Facilitators and barriers to developing romantic and sexual relationships: lived experiences of people with complex communication needs

Abstract

The aims of this study were to investigate the lived experiences of people with complex communication needs in developing romantic and sexual relationships, and identify and explore barriers and facilitators they encountered in pursuing these relationships. For the study, nine participants were interviewed. All were at least 21-years-old, used augmentative and alternative communication, and had physical and communication disabilities since childhood. A methodology employing critical hermeneutics, a form of interpretive phenomenology, and Feminist Standpoint Theory was utilized. The World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) model (2013) was used to develop questions for the semi-structured interviews. Interview data were analyzed using reflexive thematic analysis, with the ICF model and the concept of ableism used to identify four main themes: (a) Attitudes of others (ableism), (b) Communication Within Intimate Moments, (c) Assistance of Support Workers, and (d) Additional Education Related to Sexuality and Disability. Most of the barriers participants encountered related to ableist attitudes they experienced from others. Facilitators included creative communication strategies for intimate moments and using dating websites. The participants’ experiences bring attention to the need for changes in policies, practice, and research to further support people with complex communication needs in their quest to develop intimate relationships.

Keywords:

• Adult relationships
• augmentative and alternative communication
• complex communication needs
• disability and sexuality
• sex education

Human beings are social by nature and need to develop different types of relationships to meet their personal needs, survive, and enhance their well-being. Romantic and sexual relationships can meet needs of belonging, intimacy, companionship, physical touch, security, and sexual activity (Erber & Erber, 2018).

Romantic and sexual relationships are non-platonic relationships usually formed between two individuals for perceived personal benefits (Jonason & Balzarini, 2016). People pursue romantic relationships for social and emotional support, to meet physical needs for touch and sexual gratification, and to boost self-esteem and self-confidence (Jonason & Balzarini, 2016). Other sexual relationships can exist between friends who occasionally have sex together without romantic ties. These “friends-with-benefits” relationships are primarily for physical intimacy and sexual gratification (Jonason & Balzarini, 2016, p. 14). All of these types of relationships require the ability and opportunity to interact with other people, identify potential intimate partners, and form social relationships (Oudekerk et al., 2015; Simon et al., 2008). Although sexuality is a part of being human and the enjoyment of sex is innate to the character of being human, people with disabilities encounter additional challenges in expressing their sexuality, including from possibly over-protective parents, support workers, and professionals. In addition, they may be denied sex education in school, discouraged from engaging in adolescent activities that involve exploring sexuality, and find that sexual health providers are physically inaccessible (Shildrick, 2009).

People with disabilities are also more likely to experience difficulties with sexual activities than their able-bodied peers (Valvano et al., 2014), are often subjected to the misconception that they are asexual (Lee et al., 2020; Milligan & Neufeldt, 2001), and are frequently treated as children requiring protection from sexual knowledge and experience (Milligan & Neufeldt, 2001). Recent research from the Netherlands found young people with cerebral palsy enjoyed fewer opportunities to have intimate relationships than their able-bodied peers (Schmidt et al., 2020). Despite these obstacles, people with disabilities experience similar emotional, physical, and sexual feelings, desires, and needs as the general population (East & Orchard, 2014). Furthermore, the literature indicates that many lead “healthy, exciting, and fulfilled sexual lives and partake in a range of diverse forms of sexual expression” (Campbell, 2017, p. 5); however, these studies have focused predominantly on the experiences of people with intellectual or acquired disability (Czapla & Otrębski, 2018; Shikako-Thomas et al., 2013; Wiegerink, 2010).

According to Wiegerink et al. (2011), people who have grown up living with a disability require different support in exploring their sexuality and developing intimate relationships than adults who have acquired disabilities later in life. The latter often require a rehabilitation approach that helps them to adapt to new life circumstances, whereas people who have had disabilities since childhood often require a more developmental approach to support them in their sexuality and relationships. To date, there has been little research into the lived experiences of those who have grown up with physical disabilities in developing intimate relationships (Czapla & Otrębski, 2018; Sellwood et al., 2017; Shikako-Thomas et al., 2013; Wiegerink, 2010).

Another group within the disability community whose voices have not been heard with regard to sexuality and relationships is people living with complex communciation needs and physical disabilities (Sellwood et al., 2017). The majority of research relating to people with complex communication needs has been in areas relating to clinical practice, education, daily living skills, and leisure (Light & McNaughton, 2015), although some studies have found that people with complex communication needs face challenges in developing friendships and relationships (Light & McNaughton, 2015; Therrien, 2019). Environmental factors in particular have been found to make it difficult for these individuals to socialize and meet people. Traditionally, people tend to meet potential partners while socializing in public places such as hotels, clubs, and churches (Ballin & Balandin, 2007); however, these venues typically present physical access barriers (Iacono, 2014) and are often noisy, making it even more difficult for someone with complex communication needs to socialize (Ballin & Balandin, 2007). While social participation is a critical mechanism for developing romantic relationships, people with complex communication needs often have limited social networks and are socially isolated (Ballin & Balandin, 2007; Raghavendra et al., 2012).

A systematic review into perceived barriers and facilitators experienced by people with congenital physical and communication disabilities in socializing, sharing intimacy, and expressing sexuality identified the lack of research involving lived experiences of people with complex communication needs (Sellwood et al., 2017). The few references to sexuality in the relevant literature focused on protection from abuse, though some researchers called for improved access to sexual health services and counseling on sexuality and relationships.

Even in the disability field, the voices of people with complex communication needs are frequently excluded from research (Iacono, 2014). This is often due to additional considerations such as allowing adequate time for participants to use AAC devices and addressing complexities around obtaining consent (Dee-Price et al., 2021). Given the need for these voices to be heard, and current gaps in the literature, the aims of this exploratory research were to investigate the lived experiences of people with complex communication needs in developing romantic and sexual relationships, and identify barriers and facilitators they experienced as they pursued these relationships. The current study focused on the subset of people with complex communication needs who also had a physical disability from childhood.

Method

Participants

For the current study, there were nine participants: three males (Samuel, Ben, and Oscar) and six females (Amelia, Eve, Sophie, Jasmine, Emma, and Katie) aged 21 to over 70 years. To be included in the study, participants had to meet the following criteria: (a) be at least 21 years old, (b) be able to communicate in English, (c) have a physical disability since childhood, (d) have complex communication needs, (e) be able to use at least one aided AAC method (e.g., communication board or book, speech-generating device, or a tablet computer such as an iPad¹), (f) be able to provide reliable yes/no responses independently, and (g) be able to understand what they would be asked to do for the study and indicate their consent to participate.

Of the nine adults interviewed, six were from Australia and three were from Canada, the United Kingdom, and the United States. All had high school education or higher. Their daily activities included study, employment, day programs, and post-retirement activities such as leisure and academic pursuits. All used a combination of aided and unaided AAC. Unaided AAC included spelling words using natural speech, informal signing, and body gestures. Approximately 77% had dysarthric speech and the remainder had natural or no speech.

Four participants used communication assistants to “revoice” them during the interviews. Revoicing is an AAC strategy whereby a communication assistant repeats what is being communicated by a person with complex communication needs. This technique is becoming more commonly accepted, assisted by adoption into US telecommunications law, and its use in speech-to-speech relay telephone services in several countries (Kasnitz, 2020).

As this research explored sensitive, personal issues, pseudonyms have been used and several of the participants’ disabilities have been generalized. Tables 1 and 2 provide demographic information about the participants, including type of AAC used, primary communication methods, and methods of communication during the interviews.

Table 1. Participant information, including AAC device and access method.

Demographics	N	%
Sex
Female	6	67
Male	3	33
Age
21–30 years	1	11
31–40 years	5	56
41–50 years	1	11
51–60 years	1	11
61–70 years	0	0
70+ years	1	11
Country
Australia	6	67
Canada	1	11
United Kingdom	1	11
United Stated of America	1	11
Highest level of education attained
High school	3	33
Diploma^a	2	22
Tertiary (undergraduate)	2	22
Post-graduate (master or Ph.D.)	2	22
Disability
Cerebral palsy	7	78
Physical disability from childhood	2	22
Type of AAC device
Dedicated AAC	8	88
Computer tablet	4	44
Access method
Joystick	1	11
Head pointer	1	11
Direct^b	6	66
Eye gaze	1	11

^a Technical or vocational education or 2-year college; ^ball participants who used computer tablets utilized direct access method.

Table 2. Participant descriptions, including communication methods used.

Participant	Description	Communication methods
		Primary (self-report)	Used during interview^a
Amelia	Young woman with cerebral palsy	Informal signing, sign language, computer tablet	Natural speech, communication assistant, gestures, dedicated AAC device
Eve	Young woman with cerebral palsy	Natural speech, dedicated AAC device	Natural speech, gestures, typing text using chat feature in Skype
Sophie	Woman with a disability from childhood	Computer tablet, sign language, dedicated AAC device	Typing text using chat feature in Skype, gestures
Jasmine	Young woman with cerebral palsy	Natural speech, email, dedicated AAC device	Natural speech, communication assistant, gestures, dedicated AAC device^b
Emma	Woman with a disability from late childhood	Computer tablet, informal signing, natural speech	Typing text using chat feature in Skype, gestures
Katie	Young woman with cerebral palsy	Dedicated AAC device, spelling out words with eye movements to communication partner	Natural speech, communication assistant, partner-assisted auditory scanning, gestures, dedicated AAC device
Samuel	Man with cerebral palsy	Natural speech, communication assistants, computer tablet, dedicated AAC device	Natural speech, gestures, typing text using chat feature in Skype
Ben	Older man with cerebral palsy	Natural speech, communication assistants, dedicated AAC device	Natural speech, communication assistant, gestures, dedicated AAC device
Oscar	Young man with cerebral palsy	Natural speech, dedicated AAC device, handwritten notes using paper and pen	Natural speech, gestures, dedicated AAC device, handwritten notes using paper and pen^c

^a Descending order of frequency.

^b This participant emailed pre-prepared text that was confirmed as authentic by the participant during the interview.

^c This interview was conducted face-to-face.

Recruitment

Recruitment for the project occurred over a period of 25 months, starting in November 2015. It began with utilizing online advertisements on Facebook² and Twitter³; sending information about the project to two AAC-related email subscription services, Communication Matters (UK) and AGOSCI (Australia); and sending emails to people known to the researchers asking them to forward the information to potential participants. Those who expressed interest in the project received an email with the following attachments: a participant introductory letter, participant information sheet and expression of interest form, and an additional information sheet and consent form for a communication assistant if they planned to use an assistant. The information sheet advised potential participants they would be reimbursed for their time with a shopping voucher. All documents were also available to potential participants in print and online via a server hosted by Flinders University.

Due to the initial low number of people volunteering to join the study, ethics approval was sought for two additional recruitment strategies: snowball sampling and direct approach methods. Snowball sampling allowed the researchers to include, at the conclusion of each interview, an invitation for the participant to forward information about the project to other people they knew who might be interested in participating. Direct approach took two forms: (a) emailing potential participants known personally to the first author, and (b) members of the research team approaching potential participants at the ISAAC 2016 biannual conference in Canada using prepared scripts and a simplified version of the participant information sheet.

The first author assessed each expression of interest received for eligibility against criteria (a) to (e). Eligibility against criteria (f) and (g) was established face-to-face at the commencement of each interview. Although 10 participants were eventually recruited, one withdrew for personal reasons.

Consent

The participants either provided their signature or placed their mark on the consent forms to participate. To confirm participants’ ability to give informed consent, at the commencement of each interview, they were asked to demonstrate how they provide independent yes/no responses. Consent to participate was then determined using five simple questions requiring yes/no responses adapted from Balandin et al. (2006) (see Appendix A). These questions were also used to determine if the participants had read and understood the participant information sheet. Consent to video-record the interview was also obtained.

Setting and materials

All interviews, except for one, were conducted via Skype⁴. One participant, who was visiting the home city of the researchers, chose to be interviewed in person. This interview was conducted in a meeting room at the city campus of Flinders University. Conducting the interviews face-to-face (online or in-person), enabled the first author to watch for visual cues to determine the authenticity of participants’ contributions and facilitated immediate responses to their nuances and emotional states.

Each session was video recorded to ensure participants’ responses, including visual forms of communication such as gestures and body language, were accurately captured. The interviews conducted online were recorded using Skype. A digital video camcorder was used to provide a backup recording of the video call. The in-person interview was recorded using only the camcorder. A hand-held digital voice recorder was used during all interviews to record a backup of the audio.

A set of guiding interview questions was developed to gather background information about the participants as well as details about their social relationships and romantic and sexual experiences (see Appendix A). The Experiential Questions section of the interviews was structured to reflect the ICF model (WHO, 2013).

Research design

This research utilized a semi-structured interview, qualitative design to explore the lived experiences of people with complex communication needs in developing romantic and sexual relationships. A theoretical framework incorporating critical hermeneutic phenomenology (Lopez & Willis, 2004) and Feminist Standpoint Theory (Haraway, 1988) was developed to provide a conceptual foundation for the research. This framework also drew on the concept of ableism (Campbell, 2017) and the ICF (WHO, 2013) model.

Critical hermeneutic phenomenology is a form of hermeneutic phenomenology, which is part of the interpretive tradition in qualitative research (Lopez & Willis, 2004). Hermeneutic phenomenology recognizes that it is impossible for the researcher to separate from their prior knowledge of the phenomena being researched (Heidegger, 1962). The aim is to generate understanding of a participant’s experiences through interpretive inquiry (Lopez & Willis, 2004). This allows the researcher to use a theoretical framework as a means of focusing research questions and interpreting data. It also acknowledges the value of researchers drawing on their own existing knowledge and insights to enrich understanding of participants’ contributions. A critical hermeneutics approach consciously attempts to hear the voices of people who are marginalized and delves below the surface of the participants’ experiences to critique embedded social power structures (Lopez & Willis, 2004).

There is a general assumption in critical hermeneutic phenomenology that the researcher is external to the cohort being studied. Because the first author also had complex communication needs, Feminist Standpoint Theory was employed. This theory recognizes the position of the researcher as an inside knower with situated knowledge that enables them to access knowledge that may not be available to an outsider researcher (Haraway, 1988). While the lived experience of the researcher is not the same as that of the participants, Rackensperger (2012) suggests that participants may be more open and honest in their responses to interview questions when researchers share similar lived experiences.

The notion of ableism provided a conceptual understanding of the discrimination people with disabilities face (Campbell, 2017). The ICF model (WHO, 2013) emphasized the complex nature of disability by setting up a structure within which it could be explored. Light and McNaughton (2015) argue that the ICF provides a framework for designing interventions and research.

Reflexive thematic analysis was chosen as the method of data analysis, utilizing the six phases of thematic analysis proposed by Braun and Clarke (2012). Reflexive thematic analysis is recognized as a robust method for systematically coding qualitative data and developing themes from patterns identified in the data (Braun & Clarke, 2014) and also recognizes researcher subjectivity as a resource for knowledge production (Braun & Clarke, 2022). Rackensperger (2012) asserts that, “researchers […] having similar characteristics to participants may lead to differences in interpreting data from researchers who do not share characteristics with their participants” (p.108) and that such unique perspectives can generate richer understanding of the phenomenon being investigated.

All required approvals, including for additional snowball sampling and direct recruitment approaches, were obtained from the Flinders University Human Research Ethics Committee.

Researchers

The first author has a congenital physical disability and complex communication needs and uses augmentative and alternative communication (AAC), including a speech-generating device. His lived experience informed the current research, and he made a conscious effort to listen to the voices of those who are not often heard concerning a very personal and “taboo” topic to encourage a much-needed conversation within the AAC and disability fields. Because the first author had complex communication needs, the university provided him with an academic assistant throughout his Ph.D. candidature. Under direction of the first author, the academic assistant provided support for the study that included taking dictation, acting as a communication assistant in meetings and during the participant interviews, and assisting with typing transcripts of the interviews. All of the authors collaborated in the development of the themes; the second and third authors each read several of the transcripts. All three authors, together, discussed, reviewed and refined the themes to ensure they reflected the data (Braun & Clarke, 2022) and to address the risk of the first author unconsciously presuming that the participants’ experiences were the same as his own.

Procedures

Pilot interviews

Two in-person pilot interview sessions were conducted to refine the interview questions. The first session was with an able-bodied Ph.D. student to test the basic presentation. The second session was with a person who had cerebral palsy and dysarthric speech but did not use aided AAC. As the pilot interview participants did not meet the inclusion criteria, the findings were not included in the data for the project. The pilot sessions resulted in improvements to three of the interview questions, which were revised to enhance clarity; and also highlighted the amount of physical energy required by the first author to conduct the interviews, which informed scheduling of the actual sessions.

Data collection

Nine semi-structured interviews were conducted. Each interview was allocated 3 h. Six participants chose to complete the interview in a single session, while three broke their interviews into multiple sessions, which enabled them to manage the additional physical, emotional, and cognitive effort required due to their disabilities. Most of the participants used the full allocated time. If a participant elected to use a communication assistant, at the beginning of the interview the first author spoke with the assistant to ensure they understood that their role was primarily to revoice the participant’s responses.

While conducting the interviews, the first author communicated via his AAC device, natural speech, gestures, and communication assistant. All participants had difficulty understanding the first author’s AAC device over Skype, so he mainly used natural speech that was revoiced by his assistant.

Communication breakdowns are a common feature in any conversation with a person with complex communication needs. The fact that the first author also had complex communication needs compounded the number of communication breakdowns. This also meant, however, that both he and the participants had many years of experience at navigating such breakdowns; thus, when communication breakdowns occurred, they were able to use numerous strategies to ensure that intended meaning was communicated. These strategies included repeating key words, coming at the topic from a different angle, using AAC devices, typing using Skype’s chat feature, and asking communication assistants to revoice or summarize. The first author always ensured that a resolution of a communication breakdown was achieved by clarifying meaning with participants and asking them to confirm that any summaries were accurate. Asking direct yes/no questions of the participants allowed him to confirm that a particular revoicing reflected the participant’s perspective and had not been influenced by the assistant (Wickenden, 2011). On occasions when he thought the communication assistants might be contributing their own opinions or taking over the conversation, the first author would promptly remind the assistants of their role to revoice the participant within the interview and to not contribute their perceptions.

Interviews were transcribed by the first author and his academic assistant. The video recordings helped with the transcription process as it was possible to observe gestures and facial expressions to assist with clarifying meaning. To assist with analysis, observations such as body language, gestures, and communication issues were recorded. Verbatim transcription of the first two interviews took approximately 30 h. Most of the time was taken with understanding the speech of the interviewer and the participants and transcribing each utterance, including communication breakdowns. After transcribing the first two interviews, it was decided that communication breakdowns and their resolutions would be noted but not transcribed in detail. This decision was made because the research was not about communication methods and breakdowns but rather the lived experiences of participants. It was also decided that including every utterance in the transcript would introduce unnecessary and irrelevant data that would serve to distract from the intended meaning and increase the difficulty of analyzing the participants’ experiences.

When transcribing direct quotes, spelling and grammatical errors are usually denoted; however, responses from participants who typed their answers contained a high number of spelling and grammatical errors. To maintain the integrity of these responses and not detract from the participants’ intended meaning, it was decided not to use sic erat scriptum [sic] to denote these errors.

Data analysis

Per Braun and Clarke (2012), the data analysis was an iterative process. The first author spent 2 weeks immersing himself in the data by watching the video recordings of the interviews and reading through each of the transcripts several times. Then, open coding commenced, using NVivo 11 software (QSR International, 2015)⁵. This involved coding actions, places, relationships, sentiments, conflicts, and other matters of interest in the transcripts. After numerous iterations, themes were developed using the structure of the ICF (WHO, 2013) model as a framing device to identify the types of environmental factors that acted as barriers and facilitators in the participants’ experiences.

Reliability/integrity

Member checking was performed through emailing the participants a clean copy of the transcripts of their interviews with a request to confirm the accuracy of transcripts and return them with any amendments within 10 days. Words that had been difficult to accurately transcribe by the first author were highlighted in yellow. Most participants confirmed (via email) that the transcripts were accurate. Three returned their transcripts with minor changes that were subsequently noted. The majority of the corrections were clarifications of words highlighted in yellow. In one of the returned transcripts, the participant corrected two transcription errors: “boyfriend” was changed to “male friend” and “normal man” was changed to “able body male.”

Results

Nine people who had complex communication needs were interviewed about their experiences in developing romantic and sexual relationships (see Table 3). Although the experiences the participants discussed within the interviews were diverse, common experiences and factors influenced the development of their relationships. Participants were not directly asked about their relationship status during the interviews, however analysis of the interview data suggested that the majority were single; two were in romantic relationships, and two were in sexual relationships. Many met their partners in places of public entertainment, others met them online, and some sexual relationships developed from existing friendships. One participant discussed sexual relationships that had developed with a number of support workers. Five of the experiences were recent at the time of the interviews, five were in the last 10 years, and many involved relationships that started during childhood and teen years.

Table 3. Participant sexual and relationship experiences.

Participant	Summary of experiences
Amelia	Discussed two sexual experiences with men who also had cerebral palsy: (a) being in a swimming pool with a young man who made sexual advances, and (b) having support workers help her boyfriend get into bed with her.
Eve	Discussed two relationships: (a) with a boyfriend who also had cerebral palsy who she had known since childhood and had dated periodically, and (b) with an able-bodied male friend with whom she had hoped to develop a relationship beyond friendship but did not.
Sophie	Discussed two experiences: (a) a relationship with a fellow university student she was keen to develop beyond friendship yet seeing a reflection of the two of them in a window caused her to doubt her sexual desirability, and (b) an occasion when she was teaching a friend sign language and they ended up in bed.
Jasmine	Described an experience of being at a concert when an able-bodied male started to dance with her. They were getting on very well, but other people interjected and guided him away from her and she never saw him again.
Emma	Discussed an experience of being an active member of a group of young people and had sex with a male member of the group. The other males in the group reacted in an overprotective way, punishing him for “taking advantage of her.”
Katie	Discussed two relationships: (a) with her fiancé, who also had complex communication needs; they both lived in supported accommodation and could only have intimate physical contact occasionally on weekends if support staff allowed and assisted them to be on the floor together, and (b) with a male friend who became a “friend with benefits” several years after her fiancé died in an accident.
Samuel	Discussed two experiences: (a) acting out fetishes with another homosexual male with a severe disability, including undressing on the roof of a public building; and (b) developing communication methods to use during intimate activities when they were unable to see each other’s faces.
Ben	Discussed several relationships: (a) with his (ex)wife, (b) with a long-term support worker who became a sexual partner, and (c) with a sex worker who became a regular support worker.
Oscar	Discussed using LBGTQI dating websites to connect with other homosexual males for sex. He previously enjoyed seeing the reaction of potential sexual partners when they realized he had a disability. Now he is more upfront about his disability before meeting in person.

Note. LGBTQI: Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Intersex.

Four themes were generated from the data: (a) Attitudes of Others (i.e., ableism), (b) Communication Within Intimate Moments, (c) Assistance of Support Workers, and (d) Additional Education Related to Sexuality and Disability.

Attitudes of others (ableism)

One of the major barriers participants faced in developing relationships was the presence of ableism, which was evident in the attitudes of others. While none of the participants used the term ableism, the data indicated evidence of ableism in many of their experiences of attempting to develop relationships.

For example, Jasmine spoke of other people making decisions on her behalf without consultation when a male approached her at a concert and started to dance with her. Her friends, as well as venue security, “kinda chased him away and I hadn't been able to give him my name. […] I felt like I'd done something bad.” She reported feeling that her friends prevented an opportunity for her to flirt and enjoy the attention of a potential partner. She acknowledged the individual who approached her may not have been “a perfect guy” but added, “I wish I could have had a bit of fun with him.” Jasmine indicated the overprotective behavior of friends denied her the opportunity and autonomy to socialize as she chose. She expressed frustration at having her rights repeatedly undermined, even by people who knew her well: “I just hate my right to choose being taken from me again and again.”

Similarly, Emma reported that she felt included as part of her friendship group, which mainly consisted of able-bodied individuals, but stated that when she had sex with one of her male friends, “The other guys were very protective of me, and they had a kangaroo court scenario within their rat pack and he was punished for having sex that i initiated.” She wrote, “notion of pwd [people with disabilities] not being sexual beings, or being overly sexualised […] is just another example of oppression,” and went on to suggest that the way the other males ostracized the friend with whom she had sex could have been related to their (able-bodied) perception of her sexuality and disability.

Intriguingly, there was some evidence in the data that participants may have internalized ableist attitudes of others. For example, Sophie reported an experience in which she hoped a platonic relationship with an able-bodied male would develop into something more. She described feeling shocked when seeing a reflection of them together as they walked past a window and said, “I saw my body as the world must see me.” She reported that this caused her to doubt her attractiveness to him and that it took her several years to regain her self-esteem after this experience.

One of the facilitators that enabled participants to subvert ableist attitudes was the use of online dating sites. Three participants discussed using dating websites to meet potential partners, including the two female participants who had formed long-term relationships. Jasmine said the online environment allowed her to be in control of developing relationships, saying, “I got to know him without anyone else getting involved. Nobody has managed to take him away from me yet.” This type of control was seen to empower some of the participants to disclose information about their disability when and how they chose to do so. For example, Oscar indicated he used to not disclose his disability to potential partners until meeting face-to-face. “Like when I would go and meet people online I would turn up to his house. […] Because I wanted to see what reactions I would get out of him, like I would turn up … I would improvise.” He explained, however, that he had recently decided it was more helpful to tell potential partners about his disability before meeting them:

So, if someone wanted to meet me today, like I would tell him I have cerebral palsy and I would ask him if he knows what it is. […] because I don’t want to waste my time but most people are really good about it. There’s always an odd one who is a little bit uncomfortable.

When meeting new people face-to-face, being introduced by friends was identified as a facilitator. Jasmine said, “I have to be introduced.” In online contexts, both Jasmine and Emma found it easier to allow a partner to get to know them before having to worry about any additional disability-related factors. Emma reported that she often disclosed her disability only after becoming better acquainted, using humor to overcome possible negative attitudes: “i say i have a disability n can’t talk, but that makes me almost perfect cos i can’t whinge or argue - put a positive spin on it”.

Communication within intimate moments

Several participants indicated that accessibility of AAC devices in bed was a major issue. For example, Katie reported, “It’s hard to communicate when we are in bed together when I don’t have my communication [device].” Participants reported their AAC devices were either physically impossible to access or awkward to use. To compensate for this lack of accessibility, participants indicated a need to be innovative in their unaided communication strategies to facilitate their sexual relationships. Samuel described the method he used to communicate with his partner: “When we slept together when if i was unable to see [his face], i put my finger in his mouth., start with 'before L' and [he] would bite/suck me to communicate [using the alphabet].” His partner was able to spell out words he wanted to communicate to Samuel. Katie also reported communication in bed with partners had been problematic. Since she was unable to use her AAC device in bed, she discussed the communication methods she adopted to overcome this issue with her sexual partner: “We had to use yes or no questions” and “Going through the alphabet.” When asked if she used any quick gestures she replied, “A smile registering good.” Many of these unaided AAC strategies, however, were still reported to be challenging and slow.

Several female participants highlighted their significant reliance on able-bodied partners during sex because of their own inability to communicate effectively. Jasmine emphasized the importance of having a partner who showed her respect while lovemaking and who was open to learning what suited her:

It is important to acknowledge that when sex happens for people with CP, your spasm, and you just can’t communicate. […] In my opinion it takes a very special man to make love to a woman with CP without hurting her […] It helps if he is really very, very open about sex, as he must rely on both her bodily responses and the feedback she gives afterwards.

Ben acknowledged the extra effort required of his sexual partners because of his communication disability by saying, “My intelligibility must have affected in almost all my relationships. The women that I am with have to make a big effort to understand me.”

Assistance of support workers

Paid disability support workers who provided personal care and assistance with daily activities were discussed as being facilitators in some situations and barriers in others. Some participants would use support workers to facilitate communication while socializing. When asked what makes communicating easier when going out, Samuel stated his “personal assistant primilary.” Jasmine reported that her admirer’s support worker played an active role in facilitating the couple’s private correspondence, by-passing the gatekeeper—her mother—who would otherwise have prevented their communication. “His [support worker] was very good at doing what she was told and he’d get exactly what he wanted.”

Amelia spoke of needing to persuade support staff to put her and her boyfriend into bed together. Katie also discussed the need for assistance from support workers for her and her fiancé to be on the floor together; however, this assistance was rarely provided:

We couldn’t do much because we were in chairs […] Some times on Saturdays […] Staff made it difficult because of their attitude and values. They made it difficult because of staff. The staff wouldn’t agree to let us spend physical time together outside of the chairs.

Education related to sexuality and disability

Another hindrance to the development of sexual relationships was having been, as Samuel put it, “somehow excludes from sex education.” There was a perception by participants that school officials and teachers did not believe they needed sex education. For example, Jasmine expressed that, “Sex is reasonably painful if you’re mid-spasm and your partner wants to enter you […] Disability sex education would be nice.”

Oscar identified that having his partner accept his disability was an important aspect of the relationship, saying, “My physical disability didn’t get in the way, but it was so lovely, he was so open-minded.” Yet, in discussing experiences of meeting men from dating websites, Oscar expressed he grew tired of needing to provide each new potential partner with disability awareness and information on cerebral palsy:

I have a lot of stories where men were … I would arrive and a man would like open the door, look at me and decide he don’t want to be with me. It happened a lot. […] It was a lack of knowledge maybe, a lack of awareness. Like because some people have never met anyone with a disability before, so when I rock up I open the door, it is like people not knowing how to react.

Eve agreed that partners of people with complex communication needs require knowledge of their disability and its impact on lovemaking. Her advice to others was, “If you decide to be in a sexual relationship with anyone, make sure that that person knows about your disability and is able to accept you for who you are.”

Discussion

This exploratory research draws on the perspectives of nine adults with complex communication needs with regard to developing romantic and sexual relationships, and contributes knowledge to both the field of AAC and the broader field of disability and sexuality. As Shildrick (2009) argues, it is not enough to focus on identifying attitudinal barriers; there is a need to provide understanding of the causes behind the barriers. Providing this deeper understanding can stimulate conversation and engagement for social change (hooks, 2010).

Attitudes of others: ableism

The prevalence of ableism within the lived experiences of people with disabilities is often not recognized or acknowledged (McRuer, 2010). The findings of the current study showed that ableist attitudes on the part of others, including strangers, friends, and family members, were rife throughout many of the participants’ experiences. For example, Katie’s support workers’ attitudes often prevented her from spending intimate time with her lover, Emma’s male friend was castigated for having sex that she initiated, Jasmine’s dance partner was escorted away from her without her consent, and Oscar felt the need to change his strategy around revealing his disability to potential partners.

While none of the participants used the term ableism in the interviews, the first author conjectured, “Could it be we are so immersed in it that we do not recognize it?” According to McRuer (2010), if disabled people are constantly immersed in ableism encountered in the attitudes of others, they can internalize the ideology. For example, when Sophie was walking with her desired partner and saw their reflection in a window, it was likely internalized ableism (Shildrick, 2009) that caused her to doubt her attractiveness to him.

On the other hand, the participants reported several methods they used to subvert ableism. For example, Jasmine discussed needing to be introduced by her friends. While superficially this might seem obvious, it was quite profound. Jasmine seemed to suggest she needed more than a basic exchange of names; she needed her friends to take a more deliberate approach to introducing her. People with complex communication needs may benefit from using a strategy of giving permission to their friends to provide additional information when introducing them. This could include information regarding their methods of communication, and potentially common interests, preferences or personality traits. Deliberate introduction could provide scaffolding to assist with developing new friendships.

Another method the participants employed to subvert ableism was the use of dating websites when meeting new people and attempting to form relationships with potential romantic and sexual partners. Unlike face-to-face interactions, the online environment permits a degree of anonymity and empowers people to disclose information about their disability when they choose to do so, as the person whom they are pursuing may not be aware of their disability (Bennett, 2017). Several participants discussed how these sites assisted them to overcome possible negative attitudes of others toward their disability by allowing a potential date to get to know them before delving into the complexities of disability-related issues.

Arguably, one of the products of ableism that was evident within participants’ experiences was the idea of a type of “invisible line” that, once crossed by a person with a disability, can invoke an unexpectedly negative or even extreme response from within a social group. The notion of crossing such an invisible line gives insight into the pervasive, yet often subtle, ableism in the lives of people with disabilities and particularly those with complex communication needs. One example of this was Emma’s experience after she had sex with one of the males within her friendship group, and the rest of the group suddenly ostracized him. Similarly, in Jasmine’s experience at the concert, other people quickly intervened without her permission and ushered a potential partner away. In these two situations, the participants believed they were behaving within the social norms of their groups until the dynamics changed abruptly and they experienced sudden disapproval from their peers. While their friends probably felt they were being helpful, their ableist actions unconsciously demeaned the two women, treating them as incapable of making mature decisions.

Communication within intimate moments

Most of the aided and unaided AAC strategies the participants reported that they used had their shortcomings and did not always adequately support them in their social communication. This substantiates previous findings regarding the shortcomings of AAC devices within social settings (Balandin, 2011; Ballin & Balandin, 2007; Beukelman & Mirenda, 2013). Participants in the current study, however, indicated that these shortcomings were exacerbated in intimate moments, especially when in bed. AAC devices were either difficult or impossible to access, and although most participants described unaided AAC solutions they used to communicate in bed, maintaining effective communication throughout intimacy was challenging and slow. One creative unaided solution was the alphabet-based strategy Samuel developed with his partner, who also had complex communication needs, which involved his partner biting or sucking his finger to spell out words.

While all participants referred to having a certain level of autonomy within their relationships, this was often jeopardized in intimate moments due to poor access to effective AAC solutions. Ben acknowledged the additional effort that his partners needed to exert to ensure effective communication in bed. Jasmine’s statement about her vulnerability due to her body spasms and lack of ability to communicate while having sex highlights several issues: the power of the partner, the extraordinary trust people with complex communication needs must have in their partners, and the vital need for their partners to provide them with constant communication opportunities during all stages of sexual activity.

Assistance of support workers

Support workers play an important role in the lives of people with complex communication needs. Their role is usually seen as providing personal care, yet several participants mentioned support workers assisting with socialization. As Shuttleworth (2000a) pointed out, dating is a complex activity, especially for someone who needs additional assistance with eating and toileting as well as communication. Relying on support workers for assistance with social participation can be a double-edged sword because the presence of a third person changes interaction dynamics and can interfere with the development of the relationship (Dattilo et al., 2008; Shuttleworth, 2000b).

Workplace policies of service providers can create barriers for clients who receive assistance on dates and with sexual activity (Collier et al., 2006; Shuttleworth, 2000a, 2000b). For people with disabilities, private spaces often become public places because they are workplaces for support workers. Sexual needs have to coexist with workplace safety of support workers, whose welfare generally takes precedence over the sexual expression of clients (Shildrick, 2009). Furthermore, many service providers do not have policies surrounding these types of services or rarely make referrals to providers that do offer them, and this ambiguity can put all parties at risk (Browne & Russell, 2005).

People with disabilities must often navigate government funding systems and policies of support worker agencies to find ways to express their sexuality. Even though there are support workers who see assistance with sexual activities as part of supporting their clients’ well-being, it can be challenging for people with disabilities to find them (Hall, 2018; Shildrick, 2009). Katie and Amelia, for example, indicated that they relied on workers whose attitudes and values made them open to assisting with intimate relationships, but frequently had to seek them out. Having to negotiate this type of support with paid staff, especially when it may fall outside the policies and practices of agencies, further increases the difficulty for people whose communication is already an issue. Typically high staff turnover rates add to the ongoing difficulties associated with finding workers who are willing and can be trusted to provide the type of support needed in this context.

Education related to sexuality and disability

While most of the participants had engaged in sexual activities, many reported having inadequate sexual knowledge, including in relation to their physical disabilities. Jasmine indicated her disability had a direct impact on her sexual participation, suggesting that she lacked appropriate information relating to her disability that could have improved her sexual well-being. This echoes the participants in Collier et al. (2006), who also had complex communication needs and were frustrated at the lack of relationship and sexual education they received as adolescents. Although adolescents with disabilities should receive sex education as part of their high school curriculum, the current study highlights the need for additional sex education that specifically addresses the impact of people’s disabilities on their sex lives.

Able-bodied young people gain much of their sexuality knowledge through talking with peers, but those with complex communication needs have limited opportunities to explore these topics (Anderson et al., 2011; Collier et al., 2006). For example, participants in East and Orchard (2014) suggested that even among their peers who also had disabilities, young people did not often talk about sex in relation to their disabilities. One participant suggested the topic was generally an “elephant in the room.” This could be because, for many people with disabilities, sexuality is accompanied by strong feelings of rejection and oppression (Finger, 1992).

Retznik et al. (2017) claimed there was a correlation between success in romance and sexuality for students with physical disabilities and attending a mainstream school with appropriate additional support staff and having supportive teachers and parents. The participants in this current study talked little about their schooling but when they did, it was apparent they did not receive this type of support. Bahner (2018) suggested that, in addition to standard sex education, all students could benefit from access to additional curricula pertaining to disabilities and sex. It should be noted that people can experience the same type of disability in different ways and that environmental factors can also have an impact; however, there are some experiences shared by people with the same disability.

Partners can also benefit from access to information on sex and disability. Eve and Jasmine expressed the need to ensure their sexual partners were aware of the impact of their disability on their sexual activities. In a relationship that develops over time, people with complex communication needs have the opportunity to ensure their partners have the required information. Yet, if relationships escalate quickly to being sexual, as in several of the experiences described in the current study, it is vital to be able to provide this information effectively as the situation demands. Jasmine highlighted the issue that, due to her spasticity, she was often not able to communicate while having sex and therefore was not able to provide relevant information in the moment. For people with complex communication needs, thought and planning must generally precede intimate activities, as with many other aspects of life. When circumstances arise where such planning is not possible, opportunities to participate are often foregone or may be undertaken unsafely.

Implications for practice

The findings have potential implications for several areas of practice, including educators; disability support worker agencies; AAC practitioners; and AAC designers, manufacturers, and suppliers.

Educators

Teachers should be provided with access to appropriate material in order to offer comprehensive sex education for students with disabilities. This would include exploring communication strategies for safe sexual practices. Students with complex communication needs could also benefit from formal learning about the concept of ableism. Topics could include ableist attitudes and a history of the disability rights movement, to provide a context for improved understanding of the phenomenon.

To maintain healthy relationships and well-being, it is essential for people with complex communication needs to have access to relationship and sexual health services that go beyond standard sex education (Collier et al., 2006) to include disability-specific sex and sexuality information. It is vital for these services to be available to all people with disabilities throughout their lives (WHO, 2011); however, even mainstream services are difficult to access as there are insufficient staff trained to understand and support the requirements of people with complex communication needs (Collier et al., 2006; Solarsh, 2012). There has been a call for this type of service for more than a decade (Collier et al., 2006; Emens, 2009).

Disability support worker agencies

At present there seems to be a policy “grey area” regarding provision of the support required by people with complex communication needs in expressing their sexuality and participating in intimate adult relationships. Disability support worker agencies need clear policies governing the provision of personal care support during sexual activity.

AAC practitioners

People with complex communication needs require flexible AAC solutions that enable them to communicate in a variety of settings, including intimate moments in which both enjoyment and safety are vital. This may involve multiple AAC solutions. Creating these solutions requires creative thinking beyond traditional therapy models. The participants revealed innovative abilities to improvise methods of communication when having sex. This demonstrates that the knowledge and expertise of people with complex communication needs should be fostered, and that their voices should be included in the design and development of interventions; this, in turn, will enhance their own knowledge and problem-solving skills.

AAC designers, manufacturers, and suppliers

Participants indicated their AAC devices did not adequately support their communication while socializing, let alone during lovemaking. As most AAC designers, manufacturers, and suppliers are able-bodied, it could be argued that their devices are unintentionally limited by ableist attitudes. While AAC manufacturers and suppliers actively encourage users of communication devices to have input into product design, there are complex issues surrounding device accessibility, positioning, and the need for flexibility. Despite attempts to be inclusive, proposed solutions are generally filtered through able-bodied persons who ultimately decide what is produced.

New wearable technology is being explored in the assistive technology field for people with disabilities (Mulfari et al., 2017) and this could create opportunities for solutions that assist people with complex communication needs to converse with their partners while having sex. The AAC industry needs to understand the limitations of existing devices in social and intimate contexts, and recognize the potential market opportunities available for devices that are more flexible and effective in meeting the needs of individuals who use AAC.

Limitations and future directions

Several limitations need to be considered when interpreting the findings. For example, data may not be representative due to the small number of participants. Small scale qualitative research such as this is useful in understanding phenomena that are little known, but to confirm the findings, large scale quantitative research is needed (Jonason & Balzarini, 2016). Any generalizations should be made carefully. In addition, although there are benefits to using Feminist Standpoint Theory, the first author’s standpoint also brings with it his biases and prejudices. It is acknowledged that the first author’s contribution may be different from interpretation and knowledge-generation of researchers using other theoretical perspectives. Finally, communication difficulties experienced by both the researcher and the participants meant the 3-h time limit for each interview was barely sufficient. In retrospect, it would have been preferable to have multiple 3-h sessions over a 6-month period. Analyzing data from one interview to help plan for the next would have provided the interviewer with a richer understanding of the participants’ experiences.

In terms of future research, more work is required into the range of topics that could be included in sex and relationship education, to better equip people with complex communication needs to develop intimate relationships. Future research could also investigate communication methods and strategies for imparting information relating to one’s disability to potential sexual partners.

Conclusion

The current research has only scratched the surface but nevertheless sheds light on experiences, barriers, and facilitators faced by individuals with complex communication needs in developing romantic and sexual relationships. There is a clear requirement for more conversations and investigations within the AAC field regarding the importance of supportive family members, friends, and paid staff in countering ableist attitudes and facilitating social and sexual interactions; the need for support worker agencies to review policies and practices with a view to providing more opportunities for intimacy; and the need for AAC manufacturers and practitioners to develop tools and strategies that can adequately support communication in intimate settings for individuals with complex communication needs.

Acknowledgements

Portions of this article were submitted by the first author in partial fulfillment of his Ph.D. requirements at Flinders University. The authors would like to offer their gratitude and thanks to the participants who so graciously discussed their personal experiences. The first author would also like to express thanks to David Roberts and Ferg for their academic support work.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1 The iPad^© is a product of Apple Inc., Cupertino, CA. www.apple.com

2 Facebook™ is an online social networking and media service. www.facebook.com

3 Twitter™ is an online social and news network in which users post short messages or tweets. www.twitter.com

4 Skype™ is an instant messaging computer software program and a product of Skype Technologies, S.A.R.L. Luxembourg City. www.skype.com/en/

5 NVivo is a product of QSR International. https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home

Appendix A

Guiding interview questions

1. Participant Details

This information will be collected prior to the start of the recording. This is only for administrative purposes and will not be included in the research. The only other people who may see this are my academic assistant and my three supervisors.

Contact details such as email address, phone number and postal address are needed in order to clarify information where required.

Name:

Phone number or email address:

Postal Address:

Age:

City or Town of residence, country:

2. Introduction

2.1. Thank you for agreeing to participate in this research.

  I hope that it will be an enjoyable time. Please feel free to ask any questions throughout the interview and to ask for a break if you feel you need it. Firstly, about my research: it is exploring the experiences of people with Complex Communication Needs in getting into and keeping romantic or sexual relationships.

  I will be using my AAC device and my own speech throughout the interview.

2.2. Introduce academic assistant and explain his role.

  This is my academic assistant. He will be assisting me in this interview with communication. If at any point you do not understand me, I will use my AAC device or ask him to re-voice what I said.

2.3. Confirmations

  Before we start the actual interview, we need to go through a couple of things. These may seem tedious and unnecessary; however, they are requirements of the university.

2.4. Establishing reliable Yes and No responses

  Firstly, we need to work out a reliable Yes/No response that you can do without assistance. How do you want to do this?

2.5. Video-recording

  Ok, now we have established how you can communicate Yes and No, I need to ask again, as I asked before the video camera was turned on, are you happy for me to video record this interview?

2.6. Confirming ability to give consent

  I am going to ask you five questions that will require Yes or No answers. These next five questions are to make sure you understand and want to take part in this interview. Please answer them to the best of your ability with a simple Yes or No.

  2.6.1. OK, the first question is. Are you being forced to participate or are you being pressured to participate in this interview?

  2.6.2. Can you say that you want to stop being interviewed at any time?

  2.6.3. Could you be interviewed over several sessions?

  2.6.4. Will your real name appear in the final thesis or any publication of this research?

  2.6.5. Can anyone other than me, my assistant and supervisors access your answers?

  [Great, you answered correctly in these questions. But please remember when we get into the interview questions there are no right or wrong answers, you can answer them how you feel is right for you.

  OR

  It seems that you have trouble with understanding the Participant Information Sheet about this project. Unfortunately, we cannot continue with the interview at this point, so, would you like to read the information sheet again? I can go through it with you, and try these questions again.]

  (It would be unlikely that I would need to use the second option, I would hopefully pick up their ability before the commencement of the interview.)

2.7. Information sheet

  2.7.1. From the answers you have just given I can tell that you have read the Participant Information Sheet. Do you have any questions about it?

  2.7.2. Do you give consent to participate in this interview?

  2.7.3. The role of the communication assistant will be confirmed (if one is present).

  2.7.4. As you are using a communication assistant in the interview, I need to stress that I am really interested in what you want to say, so I ask both our assistants to ensure that they only revoice what we are saying. It is OK if you ask them to explain something further, but when this happens, I will check with you that they have relayed what you intended.

Guiding questions

Now, we are ready to begin the actual interview. There are four sections of the interview. The first set of questions is concerned with your personal background. The next is about the kind of social interactions you have. This is followed by a look at your friendships and relationships, and the last set explores some of your experiences in more detail.

I will remind you again that you may skip on any questions that you don’t wish to answer, and we can have a break whenever we feel the need.

3. Background

OK, let’s start. In this section we discuss a bit about where you live, your interests, education, employment, and your disability. We also touch on the way you communicate.

3.1. Describe your home.

  3.1.1. How many people do you live with?

  3.1.2. What kind of accommodation?

  3.1.3. Do you feel that you are free to live as you like?

3.2. Describe the town or city you live in.

3.3. What do you do with your time?

  3.3.1. Would you like to tell me about some of your hobbies and Interests?

  3.3.2. Would you like to tell me about your friends?

  3.3.3. Would you like to tell me about your work?

3.4. What is your primary disability?

3.5. What is your primary way of communicating?

3.6. What are some of the other kinds of ways you communicate?

3.7. When do you use these ways of communication?

  We are at the end of the first section. Well done. Would you like to have a break, or would you prefer to continue?

4. Social Interaction

These next questions are around the kind of social interactions you have experienced.

4.1. Tell me about your social life

  4.1.1. What are some of the social events and activities you attend?

  4.1.2. How often do you go out to them?

  4.1.3. Who do you go with?

  4.1.4. Who do you communicate with most in these events?

4.2. What makes it easy for you communicating when you go out?

4.3. What makes communicating difficult for you at social events?

4.4. What makes it difficult for you to meet new people in social events?

4.5. What makes it easier for you to meet new people in social events?

We are at the end of the second section. Well done. Would you like to have a break, or would you prefer to continue?

5. Relationships and Friendships

The questions in this section explore friendships and intimate relationships. Remember, you do not have to answer any question that you don’t want to.

5.1. In your teen years, what kind of close intimate relationships did you have?

5.2. Similarly to the last question, what kind of intimate relationships have you had?

5.3. Can you separate the two? First teen years and then adult life.

5.4. What kind of people do you prefer in intimate relationships?

5.5. Are you satisfied with the intimate relationships you have had?

5.6. Could you explain why you said that?

5.7. How easy is it for you to express your sexuality?

5.8. What does a satisfying sex life mean to you?

6. Experiential Questions

In this section I would like us to explore some experiences you have had in relation to romantic or sexual relationships. Here are some questions that will help guide us in this. The experiences you choose to discuss could be when you first saw your potential partner, a particular date, when a friendship developed into something more, a sexual encounter.

6.1. Activity and Participation

6.1.1. What is the experience you are going to describe?

6.1.2. What were you doing?

6.2. Body Functions and Structures

  6.2.1. What effect did your physical disability have on your experience?

  6.2.2. What effect did your communication have on your experience?

6.3. Personal Factors

  6.3.1. How did your personal attributes, the things that make you who you are, affect your experience?

6.4. Environmental Factors

  6.4.1. How did the way you communicate help or hinder you?

  6.4.2. How did people around you help or hinder you?

  6.4.3. How did things around you help or hinder you?

6.5. Would you like to share another experience?

7. Closing

7.1. Great stuff. We are at the end of the interview. However, I would like to give you a chance to add anything further.

7.2. Have you any advice you would like to pass on about romantic or sexual relationships for people similar to us?

7.3. Do you have any questions you would like to ask or comments that you would like to make?

7.4. If you can think of anyone else who might be interested in participating in this research, can you please encourage them to contact me or visit the research website?

7.5. Once again, thank you for your time. Within the next week my academic assistant and I will be using the video to prepare a transcript. The transcript and the video will be securely stored and backed up. The only people who will have access to this information will be my academic assistants and my three supervisors, and this will be only through me. Do you have any questions regarding this?

7.6. The transcript of the interview will be sent to you to review, and I would ask you to read through it and let me know of any corrections within 10 days by email. If I do not hear from you within 10 days, I will take it that you do not have corrections to the transcript.

7.7. If there are any issues arising from the transcript that you would like to discuss or if there is any additional information that you would like to contribute, I am happy to arrange a follow up interview.

7.8. We have reached the end of the interview. I hope that you have enjoyed the process and not found it too stressful. I just want to thank you for all your time and for participating in it.