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Journal of Applied Research in Intellectual Disabilities 2002, 15, 285296

Attitudes towards Sexuality, Sterilization


and Parenting Rights of Persons with
Intellectual Disabilities
M. Aunos
Department de Psychologie Orthopedagogie, Universite de Quebec a` Montreal,
Montreal, Quebec, Canada

M. A. Feldman
Department of Psychology, Queens University, Kingston, Ontario, Canada
Paper accepted August 2002
Background and Methods We review articles pertaining to attitudes towards sexuality, sterilization, procreation and parenting by people with intellectual disabilities. Most empirical studies
were conducted after the appearance of the principles of normalization and role valorization in
the 1970s.
Results Across studies, special education teachers and university students appear to hold more
positive attitudes towards sexuality and sexuality education programs than parents and service
workers. People with intellectual disabilities have conservative attitudes towards sexual intercourse and homosexuality, but may be accepting intimate contact by familiar persons. Despite
the ban on involuntary sterilization, it appears that many parents and teachers of persons with
intellectual disabilities still support it as a form of contraception, especially for persons with
severe intellectual disabilities. Likewise, attitudes towards parenting by persons with intellectual
disabilities remain negative, and these attitudes may adversely affect the provision of competencyenhancing supports and services for parents with intellectual disabilities and their children.
Conclusions It is recommended that new studies should be undertaken, comparing attitudes
across different groups involved with persons with intellectual disabilities and examining the
impact of prejudicial attitudes on sexual expression and parenting by persons with intellectual
disabilities.

Introduction
It is now recognized that persons with intellectual disabilities have the same sexual
needs and desires as persons without intellectual disabilities (Mitchell et al. 1978).
Sexuality is seen as a key concept in the process of normalization. Persons with
intellectual disabilities have the right to: experience intimacy and reciprocal affection;
express their needs according to social norms; receive sexual education and family
planning services; marry, procreate and receive needed services and supports (Kempton
1980 reported in Trudel & Desjardins 1992).
Despite the advances made by people with intellectual disabilities in securing their
sexual rights, it is uncertain whether attitudes of the society have adjusted accordingly.
This paper reviews research on attitudes of parents, service workers, teachers and
persons with intellectual disabilities on sexuality, sterilization, marriage and parenting
of persons with intellectual disabilities (literature review included English and French
publications and dissertations). Differences in opinions and changes in attitudes over
time will be highlighted, where possible. Also, a hypothetical model regarding the effect
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of different elements in a persons life on parenting as well as a discussion on the legal


implications and the process of changing attitudes is presented.

Attitudes on sexuality
People with disabilities have encountered different obstacles in their social adjustment
and social acceptance, particularly with respect to sexuality (Toomey 1993; Donnell et al.
1999). A lack of knowledge and contact with persons with intellectual disabilities leads
many people to view people with intellectual disabilities as sexually deviant (Toomey
1993) or asexual (Bemish 1987; DeLoach 1994) and incapable of having a long-term
sexual relationship (DeLoach 1994). Ironically, people with intellectual disabilities have a
high risk of sexual exploitation and assault by (familiar) persons without disabilities
(Sobsey 1994).
Personnel working with people with intellectual disabilities
A majority of direct-care workers accept certain sexual behaviours like masturbation,
hugging and brief kissing, in persons with intellectual disabilities (Mitchel et al. 1978;
Craft & Craft 1981; Mulhern, 1975 in McCabe 1993; Owen et al. 2000). Disapproval
increases the greater the degree of intimacy of sexual contact of persons with intellectual
disabilities (McCabe 1993; Mulhern, 1975 in Holmes 1998; Owen et al. 2000). For example,
approximately 72% of 117 workers surveyed, felt that limited heterosexual contact (i.e.
holding hands) by people with intellectual disabilities is acceptable everywhere, but only
9% of personnel approved of sexual intercourse between persons with intellectual
disabilities (Mitchell et al. 1978). Mitchell et al. (1978) also found that a majority of
service workers felt that there was an excessive amount of inappropriate sexual
behaviour amongst people with intellectual disabilities. Unfortunately, their study
did not evaluate the differences in attitudes towards sexuality of people with and
without intellectual disabilities.
Variables that affect service workers attitudes include their age (Brantlinger 1983;
Trudel & Desjardins 1992; Murray & Minnes 1994), type of institution they work in, their
religion, the frequency of interaction with their clients (Brantlinger 1983; Trudel &
Desjardins 1992) and their profession (Matilsky 1978; Trudel & Desjardins 1992; Murray &
Minnes 1994). Both administrators and service workers attitudes were more repressive
and negative towards the expression of sexuality of people with intellectual disabilities
than towards the sexuality of people with other (e.g. physical) limitations (Dupras et al.
1984; Trudel & Desjardins 1992). Furthermore, young and better educated professionals
(e.g. social workers) usually have more liberal attitudes towards sexuality of people with
intellectual disabilities than direct-care workers (Matilsky 1978; Brantlinger 1983;
Murray & Minnes 1994; Murray et al. 1999). Community group homes staff held more
positive attitudes towards the expression of sexuality of people with intellectual disabilities than institutional staff, who were, in turn, more open minded than nursing home
staff (Brantlinger 1983). Nonetheless, in general, direct-care staff think that persons with
intellectual disabilities should be discouraged from having sexual relations (Craft &
Craft 1981; Craft 1983; Trudel & Desjardins 1992) in order to avoid pregnancy, law suits,
and conflicts with the parents of their clients (Giami 1987; Trudel & Desjardins 1992).
More accepting attitudes were correlated with knowledge of sexuality in persons with
intellectual disabilities and positive attitudes towards sexuality in general (Daniels 1976).
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Teachers
Teachers generally have positive attitudes towards educational programmes on sexuality and family planning for teenagers with mild intellectual disabilities (Brantlinger
1992b). Unfortunately, even though many teachers were in favour of sexual education
programmes, few have actually taught a course on sexuality because of lack of personal
knowledge, fear of community reactions, and lack of administration support. Furthermore, male teachers were more concerned about special sexual education than female
teachers, perhaps because the men feared others judging them as having ulterior motives
or they perceived sexual education as being a womans role and responsibility
(Brantlinger 1985, 1989). Nonetheless, compared to parents of children with intellectual
disabilities or service workers, special education teachers had more positive attitudes
towards sexuality and sexuality education programmes (Brantlinger 1985).
University students
McEwen (1977) reported that more than half of the 90 students surveyed had favourable
attitudes concerning the right of people with intellectual disabilities to have sexual
intercourse. Fifty-two per cent added that people with intellectual disabilities should be
allowed to have sexual intercourse only if married and about 75% of them also agreed
that birth control measures should be provided to them. Prospective special education
teachers also held positive attitudes towards sexuality and self-determination of persons
with intellectual disabilities, and a course on sexuality and persons with a disability
further strengthened those views (Bemish 1987). Another study found no difference in
attitudes between undergraduate students studying social work, education or special
education (Hagen et al. 1983). The more positive and intimate the contact with people
with intellectual disabilities (e.g. if they had a sibling with intellectual disabilities), the
more liberal was the students attitudes were towards the right of people with intellectual disabilities to express their sexuality.
Parents of children with intellectual disabilities
Many parents of children with intellectual disabilities held ambivalent or restrictive
attitudes and avoided talking about sex with their children with intellectual disabilities
(Dupras & Tremblay 1981; Brantlinger 1985). Parents were more accepting if their
offspring was in a stable relationship (Dupras & Tremblay 1981) and girls received
more information on sexuality from their parents than boys (Alcorn 1974). With parents
avoiding the subject and special education generally not offering a curriculum on
sexuality (Alcorn 1974; Brantlinger 1985), children and adolescents with intellectual
disabilities may not receive adequate information on sexuality. This is turn may make
them susceptible to abuse (Owen et al. 2000).
People with intellectual disabilities
Brantlinger (1985) reports that 10 out of 13 students, aged from 14 to 17 years, thought or
acted as if sex was a dirty and nasty business, but only three students disapproved of
intercourse outside of marriage. Eight students had negative attitudes and five had more
tolerant attitudes towards homosexuality. Persons with intellectual disabilities were less
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knowledgeable concerning sexual topics than peers without disability (Edmonson &
Wish 1975 in McCabe & Schreck 1992; McCabe & Schreck 1992; Szollos & McCabe 1995;
McCabe & Cummings 1996). Compared to first-year university students, people with
intellectual disabilities had less negative attitudes towards sexual abuse and promiscuous sex, but more negative or conservative attitudes towards dating, the use of
condoms, homosexuality, masturbation, oral sex and intercourse than the students
(McCabe & Cummings 1996; Timmers, Ducharme, & Jacob, 1981 in Lunsky & Konstantareas 1998). Finally, men and women with intellectual disabilities held similar
conservative attitudes concerning sexuality expression except that women with intellectual disabilities had more positive attitudes towards marriage (Szollos & McCabe
1995).
More recent studies suggest that adults with intellectual disabilities still hold negative attitudes towards sexuality (Lunsky & Konstantareas 1998; Owen et al. 2000).
Persons with intellectual disabilities had less positive attitudes towards sexual activities
than those with autism, who in turn had less positive attitudes than undergraduate
students (Lunsky & Konstantareas 1998). Nearly all undergraduate students, but only
50% of persons with intellectual disabilities approved of masturbation and pornography;
80% of students accepted homosexuality, compared to 33% of respondents with intellectual disabilities. Owen et al. (2000) found that adults with intellectual disabilities
thought that sexual relationships were wrong no matter who the partner, but they
did condone affectionate touching of a leg, kissing or hugging, especially with familiar, but unrelated, care providers. Also, more than 50% of the sample accepted or
were indifferent to receiving a kiss on the lips from workers they have known for a
long time.
Conclusions
Looking across studies, special education teachers and university students seem to have
more positive attitudes towards sexuality and sex-education programmes than parents
and service workers. But, even though some people are more inclined to accept sexual
expression from people with intellectual disabilities, their sexuality may still evoke
feelings of discomfort (Heshusius 1982). Parents of children with intellectual disabilities
generally feel uneasy towards and attempt to restrict their childs sexual expression
(Craft & Craft 1981; Dupras & Tremblay 1981). Service workers ambivalent and negative
attitudes of the 1970s and 1980s (Dupras et al. 1984; Dupras & Le vy 1984; Trudel &
Desjardins 1992), may be giving way to increasingly liberal attitudes (Holmes 1998;
Murray et al. 1999). As for people with intellectual disabilities, themselves, they still seem
to have conservative attitudes towards sexual intercourse and homosexuality (Lunsky &
Konstantareas 1998; Owen et al. 2000). There is a pressing need for more updated studies
comparing attitudes across types of respondents, determining what factors affect
attitude and how attitude affects caregivers support. Research also is needed evaluating
the impact of sexuality courses for persons with intellectual disabilities on sexual
attitudes and behaviours.

Attitudes towards sterilization


Studies conducted in the 1970s found that up to 80% of parents and service workers
favoured sterilization of persons with intellectual disabilities as a form of birth control
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(Alcorn 1974; Whitcraft & Jones 1974; David et al. 1976; Wolf & Zarfas 1982; Wolfe
1997). Alcorn (1974) found that half of the parents surveyed were considering sterilization for their child with intellectual disabilities, and a third were hesitant about
other forms of contraception. Wheeless (1975) reported that 95% of parents who had
already sterilized their child were pleased with the operation and had no regrets.
Parents of lower functioning or older children (>15 years old) held more favourable
views towards sterilization than parents of higher functioning or younger children
(Wolf & Zarfas 1982). Since these studies, sterilization of persons with intellectual
disabilities has been banned in most jurisdictions. Nonetheless, a recent study found
that all of the 98 teachers and school administrators surveyed were more inclined to
support sterilization when the intellectual disability was more severe and most of
them were in favour of sterilization of people with intellectual disabilities, even
though it was against the law (Wolfe 1997). Physicians have voiced objections
towards the sterilization of people with intellectual disabilities for contraception,
although they often continued to practice it (Brantlinger 1992a). Although many
advocates support the ban on involuntary sterilization, they argue that to be consistent
with normalization principles, adults with intellectual disabilities should have the
right to chose to be sterilized if they were able to make an informed and free decision
(Bass 1978).

Attitudes towards marriage and parenting


Parents of children with intellectual disabilities
Generally, about 75% of parents surveyed were against their children marrying
and raising children; the parents felt that their children would lack the capacity to
parent on their own (Alcorn 1974; Whitcraft & Jones 1974; Dupras & Tremblay 1981;
Wolf & Zarfas 1982). A majority of parents were against marriage even if their child
would use contraception (Alcorn 1974). Interestingly, parents of males with intellectual disabilities rated their childrens parenting capacity higher than parents of
females with intellectual disabilities of the same level of functioning (Wolfe & Zarfas
1982).
Special education teachers
Like parents, many teachers and professionals working with people with intellectual
disabilities are against marriage and parenthood for persons with intellectual disabilities
(Leyser & Abrams 1982; Brantlinger 1988a,b, 1992a; Wolfe 1997). For example, in
Brantlinger (1988a), 14 of 22 (64%) special education teachers said that people with
intellectual disabilities should never have children. Twenty teachers (91%) were concerned about the renewal of the cycle of poverty, special education and low parenting
abilities. Some teachers felt that a few of their students could have good parenting
abilities with training. Teachers were more optimistic when mothers with intellectual
disabilities decided to stay in school and were in strong relationships. Nonetheless,
attitudes of educators (and parents) may be more negative now than 20 years ago and
they want increased emphasis towards prevention of pregnancy in sexual education
programmes (Griffiths & Lunsky 2000).
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Figure 1 A parenting interactional model applicable to parents with intellectual disabilities. Items in italics are possible impediments to effective
parenting and optimal child outcomes. Reprinted with the permission of NADD Press.

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Service workers and professionals


In one study, 60% of 131 service workers felt that people with intellectual disabilities
should have the right to get married and have children but only if they can hold a good
job, if they have good personal abilities and a strong sense of responsibility (Coleman &
Murphy 1980). Some workers felt that persons with intellectual disabilities should only
be allowed to marry if they agree to be sterilized. More recent studies suggest that the
majority of professionals maintain major concerns about marriage and parenting for
persons with intellectual disabilities (Brantlinger 1992a; Wolfe 1997).
People with intellectual disabilities
Not surprisingly, a majority (6090%) of persons with mild intellectual disabilities want
to marry and raise a child (David et al. 1976; Brantlinger 1985; Gan et al. 1977 reported in
Bass 1978). Most of them are against using abortion or adoption processes for their own
means, even though they think that adoption is a more acceptable solution than abortion
(Brantlinger 1985). They also preferred having a small number of children because of the
costs and effort needed in raising them (David et al. 1976).

Model of parenting and the influence of attitudes


There is increasing recognition that parenting difficulties of people with intellectual
disabilities is not solely a function of their cognitive limitations (Tymchuk & Feldman
1991; Feldman 2002). Consistent with ecological theories of parenting (Belsky 1984;
Bronfenbrenner 1986), numerous past and present parent, child, and family ecological
factors will affect parenting style and child outcomes in families where the parent
has intellectual disabilities (Feldman 2002). Feldman (2002) has proposed an interactional model (see Fig. 1) that (among other things) recognizes that attitudinal social
factors and related experiences may have unique influence on parents with intellectual
disabilities. It is recognized that some of the illustrated relationships may be bi-directional and other relationships not shown may exist, but only the more powerful
hypothesized relationships are presented. This model currently is undergoing empirical
evaluation.
We highlight two areas of the model that are related to the attitudes of others towards
the parents social factors and social support. The model hypothesizes that discrimination and stigmatization experienced by persons with intellectual disabilities may
adversely affect the parents psychological well-being and access to appropriate supports, that in turn affect parenting abilities. Many adults with intellectual disabilities
understand and dread the stigma of a diagnostic label (Bogdan & Taylor 1976). In
response, they may take on a cloak of competence (Edgerton & Bercovici 1976),
adopting strategies that make them look more able than they are. For example, they
may be reticent to admit that they need help and eschew offers of assistance. This
approach may work in some situations to leave an impression of competence, but it is
detrimental when one is a parent. A parent with intellectual disabilities who maintains
he/she is doing just fine and (in the face of evidence to the contrary) rejects help
reinforces the prevailing stereotype that he/she lacks good judgement, is unrealistic
about the demands of parenting, and is not motivated to improve. By putting on the
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cloak of competence, he/she ironically may provide further evidence to those predisposed to document areas of parental incompetence. Hence, as seen in Fig. 1, the model
proposes a link between the parents history and social support through social factors,
such as discrimination and stigmatization.
The interactional parenting model recognizes the important influence of social
support and services on parenting. Social support in and of itself may not necessarily
be beneficial to the family. Tucker and Johnson (1989) describe two types of social
support for parents with intellectual disabilities competency inhibiting and competency enhancing. If family members, service workers, and significant others express
negative attitudes and discourage independence, then the cooperation and competency of parents with intellectual disabilities may be adversely affected. On the other
hand, when there is an attitude of empowerment of the family, supports and services
are generally well received and are more effective (Espe-Sherwindt & Kerlin 1990;
Llewellyn & Bridgen 1995). Indeed, support satisfaction, but not support size or need,
was significantly related to positive parentchild interactions (Feldman et al. 2002). This
study suggests that attitudes towards parents with intellectual disabilities and how
supports are provided may influence their parenting competence. Further research is
needed to determine the way attitudes of persons in the familys social support network
influence the type and impact of support and services they provide to parents with
intellectual disabilities.

Legal decisions and the influence of attitudes


Negative stereotypes about persons with intellectual disabilities still affect and influence
the decision-making process in the legal system regarding family preservation. These
parents are over-represented in custody hearings in Australia, Canada and the US and
often lose their children without evidence of child maltreatment (Vogel 1987; Hertz 1979;
Hayman 1990; Glaun & Brown 1999; McConnell et al. 2000). Termination of parenting
rights often is based on the misconceptions that the parents intellectual disabilities
automatically makes them incapable of adequately raising children, and that they lack
the potential to learn (Espe-Sherwindt & Kerlin 1990; Feldman 1994). Often, parents with
intellectual disabilities are scrutinized very closely and held to higher standards that
may be applied to other parents. Examples of outright discrimination in custody cases
abound (Vogel 1987; Hayman 1990; McConnell et al. 2000). Furthermore, the evidence
used to judge potential for parental inadequacy may be based on unfair and invalid
assessment procedures (i.e. an IQ test and hypothetical questions about parenting)
(Tymchuk & Feldman 1991). These nave and prejudicial attitudes and practices may
lead to premature termination of parenting rights contrary to family legislation that
almost universally requires that this action should be a last resort and that the state has
an obligation to make efforts to keep families together. Much more work is needed to
inform and educate child protection workers, psychologists, judges, and lawyers that
many factors in addition to (or instead of) the parents intellectual disabilities affects
parenting (Feldman 2002) and that many of these parents are quite capable of learning to
provide acceptable child-care, stimulation, nurturance, and affection to their children
(Feldman 1994). It is hoped that through ongoing research and education more informed
and humane custody decisions will then be made, and negative attitudes will begin to
change.
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Conclusion
Despite the progress made since the 1970s, it appears that workers, professionals and
parents of persons with intellectual disabilities are still strongly against procreation and
in favour of sterilization. These negative attitudes are associated with outdated and
perhaps prejudicial practices, particularly with respect to parenting. Unfortunately, most
of this attitude research is 20 years old and may be outdated. New studies are needed to
assess attitude change over time and across different interested parties (parents,
teachers, professionals, judges, workers, people with intellectual disabilities). The generally positive portrayal and response to the recent feature film, I Am Sam suggest that
when the issue of parenting by persons with intellectual disabilities is made personal, the
public respond favourably.
Future studies should evaluate the effects of prejudicial attitudes on sexual expression
and parenting by people with intellectual disabilities. The effects of information and
education of current research findings and availability of competency-promoting services (particularly with respect to parenting) on attitudes and practices should also be
examined. Attitudes towards sexuality and parenting in persons with intellectual
disabilities seem to be the last frontier towards complete acceptance of people with
intellectual disabilities as full members of society.

Correspondence
Any correspondence should be directed to Dr Maurice Feldman, Department of Psychology, Queens University, Kingston, Ontario, Canada K7L 3N6 (e-mail: feldman@
psyc.queensu.ca).

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