Staff member's views and attitudes to supporting people with an Intellectual Disability: A multi- method investigation of intimate relationships and sexuality

Background: Staff member's views and attitudes can have a significant impact on people with an intellectual disability. This study explores staff attitudes and experiences of people with an intellectual disability's expression of relationships and sexuality across service providers in Ireland.

DEFFEW Et al. (Brown & McCann, 2018). This is thought to be a result of service providers, staff and wider society holding a "protective stance" about people with an Intellectual Disability's sexuality (Rushbrooke et al., 2014). Furthermore, as many people with intellectual disabilities rely on staff support for many aspects of their life; staff values and beliefs can greatly inform a person with an intellectual disability's day-to-day living (Meaney-Tavares & Gavidia-Payne, 2012).
People with intellectual disabilities might seek education, guidance and support for expressing their sexuality ) and so staff members' viewpoints and their resulting actions can either suppress or support a person's expression of sexuality (Gilmore & Chambers, 2010).
There are contradictory reports regarding staff demographics being linked with liberal or conservative viewpoints towards sexuality for people with intellectual disabilities. Younger staff have been found to have more liberal views on sexuality (Cuskelly & Bryde, 2004) whereas, Gilmore and Chambers (2010) noted no differences in attitudes based on age or those with higher education. Other research shows higher education, alongside professional or managerial positions being associated with being liberal in this area (Saxe & Flanagan, 2013). By contrast, staff with strong religious beliefs have been found to hold more conservative viewpoints (Meaney-Tavares & Gavidia-Payne, 2012).
A person's level of intellectual disability and their perceived vulnerability are also seen to influence staff attitudes towards a person with intellectual disability's sexual expression (Ćwirynkalo et al., 2017), with staff adhering to a more restrictive role towards sexual expression in those with severe and profound intellectual disability . The potential risk related to sexual abuse and accusations of staff inappropriateness has been documented as protective justification to not engage in conversations and support in relation to intimate relationships (Young et al., 2012). In contrast, Yool et al. (2003) acknowledge that the level of intellectual disability may require different levels of advocacy, though they document how staff see sexuality as part of being human, and as a result, that no one should be denied their opportunity to express it.
Currently, in Ireland, is it not a requirement that staff receive training on Sexuality and Relationships if employed within an Intellectual Disability Service. Notwithstanding, providing support around sexuality and relationships is expected by staff, though specific training, while not mandatory, is advised by the National Health Information and Quality Authority (HIQA, 2014). Furthermore, on a systems level, some staff perceive sexuality as an extremely private matter where they believe it should not be discussed as part of their employment (Wilson et al., 2011). Staff can feel uncomfortable and have great difficulty in broaching the subject (Lockheart et al., 2009;Rushbrooke et al., 2014). Research indicates that staff do not receive adequate training regarding relationships and sexuality for people with intellectual disabilities, resulting in staff feeling unsupported by their service providers (Abbott & Howarth, 2007;Lafferty et al., 2012). Wilson et al. (2011) highlight that staff are constraint under the backdrop of organisational policy and are offered little in the way of assistance on day-to-day challenges and ethical issues. While staff regularly face these issues, they recognise the importance of sexuality training (Bernert, 2011). While 95% of staff sampled have requested specific sexuality training (Evans et al., 2009), McConkey andRyan (2001) report that just 25% of staff received sexuality training, with similar rates reported by others, that is, 12%  and 18.3% (Pebdani, 2016).
Staff views and attitudes on this matter are still not clearly understood (Pebdani, 2016). It, therefore, remains important to try and understand different values and beliefs that staff have in relation to people with intellectual disability's expression of sexuality, as staff report that it is difficult to ignore their personal attitudes and beliefs.
This research aims to investigate staff views and attitudes using both qualitative and quantitative methods, while specifically considering the impact of variables such as gender, age, education levels, religious beliefs and previous training on these attitudes. Based on the existing literature and knowledge base, the following hypotheses are proposed: H1: Staff would have more conservative attitudes towards sexuality based on factors of older age, lower education levels, active practising of their religion and poor attendance of training in the area.
The qualitative section is an exploratory overview of staff members current opinions on the area as a collective staff unit, as our approach is to consider the service perspective. In line with that our qualitative component focussed on their collective appraisals of the supports and structures offered in their services.

| Sample
A list of registered Irish Adult Intellectual Disability services was acquired from the Irish Health Information and Quality Authority (HIQA). From this list, eight Irish service providers were selected to be contacted based on their geographical location and the size of their service (>100 employees). Five of the eight service providers responded. Following ethical approval from each service provider, an email was circulated to staff by an on-site administrator in line with current data protection regulations. Staff were presented with the relevant information, consent and a link to the anonymous online survey. Survey data were collected via an online survey Questback (https://www.quest back.com). Organisations and research participants were informed of the voluntary nature of the study.
After 2-3 weeks, staff were sent a follow-up prompt email by the administrator. was stipulated that these employees needed to be actively working during the time of data collection to best represent their views on this matter. There were no other exclusion criteria. All employee management strata were considered: management, Allied Health Professionals (AHPs), frontline staff and administration. While not all staff members have direct, frontline care roles, their views and attitudes inform, and are informed by, the organisational culture, and so they were invited to participate. Further details, including breakdown of staff occupation, are presented in Table 1.

| Participants
The online survey consisted of demographic questions and open-ended questions on staff member's opinions on the potential barriers and future recommendations for this area. It also included the Attitudes to Sexuality Questionnaire-Individuals with an Intellectual Disability (ASQ-ID). This 34-item questionnaire was originally developed by Cuskelly and Bryde (2004) and later revised by Cuskelly and Gilmore (2007). Cuskelly and Gilmore (2007) revised version contains four subscales; Sexual Rights (13 items); Parenting (seven items); Non-Reproductive Sexual Behaviour (five items) and Self-Control (three items). These individual subscales have good internal consistency (α = .93, .88, .84 and .67, respectively).

| Data processing and analysis
Statistical analyses were performed using SPSS Version 24.
Descriptive statistics were used to report the sample characteristics with demographic data reported as frequencies and percentages for categorical data and means with a standard deviation for continuous variables (See Table 1). Preliminary analyses revealed no violations of normality. Comparative statistics were conducted using an independent sample t-test, and Analysis of Variance (ANOVA), with posthoc analyses, as relevant. Statistical significance was set at p < .05, and all tests were two-tailed. The a priori power analyses indicate that ANOVA set to an alpha value of .05, with power of .95 to detect a large effect size, with a potential 5-group stratification, that is, Age, requires a total sample of N = 80. Effect Size (ES) is reported as Cohen's d.
Open-ended questions were included in the survey to include a qualitative component. The responses were analysed by the lead author utilising Braun and Clarke's (2006) phases of Thematic Analysis.
These phases include familiarising oneself with the data; examining for patterns, and sorting the data into potential subthemes and superordinate themes. An inductive approach was used to code the text to thematically similar concepts, followed by grouping into multiple subthemes, which were then synthesised into superordinate or master themes. In line with the Braun and Clarke (2006) model, these themes were developed from the data rather (inductively) than from a predefined framework. Subthemes were reviewed and extracts were discussed with the co-authors to ensure the themes were thematically coherent across the framework. The specific questions which informed the qualitative component are reported in Table S1.

| ASQ-ID analysis
A summary of the ASQ-ID results is presented in Table 2 below.
It outlines the four predefined factors/subscales as described above. The overall mean scores of the ASQ-ID were high, indicating that staff attitudes on sexual expression for people with an intellectual disability were liberal. A series of ANOVA were conducted to investigate whether there was a significant difference within the group when stratified on gender, age category, education level, practising of religion and training with the ASQ-ID total scores and subscales.

| Gender
When comparing the ASQ-ID total scores, or the individual sub-

| Staff age
Participants self-selected their age from one of the five catego-

| Practising religion
This comparison found that people who self-reported that they actively practised their religion had statistically significant differences on the subscale Non-Reproductive Sexual Behaviour compared to staff who did not practice their religion, suggesting that participants who practised their religion had more conservative attitudes towards people with an intellectual disabilities' non-reproductive behaviour compared to participants who did not practice their religion (M = 19.72, SD = 3.76; M = 22.67, SD = 2.54, respectively; F (2,83) = 6.586, p = .002, ES = .688).

| Received training
This comparison found that people who received training on Relationships and Sexuality had statistically significant difference on ASQ-ID total scores to staff who did not receive training, suggesting that participants who received training had more positive attitudes towards sexuality compared to participants who had not reporting that they had received training regarding sexual and intimate relationships (see Figure 1). However, of the staff that had received training, 83.3% of them found it beneficial. Figure

| QUALITATIVE RE S P ONS E S
Three central themes were developed from the data. These included: "Unsupported and Frustrated," "Taboo Subject Matter" and "People with an intellectual disability's Vulnerability and Access to Education." Each theme is presented in turn and supported by a selection of quotes from the staff responses.

| Theme 1 -Unsupported and frustrated
Staff identified with feelings of being "unsupported" and "frustrated" when working with issues of sexuality and intimate relationships.

| Policy and guidance
Staff spoke about feeling unsupported by management structures in their services, reporting a lack of guidance in dealing with day-to-day issues. They reported that policy guidance in this area was "unclear" and "restrictive," with some staff stating that their service policy "doesn't reflect what we do in the house." Staff reflected that they found this conflicting situation regrettable. However, because of their perception of poor service guidance and restrictions, they found it necessary to work under their own initiatives. These understandings highlight how service guidance and the practical day-to-day application in the services might not be one and the same. Staff also stated they found the policy in their services to be out of date in both its age and its approach. With one staff noting that they "read it on induction, some 8/10 years ago. Before completing this (survey), I looked again at the policy. It hasn't been updated in that time." Frontline staff also noted in the past when they had sought clarity from management and Allied Health professionals, it was not always forthcoming.
They reflected that they were often left to work under their own initiative.

| Training
Staff consistently noted the lack of training as their main grievance with services included in this study. They cited the provision of training as one of the critical elements for improving their capacity to work with these matters. However, they reported a lack of emphasis in services to support such training, with time and resources instead directed towards other service initiatives.
Staff spoke about their frustration about not being able to access training even when they expressed a wish to attend these events.
They referenced the basic need for such training in their work. "I cannot get a place…. I have heard of a (internal) programme, but this was limited to only 3 places from our Service… All staff should have training…. It's a basic need in our work." Staff described how they would often seek outside training resources as they felt they would not get the required training in their own service. "I sought this (training) out myself. None has been offered in the Service I work in for many years."

| Uncomfortable and anxiety provoking
Staff recorded their internal conflict of wanting to protect the individuals they supported while also promoting their autonomy.

| Theme 2 -Taboo subject matter
Staff recorded that sexuality and relationships were very much under-discussed in services. They described it as being very much a "taboo subject matter." With one staff remarking that they were so "so glad (that this study was) shining a light into this subject matter, which largely exists in whispers and covert documents."

| Lack of discussion and recognition
Staff noted that there was a longstanding standard of secrecy on the subject. Staff reported how people with an intellectual disability "were told in the 80's 'don't be at yourself because that's dirty', you'll get AIDS (older persons who use the service will tell you this)." that "plans are for platonic relationships." Respondents noted their own shock in realising that they had never seen "intimate relationships" recorded in the "care plans" in their service. "I have never seen it mentioned in any-it's actually shocking when you think about it."

| Sexuality
Staff also discussed that although relationships and expression of sexuality was a taboo matter. When it came to people who identify as LGBTQ+, the door was firmly closed. Staff reported that sexuality was never discussed, that this topic was way too sensitive for their services. "Being gay is never even mentioned as a possibility. Sad but true." Staff felt that there would not be meaningful support for people with an intellectual disability who identified as LGBTQ+ in their Service. "If LGBT-not a hope of meaningful support."

| Conservatism and religion
Staff spoke about the conservative philosophy of their service providers. They detailed how religious teachings were very much part of the founding culture, and these viewpoints still existed in services today. They discussed how the religious and cultural history created a closed dialogue around this subject matter "It reveals much about our own attitudes as an organisation. Don't tell people as it will enrage the conservatives and the church." Staff recorded their want for more open discussions around relationships and sexuality and for services and staff not to block these types of conversations.
They noted that these discussions should be at both the local and national level.

| A person with an intellectual disability's identity
Staff expressed their frustration at the "taboo" nature of this matter.
They discussed their recognition that "It's a human desire to be loved emotionally and physically, we need to give the people we support an opportunity for that." However, they reflected how the lack of open discussion had repressed people with an intellectual disability's expression of sexuality. They reported that a lack of conversations on the matter has led to restrictive and less open and positive supports for people with an intellectual disability. Staff noted that this was leaving people with an intellectual disability to express their sexuality "In a hidden manner, scared of being criticised and ridiculed." They stated that services are doing people with an intellectual disability an injustice in this area and would become more comfortable working with these issues when more open dialogue is generated on this matter.

| Negative associations of sexuality
Staff reported that when issues around people with an intellectual disability's sexuality were discussed these were often reported to be about negative experiences. They stated that sexuality was usually discussed in services in relation to crisis support meetings because of inappropriate behaviours. "I support people when issues arise around the appropriateness of masturbation, usually when a difficulty has arisen. Almost always a reactive rather than a proactive response." Staff observed that references to people with an intellectual disability's sexuality were usually found in people with an intellectual disability's "Behaviour Support Plans," where staff focus would be on limiting behaviours through different strategies. Issues around inappropriate masturbation, public nudity and inappropriate touching were cited among staff. Staff also reported that this reactionary method of sexuality occurred in relation to their Sexual Education. They remarked that people with an intellectual disability were usually given Sexual Education instruction as a reactive strategy to behaviours. Staff expressed their frustration that very little was done proactively in this regard. "Service users need sex education…. everyone should have an opportunity to get this…I have seen one or two instances where service users got this, but it was for challenging behaviour." Staff did record a few positive associations around people with an intellectual disability's sexuality, with limited references to handholding and kisses on the cheek with other people with an intellectual disability.
However, they noted that people with an intellectual disability's main form of sexual expression was masturbation in their bedroom.

| Theme 3 -Vulnerability and access to education
Staff recognised that their work in this area was very much a "safety versus autonomy" issue. They expressed their insight on the potential vulnerability of people with an intellectual disability and they also recognised that Sexual Education for people with an intellectual disability was a key protection in this regard.

| Vulnerability
Staff generally supported people with an intellectual disability to engage in relationships and noted that it was an essential aspect of the person's rights. However, they reflected on their conflicting views on this issue concerning the person's level of intellectual disability, with staff stating their specific concerns about people with severe and profound intellectual disability. "They are very vulnerable, and I don't think they have the capability of understanding sex and relationships. Even with moderate intellectual disability would struggle.
It is hard to think about supporting them without giving protecting them." Staff also expressed their feelings around vulnerability when considering if people with an intellectual disability in their service would have children. They noted that "I just wouldn't know how a person with an intellectual disability would cope in that situation or be supported in helping to bring up this child or children." They reflected that people with an intellectual disability in their services would need considerable support with these issues.

| Improved access to sex education
Staff demonstrated the need for people with an intellectual disability to be further resourced in their knowledge on sexual matters and called for services to offer "educational materials to further advance understanding so that they can express their sexual feelings in a safe environment." They cited the need for people with an intellectual disability to receive sexual education and underlined its value in taking place before people with an intellectual disability entered Adult intellectual disability services. Staff stressed that the importance of early education that continued throughout their lifespan would be the most beneficial. "Sexual education should be a gradual process that starts when the person is young and is taught about his/her own body and continue on from there. Every opportunity to share with the person should be utilised." They noted that this should be recursive, building upon the person's skill level and that every opportunity for sharing of knowledge and information on this subject area should be taken. They recognised that providing people with an intellectual disability with educational supports in these matters would lead to greater information and therefore protection against potential abuses.

| Mixed-method data synthesis
As above, individuals tended to report a more conservative view or more liberal view on the topic of relationships and sexuality.
Stratifying participants in this way then allowed us to synthesis some of the findings. For one individual with a higher conservative view, they reported that "I feel I was very against a person with an intellectual disability having children in my survey, I just wouldn't know how a person with an intellectual disability would cope in that situation or be supported in helping to bring up this child." Another person reported "some of clients do not have insights into relationships, if some had children, they would not be able to cope." Both responses appear to relate to the capacity to cope, whereas others report that "many people I have supported show little or no interest in sex or sexuality." This is in contrast to those who have a more liberal view reported in the quantitative measures who note that'we all want to be loved and we all want to have sex. All staff need to recognise that those we support have the same desires'. Another individual recognises the need for training but also considers the individual with an intellectual disability in saying "we need more training in this area and time to do so. It is an important part of our lives, so it is also part of those we support."

| DISCUSS ION
The aim of this study was to investigate staff attitudes and views on supporting a person with an intellectual disability in the area of relationships and sexuality. Staff reported their frustrations about being unsupported in training and with local policy guidance. They also commented on the conservative nature of services with reference to the lack of discussion and the impact that religion had on people with an intellectual disability's expression of sexuality. Staff discussed barriers to sexual orientation and their service provider's focus on negative associations of sexuality. Staff also noted the vulnerability of people with an intellectual disability and expressed their need for improved sex education. Meanwhile, staff attitudes to sexuality were found to be more conservative for staff that were older, actively practised their religion, had a lower educational level and were not trained in the area. This study detailed some conservative attitudes and beliefs for some staff in relation to sexuality and relationships, while qualitatively the second arm of the study with the same staff reported frustrations with services, in terms of the services support and guidance and their conservative methods of delivery. More conservative viewpoints reported on the survey, over and above the qualitative responses, may be accounted for when considering the Likert nature of the quantitative component rela- tive to the open-ended nature of the qualitative component. This may lead to people providing richer data if they resonated with the topic, as described further in the strengths and limitations of the study. By investigating the congruency between the quantitative and qualitative data, it is clear to see that people with a more conservative view largely report a desire to support the individual, a sense of protectiveness, and a concern regarding the individual with an intellectual disabilities well-being. While this cannot be said for all responses, it highlights the role of targeted psychoeducation and support services in the area. People who reported more liberal views and outcomes reported aspects of desire, emotional well-being, and physicality, while making connection and reference to themselves e.g., "we all want […]," "it is an important part of our lives […]."

| Training and policy guidance
Staff reported their frustration of not having training available in their service, this was evidenced by the low numbers of staff that reported receiving training in this study. Previous research has indicated similar low figures for training (Pebdani, 2016). Staff spoke about their feelings of fear and anxiety in working with these issues as a result of to being unprepared and under-resourced. Research highlights that staff are sometimes the only support that people with an intellectual disability have on these matters (Kelly et al., 2009), and that it is important that staff are comfortable in their ability to work with these situations (Gardiner & Braddon, 2009). Training for staff is fundamental to the promotion of people with an intellectual disability's rights in this area. Training improves dialogue; it shifts negative perceptions which can increase liberal attitudes and decrease the taboo nature of the subject matter and has the potential to normalised life experiences for people with an intellectual disability (Gilmore & Chambers, 2010).
Staff also reported that policy and guidance did not replicate what they did in services. This viewpoint has been previously documented in other research (Grace et al., 2017;Hollomotz, 2009).
Incongruence with staff practice and organisation principles can impact on service provision as staff may work under their own initiative, principally guided by their own values and morals (Carnaby & Cambridge, 2006). This study would suggest that services need to improve their level of training support for staff, by creating strong, evidence-based and practical policy guidance in this area.

| Taboo subject matter and staff embarrassment
Twenty years ago, research represented intimate relationships and sexuality for people with an intellectual disability as a taboo subject (McCabe, 1999;McCarthy, 1999;Ryan & McConkey, 2000).
This current study reflected the same theme. Staff reflected on the lack of discussion in this area and how it directly impacted on people with an intellectual disability in their services, reporting that it closed down conversations and made people with an intellectual disability express their sexuality in a hidden manner. Staff also reported on the absence of "intimate relationships" in the people with an intellectual disability's Care Plans. They reflected how this was an example of services keeping this subject matter off the agenda, yet with adequate training frontline staff and allied health professions may be supported to integrate this into routine care plans.
Staff recorded their embarrassment in working with people with an intellectual disability regarding sexuality. Previous studies have highlighted similar themes of staff embarrassment in relation to these subject matters (Lockheart et al., 2009;Wilson et al., 2011) and have linked their conservative and religious upbringing as possible rationales for these embarrassing feelings (Lafferty et al., 2012). It is suggested that improved access to training and dialogue in services about these subjects would allow staff to become more comfortable in discussing this subject matter and increase their confidence in dealing with these issues with people with an intellectual disability.

| Sexuality
Staff reported that people who identify as LGBTQ+ were not supported by their services; previous research has reported similar findings (Abbott & Howarth, 2007;Clarke & Finnegan, 2005).
Meanwhile, staff who actively practised religion were found to have more conservative perspectives on sexuality, consistent with previous research (Saxe & Flanagan, 2013). This study's findings imply that belief systems have the potential to interfere with staff work practices. This is a worrying development, with national figures of between 4% and 8% of Irish people identifying as LGBTQ+ (O'Brien, 2015). There is potential that people with an intellectual disability rights are being suppressed because of their adult intellectual disability service provision. Understanding the potential of preconceived prejudices or opinions that staff may have on this subject can directly impinge on people with an intellectual disability's rights. It is, therefore, imperative, that policy, practice and staff attitudes in relation to sexuality are reviewed and monitored.

| Negative associations of sexuality
Staff associations around sexuality in their services were predominantly based on negative interactions. Staff reported that their experiences of sexuality were usually in terms of curtailing "inappropriate behaviours" through an individual's "Behaviour Support Plans." Previous research has reported similar staff experiences of people with an intellectual disability sexuality in their services (Abbott & Burns, 2007;Lafferty et al., 2012). Staff reported that the sexuality of people with an intellectual disability in services was expressed primarily through behaviour support strategies.
They outlined how service providers associated people with an intellectual disability's sexuality with "masturbation in their room" or by "dealing with inappropriate behaviours." Staff member's association of people with an intellectual disability's sexual expression primarily through behaviour support strategies; creates a riskaverse environment, rather than one that supports opportunities for people with an intellectual disability to express their sexuality.
Considerable work is needed to support clinical teams and frontline staff in this area because there is potential for protectionist and risk-oriented practices to overshadow people with an intellectual disability rights. It is suggested that services need to reflect on sexuality, and what this means to the individual as part of their overall quality of life.

| Strengths and limitations
Given the relatively small sample size of staff participants obtained, it is difficult to indicate how generalisable this study is to all staff and service providers. However, a multi-site sample allowed for multiple viewpoints from different service providers/ethos. This wide geographical representation meant the study was less vulnerable to area-specific difficulties. This is a particular strength of this study as different service providers have been recognised to have diverging viewpoints on this subject matter . Another strength of this study was that it was conducted online, providing staff with an opportunity to answer true to their attitudes and beliefs, rather than give socially desirable responses.
Both a strength and a limitation is the sampling across a number of occupations within services. While this allows for a greater organisational and systemic context to be considered, a future study may wish to recruit specific staff roles in order to ascertain specific experiences and opinions, for example, frontline residential.
Future research could also ascertain in detail, the specific previous training that staff have received, in order to better understand the mediating effect on attitudes. Finally, the methodological design of the study also allowed for a greater in-depth understanding of staff experiences which is both a potential strength and limitation.
While this approach offers participants the opportunity to provide richer accounts of their experiences, it may also be a limitation as potentially only those passionate about change in the area will provide detailed accounts of their experiences, thoughts and feelings.

| Clinical implications and future research
Recommendations for clinical practice and future research are multifaceted; incorporating suggestions for service providers, staff and people with an intellectual disability. The provision of training for all staff employed in adult intellectual disability services is essential.
Training removes uncertainty and replaces it with clarity for both staff and people with an intellectual disability. It can provide safe parameters for staff to work within and reduce their preconceived attitudes and viewpoints by providing a consistent approach and shared understanding (Cuskelly & Bryde, 2004), as well as allowing them to engage in positive risk-taking practices, for example, discussing matters of intimate relationships with a chaperone present.
While research demonstrates that improved Sexual Education for people with an intellectual disability can offset potential vulnerabilities by increasing their capacity in these areas, the majority of staff who engaged in this study reported a lack of training in the area. It is, therefore, incumbent of services to upskill staff to provide these educational resources. Future research in this area could incorporate the design of staff training. It is suggested that "active research approaches" where staff inform and guide the training through focussed workshops would allow for practical input while also remaining cognisant to the existing literature. Lastly, future research could also investigate service policy documents in relation to intimate relationships, and compare not only between services but also consider inter/national legislation for the standard of care.

| CON CLUS ION
Ten years ago, there was a series of Irish publications on this subject matter outlining similar themes in relation to staff being unsupported, a lack of discussion on the subject and poor sex education resources for people with an intellectual disability Gardiner & Braddon, 2009;Healy et al., 2009;Kelly et al., 2009). In more recent times, there have been significant shifts in the Irish public's attitude to sexuality and relationships, which can be seen culturally in 2015 when Ireland became the first country to legalise same-sex marriage by popular vote. This present study demonstrates that effectively very little has changed for staff supporting people with an intellectual disability in those intervening years in relation to sexuality and relationships. It becomes imperative to lay down the marker and ensure that researchers are not making the same observations in another 10 years. It is, therefore, vital that service providers and staff progress forward in the interest of people with an intellectual disability. As a fundamental human right, people with an intellectual disability are required to have the ability to express their sexuality freely. It is, therefore, essential that service providers and staff aid them in fulfilling this right. It is with this understanding that this research is a call to action; it is a call for change.

ACK N OWLED G EM ENT
The research team would like to thank the staff members who took part in this study, and to the host organisations for their interest in facilitating this research.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that supports the findings of this study are available from the corresponding author upon reasonable request.