We have a teenage son with autism, and as he continues into adulthood we are concerned about being prepared to address specific issues related to sexuality and safety. What are the most important issues for us to consider and what skills should we target to maximize his safety and healthy development?
Answered by Frank Cicero, PhD, BCBA
Director of Psychological Services, Eden II Programs
This is a particularly difficult question to answer without being familiar with your son. As we all know, the autism spectrum is extremely varied with how it manifests in different individuals. Interests and abilities within sexuality, regardless of ASD, also differ widely across individuals. Put the two together and you have a content area that needs to be assessed and taught with the utmost of individuality and precision. One guiding principle to keep in mind is to make sure your son knows enough to ensure he is socially appropriate and physically safe. From there, decisions on what to teach and how to teach it, however, are not as difficult as you may be thinking. A good place to start is to assess what your son appears interested in doing and identify ways that he can go about it safely. An important point to keep in mind is that there are appropriate and inappropriate sexual behaviors. Think of sexual behavior as a behavior that needs to be shaped into being more appropriate. For example, if your son is exposing himself in public places in an attempt to masturbate, the issue is not that his desire to masturbate is wrong, but rather that he needs to be taught the boundaries and rules of when and where it is appropriate to do so. Similarly, if your son is very awkward in asking a girl out on a date and shows increases in stereotypic behavior in situations that make him anxious, we would need to teach him the social skills necessary to be successful. It may also be helpful to teach him strategies to overcome his anxiety, thereby diminishing his stereotypic behavior.
As stated earlier, you can see that the “sexuality curriculum” necessary for individuals on the autism spectrum will be very broad. What you teach and how you teach it will need to be highly individualized. So, the first thing to do is to assess what your son seems to be interested in doing and how you can best shape his behavior in order for him to be most socially appropriate, physically safe and personally satisfied. The next step would be to decide on a teaching method that will best shape his behavior. Rely on the teaching methods, techniques and materials that have been successful in the past to teach your son other skills such as how to brush his teeth, how to play a board game with peers or how to sit appropriately in a chair while in school. Use the teaching methods that you know work best with your son and simply change the target behavior. For example, if your son learned many self-care skills through a visual schedule and task analysis, you can use that same technique to teach the appropriate steps and behaviors associated with masturbation. If your son learned his colors, letters and numbers through traditional discrete trial instruction using expressive and receptive identification of picture cards, you can use that technique to teach private vs. public spaces. While these are just a few examples, the point is to match up the skill to be taught with the teaching methods that have been most successful in teaching your son new skills. Some examples of useful teaching techniques within the applied behavior analytic literature include social stories, social scripts, video modeling, discrete trial instruction, task analysis, picture schedules, written schedules, verbal and physical prompting and prompt fading, practice with verbal feedback, and role playing. Do not let the sexual nature of what needs to be taught prevent you from using a teaching method that you know would work.
Unlike programs which target academic, self-management or general social skills, those related to sexuality require a greater level of discretion as to when, where, and by whom these skills should be taught. For example, teaching masturbation skills such as understanding where it is acceptable to do it, defining and setting up private time, and ensuring privacy (e.g., door closed, curtains closed) are more appropriate to be taught at home, not in a classroom. Similarly, practicing a dating script should probably be done one-on-one versus with a group of peers at school. However, ensuring that your son practices personal safety behaviors in a bathroom (e.g., locking a stall door, appropriate behavior for using a urinal) involves skills that can be generalized across all environments.
Although the details of the way ASD presents across individuals vary, social awareness and social skills deficits are core deficits. Difficulties in social knowledge can lead to problems with appropriate sexual expression. We need to teach and practice social skills that are necessary for the individual to engage in appropriate sexual behavior. For some individuals on the spectrum, that might mean teaching such skills as: when and where it is appropriate to remove your clothing, how to appropriately express affection, and when and where it is appropriate to watch adult media. For others, we might focus on teaching the appropriate social skills necessary to navigate a first date, to deal with rejection or to move a romantic relationship to the next level.
Due to possible cognitive deficits, issues with abstract problem solving and attention, and/or a lack of opportunity to practice behaviors related to dating and sexuality, individuals on the spectrum often show deficits in knowledge when it comes to sexual behavior. If your son portrays knowledge deficits that are leading to safety concerns, sexual frustration, or inappropriate sexual behaviors, design a teaching program to fill in the knowledge gap. For example, repeated touching and rubbing of the genital areas in public is often related to a lack of knowledge of how to actually masturbate to climax. Repeated touching in public is not only a social concern, but can lead to soreness of the genitals over time. Frustration associated with a lack of climax or from being continuously interrupted by others can also lead to problem behavior. As with other tasks, masturbation as a complex skill might need to be broken down into component steps and taught as a task analysis through a picture schedule, written schedule, verbal prompting, video modeling, etc. This would be done simultaneously with a program designed to teach the difference between private and public spaces, redirection to a private space when sexually aroused and response interruption when masturbation is observed in public. If your son is interested in engaging in sexual behavior with a partner, and if it is deemed appropriate for him to be doing so, you might need to teach him the basics of sexual education, such as the mechanics of sexual intercourse and other sexual acts, reproduction and pregnancy, sexually transmitted diseases and illegal sexual behaviors that should be avoided. Often if the learner is at the level of requiring these subjects, they can be introduced through didactic lessons using visual aids (pictures and videos) where needed and an open and honest question and answer session with a nonjudgmental person they trust.
Another important area to focus on is self-protection and personal safety. There are several aspects to consider within this domain and a good place to start is in helping your son identify different types of relationships (e.g., friends, family, acquaintances, strangers) and the types of behaviors that are appropriate within each. Of course there are many complex social rules that come into play here, but again, teaching the basics can go a long way to ensuring personal safety. Targets you would want to teach and practice are:
- body part identification,
- saying “no” to others,
- identifying appropriate and inappropriate touch,
- expressing affection,
- public versus private behaviors and places
- leaving the area when needed,
- accurate reporting to others,
- identifying and avoiding unsafe social-sexual situations and behaviors.
So, in summary, you would want to identify what your son seems to desire as well as what seems to be impeding his success and/or leading to inappropriate expression. You would want to teach him the appropriate social skills and necessary information for him to be socially appropriate, sexually satisfied and physically and emotionally safe. You can always introduce additional skills as he matures and new desires and needs arise. Choose your teaching methods based on the methods that have been successful with your son in the past across other skill areas. Teaching methods should be empirically supported. A Board Certified Behavior Analyst with experience and knowledge in teaching sexuality skills to individuals on the autism spectrum would likely prove beneficial in assisting you in your program development in this area.
Citation for this article:
Cicero, F. (2015). Clinical Corner: Targeting sexuality. Science in Autism Treatment, 12(3), 17-19.