Sex care robots

2.1 The concept of care

There are different understandings of the word care that depend on context, time, and the lenses through which one looks. Oxford dictionary [13] defines care as the ‘provision of what is necessary for the health, welfare, maintenance, and protection of someone or something.’ Cambridge dictionary [14] defines care as ‘the process of protecting someone or something and providing what that person or thing needs.’ It comes as no surprise that those sectors involving the protection of someone or something include the word care: skincare, car care, childcare, repair care, homecare.

Care is not the same as social support. Socially supportive relationships typically refer to those situations where the other person would do the same in case of need and include co-workers sharing a car to go to work, borrowing eggs from the neighbors, or sharing babysitters between new parents [15]. Caring does not bring in reciprocity [16], and typically refers to parent-to-child or nurse-to-patient relationship.

Those services geared toward the provision of what is necessary for health are part of the rubric of healthcare. The Dutch healthcare system defines care as the whole of health care providers (and support staff), institutions, resources and activities directly aimed at maintaining and improving health status and the possibility of directing themselves, and on reducing, eliminating, compensating for and preventing deficits therein [17]. The National Health System(NHS) [18] from the U.K. includes care as one of the six core values of nursing, midwifery, and care staff. Care is also one of the core values identified in nursing, for instance, and has been defined as a ‘nurturing way of relating to a valued other person, towards whom one feels a personal sense of commitment and responsibility’ [15].

Personal care relates to everyday functional competencies, typically named Instrumental Activities of Daily Living, like feeding, going to the toilet, dressing, grooming, physical ambulation, bathing, laundry, shopping, housekeeping, responsibility for own medications, modes of transportation, or ability to handle finances [19]. Collins dictionary [20] defines personal care as the "help given to elderly or infirm people with essential everyday activities such as washing, dressing, and meals." The Elderly Accommodation Counsel (EAC) [21] of the U.K. sustains that it is the "assistance with dressing, feeding, washing, and toileting, as well as advice, encouragement and emotional and psychological support." EAC [21] also adds that the Department of Work and Pensions of the U.K. (DWP) defines personal care as "attention required in connection with bodily functions, which include dressing, washing, bathing or shaving, toileting, getting in or out of bed, eating, drinking, taking medication, [and] communicating. Seeing and hearing are also considered to be bodily functions." These activities are directed towards the fulfillment of some of the basic needs found vital for people. To some extent, fulfilling those needs constitutes what is primarily considered good care.

The needs of an individual motivate his/her actions. In the 1950s, Maslow arranged the basic needs of individuals in the categories physiological, safety, love and belonging, esteem, and self-actualization. According to him, the needs are arranged hierarchically, implying that lower needs (physiological) should be met before the emergence of higher needs (self-realization). If a person is deprived of food, then concerns about self-esteem may be of little importance. Based on this premise, the scientific literature has reflected on how Maslow’s basic needs hierarchy could motivate healthcare professionals toward comprehensive care of a person, not merely for survival, but toward the satisfaction of all other basic needs such as breathing, eating, sleeping, and excreting [22, 23, 24, 25]. However, other physiological aspects, such as sex, have not yet been integrated into the concept of care and improvement of patients’ wellbeing.

Maslow [26] argued that while the gratification of the need to sleep leads to alertness, vigor, and zest, and its frustration brings someone fatigue, sleepiness, lack of energy or loginess; the same could be said for sex, although there is no respectable vocabulary yet to describe the frustration and the society is not accustomed to thinking so [26, p. 66]. He also stresses the idea that ‘for the sex-starved, food-starved, or water-starved person, only sex, food, or water will ultimately serve (...) no fortuitous collocation or accidental or arbitrary juxtaposition will do (...) Nor will signals or warnings or associates of the satisfiers do; only the satisfiers themselves gratify needs.’ Sex is, therefore, a basic-need gratifier on itself that can be distinguished from love, as they are not synonymous [26, p. 44].

In his understanding, feelings of physical sating and gluts such as food, sex, and sleep, and, as by-products, the well-being, health, energy, euphoria, and the physical contentment are part of those phenomena that basic need satisfaction determines. Those persons experiencing higher levels of need satisfaction will have lower levels of tension and, consequently, will not be in a state of deprivation [22].

In this article, we support the idea that in the context of elder and disabled care, the concept of care equals meeting all the basic physiological needs, including breathing, food, water, sleep, excretion, and sex.

2.2 The sexual rights of disabled and older adults

The World Health Organization (WHO) defines sexual health as the “state of physical, mental, and social well-being concerning sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence” [27]. Although every human should be able to enjoy physical touch, intimacy, and sexual pleasure, however, disabled people are often not in the position to fully experience the joys of life in the same manner as abled people. Similarly, older adults may have sexual needs that public healthcare tend to ignore as an essential part of their well-being [28, 29].

In 1993, the United Nations stated that persons with disabilities should enjoy family life and personal integrity, and should ‘not be denied the opportunity to experience their sexuality, have sexual relationships and experience parenthood’ (Rule 9, para. 2) [30]. Art. 25 of the Convention on the Rights of Persons with Disabilities [31] subsequently enshrined it, stressing that people with disabilities should have the right to the enjoyment of the highest standard of health without discrimination based on disability. It also mentioned that States should ‘provide persons with disabilities with the same range, quality, and standard of free or affordable health care and programmes as provided to other persons, including in the area of sexual and reproductive health and population-based public health programmes.’ However, after more than 20 years of discussion, the universal access to sexual and reproductive health remains an unfinished agenda [32], as if society failed in recognizing people with disabilities as sexual beings [33].

The Sexual Health, Human Rights, and the Law report from the WHO [10] was a seven-year project that acknowledged that physically and mentally disabled and older people, among others, have difficulties in accessing appropriate sexual health services. WHO [10] concluded that people with disabilities are more likely to find inadequate healthcare provider skills and equipment to meet their needs (twice as much), to be denied care (three times as much), to be poorly treated as non-disabled (four times as much) and to experience catastrophic health expenditure (50% more). Other quantitative studies show that non-disabled people perceive people with physical disabilities as having fewer sexual and reproductive rights [34], sometimes even as asexual [11], especially women [35].

Although sexuality is a basic human need, awareness, and knowledge about it do not come straightforward for disabled populations. Some researchers even highlight that people with intellectual disabilities are ‘purposefully misinformed about sexual health to reinforce fears as a means of inhibiting sexual activity’ [11]. Many aspects constrain how people with disabilities experience and engage with themselves as sexual beings, including their particular disability but also sociocultural, religion, economics, and gender factors [36]. These aspects are also relevant for the older population, who may feel the need to conceal their sexuality to fit social norms [29]. Healthcare providers may also put barriers to this matter by considering that ‘people with intellectual disabilities or other disabilities should not have a sexual life, reproduce or look after children, and therefore should not need sexual and reproductive health services’ [10].

It could also be that organizations are confused about the legality of offering support to safe sexual expression [37]. Sometimes it also depends on who is asked. Meaney-Tavares and Gavidia-Payne [38], for instance, report that whereas staff education and attitudes towards sex rights of persons with disabilities are not related, age and occupation play a significant role: younger (20-29) and managers were more positive than older, direct workers.

Studies report that attitudes towards sexuality in the general population are more favorable than with people with some disability [38, 10]. The full realization of the sexual rights of persons with disabilities and older adults, therefore, requires more research and policies that understand the intersection of people, disability, and sexual rights [36]. These policies could represent a step forward in treating people with disabilities and the elderly in a non-discriminatory fashion concerning their sexual rights and would empower users to satisfy one of the basic human needs.

2.3 Sex care

In parallel to the work of the UN, in 1997, the World Association for Sexual Health (WAS) proclaimed the WAS Declaration of Sexual Rights (revised in 2014). Although this association declares that is a ’multidisciplinary, worldwide group of non-governmental organizations (NGOs) with the aim of promoting sexual health and sexual rights throughout the world’ [39], on their website, there is no concrete progress on how the rights of the declaration translate in daily practice.

Some countries have reflected on how could the general and abstract idea of the sexual rights of people with disabilities be translated into concrete actions. In the Netherlands, for instance, they materialize it into what has been called sex care. Although this concept lacks a precise definition, Nwanazia [40] defines sex care as a ‘sexual service for people with severe physical or mental disabilities (...) often done by professionals with a background in health care (...) focused on intimacy, physical touch and sexual satisfaction for disabled clients.’

In Europe, there is a platform called European Platform Sexual Assistance for Persons with Disabilities (EPSEAS) that brings together different non-profit organizations offering sexual services for people with disabilities and the elderly.^[1]In total, there are 12 different organizations from Belgium, Czech Republic, France, Italy, the Netherlands, Spain, and Switzerland that work towards empowering people with functional diversity to exercise their rights to sexual experiences. In Table 1 below, we have included other associations working towards the same end.

The problem with sex care, however, is that whereas it is one possibility to materialize such a right, it often comes with the question of what is the status of sex workers, and whether their rights are violated in any form, or whether a state should invest public funds in these services. Sex care is also not mainstream, so in a way, one could argue that this initiative has not been adopted successfully.

3.1 Definition of sex robot

In this article, we focus mainly on sex robots for care purposes. We ground our definitions in those outlined by the International Organization for Standardization (ISO). ISO 8373:2012 [41] defines robots as programmable devices with a degree of autonomy moving within its environment when performing tasks. Those robots non-programmable in two or more axes or lacking the required degree of autonomy are robotic devices. For autonomy, ISO 8373:2012 refers to the possibility of a system to perform tasks based on current state and sensing, with no human intervention required [41].

Inspired by the definition of personal care robots of ISO 13482:2014 [42], we define sex robots as service robots that perform actions contributing directly towards improvement in the satisfaction of the sexual needs of a user. Typical types of sex robots include humanoids with full-body or partial-body robotic functionalities; that are programmable and that incorporate a degree of freedom. Sex robotic devices can also be body parts such as arms, heads, or genitals used for sex-related tasks.

The Silicone Sex Doll models from My Doll [43] and the Heat & Sound Sex Doll Robots by Z-Onedoll [44] are examples of sex robotic devices. Both feature an internal heating system that allows the user to adjust the body temperature of the doll manually. These two sex robotic devices are not programmable and lack a degree of autonomy, and thus they are not sex robots. Other technologies such as vibrators, teledildonics, non-humanoid sex machines,^[2]artificial vaginas, electroejaculation tools, vaginal and anal eggs, and clitoral pumps could arguably be described as sex robotic devices have also been excluded in our review.

3.2 Characteristics

Sex robots incorporate a range of technologies that distinguishes them from mere silicone sex dolls that emit computeresque voice from a perpetually agape mouth, with restricted limb movements, and no physical feedback. Sex robots can display realistic sex-related body movements, have sensors to react real-time to user interaction, and can include humanlike features such as voice to have small talk with the user.

We conducted a review of some of the newest sex robots in the world, and all the information is openly accessible online.^[3]In our review of sex robots, either purchasable, in development, or not for sale, we found 12 which meet the ISO 8373-2012 definition of a robot^[4]. Of those 12 sex robots, we used content analysis [45] to identify the following categories (and subcategories within) presented in Table 2, which encompass the different characteristics of sex robots:

We investigated a wide range variety of features, including their embodiment, gender, whether they have learning capabilities, what are their social skills or their human-like behaviors. Since sexual robot companies allow users to choose different traits and feelings appealing to them so that their experience is complete [5], we also included the features that can be changed by the user, including skin tone or hair color. The following sub-sections explain in detail these features grouped in three main parts: 1) embodiment, smart connectivity, and mobility; 2) autonomous sexual awareness and responsiveness and non-autonomous actionability; and 3) artificial intelligence (AI) characteristics: learning, sociability, and human-likeness.

4.1 Sexual theme

Recent literature proves that there is no loss of libido in the older adult population [62, 63, 64]. Lindau et al. [65] show that men and women engage in sexual activities, including intercourse, oral sex, and masturbation, even in the eighth and ninth decades of their lives. Disabled persons are no different [66, 67]. Shuttleworth et al. [68] also suggest that even though the presence of dementia or functional disability, the desire for sexual intimacy remains important into old age.

Sex robots could be a tool that helps provide a safe environment for older adults and persons with disabilities to explore sexuality. Rocky, an android sex robot, can actively penetrate a user with a vibrating penis. A user could penetrate Roxxxy, a gynoid sex robot. Roxxxy is capable of performing simple sexual movements, i.e., moving back and forth from the user. This feature affords the user the ability to penetrate the sex robot without having to move at all, or very little, which may be beneficial for physically impaired users. In these cases, a female or male sex robot with a massaging sexual orifice to stimulate a male user’s genitals, like Xiaodie and Roxxxy have, could cater to the needs of a fragile user. Alternatively, a robotic arm, such as Gabriel2052, to help with masturbation could help.

On the tamer side of companionship, but still, in the sexual theme, there is intimacy. Sandberg [69] describes intimacy, specifically from the perspective of male elders, as something more than sex or other than sex: the closeness, warmth, and touch of another body. Older adults [70, 71] and disabled persons [72, 73] seek intimacy, and sex robots could help in its realization. Emma and Realdollx sex robots have internal heating systems that make them feel warm, like another person. Exoskeletons for sex purposes, which allow a sex robot to walk and move its arms, such as those which Jeni and Foxi by Android Robot Store, could accommodate another type of intimate, physical companionship, that ofwalking together hand in hand.

4.2 Emotional theme

In our review, it became apparent that while sex robots have a clear functional goal that the general public can understand, i.e., be a sexual companion, the manufacturers of these robots heavily cater to the emotional support side of their technology. To follow, some examples of emotional support-related functions sex robots demonstrate.

Some of the sex robots identified here, Emma, for example, have voice recognition, which allows them to acknowledge the user as an individual. Roxxxy and Realdollx sex robots have personalities that the user can select to best suit their needs. In the case of Realdollx models, the personality of the sex robot can adapt to the user, learning through conversation. Samantha, as well as the other sex robots from Synthea Amatus, are equipped with human-like aspects such as likes and dislikes, laughter, and moods; they can make faces, smiling, frowning, or look attentive. These non-sexual, emotional features seem to push for the understanding that sex robots could provide positive, close encounters with persons beyond purely sexual experiences.

These non-sexual functions could help vulnerable parts of the population. Severely mentally ill or disabled persons that lack social skills require patience from those who socially interact with them [74, 75]. Disabled persons might find the intrinsic patience of a robot to be valuable. Emma, for instance, uses deep learning to learn from the conversation it has with the user to build a relationship with him/her. Users can converse with Emma, who will attempt to adapt to the user conversationally without losing patience with the user.

Sex care robots could represent the merge of emotional support and sexual companionship that benefit users in aged and disabled care. Consider the persisting issue of LGBTQ+ elders feeling afraid to be ‘out and proud’ [76]. Rocky, the sex robot, could help a closeted elderly gay man who lived his life in a lavender marriage and never pursued gay relationships or sexual relations. Elderly gay men may be closeted and afraid to express their gay orientation with others for fear of judgment, denial, anxiety, inexperience, or some other reason. In this instance, using Rocky could allow that person to make up for lost time both sexually and emotionally without fear.

Since elders are using the Internet to explore or enhance their sexual identities and experiences [77], Levy [3] suggests that users could use sex robots of different genders to explore their sexuality if they never had the chance while in their current state. The possibilities for sexual exploration with sex robots go beyond the obvious, i.e., heterosexual females using gynoid sex robots and heterosexual males using androids. A user can order the sex robot Harmony with a transgender converter, i.e., Harmony has a stereotypical feminine body shape and features but can have a penis instead of a vagina. A sex robot might be a non-judgemental alternative for sexual exploration among users, including the elderly and disabled.

4.3 Educational theme

Sex care robots could be useful to help disabled persons and the elderly with cognitive challenges learn about sexuality and emotions, including consent. If Samantha is not ‘romanced’ by the user, i.e., gently touched by the user, and instead detects aggressive touching from the user using sensors across the body, it will turn itself off and give no sexual feedback. For a cognitively challenged elderly or disabled person who lacks the awareness or understanding to be able to determine if a potential sexual partner is giving consent or not, Samantha could be used to teach that person to understand the consent process better.

This may be beneficial to help elderly and disabled people identify abusive sexual behavior, which is unsettling common [11, 12]. Murphy & O’Callaghan [78] performed an empirical study that queried adults with intellectual disabilities and young persons (mean age 16.6) to comparatively assess each group’s sexual knowledge and vulnerability to abuse. They found that the participants with intellectual disabilities scored lower on all but one of the ten sets of questions regarding their understanding of consent and abuse [78]. As a result of their findings, and based on their review of the literature, Murphy & O’Callaghan [78] suggest that there needs to be better sex education for persons with intellectual disabilities, specifically on-going sex education to help reinforce the teachings. They believe that this will allow this population to exercise their sexual rights while also protecting themselves [78]. Sex care robots might be able to serve an educational purpose in providing that on-going, practical sex education for these persons.