Supporting Sex and Relationships after a brain injury
5th June 2025
Written by Caitlin Thompson
The complexities of rehabilitation after an acquired brain injury (ABI) and major disability are vast and it is known that managing the new physical, emotional, and cognitive changes can impact existing and future relationships (O’Keefe et al, 2020; McCabe et al, 2023). However, for some brain injury survivors who do not have a large support system, marital relationship, or family network, they rely on the support of professionals around them to help meet their rehabilitation goals and needs. It is therefore important that intimacy and emotional needs are not overlooked and are met for single survivors to ensure overall life satisfaction and wellbeing.
Photo by Filipp Romanovski on Unsplash
In June 2024 I attended a conference by ABI Solutions on Sex and Brain Injury. The day was hosted by Dr Giles Yeates from Rippling Minds who highlighted the importance of coaxing the conversation of sex after brain injury out of the shadows. Several speakers suggested that case managers and clinicians can do more to address this topic with their clients sufficiently which often starts by simply asking about sex. On this day there was a focus on survivors’ development of new relationships and seeking sexual relations with sex workers. Barrister Ben McCormack introduced and addressed the complex topic of how carers can and cannot support clients with their sexual relationships.
The Sexual Offences Act 2003 outlines the criminal law pertaining to care workers causing or inciting sexual activity of another person with a mental disorder with capacity for sexual relations. The ‘carer’ is anyone, in employment or not, providing care, assistance or services to the person with a mental disorder, this can include family members, friends, professionals such as solicitors and clinical staff. Therefore, the network of people this legislation impacts can be quite vast. Up until recently, there has been a lack of specific guidance and case examples in the court of where the legal line is drawn between supporting a client to meet their personal intimacy needs and what is classed as ‘causing’ sexual activity.
In 2021, a new case concerning the Secretary of State for Justice vs C and Others was disputed in court. This case involved a young man with a mental impairment who was wanting to engage in sexual relations with sex workers. He had capacity to engage in such relations and to decide about the contact he has with a sex worker. However, he lacked the capacity to manage his finances and to use the internet, creating a rather complex case requiring carers to assist him with the search for a suitable sex worker and to manage the financial transaction. The court was invited to consider whether the proposed care plan was seen as lawful.
Initially, Mr Justice Hayden decided that Mr C’s carers would not have been in breach of s39 of the Sexual Offences Act and if the plan was followed, they would not be ‘causing’ Mr C to have sex with a sex worker. However, the Court of Appeal disagreed as the carers would be creating the circumstances in which Mr C is likely to have sex with a sex worker. You can read more about this case on the Garden North Court website, here.
The result of this case law means carers can and might easily find themselves committing an offence under section 39 if they get too involved with providing certain elements of assistance to a person with a mental disorder. The difficulties of this result lie in each circumstance being different and therefore we cannot apply all of this case example to all clients and carers, rather case managers and clinicians need to focus on what can be learnt from Mr C regarding risk assessing a wide range of situations.
The real risk here is that carers and healthcare professionals are quite rightly worried about committing an offence, causing many people to avoid the topic completely, deeming it a ‘minefield’. Greg Hollingworth, a brain injury survivor from Different Strokes reported on the personal experiences of other survivors regarding their sexuality when working with professionals. The feedback outlined that a staggering amount of people did not feel comfortable enough to ask medical professionals about sex, gender, sexuality, or intimacy, so they therefore didn’t ask at all. The main outcomes that members of Different Strokes wanted professionals to know was most importantly to just bring it up, talk about sex! As not talking about it could rob a survivor of something potentially rewarding in their life and their recovery.
The less family members, carers and managers understand about this law and its implications, including the specific nature of how it may be judged in court, will limit how they can support the people they care for. Despite person-centred, holistic care approaches to brain injury survivors, often sexuality remains neglected, and many professionals rarely initiate this conversation post-injury. Perhaps there is more work to be done to address the issues of isolation in society after such injuries and ensuring professionals and care teams feel adequately trained and aware of sex and sexuality issues after brain injury and major disability.
References:
ABI Solutions Conference: Sex and Brain Injury. Controversy and Opportunity 28th June 2023.
McCabe, C., Sica, A., Doody, N., & Fortune, D. G. (2023). Self-awareness and quality of relationships after acquired brain injury: Systematic review without meta-analysis (SWiM). Neuropsychological Rehabilitation, 1-27.
O’Keeffe, F., Dunne, J., Nolan, M., Cogley, C., & Davenport, J. (2020). “The things that people can’t see” The impact of TBI on relationships: An interpretative phenomenological analysis. Brain Injury, 34(4), 496–507. https://doi.org/10.1080/02699052.2020.1725641