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Sexuality and Disability, Vol. 21, No.

2, Summer 2003 (䊚 2003)

The Attitudes of Medium-Secure Unit Staff Toward

the Sexuality of Adults with Learning Disabilities
Linda Yool, B.Sc. (Hons.),1 Peter E. Langdon,1,2,3 B.Sc. (Hons.), D.Clin.Psy.,
C.Psychol., and Kiran Garner,2 B.Sc. (Hons.), M.Sc., C.Psychol.

The attitudes of staff toward the sexuality of adults with learning disabilities
within a medium-secure hospital within the United Kingdom were examined
using qualitative research methods. Four interviews were conducted with staff
members of both sexes from differing occupations. Interviews were transcribed
and analyzed using a method adapted from Worthen and McNeill (1996). The
analysis revealed that staff members generally held liberal attitudes with re-
spect to the sexuality and masturbation. However, with respect to sexual inter-
course, homosexual relationships, and the involvement of adults with learning
disabilities in decisions regarding their own sexuality, less liberal attitudes
were detected. Concern was also noted with respect to the attitudes of female
staff members towards the sexuality of adults with learning disabilities who
have committed sexual offences. Training issues were also identified and impli-
cations for the service were discussed.
KEY WORDS: sexuality; attitudes; learning disabilities; secure unit; qualitative methods; sexual


Traditionally, services have desexualized adults with learning disabilities

or suppressed their sexual behavior through the withholding of information or
by punishing (Craft, 1987). It has been suggested that the denial of heterosexual
and homosexual identities to adults with learning disabilities has arisen as sexu-
School of Medicine, Health Policy and Practice, The University of East Anglia.
Care Perspectives, Partnerships in Care Ltd., St. John’s and Burston House Hospitals.
Address correspondence to: Dr. Peter E. Langdon, Lecturer in Clinical Psychology, School of
Medicine, Health Policy and Practice, The University of East Anglia, Norwich, NR4 7TJ, United
Kingdom; e-mail: P.Langdon噝uea.ac.uk.

0146-1044/03/0600-0137/0 䉷 2003 Human Sciences Press, Inc.

138 Yool, Langdon, and Garner

ality is considered to be a complex social construction and is conferred accord-

ing to societal status or group membership (Craft, 1987). Given that those with
learning disabilities may possess low societal status, their sexual interest and
sexuality as a result has often been suppressed (Cambridge, 1994; McKinnon,
Carey & Cournos, 1997).
However, attitudes toward the sexuality of people with learning disabilities
appear to have changed over time by becoming more liberal. Studies from the
late 70s and early 80’s suggested that the expression of sexuality was frowned
upon by staff and thought to be inappropriate (Haavik & Menninger, 1981;
Mitchell, Doctor & Butler, 1978; Saunders, 1979). One study from this time
suggested that staff would ‘tolerate’ kissing or holding hands amongst those
with learning disabilities, but the expression of other sexual behavior would be
discouraged (Haavik & Menninger, 1981). Another further study suggested that
staff may allow patients to masturbate, but again, further expression of sexu-
ality, or sexual behavior, would be discouraged (Coleman & Murphy, 1980).
However, studies from the late 80’s and 90’s suggest that attitudes have
become more liberal (Toomey, 1989; Adams, Tallon & Alcorn, 1992; Murray &
Minnes, 1994). This change in attitude may reflect a wider shift in societal
attitudes toward the sexuality of all individuals. This conclusion derives some
support from the finding that those who are younger endorse a more liberal
attitude towards the expression of sexuality by people with learning disabilities,
than those who are older (Brantlinger, 1983; Murray & Minnes, 1994).
Previous authors have discussed the impact of the deinstitutionalization
and normalization movement on the need for programs to teach appropriate
sociosexual skills to those with learning disabilities (Chapman & Pitceathly,
1984; Mitchell et al., 1978; Murray & Minnes, 1994). Furthermore, studies
have demonstrated that the success of sex education programs are dependent on
whether staff endorse positive attitudes toward the expression of sexuality by
those with learning disabilities (Chapman & Pitceathly, 1984; Mitchell et al.,
The majority of previous studies have employed the Sexuality and Mental
Retardation Inventory (SMRAI) to assess staff attitudes toward the expression
of sexuality by people with learning disabilities (Brantlinger, 1983; Murray &
Minnes, 1994). Holmes (1998) suggested that qualitative methodology would
be useful to explore such issues in more depth. However, none of these studies
have taken place with staff who work with adults with learning disabilities with
forensic histories who reside within secure facilities.
In fact, very little research has taken place within secure settings where
those with learning disabilities often have a history of offending. Only one
known study exists which has examined the attitudes of staff who work within
a medium-secure setting (Holmes, 1998). This study employed the short version
of the SMRAI (Murray & Minnes, 1994) and the results suggested that al-
Staff Attitudes Toward Sexuality of Adults with Learning Disabilities 139

though conservative attitudes remain, an emerging liberal trend was evident

(Holmes, 1998). Furthermore, the complexity of sexuality issues such as resi-
dent vulnerability, exploitation, and consent were highlighted as being impor-
tant within a medium-secure setting (Holmes, 1998).
Additionally, little is known about the attitudes of staff who work within a
secure context toward the sexuality of people with learning disabilities. Many
of these facilitates may offer sex education programs, and may provide treat-
ment services to people with learning disabilities who have committed a sexual
offence. Given the impact that the attitudes of staff may have on sex education
programs (Chapman & Pitceathly, 1984; Mitchell et al., 1978), it would be
advisable to explore the attitudes of staff employed within these facilities.
When staff endorse negative attitudes toward the sexuality of people with
learning disabilities, staff training may be appropriate (Harvey, 1983; Brant-
linger, 1987). Harvey (1983) stated that there is likely to be a need for staff
training with respect to this issue and suggested that services should develop a
supportive system of policies, guidelines and training that are inexplicably
linked. Brantlinger (1987) supported the need for training but highlighted the
necessity to evaluate staff attitudes initially. She wrote, “One of the tasks of
staff development is to evaluate the present attitude of employees. If employees
are already liberal and informed, it may not be necessary to provide training”
(Brantlinger, 1987).
Given the important service implications that staff attitudes toward the
sexuality of people with learning disabilities have, and given the lack of litera-
ture investigating the attitudes of staff who work in medium-secure settings, the
current qualitative study was undertaken. Four full-time staff members em-
ployed as a psychiatrist, senior care-worker, advocacy worker, and a domestic
employee were recruited and completed a semi-structured interview which was
subsequently transcribed and coded using the method adapted from Worthen
and McNeill (1996). The general aim of the study was to explore staff attitudes
toward the sexuality of people with learning disabilities. More specifically, the
aims of the study were, a) to gain knowledge of the attitudes held by a cross-
section of staff from different occupations, b) to highlight any training needs of
staff with respect to the sexuality of adults with learning disabilities placed in a
medium secure unit.



Four full-time staff members (X age ⳱ 45.5; SD ⳱ 8.22) were recruited

and had been in their current employment for a mean of 4.36 years (SD ⳱
140 Yool, Langdon, and Garner

1.49). Staff included reported that they had been working in the field of learn-
ing disabilities for a mean of 9.5 years (SD ⳱ 5.5). Those recruited were em-
ployed as a consultant psychiatrist, senior care-worker, advocacy worker, and a
domestic staff member. The psychiatrist and domestic staff member were male,
while the senior care-worker and advocacy worker were female.

Design and Procedure

Initially, the names of all staff employed by the medium-secure unit were
collected along with their job titles. These staff were sorted into four groups, 1)
professional, 2) care-worker, 3) non-clinical staff, and 4) support services. One
name from each profession was then drawn at random. These persons were then
approached and asked to participate in the study. Two of the people initially
approached declined to participate. Two further names were then drawn at ran-
dom and these people were asked to participate.
Each participant who consented to participate completed a demographic
questionnaire, which asked for details regarding their age, sex, martial status,
qualifications, and years working within the learning disabilities sector. Follow-
ing this, each participant completed a 40–60 minute audio-recorded semi-struc-
tured interview developed by the first author. Following the interview, partici-
pants were debriefed as to the purpose of the study. The researchers, following
a review of the current literature, developed the semi-structured interview.
Topics or themes were grouped into eight sections, and questions were used as
prompts (Table 1). Participants were told that there were no right or wrong
answers and that the interview will not be used to judge the participant in any
All interviews were then transcribed, and analyzed according to the mod-
ified method described by Worthen and McNeil (1996; Table 2), which was
based on the methods described by Giorgi (1985, 1989). Briefly, transcribed
data were broken down into individual meaning units to facilitate analysis.
Each participant’s transcript was examined until themes emerged about how the
participants felt with respect to the sexuality in people with learning disabilities.
Following this, group analysis was completed which allowed further findings to
emerge with respect to the attitudes of participants concerning the sexuality of
people with learning disabilities.


The analysis revealed the existence of ten themes at the level of the gen-
eral meaning structure. These results indicated that overall staff appeared to
Staff Attitudes Toward Sexuality of Adults with Learning Disabilities 141

Table 1. The Eight Sections and Questions that Formed the Semistructured Interview

Theme Questions

1. Understanding of the term “sexuality.” —What does the word “sexuality” mean to
2. General attitude towards sexuality and —What do you think about sexuality with re-
people with learning disabilities. spect to people with learning disabilities?
—What are your own views on people with
learning disabilities making decisions about
their own sexuality?
3. Differences the sexuality of people with —Do you think the sexuality of people with
learning disabilities. learning disabilities is different from people
without learning disabilities?
—In what way?
4. Expression of sexuality in people with —What are your views on patients expressing
learning disabilities. their sexuality?
—Should patients be allowed to: a) mastur-
bate, b) have relationships (homosexual and
heterosexual), c) have sexual intercourse
(homosexual and heterosexual), where
should they do this? d) have access to con-
traception, e) have children, and f ) have ac-
cess to pornography?
—Is there any aspect of their sexuality that
you feel they should not be allowed to ex-
5. Staff understanding of patient’s sexuality. —What do you think patients understand about
their own sexuality?
—Should they be taught/advised about issues
regarding their own sexuality?
—What should or shouldn’t they be taught?
—Whose job is it to do this?
6. Staff experience of dealing with sexuality —Have you had to deal with the sexuality is-
issues. sues of patients whilst you have been work-
ing here?
—How did you deal with this?
—How did you feel about discussing or deal-
ing with this?
—What influenced how you dealt with this?
—Is there anything that would have helped
you in this/these situation(s)?
—How often would you say you have to deal
with sexuality issues in your work here?
7. Staff training. —Have you attended training on sexuality?
—Did you find this useful?
—What issues do you think would be useful
or helpful to cover on training regarding
sexuality issues?
—What are your ideas on how best to do this?
8. Awareness of hospital policy on sexuality —Are you aware of hospital policy on sexu-
and relationships. ality and relationships?
—Does this influence how you deal with these
142 Yool, Langdon, and Garner

Table 2. Worthen and McNeill’s (1996) a) Seven-Step Qualitative Model for Individual Analysis
and b) Four-Step Model for Group Analysis

(a) Seven-Step Model for Individual Analysis

Step 1: Obtaining a sense of the whole
Each interview was listened to three times before analysis commenced to obtain a sense of the
entire interview within its context.
Step 2: Identifying meaning units
Meaning units, defined whenever there was a shift in meaning, were identified on written tran-
scripts of each participant’s data set and marked. Irrelevant items were discarded.
Step 3: Defining relevant and psychologically explicit meaning units
Meaning units that were relevant to the investigation were identified and irrelevant ones dis-
carded. The meaning units included were grammatically re-phrased, where necessary, to con-
vey the participant’s meaning more succinctly.
Step 4: Integrating meaning units
Each meaning unit was taken up as a potential theme and other units were examined for repeti-
tions and elaborations until the text had been exhausted. This process was repeated until no
more sets of integrated meaning units could be generated. Integrated meaning units were
gathered together under the study’s eight areas of interest.
Step 5: Articulating the meaning units
Each integrated set of meaning units were put into terminology that expressed the meanings in
psychological language.
Step 6: The situated meaning structure
The derived meanings of Step 5 were integrated into third person narratives which retold the
events in psychological language.
Step 7: The “essence” of attitudes toward sexuality of staff who work with people who have
learning disabilities
The final step in the analysis was to refine the material contained in the transcribed interviews
into its most concise form. This was accomplished by asking, “What overall statement best
describes the attitude of medium-secure unit staff toward the sexuality of people with learn-
ing disabilities?”
(b) Four-Step Model for Group Analysis
Step 1: Individual characteristics of participants’ accounts
All individual participant findings were collected together to form an exhaustive, inclusive list.
Step 2: Common characteristics of participants’ accounts
Characteristics shared in common by two or more participants were identified and listed. Note
was made of which participant supplied each characteristic.
Step 3: Collective characteristics of participants’ accounts
At this point only characteristics held collectively by 3 or 4 participants were retained. Note
was made of which participant supplied each characteristics.
Step 4: General meaning structure of staff attitudes towards sexuality and people with learning
disabilities in a medium-secure setting
Characteristics remaining after Step 3 were used to generate a full narrative description about staff
attitudes towards sexuality and people with learning disabilities in a medium-secure setting.

endorse a liberal attitude regarding the need of sexuality for all people, includ-
ing those with a learning disability. Additionally, a liberal oriented view was
detected with respect to the recognition of masturbation as an expression of
sexuality, and the privacy that masturbation warrants.
These findings appear consistent with the findings of previous studies
Staff Attitudes Toward Sexuality of Adults with Learning Disabilities 143

where attitudes toward the sexuality of people with learning disabilities were
reported as shifting towards the liberal (Adams et al., 1992; Holmes, 1998;
Murray & Minnes, 1994; Toomey, 1989).
However, a less liberal attitude was detected with respect to sexual rela-
tionships between clients. Also, a less liberal attitude was evident concerning
the inclusion of clients in the decision-making process with respect to decisions
about their sexuality, and homosexual relationships. The overall view that sex-
ual relationships between clients were not permitted was detected. This view, to
some degree, may be associated with the medium-secure context in which staff
work, and the population of sex offenders which are resident within the unit.
Each of the ten themes are reported and discussed below.

Theme One: Sexuality Is a Common Shared Need for All People

Participants indicated that they believed that sexuality is common amongst

all people regardless of disability as indicated by the following comments:
Sexuality is a shared need for everybody.
No group should be excluded from sexuality whatever their degree of disability.
Everybody has a right to sexuality.

These results are suggestive of a general liberal view toward the sexuality
of all people and may be a reflection of the changes that have taken place in
societal attitudes toward sexuality.

Theme Two: Factors That Restrict the Expression of Sexuality

Three factors were detected through the analysis which impact the expres-
sion of sexuality. These factors were, a) the presence of a population of sex
offenders within the secure unit, b) the ability of adults with learning disabil-
ities to provide consent to engage in a sexual relationships, and c) risk of and
vulnerability to exploitation.
This theme was evident from the following comments:
Their options are limited because we can’t have people having ultimate relations be-
cause of all the difficulties it would cause with respect to consent. We also can’t have
people who have offended sexually attacking vulnerable people.
Permitting sexual relations in a medium-secure environment is problematic because
it is difficult to allow sex-offenders to have a consenting relationship without disclosing
their past.
The most important thing is the fact that we do have a large number of sex of-
fenders and be it same sex or opposite sex or whatever, there’s got to be those things
144 Yool, Langdon, and Garner

about consent. Again, I would say that some of our patients would have problems in
understanding appropriate consent and in giving valid consent.
Another thing that gives me concern really is these people are generally quite a
vulnerable group of people and a number of them have been in exploitative relation-
ships, be it sexual, financial or even parental.

These results may reflect, to a certain degree, the medium-secure context

in which staff work.

Theme Three: Expression of Sexuality in People with Learning Disabilities Is

Different from Non-Learning Disabled Populations Due to Social Impairment

This theme was evident through the following comments.

Establishing relationships is difficult for people with learning disabilities and they need
alternative means to express their sexuality.
The majority of people within our service have problems with inter personal relation-
ships and social interactions and when you’re talking about sexual relationships, or
even personal relationships, these people have difficulty in even establishing or main-
taining this.
They are not able to pick up on non-verbal cues or appreciate the age of the partner that
they are intending to have a relationship with.

These results suggest that the participants are aware of the difficulties that
impaired sociosexual skills may have upon the appropriate expression of sexu-
ality. However, the participants did not suggest that these difficulties may be
tackled to some degree with appropriate treatments, such as sex education pro-

Theme Four: Clients Involvement in Decisions About Their Own Sexuality Is

Dependent on Their Level of Ability

This theme was suggested through the following statement.

I think people should always be involved in decisions about their own sexuality but it
depends again upon their level of understanding.
People with learning disabilities should be assisted to understand what is going on in
meetings where they are discussing their sexuality, particularly if they are less able. It
depends what level they are at really.

This theme suggests that staff may have some insight into the impact a
learning disability might have on the decision making process and some recog-
nition of the importance of advocacy was detected. However, including an indi-
vidual in the decision making process is very important to help ensure that the
individual’s view is expressed correctly and rights are not compromised un-
Staff Attitudes Toward Sexuality of Adults with Learning Disabilities 145

Theme Five: Individuals with Learning Disabilities Understand Their Own

Sexuality in the Same Way as Non-Learning Disabled Individuals

This theme was judged to be associated with the following comments.

They understand sexuality in the same way that anybody else does. People with learning
disabilities cannot be singled out as having special difficulties with understanding their
own sexuality. I think if you really think about this, it’s no different to the understanding
that people without a learning disability have.

This theme appears to contradict Theme Four. If staff endorse the belief
that people with learning disabilities understand their own sexuality in a manner
similar to that of non-learning disabled adults, then excluding them from deci-
sions about their own sexuality, dependent upon their ability, seems illogical.

Theme Six: Masturbation Should Be Permitted as an Aspect of an Individual’s

Sexuality and an Appropriate Personal and Private Space Should Be Provided
to Facilitate This

This result has been previously suggested (Coleman & Murphy, 1980), and
was evident from the following interview extracts.
Yes, not over the dinner table but of course they must be allowed to masturbate.
Yes, and they must be given privacy to do this; masturbation has to be done in a client’s
own personal private space and not in communal areas.

Theme Seven: Uncertainty Regarding the Encouragement of Homosexual

Relationships and Lack of Representation of This Relationship in the Service

This theme was evidenced by the following statements.

I don’t think there would be a problem with this but I have never had to deal with this
kind of request. People with learning disabilities should be allowed to have homosexual
relationships if this is what their need is but I’m not sure if this is allowed really.
I’m unsure of the policy on homosexual relationships but I would imagine they would be
I have never had the request for a lesbian relationship, as there are very few females in
secure environments.

The attitude detected with respect to homosexual relationships may reflect

the more general negative attitude of society towards same-sex relationships.
Although same-sex relationships are becoming more accepted, the results are
consistent with previous authors who reported that there is a lack of acceptance
of homosexual identities for adults with learning disabilities (Craft, 1987).
146 Yool, Langdon, and Garner

Theme Eight: Female Participants Aware of Separating Their Mother Role

from Their Professional Role When Working with the Sexuality Issues
of Sex Offenders

A difference in the general meaning structures between male and female

participants regarding working with sex offending clients was also noted and is
evident through Theme Eight.
This was evident from the following interview extracts.
As a mother I feel that allowing somebody who had abused children access to pornogra-
phy would be encouraging them and not treating them. As a professional, if I think that
there is a need for pornography then access should be allowed following discussion of
the issues with the clinical team.
There are obviously some people who are sectioned for sexual things and if you are
talking to a pedophile about this you don’t say that you have children because somebody
might say ‘I would like to murder your daughter or something.’ You have to separate the
issue I think.
I get on with it if it is people I have to deal with. I don’t have to love them or be their
friend, but I have to do my job.

Theme Nine: Nonclinical Staff Members Were Unsure About Whether It Was
Important for Them to Attend Training Regarding Sexuality

None of the participants had attended training on sexuality and all were
not aware of the hospital policy regarding sexuality and relationships.
Participants indicated that they were not clear about whether they should
attend training sessions on sexuality as noted through the following statements:
I think if [the hospital] felt it was important to attend sexuality training then they would
have invited us along.

Additionally, non-clinical staff reported that they felt it was unnecessary

for them to attend training on sexuality and relationships, and that this was
more important for clinical staff as suggested by the following comments.
I don’t think so really, it is more important for staff who stay on houses to have that sort
of training.

Theme Ten: In-Service Staff Training on Sexuality Should Focus on Policies

and Procedures, the Rights of Learning Disabled Individuals to Express Their
Sexuality, and Teaching Staff How to Facilitate and Support Appropriate
Expression of Clients’ Sexuality

There was agreement between participants that in-service training on sexu-

ality should focus on these issues as evidenced by the following statement.
Staff Attitudes Toward Sexuality of Adults with Learning Disabilities 147

Training should cover the rules and regulations we need to abide by. Training should get
across the fact that sexuality is a common need and nobody should be excluded from it.
Training is important for teaching staff how to help clients’ express their sexuality ap-

This result is important and suggests that staff have some understanding of
the areas that need to be addressed through a training program.

Differences in General Meaning Structure

The only apparent difference between participants was that female partici-
pants spoke about the importance of acknowledging their feelings about sex
offenders who have abused children, especially if they had children of their
own. This is a very important issue, and highlights the importance of ensuring
the provision of psychological support for staff who have to work with clients
who have committed sexual offences.
With respect to clinical vs. non-clinical staff, the only difference detected
was that non-clinical staff were unsure about having to attend training on issues
of sexuality. This may reflect an organizational opinion that non-clinical staff
may not have to encounter sexuality issues through the course of their duties.
However, one non-clinical staff member reported during the interviews that a
client had kissed them while they were carrying out their duties.
Previous research has suggested that professionals as opposed to direct
care staff may have more positive attitudes toward the expression of sexuality
by those with learning disabilities (Murray & Minnes, 1994). This finding was
not replicated as part of this study. The main reason for this is that the study did
not set out to investigate this finding further, but instead, was interested in
examining the difference between clinical and non-clinical members of staff.

Implications for the Service

Selection of Staff

Clearly, the selection of staff to work within the context of a medium-

secure unit for people with learning disabilities is important. Staff will have to
tackle and deal with the sexuality issues of clients, and they will require psy-
chological support in order to help cope with potential difficulties. Furthermore,
what is of great importance, is the selection of staff who do not endorse partic-
ularly negative attitudes towards the sexuality of those with learning disabil-
ities. For example, the selection of staff who endorse negative attitudes toward
masturbation, or homosexuality would be very concerning and potentially
might impact the effectiveness of sex education programs (Chapman & Pit-
ceathly, 1984). Should the employment of staff with negative attitudes occur,
148 Yool, Langdon, and Garner

they should be required to undertake training with respect to sexuality. There is

some evidence that such training may be successful at modifying attitudes
(Brantlinger, 1983).

Staff Training

The staff interviewed during the current study expressed a collective opin-
ion as to what should be covered in training programs on the sexuality of adults
with learning disabilities. These included policies and procedures, the rights of
learning disabled persons to express their sexuality, and teaching staff to facili-
tate and support the appropriate expression of sexuality. These findings are
consistent with the training program suggested by others where policies, train-
ing and guidelines are linked (Harvey, 1983). The current results also suggest
that training regarding homosexual relationships and sexual behavior beyond
that of masturbation would be appropriate.
One of the most remarkable findings of the current study was that none of
the participants were familiar with the local policy regarding the expression of
sexuality and relationships. This result is of concern as the possibility that staff
may act in such as manner as to contravene existing policy exists. Clearly, there
is a need to ensure that staff have a working knowledge of policies and pro-
cedures with respect to sexuality and relationships. Perhaps the most effective
method to ensure this is through a staff training program.

Future Research

Previous research has indicated that staff attitudes may have an impact
upon the outcome of sociosexual training programs (Chapman & Pitceathly,
1984; Mitchell et al., 1978). Sex education forms a part of sex-offender treat-
ment programs for people with learning disabilities (e.g., Rose et al., 2002), and
these programs may be carried out within a medium secure context. Given the
potential impact that working with sex offenders may have upon staff members,
and the relationship between staff attitudes and sociosexual training programs,
further investigation of the possible impact that staff attitudes may have upon
sociosexual training programs, or sex offender treatment groups, within a me-
dium-secure context, is warranted.


Overall, the results of the current study suggest that staff held liberal atti-
tudes with respect to the sexuality and masturbation. However, less liberal atti-
Staff Attitudes Toward Sexuality of Adults with Learning Disabilities 149

tudes, with respect to sexual intercourse, homosexual relationships, and the in-
volvement of adults with learning disabilities in decisions regarding their own
sexuality, were detected. Staff who are female also raised concern with having
to work with sex offenders. Additionally, staff were not aware of hospital policy
with regard to sexuality and relationships amongst clients. The findings have
implications for staff selection, staff training, and decision making with respect
to issues concerning the sexuality of clients.


We would like to thank the staff who participated in this study. No respon-
sibility for actions taken as a result of information contained within this docu-
ment is accepted by the authors, The University of East Anglia, or Partnerships
in Care Ltd.


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