Futureproofed Workshop #24: Intimate Health Screening for Disabled Clients
For those who see clients with disabilities
So, why might a disabled person seek out a sex worker?
To engage in a safe and consensual sexual experience.
People with a disability (PWD) are at high risk of sexual abuse and sex workers are experts in boundaries.
PWD are often subject to touch that is medicalised, and can be forced, tolerated or unwelcome.
PWD may not experience the ability to be naked on their own, and may only experience nudity when being cared for by another person.
To learn and practice social skills required for successful interactions when dating and having sex.
People with intellectual and/or psychosocial disabilities may require a safe space to practice expected social skills without risk of harm or persecution.
Families and carers may infantilise PWD well into their adulthood, which can reduce their ability to access age appropriate social gatherings or activities.
To engage with masturbation and/or partnered sexual activity when they have high physical support needs.
Common with inter-abled married couples, or couples where both people are disabled.
PWD may wish to engage with swingers parties and other adult only recreational activities, but require physical support.
Also, don’t forget, for the same reasons as everyone else!
Not all bookings with PSW will have a focus on their disability. Never assume that they require help unless they ask for it. It’s important to treat disabled clients the same way we treat our abled-bodied clients. As their disability can encompass their whole life, they just want to feel ‘normal’ when they are with you.
What is an intimate health screening?
A visual check of the genitals or any area of the body you intend to perform sexual acts (genitals, anus, mouth, hands and feet).
Remember to wash your hands before and after, and wear gloves if you wish.
It is important to remember that people with high physical support needs may not be able to perform their own personal care. Their personal hygiene is dependant on their carer, and from experience some clients may choose to not have a carer clean their genitals at all, or carers do the task poorly.
How to prepare a client and their carer for a booking
Send detailed instructions
Example template: Hi ___! I can’t wait to see you. When our booking starts, I will complete a visual sexual health screening. It is important to ensure you are prepared for your health screening by ensuring that you have:
Pulled back the foreskin and cleaned gently with warm.
Washed the pubic hair around the genitals and anus.
All dressings/medical equipment are freshly applied and clean.
If you require assistance showering/toileting I can assist you/your carer will need to be available for that at the start and end of the booking.
What you might see when working with disabled clients
Intermittent Catheters
They are:
Singe use only
Self-inserted
Clinical waste. Dispose of them the same way you dispose of used condoms.
Ensure clients who may need to use single medical equipment are shown where the rubbish bin is located. Intermittent catheters can cause micro-tears in the urethra. Semen stained pink or red isn’t an immediate cause for alarm, it is best to communicate with the client and confirm if they expected that or not.
Practical Point
Intermittent self-catheterisation is a means of giving patients control over when to void. For some cases, this may be preferable to more invasive procedures, especially if the patient is unfit for surgery or further intervention.
Condom Catheters
For client’s with a penis.
Is an external catheter option that collects urine.
Is easily removed and re-applied. If your client uses a condom catheter you can ask them to remove the catheter before their health check and shower.
Some use adhesive to attach, so a sticky residue may remain if not washed off properly.
A client may experience light urine leakage while the catheter is removed.
Indwelling Catheters
Indwelling catheters are a permanent or semi-permanent catheter that remains inside the client at all times. It is held in place with an inflated balloon inside the bladder.
Can people with indwelling catheters use a condom?
Indwelling catheters can be used with condoms, yes!
How to use a condom on a penis with an indwelling catheter
It’s best not to secure the catheter until you know how big the penis will grow to when erect. Engage in foreplay and then bend the tubing gently back and down along the shaft of the penis.
Leave some wiggle room at the top of the penis. Avoid folding the tubing back tightly, there should be a centimetres of loop at the head.
You can place a condom directly over the penis and tubing. The condom will hold the tubing in place, and the tubing also provides a rigid “bone” that helps keep the penis erect. You can also secure the tubing with a small amount of medical tape at the base on the penis shaft.
Keep in mind that it can be difficult to remove all the air from inside the condom. Pinch the condom around the tubing loop to the best of your ability before rolling the condom down the shaft.
You may also secure the rest of the tubing to the clients abdomen. Catheters with a valve can have the valve closed and urine collection bag detached for the duration of the booking.
An indwelling catheter still allows for ejaculation. The semen will seep out from around the tubing, it doesn’t come out through the tubing.
Female clients with indwelling catheters can still have penetrative vaginal sex. Again, secure the tubing to the client’s abdomen (or in a place that is comfortable for them).
Only water based lubricants should be used with clients who are using indwelling catheters.
People who use indwelling catheters often report a small amount of blood in their urine after sex. The inflated balloon inside the bladder can run on the internal walls of the bladder and cause micro tears.
Suprapubic Catheters
A catheter that enters the body and bladder through an incision in the abdomen. Placement of the incision depends on the person. They can vary up towards the belly button or down into into the bikini line.
Some people will prefer a suprapubic catheter over an indwelling catheter if they have an intimate partner/spouse.
Tape down the catheter during sexual activity, and avoid pulling on the tubing to the best of your ability. Similar to indwelling catheters, a small amount of blood may be found in the urine collection bag if the internal balloon rubs on the bladder wall.
It is best to use water based lubricants in case the lube transfers onto the tubing.
Ostomy (also known as a stoma)
Vaginal Atrophy
Women with spinal cord injury (SCI) can develop issues with lubrication.
Occurs in almost 40% of women post menopause.
Studies suggests that SCI can affect neuro-transmitters in the bowel and genital area, resulting in the atrophy of the cells.
Symptoms include:
Vaginal dryness and reduce lubrication production during sex.
Shortening/tightening of the vagina.
Reduced pubic hair.
Shrunken and pale labia.
Spotting/light bleeding after sex.
Urinary incontinence.
Painful sex.
Atrophy is made worse by not having sex. Sex is vital to bring fresh blood and oxygen to the genitals. Penetrative sex is still possible, and use water based lubricants as they are most gentle of sensitive skin.
Latex Allergy or Sensitivity
Very common for people with spina bifida (a malformation of the spinal cord during pregnancy).
Can develop in PWD after prolonged use of latex medical products. Repeated exposure increases the risk of latex allergy.
Autonomic Dysreflexia (AD)
An abnormal reaction to intense/painful stimulation from below a T6 or higher SCI, for example, ejaculation/orgasm.
Restrictive practices and other BDSM services could also trigger AD.
Symptoms include anxiety, dizziness, goosebumps, high blood pressure, sweating, incontinence, blurred vision, muscle spasms.
Sit the client up or raise their head, remove tight restrains or clothing, call for help.
Pressure Sores
WARNING GRAPHIC IMAGERY!
A pressure sore is a painful wound caused by prolonged pressure or friction. There are 3 stages of pressure sores, as seen below.
Caused by constant pressure or friction, the risk factors include:
Wheelchair users
Being bed-bound
Incontinence
Decreased sensation.
For bookings over 1 hour it is important to reposition a client every so often. Pillows are a useful tool to do this with.
Herpes vs pressure sores
Pressure sores do not bubble, or fill with liquid.
Pressure sores can have red, black and purple discolouration. Herpes are only red.
Pressure sores can show sins of infection such as puss or yellow discharge.
Herpes is found around the mouth and genital area.
Pressure sores are found where sustained pressure occurs, the back of the ankles, tail bone, around medical devices.
A client may not know they have a pressure sore, especially if they have reduced sensation or require a carer to bathe them,
Muscle Atrophy
Muscle Atrophy is,
a reduction in muscle size and strength;
can be a symptom of the disability, or a result of immobility;
Often results in further immobilisation or even difficulty breathing and swallowing.
Contractures are often associated with muscle atrophy, but can also occur with paralysis or as a result of healing burns.
Is a tightening of the muscle, tendons and ligaments.
Has reduced range of motion.
Will make manipulating the area hard, leg and pelvis muscle contractions can limit access to the genitals.
Contractures can support body weight, but shouldn’t be forcefully stretched or have weight placed upon them.
Tracheotomy
An opening in the neck that allows for a breathing tube to be inserted into the windpipe.
It can often be attached to a machine that facilitates breathing.
Kissing and oral sex is still capable, just keep in mind swallowing can be impacted.
It is not recommended to penetrate the stoma.
Clients with a tracheotomy can develop mucus plugs due to the weakened throat muscles being unable to clear mucus through coughing. A client may undergo “suctioning” if a mucus occurs. Unless you have a strong stomach, its best to leave the room.
Stoma/ostomoy complications
Mucus can leak from the anus as the bowel still produces lubrication even thought its not used.
Thrush, contact dermatitis, cellulitis, psoriasis and folliculitis are all possible complications.
Warts and herpes can also be found on a stoma site. Both are contagious.
Chlamydia and gonorrhoea are very rare but not unheard of. Signs of infection include puss and a foul odour.
Penetration of a stoma site (either for the bowel or for breathing) is heavily warned against by medical professionals. If someone asks you for stoma penetration, please take all precautions to sanitise the area before and after and use sterile gloves with correct application techniques.
Alternative options for clients with reduced genital sensation
Making out
Full body kissing
Massage
Dry humping
Face sitting
Nipple play
Anal play
Warming and cooling lubricants
Bondage
Watch porn together
Strip tease
Cuddling
Roleplay fantasy
Impact play
Latex
Piss play and golden showers
There are many different ways to curate sessions for clients with disabilities, it just takes some thinking outside of the box.
About our expert presenter: Avalon After Dark
Avalon is a Brisbane based sex worker and disability advocate with a background in support work and allied health. Avalon opened Beyond Barriers Intimacy and Dating in January 2024, and provided necessary and reasonable supports to NDIS participants. She has worked with multidisciplinary teams to provide safe and satisfying intimacy to a wide range of high physical needs clients.
