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Gay people with learning difficulties have few outlets through which to explore their sexuality and little support from their carers, leaving many isolated or even in danger. Natalie Valios searches for some solutions.

Being gay in a largely heterosexual environment brings with it a few problems. Add learning difficulties to that, and people find themselves facing a double whammy of discrimination and a whole new range of unforeseen obstacles.

Most people see the world through heterosexual glasses, says Paul Cambridge, senior lecturer in learning disability at the Tizard Centre, University of Kent at Canterbury. "Homosexuality, whether between men or women, is tolerated but still not valued."

Having a sex life is a problem for many people with learning difficulties. In many settings, carers and staff actively discourage any form of sexual activity between clients - and some would react with horror and disgust if they discovered the existence of same-sex relationships.

But even when the right to a sex life is respected and acknowledged, most people with learning difficulties - whether they live in a residential home, at home with their families or in supported living accommodation with carers - are steeped in heterosexuality. Services, in particular, are often biased because most managers are heterosexual and male, says Cambridge.

But if we accept that same-sex relationships do occur, how should carers and staff handle it, and what should be done to ensure clients' safety?

Generally, men with learning difficulties who have sex with men do not identify themselves as gay. There are various reasons for this: many are struggling to overcome the label "learning difficulty" and to think beyond that is difficult; and alternatives to the heterosexual role are not easy to come by.

Cambridge says: "There is less reason for men with learning difficulties to identify as gay than other men. If they have never been given the option to come up with a different identity then they are hardly likely to realise it."

Some do not understand what being gay means, while other men with learning difficulties have sex with both men and women, so they would not define themselves as gay, says David Thompson, manager of the Growing Older with Learning Disabilities scheme at the Foundation for People with Learning Disabilities.

There is evidence to suggest that men with learning difficulties are more likely to find sexual partners who are male rather than female - simply because the opportunities present themselves more readily. The fear of a woman with learning difficulties becoming pregnant often results in stricter rules around contact between opposite sexes, whereas it is common for men to share bedrooms and toilets.

Only a few men with learning difficulties who have sex with men are in a position to think about whether they are gay.

"First, you have to know what being gay means," says Thompson. "Then there is huge pressure not to come out because you are probably living in services with about 30 carers, so it would be like coming out to 30 parents. And where do you go with that? As a person with learning difficulties you are going to be unwelcome in gay venues, and you will still be seen as an undesirable sexual partner by many men because of your learning difficulties."

One of the biggest hurdles for gay men with learning difficulties is the lack of gay role models. Residential homes do not have a culture of discussing sexuality openly and tend to be particularly reticent on same-sex relationships.

Although gay staff may come out to other members of staff, they are cautious about coming out to clients. They may feel anxious that allegations may be made against them and sensitive to the possibility that they will be accused of imposing their sexuality on a client or "leading them astray".

This leaves people with learning difficulties few outlets through which to explore their sexuality and can give them the impression that all staff are heterosexual.

In the absence of sexuality policies, staff do not know how far they can go in discussions, and often feel unsafe talking about same-sex relationships, says Christopher Bennett, chartered clinical psychologist for a tertiary assessment and treatment service for people with learning difficulties at the Hertfordshire Partnership NHS Trust.

Generally, the subject of same-sex relationships is raised only when it has been identified as a problem, for instance when a client has been seen hanging around public toilets or has approached another man in the home. Staff are then confronted with the issue but in a negative context.

Clients are left feeling isolated and reluctant to talk about having sex with men. Also, the support networks on which gay men rely to support them - such as contact with the gay community, gay role models and family and friends who accept them as they are - are often not in place for those with learning difficulties.

"They pick up the message that it isn't good," says Thompson. "It doesn't stop them doing it, but it stops them talking about it. That makes them more vulnerable to abuse and HIV infection."

This is a particularly important issue for men with learning difficulties. Getting sex is not the problem, says Bryan Mellan, manager of Consent, which takes referrals of people with learning difficulties around relationship and sexuality issues. Most of the men he has worked with have had sexual encounters through cottaging in public toilets or cruising. Mellan is concerned about sexual health risks for men with learning difficulties because no one knows whether the sort of sex they are having is penetrative and unprotected.

Because of these risks, Mellan says clients need facts and the skills and assertiveness to negotiate with the other person about a sexual encounter. Crucially, they must also be made aware of the legal and personal consequences of cottaging and cruising.

Thompson says: "It's relatively straightforward to give people the basic information. What's difficult is getting people to do that in their sexual relationships.

"Men who go to public toilets are at greater risk. They have little control over what takes place when they have sex with men without learning difficulties. When anal sex takes place, it is generally the men with learning difficulties who are penetrated. Even if it hurts they are not able to assert themselves and tell the man, so what hope is there of them saying he has to use a condom?"

Bennett agrees that there is a discrepancy between what people know about safe sex and what they do. "It worries me that we assume that because people know how to use condoms they are using them. But what if they aren't readily available?"

Mellan would like to see more work with staff and carers on their values and their attitudes. Although some people are openly homophobic, he believes it is more likely that many are ignorant. Consent is often called in to support groups on relationships and sexuality. Mellan says: "We ask them to think about how they present issues. Do they always have a heterosexual bias, for example, do they assume that the men want girlfriends?"

There are several options for staff who want to look at the issue of sexuality and people with learning difficulties. Advocacy services specialising in working with gay men with learning difficulties could be used as a befriending service; gay outreach workers could be brought in; or if gay staff were given the right support themselves, they could become identified support workers.

Men with learning difficulties will continue to have sex with men, regardless of whether they are supported. But, by being supported, they are put at far less risk of abuse and HIV infection.