INTRODUCTION

Once, while treating Daniel, a 14-year-old teenager with a mental disability, his mother spoke about her lack of interest in sexual matters. She was a seamstress and her clients would try on clothes in front of her son, since, according to her, he had not yet awakened to the subject. At the moment she was telling this, Daniel, who was in a corner drawing, looked up and gave me a disguised smile, making it clear how mistaken his mother was about him.

The consultation with Gabriela (14 years old), a teenager with a not very significant intellectual disability, was able to be carried out, in part, without her mother being present. When asked if she had ever “had sex” with anyone, she immediately answered yes, with her teddy bear.

Scenes like these, among many others, are part of the daily care of teenagers with mental disabilities and their families. Was Daniel really as “innocent” as his mother imagined? Would Gabriela go beyond her stuffed animal?

In the social imagination, individuals with mental disabilities either have no sexual interest whatsoever, and are very often compared to “an angel” or, on the other hand, considered to have an exacerbated sexuality.

The social representation of the sexuality of people with mental disabilities is influenced by the lack of information on a subject that is still shrouded in many legends and prejudices. In this sense, medical consultations are an excellent space for discussing the issue, helping adolescents with mental disabilities to experience their sexuality in a more satisfactory way.

SEXUALITY AND ADOLESCENTS WITH MENTAL DISABILITIES

Modern authors, driven by the emergence of the contraceptive pill in the 1960s, the HIV/AIDS epidemic and gender studies in the early 1980s, have brought new research into practices and representations of sexuality. Today, there is greater flexibility in relation to new sexual practices, although some traditional values ​​remain in certain population groups(1). Greater sexual freedom can be found in some areas of society where, for example, masturbation is no longer considered perversion, just as virginity is not as highly valued(4). While

a large proportion of adolescents benefit from a more libertarian contemporary view of sexuality, as Parker argues(10), this is not the reality for those with mental disabilities, since most of them do not have their sexuality recognized. Thus, these adolescents are part of the common sense that they do not have sexuality or, when they do, it is manifested in an exacerbated way and, therefore, requires control.

Glat and Freitas(3) believe that this stereotype is an extension of the social representation of mental disability, which sees this individual between two extremes: as a “demonic being” or as “an eternal child”(3).

In adolescence, in individuals with mental disabilities, there is a contrast between the transformation of the child’s body into an adult body and the continuation of an immature function in terms of cognition, communication and social control(2). The lack of similarity with other adolescents without disabilities may be accentuated, since this is a time when the path to adult identity is blatantly followed, but for those with disabilities this path is not easy. Adolescence is prolonged, often frustrating the expectations of parents and the adolescent himself(8).

Many believe that cognitive disability is associated with a sexual deficit. This is due to the lack of systematic evidence on the sexuality of people with mental disabilities due to the greater difficulty in obtaining data through interviews(7).

The sexual behavior of people with mental disabilities is variable, since it depends on the level of their intellectual impairment, family support and social structure. Individuals with very significant intellectual impairment generally have predominantly undifferentiated sexual behavior, without establishing interpersonal relationships, with the sole purpose of satisfying their sexual impulses. The manifestation of their sexuality is generally restricted to manipulating the genitals. Those with moderate disabilities may have interpersonal relationships, but without the emotional and cultural content that characterizes an adult relationship. Those with mild mental disabilities establish friendships, may have intimate relationships and, in some situations, even form families. However, it should be emphasized that, although the possibility of forming a family is mentioned, there are no studies available on the subject(13).

For Melo and Rodrigues(9), the establishment of affective sexual relationships only affects those whose disabilities compromise their abilities very little, since they are generally prohibited in this area by their families and society in general. These restrictions result in less autonomy and few possibilities for choices.

The possibility that people with mental disabilities can fully and pleasurably exercise their sexuality is denied. This denial incorporates what Strickler(11) called a “virtual blanket of silence”. Sexuality is present, but in order for it to be “forgotten”, it is best to avoid talking about it. It is considered that the obstacle to a full and satisfactory love life is little associated with the IQ or the neurological problem present. This restriction is mainly due to the infantilization and social isolation to which they are exposed(3).

Many behaviors considered “deviant”, such as masturbation, voyeurism and exhibitionism, can be understood within the process of sexual development. The question is whether the problems of sexual behavior observed in some people with mental disabilities are not related to the difficulty in perceiving and interpreting the demands of the social environment, which does not clearly state the messages it wants to convey.

Masturbation is a prominent topic in discussions about sexuality and mental disabilities. The case in which this practice occurs compulsively or in public, often as a result of non-existent or ineffective sexual education, deserves attention and guidance. In these situations, the possibility of sexual abuse should also be investigated.

Many believe that people with mental disabilities are asexual beings who will not understand or need sexual education, and therefore do not need to receive it. In reality, several studies attest that this is not the case, since, as previously stated, sexuality develops in the same way in individuals with and without disabilities, in the vast majority of cases(12).

CONSULTATION: APPROACHING SEXUAL ASPECTS

In consultations with adolescents with mental disabilities, issues that promote their health and that also contribute to the prevention of harm to it should be addressed. It is important to emphasize that medical confidentiality, such an important requirement in a consultation with adolescents, cannot always be respected. Therefore, understanding sexuality as an integral part of the individual’s health, this item must be considered in the care, thus favoring harmonious sexual development, and also so that the exercise of sexuality occurs in the absence of discrimination, coercion and violence.

Parents very often have difficulty talking about the subject, which is unlikely to come up spontaneously during the consultation. It is up to the professional to bring the subject up for debate and, whenever possible, include the adolescents in the discussion.

The family and school would be the best places to provide information and reflections on sexuality, since sexual education is provided based on the opportunities that arise. However, what is observed is that this task is not carried out satisfactorily, and there is often an expectation that this responsibility would fall to the doctor, who would have knowledge of both the biological and erotic body.

Sexual intercourse is not always the greatest concern of these adolescents, with autoeroticism being the most frequent sexual practice. Due to the fears that exist in relation to masturbation, reprimand is frequently used as a way of inhibiting this activity, since it is considered that the practice could encourage the adolescent to seek other forms of sexual satisfaction. Parents should be assured that such an attitude is compatible with this stage of development.

Among the anamnesis data, it is important to ask about manifestations of sexuality, such as masturbation, and the possibility of spontaneous sexual intercourse, as well as to recognize whether the person with a disability is at risk of suffering sexual abuse. As difficult as it may be to approach the subject, it is important to know if there are family members with alcoholism and/or drug use problems, since these factors favor the practice of violent acts.

Although mental deficiency in itself is not a factor of vulnerability to sexual abuse(5), during the consultation it is important to investigate whether there are vulnerability factors associated with this form of violence. Among these factors we highlight the abusive use of chemical substances by a person who enjoys the adolescent’s trust, since violence is often committed by one of the caregivers of the adolescent with mental deficiency, due to the inequality of power in family relationships.

It is also important to know the level of autonomy of the adolescent. The more autonomous the adolescent, the greater the possibility that he or she will establish romantic and even sexual relationships. Given this possibility, contraception should be provided, as well as instructions on the use of condoms . Society

has certain requirements regarding the sexual behavior of individuals, therefore the socialization of adolescents with mental deficiency may be hampered by the exacerbation of the impulsiveness typical of adolescence, in addition to their reduced critical sense. The consultation is a good opportunity to show them what is public and what is private. However, this understanding is not always facilitated by parents, who rarely guarantee their privacy, mainly due to insecurity and fear. In addition, many are infantilized by their guardians. This approach should use appropriate language, according to the cognitive level of each adolescent.

CONCLUSION

The sexual manifestations of adolescents with mental disabilities worry their parents and society, which sometimes infantilize this sexuality, and sometimes fear that it will manifest itself in a socially inappropriate way.

Better social adaptation will affect their sexual behavior, which will favor their inclusion in a “two-way street”. For this to happen, participation in activities that favor social inclusion should be encouraged, especially those that promote training for work, sports and leisure. These activities, combined with school attendance, help adolescents with mental disabilities acquire concepts of responsibility and limits, in addition to improving their self-esteem.

A medical consultation is an excellent opportunity to work on these issues, especially those related to sexuality, revealing prejudices about the subject. Neither Daniel was as innocent as his mother imagined, nor Gabriela, apparently, was interested in a real partner to be able to exercise her sexuality.

Parents need to know that their children with disabilities will probably express their sexuality, whether through masturbation, dating or even, in some cases, through sexual intercourse. We believe that this will help adolescents with disabilities to not be so repressed in expressing their sexuality, and to be able to experience it in a more satisfactory way.