of the total variance in the DSARss. Two independent EFAs in males and females were also performed to confirm the suitability of this four-factor structure according to gender. The reliability of the total score and subscales ranged between .70 and .93. Likewise, correlations with other related scales were positive and significant. Temporal stability 6 months after the first application was .47. Finally, we explored the criterion-related validity of the DSARss across different SA indicators. These results, along with the absence of sound questionnaires to assess the risk of SA in people with ID, justify the use of the DSARss to assess this construct in both men and women.

The disproportionately high prevalence of learning disabilities amongst adults attending Saint Marys Sexual Assault Referral Centre

BACKGROUND

There is a dearth of reliable data on sexual assault prevalence amongst people with learning disabilities. This work aims to identify the prevalence of learning disabilities amongst adult clients attending Saint Marys Sexual Assault Referral Centre and ascertain the similarities/differences amongst clients with learning disabilities as compared to clients without.

METHOD

A short validated Learning Disability Screening Questionnaire was completed by adult clients attending Saint Marys for a forensic medical examination during a twelve-month period.

RESULTS

Amongst 679 clients who attended for an FME and completed the LDSQ, 8.2% were likely to have a learning disability and the presence of self-reported: mental health issues (X²  = 11.24, p = .001), self-harm (X²  = 5.63, p = .017) and substance misuse (X²  = 13.15906, p = .001).

CONCLUSIONS

Consistent with the broader literature, people with learning disability were over-represented in the sexually assaulted population emphasizing the importance of timely, accessible and appropriate patient-centred care for this vulnerable group.

Clinical characteristics of individuals with intellectual disability who have experienced sexual abuse. An overview of the literature

BACKGROUND

Sexual abuse in individuals with average IQ or above is associated with a wide range of behavioural, psychological and body-related characteristics. It is unknown whether individuals with intellectual disability (ID) and a history of sexual abuse suffer from similar clinical characteristics.

OBJECTIVE

The aim of the review is to provide an overview of the literature on the clinical characteristics of individuals with ID who have experienced sexual abuse.

METHOD

PubMed, Embase, PsycInfo, CINAHL, Cochrane Library and Web of Sciences were searched for relevant publications using terms related to concepts of "intellectual disability" and "sexual abuse". Two independent reviewers screened and selected articles for inclusion in the study, resulting in seven studies.

RESULTS

The studies mostly reported behavioural and psychological characteristics such as aggression, self-injury, or posttraumatic stress, anxiety or depressive symptoms associated with sexual abuse in individuals with ID. None mentioned body-related characteristics.

CONCLUSIONS

Similar to individuals with average IQ or above, sexual abuse in individuals with ID is associated with a broad range of behavioural and psychological characteristics. Conduct disorders, self-injury, inappropriate sexualised talk and poor feelings of personal safety seem to be more indicative for the ID population. Anxiety, depression and PTSD are prevalent in individuals with and without ID who both have experienced sexual abuse. Whether individuals with ID experience body-related characteristics is unclear.

Ethical dilemmas and legal aspects in contraceptive counselling for women with intellectual disability-Focus group interviews among midwives in Sweden

BACKGROUND

Few studies have explored ethical and legal issues in contraceptive counselling among women with intellectual disability (ID). This study aimed to gain a deeper understanding of these issues during midwifery contraceptive counselling.

METHOD

The present authors interviewed 19 midwives in five focus groups in Sweden 2016 - 2017 and analysed data with content analysis.

RESULTS

The participants expressed that women with intellectual disability have equal right to relationships and sexual expressions, but feared exposure to sexual exploitation/abuse. They experienced ethical dilemmas related to principles of fairness and autonomy, but strived to provide assistance in spite of the women's cognitive impairment, presence of supporting persons and uncertainty of optimal counselling. Organizational support was insufficient.

CONCLUSIONS

The midwives experienced ambivalence, uncertainty and ethical dilemmas in their counselling. They were, however, aware of legal aspects and strived for the women's best interest, right to self-determination and autonomous choices. The participants wanted better professional teamwork and support.