Sex and sexuality education is vital to supporting healthy development and preventing undesirable outcomes for individuals with autism. But while competence in sexuality education is widely discussed, it is sorely lacking in application and research.
In BHCOE’s webinar Another Kind of Spectrum: An Introduction to Behavior Analysis and Sexuality on Sept. 2, 2020, Shane T. Spiker, Ph.D., M.S., BCBA, discusses some challenges of working within the realm of sexuality and provides considerations for behavior analysts to begin developing the tools to work in in this area.
Here are some highlights from Dr. Spiker’s talk.
Sex As a Target Behavior
Sexuality behavior is complex, involving a combination of social skills, biology, verbal behavior, contextual variables, education and more. “Sexuality is not about the act alone and I think that’s a big misconception about sex and sexual behavior in general. It can be difficult to know where to start from a behavior analytic standpoint,” says Dr. Spiker.
He advises that the first place to start is understanding what the problem is, whose problem it is and in what context a behavior is occurring or not occurring. For example, masturbation itself is not a problem, but masturbation at school is an issue. Another scenario is a legally competent adult who wants to buy pornography, but the group home where he lives won’t allow it, citing religious reasons. This is an issue with the group home.
When we think about inappropriate sexual behavior as a target behavior, it’s important to have clarity on what the problem is. Inappropriate sexual behavior can range from inappropriate touch and public masturbation to self-injurious behavior and dating skill deficiency. When looking at issues around masturbation, for instance, the problem may stem from a skill deficit, performing it in inappropriate places, doing it too much or causing self-harm.
These issues may lead parents, caregivers and behavioral health professionals to intervene in ways that suppress safe and socially appropriate masturbation. When teaching a sexual behavior as a target skill, it’s important to understand all of the issues that go along with it, including family dynamics, skill deficits, safety and hygiene.
Common Behavioral Problems
Challenging behaviors can have a significant impact on the learner and family members. In fact, just one incident of inappropriate sexual behavior can have serious consequences. The behavior can result in social isolation, financial issues, safety concerns, and even legal problems and arrest.
“Our culture is far more sensitive to sexual behavior than they tend to be about aggressive, destructive or self-injurious behavior,” says Dr. Spiker. “It only takes one incident for an individual to become socially isolated and stigmatized. And if the sexual behavior is dangerous, the learner can put others at risk.”
Some of the common behavioral problems Dr. Spiker detailed in the webinar include:
- Victimization of other people.
- Deficits in discrimination, including being unable to identify the appropriate locations or partners for a behavior.
- Behavioral excess, such as sex addiction or porn addiction.
- Social awareness deficits, including limited ability to identify social cues or respond to “no.”
- Health and safety concerns, such as sexually transmitted disease and pregnancy.
- Aggressive sexual behavior.
Dr. Spiker shared the story of a patient with HIV who refused to take their retroviral medication and had unprotected sex with unknowing partners. For this patient, Dr. Spiker worked on medication compliance, with the patient earning more reinforcements for taking the retroviral medication. He also focused on educating the patient on safe sex, including obtaining and carrying condoms, and the legal consequences of failing to disclose HIV status to sex partners.
Sociosexual Education Strategies
The need to educate individuals with ASD about sociosexual issues is widely acknowledged in the clinical literature. Inappropriate sexual behaviors among those with ASD can have devastating consequences, including sexual abuse, unwanted pregnancy and inappropriate displays of sexual behavior.
“Start teaching with ample time and involve family members. Puberty and the associated anatomical, physiological and emotional changes hit quickly,” says Dr. Spiker. “It’s important to teach social skills and begin looking at whether there are prerequisite skills to teach, such as changing a menstrual pad.”
Education strategies include:
- Begin teaching the skills the individual will need to perform within the next few years. Recognize that there may be many steps of prerequisites or desensitization necessary.
- Seek out strong curriculum related to teaching sexuality education to individuals with autism.
- When working with the learner, use real words, establish physical limits, be concrete, and use images and dolls that are anatomically correct.
- Provide many learning opportunities, including models when necessary, but don’t touch the learner during teaching.
- Obtain consent from the caregivers or client (Assent for underage clients).
When conducting assessments and interventions, be mindful of how intrusive the activity is. Think about whether you can or should observe the behavior and what kinds of questions you’ll ask in order to assess the problem. Think about who is allowed to know the information that may come up; disclosing a minor’s sexual health information to parents varies by state.
Considerations for Working in Sex and Sexuality
First, there isn’t a lot of research in behavior analysis in a sexual behavior realm. Dr. Spiker says that interdisciplinary work is often needed. For example, extensive research on video modelling, environmental manipulations and human behavior exists that can be applied to the sexual health realm.
Many people assume a particular behavior is automatic or self-stimulatory, but Dr. Spiker cautions that that isn’t always the case. Some engage in a behavior for attention. “There are a hundred different management strategies, but how you actually impact behavior depends on the behavior of concern and the MO,” he says.
Environmental manipulations might work in one situation, while discrimination training to reinforce a behavior may work in another. Tasks analysis or video modelling can be effective at teaching certain socialization, behavior or daily living skills, such as taking birth control, expressing sexual feelings or putting on a condom.
Dr. Spiker advises that it is critical to understand what supports are currently in place for a patient and what you are legally allowed to implement. He advises that behavior analysts pursue additional training and mentoring before teaching sexuality. Seek out mentorship from a qualified behavior analyst or an American Association of Sexuality Educators, Counselors and Therapists (AASECT) educator.
“Don’t start teaching sexuality without additional training,” says Dr. Spiker. “This can cost you your certification. If this is an area you really want to dig into, consider getting certified through AASECT.”
Dr. Spiker also recommends the book, Cases on Teaching Sexuality Education to Individuals with Autism, by Peggy Schaefer Whitby, Ph.D., as a helpful starting resource. The book covers a range of topics, including reproductive health, prosocial behavior, sexual education and ethics.
To watch the full webinar and learn about upcoming webinars that cover issues affecting the ABA community, visit www.bhcoe.org/virtualacademy.
Stay current on issues affecting the ABA community by attending upcoming BHCOE webinars at www.bhcoe.org/events.