Sexuality Education And Individuals

with ASD: What Behavior Analysts Need

to Know.
Peter F. Gerhardt, Ed.D.
Executive Director, The EPIC School
Building Behavioural Solutions Conference
St Lawrence College Centre for Behavioural Studies
April 2018
 Disclaimer
Unpaid Affiliations
I have an association with the following programs or organizations but
receive no compensation for that association. None of the information
contained in this presentation is relevant to that association.

Paid Affiliations
I have an association with the following programs or organizations
for which I receive compensation. None of the information contained
in this presentation is relevant to that association.
 Acknowledgements
I would like recognize following individuals for their
contributions in the development of this presentation:
• Megan Atthowe, R.N., M.S., BCBA;
• Frank Cicero, Ph.D., BCBA
• Joanne Gerenser, Ph.D.;
• Isabelle Henault, Ph.D.;
• Lisa Mitchell, LCSW;
• Bobby Newman, Ph.D. BCBA;
• Sorah Stein, M.S., BCBA;
• Zosia Zaks, M.A., BCBA, and
• Many, many students, adults, and families.
 Presentation Notes
As a general rule I try to avoid using the terms “high
functioning” or “low functioning” to describe where someone
falls on the autism spectrum. The reason is that these terms
often just describe someone’s degree of vocal verbal behavior
than any actual level of functioning. So instead I try to use
“high verbal” or “low verbal” which I think is more accurate.

A primary challenge in preparing a presentation on the

subject of sexuality is the complexity of the topic and the
diversity of the autism spectrum. As such, biological
development and the resulting behavioral manifestations are
the only commonalities cross spectrum. As such, when
working in this area the assessment of individual
competencies, interests, deficits, excesses, etc. is essential.
 Presentation Notes
A secondary challenge is the cultural context of sexuality that
makes this presentation somewhat challenging to prepare
and, at times, deliver. For our purposes, a culture can be
understood as a collection of social norms in as small a unit as
a single family or as large a unit as a Nation, Region, or
Religion. While I do make an effort to be aware of such
differences, there is always the chance for error. Should such
an error occur, it is accidental.

I tend to use the terms ”sex education” and “sexuality

education” interchangeably but they are different, mostly in
interpretation. Sex Education is tends to refer to the biology
of sex while Sexuality Education tends to refer to the social
and interpersonal context of sex.
For the record…
I am a behavior analyst who happens
to worm with individuals with autism
AND an autism professional who
happens to be a behavior analyst AND
an educator who works to understand
autism and behavior analysis AND a
community advocate for my students
and clients AND….
 This is important because
If you work with young kids you get to be a specialist.
Whether you’re a special educator, speech pathologist,
occupational therapist, or board certified behavior analyst,
you get to be a specialist.

When working with adolescents and young adults you don’t

get to be a specialist and, instead, need to be something of
generalist. In other words, you need a good working
knowledge of ABA, positive behavior support, Government
services and resources, mental health concerns, medication
side effects, sexuality, menstrual care, job development, job
coaching, community-based instruction, generalized systems
of communication, staff training, community training, and
that’s just to start.
 And I am a
community
advocate
because if…
Then will take that village plus 2 small towns, a mid-
sized city, a chapter of the Hells Angels, three
communes, an international coalition, an on-call
medical team, 7 lawyers, 4 government officials, a
fleet of vehicles and, well, alcohol to raise a child with
ASD to a preferred, positive, included and safe
adulthood. Unfortunately, none of that happens on
its own,
My point is no one can
do this on their own. It
really is important to
know what you don’t
know and then look for
that knowledge.
 The following presentation
contains language and
TV imagery of a sexual nature and
may be considered
MA inappropriate for younger
listeners and viewers.
“No group in this country faces the sort of sexual
and reproductive restrictions disabled people do:
we are frequently preventing them from marrying,
bearing or rearing children, learning about
sexuality, having sexual relationships and having
access to sexual literature [ ] sexual confusion
arises as a consequence of society forcing us to
internalize the notion that we are sexually
inferior.” (Waxman, 1994, p. 86-86).

Waxman, B.F., (1994). It’s time to politicize our sexual oppression. In B. Shaw
(Ed.), The Ragged Edge: The Disability Experience from the First 15-Years of
the Disability Rag. (p. 82-87) Louisville, KY, The Avocado Press.
Richards, et al (2006) noted that, historically, individuals
with DD have been viewed as sexually deviant, prone to
criminality, asexual, and problematic to society.
Despite significant progress over the last 5 decades [ ]
the sexuality of individuals with DD is still grossly
misunderstood by society. And although today the
sexuality of individuals with DD is not entirely
ignored, nor is sexual behavior universally punished,
the perception that people with developmental
disabilities as perpetual children, irrespective of their
age, still lingers with significant, negative
consequences.
Richards, D., Miodrag, N., & Watson, S. L. (2006). Sexuality and developmental disability:
Obstacles to healthy sexuality throughout the lifespan. Developmental Disabilities Bulletin,
34(1-2), 137-155.
Griffiths, (1999) noted that most
learners with a developmental disability
receive sexuality education only after
having engaged in sexual behavior that is
considered inappropriate, offensive or
potentially dangerous. This may be
considered somewhat akin to closing the
barn door after the horse has run.
 Prudish Promiscuity?
Sex and sexuality, as serious topics for
discussion, are ones that many of us would
rather avoid than address. In fact,
according to the CDC fewer than half of all
high schools and only 20% of middle
schools offer a comprehensive Sex Ed
curriculum. Further, only 23 states
mandate Sex Ed at all and, of those, only
13 require it to be medically accurate.
(Orenstein, 2016)

Orenstein, P. (March 20, 2016). When did porn become sex ed? New York
Times Sunday Review. pp1, 6.
 Now add to that the
personal and societal
constraints that move
sexual behavior out of
the realm of simple
behavior and we have
a cohort of skills in
which there is high
interest but limited
knowledge.
 But let’s not forget there is, historically,
more than a touch of misogyny in all this…
Why ABA to teach this stuff?
Sex is just behavior. Whatever
body part(s) is involved it is all just
behavior.

-J. Bering, (2012)

There continues to be “lack of
evidence [supporting the]
effectiveness of sex education and
training for persons with DD” (Duval,
2002, p. 453) which Behavior
Analysis is able to provide.
 Many of the basic instructional goals in sexuality
education boil down to both simple and complex
discrimination skills. For example:
 Boy or Girl
 Men’s room or Lady’s room (or Blokes v. Shielas; Senors v.
Senoritas; M v. W; and so on…)
 Where or with who you can/cannot:
 Be naked
 Masturbate
 Curse
 Help with toileting or menstrual care
 Leave school with
 Touch certain parts of your body
 Working Definitions…
 Sexuality is an integral part of the personality of everyone:
man, woman, and child. It is a basic need and an aspect of
being human that cannot be separated from other aspects of
human life. Sexuality is not synonymous with sexual
intercourse [and it] influences thoughts feelings, actions,
and interactions and thereby our mental and physical
health” (WHO, 1975)
 Sex can simply mean gender, whether you’re male or female.
Sex can also mean the physical act of sexual intercourse.
 Sexuality education is a life-long process that encompasses
many things: the biological, socio-cultural, psychological
and spiritual dimensions of sexuality.
 Further complicating things…
 There are different types of sexual
language including:
 Formal/polite – Vagina
 Technical – Labia, Cervix, Clitoris, Vulva
 Cute – Va-jay-jay, Muffin, Little man in
the boat, Punani, Lady parts, etc.
 Slang – Sn*tch, Be*ver, Tw*t, P*ssy, etc.
 65 of the over 250 slang terms for Vagina
1.Cunt 22. Peach 44. Nappy Dugout
2. Pussy 23. Snake Pit 45. Fur Pipe
3. Bearded Clam 24. Cock Holster 46. Flitter
4. Vagina 25. Snatch 47. Dinner
5. Soft Shelled Tuna Taco 26. Chonch 48. Meat Tunnel
6. Camel Toe 27. Pinoché 49. Fuck Hole
7. Slit 28. Hatchet Wound 50. Gash (Bleeding)
8. Cockpit 29. Stinky Pink 51. Roast Beef
9. Cum Dumpster 30. Moose Knuckle 52. Penis Coffin
10. Fuzzy Taco 31. Small Aquatic Animal 53. Flower Bud
11. Air Pipe 32. Fetus Factory 54. Pin Cushion
12. Twat 33. Pudunda 55. Velvet-Lined Meat Wallet
13. Beaver 34. Arm Sleeves 56. Cooter
14. Tuna Town 35. Finger Warmer 57. Fur Burger
15. Punani 36. Bottle Holder 58. Fuzzy Credit Card
16. Puntang 37. Anal Alternative 59. Pee-Pee
17. ECD 38. Susan 60. Miss Flappy
18. Sweaty Love Box 39. Land Down Under 61. Texas Tunnel
19. Coochie 40. Joy Trail 62. Front Butt
20. Stabin' Cabin 41. Tunnel of Love 63. Penis Fly Trap
21. Muff 42. Crotch Sink 64. Red Snapper
43. Sex 65. Box
 68 of the over 250 slang terms for Penis/Testicles
1. Pecker 23. 23. Hammer 1. Balls
2. Johnson 24. Screwdriver 2. Stones
3. Prick 25. Screw 3. Family Jewels
4. Dick 26. Nail 4. Meatballs
5. Cock 27. Joystick 5. Reece's Pieces
6. Rooster 28. Elevator 6. Nuts
7. Lil' Billy 29. Floppy Drive 7. Coconuts
8. Wang 30. Hard Drive 8. Weights
9. Octagon 31. Hardware 9. Walnuts
10. Lil' Stevie 32. Gearshift 10. Gonads
11. Snake 33. The worm 11. Dumbbells
12. Python 34. Bookworm 12. Truffles
13. Cobra 35. Basalisk 13. The sperm factory
14. One eyed monster 36. Wand 14. Peanuts
15. Trouser snake 37. Sword 15. Chestnuts
16. Tramp killer 38. Boomerang 16. Package
17. Slut slayer 39. Hot pocket 17. Grenades
18. Lil' Buddy 40. Shaft 18. Huevos
19. Lil' Friend 41. Cyclops 19. Itchy and Scratchy
20. Halfmast 42. Knight 20. Beavis and Butthead
21. Tool 43. WMD 21. Easter eggs
22. Drill 44. Weiner 22. The two amigos
45. Hot dog 23. Maracas
 In addition…
Individuals with autism can be
concrete thinkers who
interpret things literally. For
example:
Some responses of adults with autism during
an assessment* of sexual knowledge

Q: Tell me about this

picture.

A: “[T]he people
were sitting on
the couch ‘being
friends’.”
http://www.camboday.com/UnderstandingSex/healthsex/img/sex_sofa.jpg

(Konstantareas & Lunsky, 1997, p. 411)

 Some responses of adults with autism during
an assessment* of sexual knowledge

Q: What does this

picture show?

A: “[t]wo people lying

on a towel.”

http://www.ural.ru/gallery/news/people/sex/bed.jpg

(Konstantareas & Lunsky, 1997, p. 410)

 Some responses of adults with autism during
an assessment* of sexual knowledge

Q: What is this man

doing?

A: “[T]he hand is
somewhere; he
chopped it off.”

http://www.reuniting.info/images/0bedSM.jpg
(Konstantareas & Lunsky, 1997, p. 411)
In the the field of Applied Behavior Analysis
Malott (1996) is the
most frequently cited
behavior analytic article
on human sexuality/
gender orientation.
Unfortunately, a very
large body of research,
(and an informed
public) contradicts
Malott’s assertions.
 Malott (1996)
• “This article presents a behavior-analytic view suggesting that
biological factors, whether genetic or otherwise, have little to do
with our preference for same-gender or opposite-gender sexual
attraction. (p. 127).

• ”All of this suggests to me that we are are born bisexual or even

multi-sexual (i.e., susceptible to sexual reinforcers from a wide
variety of sources). It is only through our behavior history that
become more focused in our sexual behavior and in our
preferences for, and aversions against, specific sources of sexual
stimulation.” (p. 130)

• “[ ] this behavior analytic world view suggests that our

biological inheritance has no more to do with our preferences of
our sexual stimulation than it does with our preference for [ ]
auditory stimulation.” (p. 138)
But back to sex education
 Central to Sexuality Education Is…

1. An understanding of sexuality from a

factual, or biological, perspective and
2. A basic understanding of personal safety.

So if you are uncomfortable with the

topic in general, the most important
facets are very basic.
As a general rule of thumb about
60% of sexuality education should
be at home, about 37% can be
done in the context of the school
and, when necessary, about 3% by
specialists. But I sort of just made
that up
Risk and sex education
 Risk
Risk is impossible to avoid. What we do
about risk, however, depends on the
options we have as a function of the
outcomes (Fischhoff & Kadvany, 2011).
While risk is unavoidable ignoring risk,
under the guise of safety, only invites
greater risk for the individual in question.

(Fischhoff, B., & Kadvany, J. (2011). Risk: A Very Short

Introduction. New York: Oxford University Press
 To Control for Risk
You need to know the limits of your expertise
before venturing deeply into behavioral
intervention in sex education.

As we will discuss, some areas of intervention

are quite basic and straightforward. Others
complex from the start.

When in doubt, get help from someone more

expert in this area.
 To Control for Risk
Start with a good understanding of
typical sexual development. This allows
you to determine:
• What is,
• or what is not
• appropriate or inappropriate sexual behavior

and, therefore, a potential target for

intervention.
 To Control the Degree of Risk
You need to understand the role that context plays in
determining what is appropriate behavior and what is
inappropriate behavior.

Appropriate Inappropriate
Private masturbation Pubic masturbation
For men, adjusting your genitalia Standing up to openly adjust your
out of view of others. genitalia at a meeting.
Private discussions of preferences Public discussion of the same.
in sex toys
Watching porn out of public view Watching porn on your laptop on
a plane

But these boundaries are not always set in stone and tend
to evolve over time.
 To Control for Risk
Your agency, school, program, or clinic
needs to have an established policy
outlining the conditions under which
sexuality intervention can be provided
and by whom.

At EPIC, there is a policy on both

Instructional Risk and Sex Education.
 The EPIC School
Policy on
Instructional Risk
The EPIC School
Policy on Sex
Education
The EPIC School
Policy on Sex
Education
 We are Sexual Beings
Typical children are taught many things about their own
sexuality from the day they were born. For example, they
learn:
 How they can be touched by others and the identify of
those “others”;
 Who they can touch and in what way/place;
 The way their bodies feel to them;
 What is okay and not okay to do;
 The words that family members use (and don’t use) to
refer to parts of the body; and

 In addition, as we grow they acquire a great deal of

information from outside sources including
television, music, friends, etc.
And, yes, we can just
ignore this nonsense
 Typical Sexual Development
Exploring and touching private parts, in public and in private
Rubbing private parts (with hand or against objects)
Preschool Showing private parts to others
Trying to touch mother’s or other women’s breasts
children (less Removing clothes and wanting to be naked
than 4 years) Attempting to see other people when they are naked, undressing, or in
bathroom
Talking to other children about bodily functions such as “poop” and “pee”
Purposefully touching private parts (masturbation)in public and private
Young Children Attempting to see other people when they are naked or undressing
Mimicking dating behavior (such as kissing, or holding hands)
(approximately 4- Talking about private parts and using “naughty” words, in absence of
6 years) meaning Exploring private parts with children their own age (such as
“playing doctor”, “I’ll show you mine if you show me yours,” etc.)
Purposefully touching private parts in private
Playing games with children that involve sexual behavior ( “playing family”)
School-Aged Attempting to see other people naked or undressing
Children Looking at pictures of naked or partially naked people
(approximately 7- Viewing/listening to sexual content in media
Wanting more privacy, e.g., not wanting to undress in front of other people;
12 years)
reluctant to talk to adults about sexual issues
Beginnings of sexual attraction to/interest in peers
Source: National Child Traumatic Stress Network (2009). Sexual development and behavior in children.
Downloaded from: http://nctsn.org/nctsn_assets/pdfs/caring/sexualdevelopmentandbehavior.pdf
Safety Information Typical Children Need
and are Taught

Preschool Children (less than 4 years)

 The difference between “okay” touch and “not
okay” touches
 Your body belongs to you
 You can say “no” to being touched, even by
grownups
 No one has the right to touch your genitals
 You can say “no” when grownups ask you to do
things such as touching genitals
 Who to tell if people do “not okay” things to you,
or ask you to do “not okay” things to them
 Safety Information Typical Children
Need and are Taught
Young Children Safety Information (4-6 years)
 Sexual abuse = someone touches your body/genitals or asks
you to touch theirs
 It is sexual abuse even if it is by someone you know
 Sexual abuse is NEVER the child’s fault
 If a stranger tries to get you to go with him or her, run and tell
a parent, teacher, neighbor, police officer, or other trusted
adult
School-Aged Children (7-12 years)
 Sexual abuse may or may not involve touch
 How to maintain safety and personal boundaries
 Technology risks including chatting or meeting people online
 How to recognize and avoid risky social situations
 Sexual abuse doesn’t always feel bad.
Then There’s Puberty
 Puberty
 The sequence of events by which a child
becomes an adult
 Characterized by the beginning secretion of
gonadal hormones, development of secondary
sexual characteristics, and reproductive
functions.
 In girls puberty normally beings after age 8
with the biological process largely completed
by age 16.
 In boys puberty normally begins at age 9 and is
largely completed by age 18.
 Onset of Puberty
 Over the past 2-3 decades the age onset for puberty has
decreased.

 For girls, breast development, typical of 11-year-olds a

generation ago, is now often occurring in 7-year-olds.

 Research indicates that childhood obesity may be the primary

cause.

 However, family stress and chemical exposures in the

environment may also play a role. The research is, however,
unclear as to degree of contribution.

 For boys, the data are murkier, but one study did suggest that
they, too, may be starting puberty earlier than before—
perhaps by as much as six months to two years. (Maron,
2015)
 Puberty and ASD
 There is a tendency for parents and professionals to
misinterpret:
 The emotional impact of puberty/adolescence on
individuals with ASD.
 Such things as reflex, or spontaneous, erections at the
onset of puberty in males.
 All genital stimulation, which often begins in the womb,
is not masturbation
 The importance of anticipating puberty and
adolescence and planning for such. Hence, the “5-year
rule”
 ASD, Puberty, and Behavior
 There is an ongoing discussion regarding the relationship
between puberty and the display of challenging behavior.
What we lack, however, are actual data. What seems to be
true, however, is:
 For some individuals the onset of puberty may be associated with an
increase in challenging behavior.
 This increase, however, may then be reinforced as a result of their
newly realized increase in size and strength (i.e., the behavior is now
more effective).
 We do tend to see behavior challenges associated with menstrual
cycles and some research indicates that females with ASD present
with more challenges than their peers with other disabilities.
 A new class of behavior, sexual stimulation, may develop. But
absent a functional assessment of sexual stimulation, it is generally
assumed to be maintained by automatic reinforcement which is not
always the case.
 Puberty and ASD
During puberty we can expect a certain
percentage of individuals with ASD to
develop a seizure disorder. Estimates of
seizure disorders among individuals
with ASD range from 20 to 40 percent,
with the highest rates among those
most severely impaired by autism.
Mental Health Concerns During Adolescence
Children & adults who have a DD and a
co-existing psychiatric disorder are one of
the most underserved cohorts in the US.
Beginning in adolescence, individuals
with a developmental disability are two
to four times more likely to have a
psychiatric disorder than their
Neurotypical peers. (Fletcher, et al.,
2007)
 Anxiety Disorders
Vasa, et al (2013) examined age-related differences
in the prevalence and anxiety in a large sample of
children & adolescents with ASD in the US and
Canada. Findings indicated that:
 The prevalence of anxiety in each age group exceeded
the prevalence of anxiety in the general population.
 Adolescents and school age children had the highest
prevalence of clinical (40%) and subclinical anxiety
(26%), respectively.

Vasa, R. A., et al, (2013). Age-related differences in the prevalence and correlates
of anxiety in youth with autism spectrum disorders. Research in Autism Spectrum
Disorders, 7(11), 1358-1369.
 Psychotropic Medication Use in ASD
Spencer, et al., (2013) examined rates of
psychotropic use and polypharmacy among insured
children with (ASD from 2001 to 2009. The results
indicated that, among children with ASD,
 64% had filled a prescription for at least 1
psychotropic medication;
 35% had evidence of psychotropic polypharmacy (≥2
classes), and;
 15% used medications from ≥3 classes concurrently.

 Median length of polypharmacy was 346 days.

Spencer, D., Marshall, J., Post, B., Kulakodlu, M., Newschaffer, C. Dennen, T., Azocar, F., & Jain, A.
(2013). Psychotropic medication use and polypharmacy in children with autism spectrum
disorders. Pediatrics. Nov;132(5):833-40.
But that’s the easy stuff, sort of:

Sex and sexuality, as serious topics

for discussion, are ones that many
of us would rather avoid than
address. This may be even more
true when the issue is sexuality
and learners with ASD.
 So really, how much research is there on
impact of sexuality education and related
interventions in ASD?
In fact, a recent literature review found
 A total of JUST 12 studies on intervention with
inappropriate sexual behavior that met the criteria of:
 Published in English in academic, peer-reviewed
journals;
 The participants in the study included at least one child
with a DD younger than 18 years of age;
 The studies were required to have examined the efficacy
of the treatment approach as a treatment for ISB; and,
 The studies were included outcome measures that
examined the effect of treatment on ISB, including direct
observation measures and standardized assessment
tools.
McLay, L., et al, (2015). A systematic review of interventions of inappropriate sexual behavior in children
and adolescents with developmental disabilities. Review Journal of Autism and Developmental Disorders, 2,
357-373.
 Holmes, et al., (2016)
 Holmes, et al., surveyed (online) 203 Pediatricians who
regularly cared for individuals with ASD regarding their
experiences providing information and care to individuals
and their families in the area of sexuality.

 While most of those sampled acknowledged the

importance of addressing sexuality related issues, very
few of them actually did. Reasons included:
 Personal or parental discomfort with the topic
 Lack of training
 Absence of any relevant materials on the topic, and
 Logistical challenges such as limited time.
 In a 2017study out of the Netherlands
 Stoffelen, et al., surveyed the Individualized Service
Plans (ISPs) of 187 individuals with ID from 7 different
provider agencies.

 Of the number, 159 (60 male/99 female) contained

some “reference to aspects of sexuality.” These
references were:
 Mostly descriptive
 Offered little direction for intervention
 Primarily described negative or problematic aspects of
sexuality.

 References to sexual education, treatment,

intervention or support were rare.
 A few things we probably do know
(Kellaher, D., 2015)

 At least some of our gap in understand sexuality and

sexual behavior in ASD stems from an general lack of
understanding about sexuality and sexual behavior.
 High verbal individuals appear similar to typical
peers in terms of sexual interest.
 While high verbal adults may know the language of
sexuality, this does not seem to equate to qualitative
or quantitative knowledge or behavior.
 A few things we probably do know
(Kellaher, D., 2015)
 Although data are limited there are published reports of
paraphilic behavior among HV males but none involving
HV females. The gender difference is due, most likely, to
multiple confounding variables but it does appear that
every permutation of sexual behavior we see in the typical
community exists in the HV/ASD community.

 In ASD, however, some paraphilic behavior represent

“counterfeit deviance” (Hingsburger, Griffiths, & Quinsey,
1991) in that it originates from an absence of knowledge,
experience, or specific social competencies.
Kellaher, D.C. (2015). Sexual behavior and ASD: An update and discussion. Current Psychiatry Reports,
17, Published online March 2015

Hingsburger, D., Griffiths, D., & Quinsey, V. (1991). Detecting counterfeit deviance: differentiating sexual
deviance from sexual inappropriatness. Habilitative Mental Healthcare Newsletter, 51-54.
 In regards to sex ed and IDD
McDaniels & Fleming (2016), in their literature review on
sexual education with individuals with ID concluded that:
 As a result inadequate sexual education Individuals with ID
are placed at a greater risk for sexual abuse, STDs, and
misinformation than warranted.

 Formal, individualized, and specific sexual education for

learners with ID is lacking.

 There is a paucity of published data resulting in little

information as to appropriate and empirically validated sexual
education content and processes for learners with ID

McDaniels, B, & Fleming, A., (2016). Sexuality Education and Intellectual Disability:
Time to Address the Challenge. Sexuality and Disability, 34, 215-225.
 Gender Identity
 In comparing a large sample of adolescents with ASD to
typical peers more people with ASD, especially women,
reported sexual attraction to both same- and opposite-sex
partners. A notable number of adolescents with ASD,
again more women than men, reported gender non-
conforming feelings. As such, gender identity and sexual
diversity needs to be taken into account in the provision of
sexuality education (Dewinter, DeGraaf, & Begeer, 2017)

Dewinter, J., De Graaf, H.,, & Begeer, S. (2017). Sexual Orientation, Gender Identity, and
Romantic Relationships in Adolescents and Adults with Autism Spectrum Disorder.
Journal of Autism and Developmental Disorders, 47, 2927-2934
A Couple of Good Reasons
Why We Should Teach
Human Sexuality Education
To Individuals With Autism
Spectrum Disorders
 6
They Have The
Same Hormones
& Urges & Need
To Make The
Same Choices As
Their Peers
 5
All sexual behavior is
social behavior and, as
such, is particularly
challenging for
individuals with ASD
 4

The Internet and

other readily
accessible media
 Were you aware that…
Porn has become a central
mediator of young people’s sexual
understanding and experience and
a “go to” source for information of
sex and sexuality in the absence of
any formal sex education (Crabbe
& Corlette, 2010).
Crabbe, M. & Corlette, D. (2010) Eroticizing inequality: Technology, pornography,
and young people. DVRCV Quarterly. 3, 1-6. Accessed on line on 3/36/16
at:http://www.awe.asn.au/drupal/sites/default/files/Crabbe%20Corlett%20Erotici
sing%20Inequality.pdf
 Just how accessible is pornography?
Research (Mitchell, Finkelhor, & Wolak, 2003;
Mitchell, Jones, Finkelhor & Wolak, 2014 )
indicates that that approximately 25% of
youth had unwanted exposure to sexual
pictures on the Internet in the past year. The
use of filtering and blocking software can results
in modest reductions in unwanted exposure is
far from fool proof.
Mitchell, K. J.; Finkelhor, D,; and Wolak, J. (2003). The exposure of youth to unwanted sexual
material on the internet: A national survey of risk, impact, and prevention. Youth Society, 34,
330-358.

Mitchell, K.J., Jones, L., Finkelhor, D., & Wolak, J. (February, 2014). Trends in Unwanted
Exposure to Sexual Material: Findings from the Youth Internet Safety Studies. University of
New Hampshire, Crimes Against Children Research Center Report.
For example, a search for “woman in kitchen”
in Bing images with the safe filter off finds:
And then there is Rule 34: “If it exists, it
exists as internet porn. No Exceptions.”
Just one example:
Lego Porn
But there is porn based upon:
The Flintstones Family Circus
Star Wars The Simpsons
Barbie Family Guy
Scooby Doo The Big Bang Theory
Disney Batman, Wonder
Star Trek Woman, Superman, etc.
Archie, Betty & Veronica King of the Hill
Zits Alice in Wonderland
Dennis the Menace Harry Potter
Archer Blondie & Dagwood
The Progressive LuAnn
Insurance Lady Dr. Seuss
For Better or Worse And so on…
But there is more to the internet
than porn or Rule #34.
 From a new eboo friend
"Hey, I added you since you look familiar, but
once I looked at your page I knew I was
mistaken.. but hey, you seem like a good guy
so i'll just introduce myself :) I’m quirky, funny,
and never afraid to have a good time.. I
recently moved here about six months ago
from a small town in Idaho for work and like
it so far! Check out my profile.. if you want to I
would love to meet sometime for lunch. Any
way. I wanted to attach more photos of me
but its giving me some stupid error! If you
give me your email addy I can send the pics to
you that way. Hope to hear from you soon!"
From another new friend
How are you doing today?? you are a
really cool and enchanting dude that's
why i did opt for a message to you ok
winks....Just want to know more about
you with due respect that's if you
don't mind. do take care and have a
wonderful day feel free to reply
ok.....with regards Fiona
A recent (2/2016) friend
Autism Specific Internet Dating
 3

Sexual Abuse
 We don’t have good numbers
 Brown-Lavoie, Viecili, & Weiss (2014)
noted that individuals with ASD reported
higher levels of sexual victimization that
did typical controls.
 Mandell et al (2005) reported that 18.5%
of their sample (156 children) had been
physically abused while 16.6% had been
sexually abused.
Brown-Lavoie, S.M., Vieceli, M.A., & Weiss, J.A., (2014). Sexual knowledge and victimization in adults with ASD. Journal of
Autism and Developmental Disorders, 44, 2185-2196
Sevlever, M., Roth, M.E. & Gillis, J.M. (2013). Sexual abuse and offending in ASD. Sexuality and Disability. 31, 189-200.
Mandell, D.S., et al (2005). The prevalence and correlates of abuse among children with autism served in
comprehensive community-based mental health settings. Child Abuse and Neglect. 29, 1359-1372.
 We don’t have good numbers
 Spencer, et al (2005) reported that children
with ID are were 4 times more likely to be
sexually abused than their typical peers.
 Sevlever, Roth, & Gillis (2013) noted that more
systematic research on the prevalence and risk
factors of sexual abuse and offending is in great
need if we are to adequately address this issue.
The bottom line, this is an area where Behavior
Analysis may have it’s greatest impact.

Brown-Lavoie, S.M., Vieceli, M.A., & Weiss, J.A., (2014). Sexual knowledge and victimization in adults with ASD. Journal of
Autism and Developmental Disorders, 44, 2185-2196
Sevlever, M., Roth, M.E. & Gillis, J.M. (2013). Sexual abuse and offending in ASD. Sexuality and Disability. 31, 189-200.
Mandell, D.S., et al (2005). The prevalence and correlates of abuse among children with autism served in
comprehensive community-based mental health settings. Child Abuse and Neglect. 29, 1359-1372.
 Target skills to reduce abuse
 Target discrimination between who can/cannot touch the
individual and where on his or her body. This includes
hugs, kisses, tickles, etc.
 Target independent toileting, showering, menstrual care,
and dressing.
 Target closing and locking bathroom doors.
 Target independent public restroom use.
 Target functional noncompliance via the word “No”.
 Target the recall of temporally distant events and report
where instances of physical contact.

(American Academy of Pediatrics, 1996; Nehring, 2005; Roth & Morse, 1994;
Volkmar & Wiesner, 2004)
 Avoidance of Sexual Abuse (Kim, 2016)
 In one of the few intervention studies, Kim (2016)
demonstrated the potential effectiveness of one specific sexual
abuse avoidance intervention with 3 girls with mild/moderate
ID in South Korea

 Training consisted of 9 role-play scenarios representing 3 types

of sexually inappropriate behavior (removing clothing, kissing,
touching an individual’s genitalia). There were 5 training
sessions for each scenario lasting 25-30 minutes.

 Avoidance skills were acquired by all 3 girls and generalized to

untrained environments. Skills were maintained 20-weeks
later.

 The extent to which these findings are readily generalizable to

individuals with ASD is unclear for a number of reasons.
Include Safety
Skills
 Safety Skills
 Safety skill intervention is extremely complex
given that:
 Many safety skills are rarely used and used only in very
specific situations.
 Fear, a factor in the acquisition of some safety skills in
typical learners, is far less a factor with learners with
ASD.
 Effective, community-referenced safety skills generally
require a some understanding of conditional probability
as a function of multiple stimuli.
 Safety skills reduce the possibility of harm, they do not
eliminate the possibility of harm.
 The acquisition of safety skills generally requires a degree
of error-based learning.
 Safety Skills
Physical Safety Social Safety Emotional
Simple Discrim Skills Safety
Hot/Cold, Wet/Dry, Response to
Light/Dark, Failure in either the
Sharp/Dull, Stop/Go, physical or social
Quiet/Loud, ETC safety domain.
Intervention may take
Complex Discrim form of BST, CBT, or
Skills systematic
Near/Far, Many/Few, desensitizing.
Fast/Slow, High/Low,
ETC
Multiple Discrim
Skills
Cold/Wet/Red v
Cold/Dry/Red Accurate?
Always – Sometimes – Rarely –
Situational Discrim Skills Never
Where, When Who, What, How
Stranger/Mall v Stranger/Home,
Fast Car/My Street, Fast Car/Cross Street
 BST and Safety Skills
 Safety skills are important for learners with autism
and should be addressed comprehensively over the
course of the learner’s schooling and across the
lifespan. An effective method to teach safety skills is
Behavioral Skills Training (BST). BST is a
comprehensive teaching method which includes
delivering instructions to the learner, modeling the
correct response, rehearsing the correct response in
both pretend and more naturalistic environments,
and delivering feedback to the participant regarding
their actions. (Beck & Miltenberger, 2009; Gunby,
Carr & LeBlanc, 2010; Johnson et al., 2006) and how
to seek assistance when lost (Pan-Skadden et al.,
2009).
 Error-based learning.
 “Learning from errors is one of the basic principles of
motor skill acquisition” (Seidler, Kwak, Fling, & Bernard,
2013, p.1)
 Medical training must at some point use live patients to
hone the skills of health professionals. But there is also an
obligation to provide optimal treatment and to ensure
patients’ safety and well-being. Balancing these 2 needs
represents a fundamental ethical tension in medical
education. Simulation-based learning can help mitigate
this tension by developing health professionals’
knowledge, skills, and attitudes while protecting patients
from unnecessary risk. Simulation-based training has
been institutionalized in other high-hazard professions,
such as aviation, nuclear power, and the military, to
maximize training safety and minimize risk (Ziv, et al,
2006).
Seidler, R. D., Kwak, Y., Fling, B. W., & Bernard, J. A. (2013). Neurocognitive Mechanisms of Error-Based Motor Learning. Advances in
Experimental Medicine and Biology, 782, 1-21

Ziv, Amitai MD; Wolpe, Paul Root PhD; Small, Stephen D. MD; Glick, Shimon MD , (2006). Simulation-Based Medical Education: An Ethical
Imperative. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: 252-256
 2
The Criminal Justice System
  Individuals with intellectual and other developmental
disabilities present unique characteristics that may
contribute to the development of behavior considered
offensive or criminal (Griffiths & Fedoroff, 2008).
 Low levels of sexual knowledge coupled with high levels
of interest/motivation and limited understanding of
sexual rights and legalities (Pecora, Mesibov, & Stokes,
2016) are associated with higher rates of involvement in
the criminal justice system than might otherwise
expected (e.g., Loftin & Hartlage, 2015).

Griffiths, D. & Federoff, J.P., (2008). Persons with Intellectual Disabilities Who Sexually Offend. In F.M. Saleh, A.J. Grudzinskas, J.M.
Bradford, & D.J. Brodsky (Eds) Sex Offenders: Identification, Risk Assessment, Treatment, and Legal Issues, p 352-374. New York:
Oxford University Press.

Pecora, L.A., Mesibov, G.B., & Stokes, M.A., (2016). Sexuality in High-Functioning Autism: A Systematic Review and Meta-Analysis.
Journal of Autism and Developmental Disorders
 There is a very small, but growing, body
of research on individuals with ASD who
are sexually abusive or commit sexually-
based crimes (Ray, Marks, & Bray-
Garretson, 2004; Duncan, et al, 2016).
 In any such situation it is important not
to make quick assumptions as to the
function of the behavior in question. Ask
the right questions and collect the right
data.
 1
Because They Are People & Like All People
Individuals with Autism Have The Right
To Learn All They Can To Enable Them To
Become Sexually Healthy Persons
Public/Private Discriminations at Home

 From an early age families need to be clear

and consistent with family rules about privacy
 Restrict nudity in public parts of the house
 Dress and undress in bedroom or bathroom
 Close doors and window shades for private
activities
 Teach use of robe
 Caregivers should model knocking on closed
doors before going in
(American Academy of Pediatrics, 1996; NICHCY, 1992; SIECUS, 2001)
 Guidelines for teaching
 Think ahead and be proactive
 Be concrete
 Serious, calm, supportive
 Break larger areas of information into smaller, more
manageable blocks
 Be consistent, be repetitive
 What are the practical implications
 Teach all steps and in the correct order
 Consider using multiple instructional mediums
 Incorporate the social dimension of sexuality when and
wherever appropriate

*Source: L. Mitchell, RCSW, The Cody Center

 The 6 Rules of Presentation:
 Simple
 Visual
 Individualized
 Repetitive
 Fun
 Concrete
 Teaching materials

 Commercial products include:

 Anatomically-correct dolls
 Anatomical models of body parts
 Written materials and pictures
 Slide shows and videos
 Shop carefully-- most products
 were not created for people
with ASD, and they are
expensive
 Teaching materials
 Creating your own is easy and less costly

 Resources include:
 Medical and nursing textbooks
 Patient education materials
 Sexuality education books at the library
 Google Image search
 Planned Parenthood
 Homemade digital photos & videos (NOT of nudity or
private activities)
Guidelines for making materials

For example…
This is Nancy
Which one is Nancy?
Which is Nancy?
Four Basic Areas of Instruction
 Provision of accurate Information
 Development of the necessary social
competencies
 Development personal values
 Promotion of individual safety
Information
 Central Instructional Concepts
 Public versus private behavior
 Good touch versus bad touch
 Proper names of body parts
 “Improper” names of body parts
 Personal boundaries/personal spaces
 Masturbation
 Avoidance of danger/Abuse prevention
 Social skills and relationship building
 Dating skills
 Personal responsibility and values
What to teach and when… some general
guidelines.*
 Preschool through Elementary
 Boys v. girls
 Public v. private
 Basic facts inc. body parts
 Introduction to puberty (your changing
body)
 Introduction to menstrual care
 Appropriate v. inappropriate touching
 Bathing, dressing, and privacy

Source: Schwier, K.M., & Hingsburger, D. (2000)

 Middle School & Beyond

 Puberty & Menstruation (if not yet addressed)

 Ejaculation and wet dreams (if not yet addressed)
 How to say “no” (if not yet addressed)
 Masturbation (if not yet addressed)
 Public v private behavior
 Public restroom use
 Attraction and sexual feelings
 Relationships and dating
 Personal responsibility and family values
 Sexual preference
 Laws regarding sexuality
 Pregnancy, safe sex, birth control
 Etc.
The same techniques we use to teach other
behaviors can be used in this area too
 Activity Schedules
 Shaping
 Chaining
 Prompting
 Video-Modeling
 Discrete Trial Instruction
 Massed Practice
 Functional Assessment
Preventing Problems with Masturbation
 Early on designate where it is OK to
masturbate
 Individual’s bedroom
 Avoid teaching use of bathroom
 Teach rules for appropriate time/
place
 Teach sometimes it’s not an option
 Schedule private time

(Baxley & Zendell, 2005; Koller, 2000; NICHCY, 1992; Volkmar & Wiesner, 2004)
 Intervention with Situationally Problematic
Masturbation
 Interrupt the behavior as soon as possible but
don’t punish or overreact
 Remind the individual of the rules for
appropriate masturbation (referring to any
visual supports necessary)
 Redirect the student to:
 An activity that requires use of hands
 A physical activity
 An activity that requires intense focus
 To his/her bedroom, if available
 Reinforce student when he/she is engaging in
appropriate behavior
(Baxley & Zendell, 2005; Koller, 2000; NICHCY, 1992; Volkmar & Wiesner, 2004)
 VALUES
(I am not going to talk about values)
SOCIAL COMPETENCE
\\
 Social Skills
A social skill is any skill that facilitates
interaction and communication with
others. Social rules and relations are created,
communicated, and changed in verbal and
nonverbal ways. The process of learning these
skills is called socialization.

https://en.wikipedia.org/wiki/Social_skills
 Social Competence
Social competence in adolescents and
adults with ASD refers to the ability to
shift between skills in a social
repertiore as a function of context and
need.
 The Function of Social Skills

Social skills are mediated by their

outcome in that they are used to
acquire desirables and avoid
negatives while navigating the
environment and manipulating
others in that environment.
 What's Not Much.
Hi! Not Much
Up? You?

Social Skills are NOT Linear

But rather logarithmic in nature
Person 1 Person 2 Person 1 Person 2

Not much Nada

What’s up?

How are Fine, you?

you? Been
around
HI

Hanging
How's it well
hanging?
All good
Been busy,
you?

What's
happening? Where you
been?
 In other words…
"A greeting...is a social skill that is thought to be simple.
However, further analysis shows this skill, which most take
for granted, to be extremely complex. How a child greets a
friend in the classroom differs from the type of greeting that
would be used if the two met at the local mall. The greeting
used the first time the child sees a friend differs from the
greeting exchanged when they see each other 30 minutes
later. Further, words and actions for greetings differ,
depending on whether the child is greeting a teacher or a
peer.... [G]reetings are complex, as are most social skills.”

Myles & Simpson (2001)

There do appear to be some elements that seem to
contribute to a worthwhile social skills interventon. In
children with ASD. For example, Krasny et al (2003)
and Williams, et al (2007) discuss the following
"essential ingredients" for effective social skill
intervention:
 Make the abstract concrete
 Provide structure and predictability
 Provide scaffolded language support (simplify
language and group children by language level)
 Provide multiple and varied learning opportunities
 Select relevant goals (such that issues most central
to ASD are addressed)
  Program in a sequential and progressive manner
 Provide opportunities for programmed
generalization and ongoing practice (so skills are
applied outside group setting)
 Increase social motivation
 Increase social initiations
 Reduce interfering behaviors (reinforce positive
behaviors by, for example, maintaining behavior
charts and reinforcing desired behavior with stars)
Krasny, L., Williams, B. J., Provencal, S., & Ozonoff, S. (2003). Social skills interventions for the
autism spectrum: Essential ingredients and a model curriculum. Child and Adolescent
Psychiatric Clinics of North America, 12(1), 107-122.

Williams White, S., Koenig, K., & Scahill, L. (2007). Social skills development in children with
autism spectrum disorders: A review of the intervention research. Journal of Autism and
Developmental Disorders, 37(10), 1858-1868.
Challenges to Sexuality Education for
Learners with ASD.
 The social dimension of sexual behavior
 Differentiation between public and
private behavior and reality v. fantasy
 Ensuring the maintenance of learned
skills, particularly those associated with
sexual safety
 Balancing individual safety with
personal respect and individual rights
 Issues related to law enforcement
Some Resources
Some Resources
Some Resources
So to wrap this up…
A Growing Concern
 Access to Adequate Healthcare
Croen, (2015), reported that adults with autism had significantly increased
rates of all major psychiatric disorders and nearly all medical conditions
were significantly more common in adults with autism, including immune
conditions, GI and sleep disorders, seizure, obesity, dyslipidemia,
hypertension, and diabetes. Rarer conditions, such as stroke and Parkinson’s
disease, were also significantly more common among adults with autism.

Cheak-Zamora, et al, (2013) found that youth with ASD experience disparities
in access to Healthcare Transition Services and youth with comorbid
conditions are at greatest risk for poor access to Healthcare Transition
Services.

"This is an impending health care or community care crisis. The services that
are available vary from state to state, but often the resources just aren't
there." Dr. Joseph Cubells, Director of Medical and Adult Services at the Emory
Autism Center

Bruder, et al (2012) noted that while there is a small cohort of physicians in

Connecticut that provide medical care for adults with ASD, the majority of
those who do have adult ASD patients actually serve very few.
 *

*Stolen, without permission, from the University of Houston, Clear Lake ABA
Program Website.