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Objectives

• Attendees will become aware of typical patterns of development in puberty, with regard to physical, social and psycho-sexual domains of functioning. • Participants will be able to identify how the core deficits of autism hinder the development of age- Autism and Sexuality appropriate psycho-sexual functioning. • Participants will gain practical strategies for addressing psycho-sexual development via Eva R. Markham, Ed.D. education. Associate Professor, Pediatrics Weisskopf Center

Objectives Puberty and Adolescence

• Overview of puberty • Puberty is the time when sexual and physical • Overview of normal sexual development characteristics mature. It is triggered by • Discussion of the intersection of autism and hormonal changes. puberty • Adolescence is the period between puberty and adulthood. It is more socially defined.

Sexuality Gender Identity

• Gender identity is defined as a personal conception 1. The condition of being characterized and of oneself as male or female (or rarely, both or distinguished by sex. neither). • This concept is intimately related to the concept of 2. Concern with or interest in sexual activity. gender role, which is defined as the outward 3. Sexual character or potency. manifestations of personality that reflect the gender • The American Heritage® Dictionary of the English identity. Gender identity, in nearly all instances, is Language, Fourth Edition copyright ©2000 by self-identified, as a result of a combination of inherent Houghton Mifflin Company. Updated in 2009. and extrinsic or environmental factors. Published by Houghton Mifflin Company. All rights • Gender role, on the other , is manifested within reserved. society by observable factors such as behavior and appearance.

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Typical Changes in Adolescence Puberty in Boys

• Increased attention to physical appearance • Testicular enlargement • Increased height • Interest in romantic love • Increased shoulder width • Increased need for independence • Genital growth • Mood changes • Body and facial growth • Desire for peer approval • Nighttime ejaculations • Masturbation • Voice changes • Sometimes acne

Puberty in Girls Sexual Development

• development • Body hair increase • Sexual behaviors occur across the course of • Increased height life. • Increased hip size • Adolescence tends to bring an intensification • Menstruation of sexual interest and activity, coinciding with the onset of puberty. • Sometimes acne

Age 0-1 Age 2-5

• Child continues to be interested in own body. • Child discovers pleasant sensations by • Child may note differences and ask questions. experience. • “Bad words” may appear. • Most important activities, like feeding, involve • Child may model adult behavior physical closeness. indiscriminately. • Child may monitor other’s reactions to • Peer exploration may occur. touching themselves and adjust behavior.

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Age 6-12 Age 13+

• Self-stimulation may continue. • Rapid growth • Peer exploration may occur (will be more • Sexual maturity – can reproduce. secretive than earlier). • Interest in sexual experience. • Develop sense of modesty/ privacy. • Continued self-stimulation. • “Boyfriends” and “girlfriends”. • Intimacy in relationships. • Onset of puberty • Parental input critical.

Autism Spectrum Disorders Autism and Sexuality

• Qualitative impairment in verbal and • Children learn gender specific behavior by nonverbal communication. observing and modeling the behavior of others. • Qualitative impairment in social interaction. • Children are reinforced by adults for gender • Restricted, repetitive, stereotypical behaviors. appropriate behavior. • Sensory issues. • Children with autism are less likely to learn though modeling and are not as motivated by adult attention, etc.

Autism and Sexuality Autism and Sexuality

• Peer pressure is less of a factor in some • May fail to internalize privacy/ modesty cases. norms. • The “adolescent awfuls” may seem to be • May over-generalize greetings, touching others,and other behaviors that are delayed relative to typically developing peers. acceptable in young children but not in • May continue to show interests peers deem adolescents or adults. “babyish”. • May lack social and communication skills needed to facilitate relationship development.

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Assessment of Sexual Individualized Curriculum Knowledge

• Young people need to understand what • Age, language, social interest, and “private” is and be able to identify private developmental level direct teaching plan. body parts, activities, conversation topics, etc. • Visual materials are helpful. • Young people need to have factual information about sexual development and be • Schedules, scripts, etc. may provide guides able to develop comfort with their own for successful actions. sexuality.

Safety Issues Personal Hygiene

• Personal body safety concerns. • Grooming and personal hygiene routines may • Sexual feelings and activities. have to be taught and reinforced. • Sexually transmitted diseases. • Use visuals, social stories, etc. for teaching. • Contraception.

Social Skills Cultural Context

• Initiating interaction. • Family • Chatting with someone. • Peer group • Asking for a date or other contact. • Religious community • Planning the date. • Community • What to do on the date. • Nation • Intimacy skills.

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Sexuality and Sex Education Parental Communication

The existing research suggests that there is a high The author found that parents want support in frequency of sexual behaviors among individuals addressing sexual development in their ASD with these disorders. A number of these behaviors children. Specific concerns involved personal may become problematic for caregivers and service safety and assuring that people do not providers. This may jeopardize the inclusion of this misinterpret their child's behavior. The authors group in educational and community settings. The felt that parents needed a longer term focus existing sex education programs for individuals with including sexual decision-making, and ASD are reviewed, highlighting the major components of programs tailored to this population. normative sexual behavior as the young people (Sullivan and Caterino, 2007) mature. (Ballan, 2011

Sexuality Education Social Stories

Appropriate education in sexuality is critical to the development of a person’s positive self-esteem. Although no research identifies the specific The development of a healthy self-image may application of Social Stories to sexuality overcome potential feelings of depression and education, the technique’s utility for this loneliness for the person with autism. This paper addresses the need for and challenges to providing purpose is felt to be self-evident. The authors sexuality education to individuals with autism. It review the technique and propose how this summarizes teaching methods and approaches might be utilized in preparing persons with ASD which have proven to be successful with this for appropriate socio-sexual development. population. (Koller, 2000) (Tarnai & Wolfe,2008).

Sociosexuality Education and Sexuality and Relationship ABA Education

The authors discuss their work in a British Recognizing the value of ABA techniques and residential treatment setting. Based upon their their support in the research on autism, the research with the ASD residents of the authors propose several distinct techniques to program, the authors developed a specific use in sociosexual education. Video modeling, teaching plan for sexuality and relationship visual strategies, social stories, social scripts, issues. The paid special attention to staff and task analysis can all be used to facilitate training in the appropriate delivery of this sort of successful development. (Wolfe, P.S., Condo, intervention. Their model has been widely B., Hardaway, E. (2009) adopted in British settings. (Hatton and Tector, 2010).

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Problem Sexual Behavior Problem Sexual Behavior

• Behavioral issues. • Partner selection difficulty. Analysis of the “problem behavior” should • Lack of knowledge. guide development of a teaching plan to • Medical issues. teach acceptable behavior. • Sensory-related.

Team Work Intentional

Family, school staff, health care providers, Intentionality in integrating sexuality related mental health professionals, clergy, and material into the program of the youngster with others may all be needed to address an autism spectrum disorder offers the best way sexuality related issues. to allow optimal quality of life with regard to this aspect of human experience.

Sexuality and Autism Sex-typical Play

Girls with autism did not show the typical female • There is a small, but growing body of preferences in non-pretend play activities. Boys research on this topic. with autism did show a preference for male • Literature is focused on: preferences in their non-pretend play. Girls with autism showed more pretend play than boys – Sexual experience with autism. The authors determined that their – Problem sexual behavior data provided partial support for the fetal • • Gender dysphoria androgen theory of autism. (Knickmeyer, • Sexual offenses Wheelwright & Baron-Cohen, 2007)

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Transsexuality Gender Identity Disorder

Transsexualism is an individual's identification In the United States, the American Psychiatric Association permits a diagnosis of gender identity disorder if the four with a gender inconsistent or not culturally diagnostic criteria in the Diagnostic and Statistical Manual of associated with their assigned sex. Simply put, Mental Disorders, 4thEdition, Text-Revised (DSM-IV-TR) are it defines a person whose assigned sex at birth met. The criteria are: • Long-standing and strong identification with another conflicts with their psychological gender. A gender medical diagnosis can be made if a person • Long-standing disquiet about the sex assigned or a sense experiences discomfort as a result of a desire to of incongruity in the gender-assigned role of that sex • The diagnosis is not made if the individual also has be a member of the opposite sex, or if a person physical intersex characteristics. experiences impaired functioning or distress as • Significant clinical discomfort or impairment at work, social a result of that gender identification situations, or other important life areas.

Transsexuality and Autistic Paraphilias Traits

A British study found that persons with The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the prevailing Transsexualism had higher levels of Autistic resource for diagnostic criteria of paraphilias, describes traits, as measured by a particular instrument, the essential feature of paraphilias as recurrent, intense, sexual urges and sexually arousing fantasies than did other persons. The level of generally involving nonhuman objects, the suffering or symptomatology was however lower than that humiliation of oneself or partner, or children or other non consenting persons. The DSM-IV-TR describes the found in persons having Asperger’s. (Jones, more commonly observed paraphilias and makes Wheelwright, Farrell, Martin, Green, Di Ceglie reference to several other examples. People who experience one may also experience other & Baron-Cohen, 2011). paraphilias.

Paraphilias Paraphilias

The DSM-IV-TR lists the following paraphilias: Masochism: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer. : the recurrent urge or behavior to Sadism: the recurrent urge or behavior involving acts in which expose one's genitals to an unsuspecting person. the pain or humiliation of the victim is sexually exciting. Fetishism: the use of non-sexual or nonliving objects : the recurrent urge or behavior to observe an or part of a person's body to gain sexual excitement. unsuspecting person who is naked, disrobing or Partialism refers to fetishes specifically involving engaging in sexual activities, or may not be sexual in nature at non-sexual parts of the body. all. : the recurrent urges or behavior of Transvestite fetishism: a towards the clothing of the opposite gender. touching or rubbing against a non-consenting person.

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Sexual Behavior Sex Offending

A study looked at 24 men, with HFA, in a residential A study looked at a 14 year old with setting. The number of bisexual orientations appeared Asperger’s Disorder who was considered a high. Ritual-sexual use of objects and sensory Sex Offender and also a Sex Addict. He fascinations with a sexual connotation were sometimes underwent treatment and utilized community present. A paraphilia was present in two subjects. About resources, such as 12 step groups. His one third of the group needed intervention regarding treatment period extended over 5 years. sexual development or behavior. (Hellemans, (Griffin-Shelley, 2010). Colson, Verbraeken & Vermeiren&Deboutte, 2007).

PDD and Sexual Offenses Violent Offenders

Juvenile delinquents in Japan, diagnosed In a study done in Sweden, looking at with PDDs were found to have more adverse hospitalized individuals, being male and environmental events. The rate of sexually having co-morbid conditions increased the related offenses was more than twice the rate likelihood of persons having Asperger’s being found in non-PDD youth involved in the violent offenders. Violent sex offenses were juvenile justice system. (Kumagamia and not common, but did occur.(Langstrom, Matsuurab, 2009). Grann, Ruchkin, Sjostedt & Fazel, 2009)

Transgenderism and Paraphilias

Asperger’s Disorder is over-represented among people presenting to sexual disorder clinics, Contact: both with transgenderism and with paraphilias. Eva R. Markham, Ed.D. Object relations and self-psychology theories suggest that both physical and emotional 502-852-7528 interaction between infant and parent are [email protected] essential to normal maturation including sexual and gender maturation. (Robinow, 2009).

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