4th International Autism Conference Cardiff 21st to 22nd June 2011

1. Psychosexual Development in ASD 4th International Autism Conference Cardiff 21st to 22nd June 2011 Lynne Moxon BA, MSc. PGCE, C.Psychol, AFBPsS FIfL

2. Sexual development and curiosity are normal developmental processes • Bolton (2006) argues that difficulties in sexual experience, sexual expression and relationships are inevitablegiven the core deficits in Autism Spectrum Disorders.

3. Key milestones of adolescent development include attaining an adult body capable of reproducing, having and maintaining intimate relationships, managing a range of complex emotions, and independently thinking and problem solving.

4. Psychosexual development of children and young people • There is a lack of literature on childhood sexuality • Little is known about 'normal sexual development' • Sexual behaviors are common in children. More than 50% of children will engage in some type of sexual behaviour before their 13th birthday • (Gil and Cavanagh-Johnson, 1993; Ryan and Lane, 1997 Kellogg 2009)

5. 3-6 years Focus on developmental level rather than age when assessing behaviour

6. The sexual behaviour of young people can be seen on a continuum from mutually agreed experimentation to very serious crimes such as stalking and rape. • Many children engage in activities that form a normal part of their sexual development. Sexual experiences before 13 years of age- 73% recalled engaging in sexual behaviours with other children, 34% recalled showing their genitals to another child, 16% recalled simulating intercourse with another child 5% recalled inserting an object in the vagina or rectum of another child. • Much of this behaviour is not abusive and forms an important and necessary part of the learning process. Other types of behaviour are harmful and not appropriate. You can be put on the sexual offenders register at 14.

7. Experimenting at an increasingly young age • Knowledge of age-appropriate sexual behaviours that vary with situational and environmental factors can assist in differentiating normal sexual behaviours from sexual behaviour problems. • Sexuality of individuals with ASD has been little studied.

8. The physical and emotional changes that occur in adolescence are part of the process of sexual maturity. A young person with ASD’s psychological and social maturity does not keep pace with their physical maturity irrespective of ability. • The specific nature of ASD has inherent limitations in the area of social awareness as a defining element making the achievement of personal sexual identity much more complex. (Tissot 2009) • Despite these inherent limitations, people with autism will be interested in discovering a personal sexual identity and in establishing sexual relationships with others (Tarnai and Wolfe, 2008).

9. Where do we start? 1.Public, Private, Personal Space 2. Teach the rules 3. Give information 4. Do not encourage behaviour which would later be interpreted as sexual.

10. Public, Private, Personal Space

11. Personal space

12. By not seeing that a child is growing toward adulthood, parents may not feel moved to begin teaching boundaries. Most of the incidents which lead to trouble for young people with developmental difficulties, autism or learning difficulties are "boundary violations" brought on by the impulse of a moment. How would you manage your sexuality if you had no sex education, could not ask/talk to anyone and did not have access to books or other written or visual material?

13. Teach the rules….. • Structure is important for people with ASD. If you did not know the rules for social situations you would be anxious. • Consistency is important but social rules are flexible

14. Rules, information, communication

15. Is this Public or Privatebehaviour?5 point scale 543 2 1

16. 543 2 1

17. 543 2 1

18. 543 2 1

19. 543 2 1

20. Social rules change with age and place

21. Will I get into trouble?

22. Young people are increasingly bombarded by sexual images and there is an increase in casual sex. • 70% of children,12 to 15 report unintended exposure to porn websites • 58% of teenagers view porn regularly • Boys may be pressurised into having sex • Girls use porn to measure their sexual performance (63% of girls aspire to be glamour models) • There is a dangerous lack of knowledge about STIs

23. Sexualisation is the imposition of adult sexuality on to children and young people before they are capable of dealing with it, mentally, emotionally or physically.

24. Sexualisation of Young People ReviewHome Office 2010 • In addressing these issues we must not forget that sexual curiosity is a normal feature of childhood and therefore we need to provide young people with the tools that will enable them to deal with sexual content safely and successfully.

25. Key milestones of adolescent development include attaining an adult body capable of reproducing, having and maintaining intimate relationships, managing a range of complex emotions, and independently thinking and problem solving.

26. Sexual images and pornography • Over the past three decades there has been a dramatic increase in the use of sexualised imagery in advertising. • While most of this imagery features women, there has also been a significant increase in the number of sexualised images of children. • Home Office : “It is no longer a case of if a young person will be exposed to pornography but when.”

27. Shades of blue. Calvin Klein uses an image of group sex to sell jeans • The world is saturated by more images today than at any other time in our modern history. Behind each of these images lies a message about expectations, values and ideals.

28. The Influence And Impact Of Pornography On Young People • Hardcore material is widely available on the internet with 25%of all searches seeking access to one of the 1.3 million porn websites. • Among young people with at least weekly internet use, 57% reported having come into contact withonline pornography(for one third this was an accidental occurance whilst searching for something else) • 70% of young people aged 15-17 report unintended exposure to pornography • 58% of teenagers view porn regularly • 1 in 10 view it every day • Online porn is where most is viewed • The average age that males start to access porn is 10/11

30. CASE STUDY • Charlie is 16 years old and has been collecting abusive images of children. Charlie gave his mother the impression he was being groomed on the internet and he had little understanding of the danger of downloading such pictures. To him like were like his Pokemon collection of cards and ‘they can’t be against the law or they would not be allowed on the internet’.  • How might this have been addressed earlier? • Can you think of any suggestions to help Charlie and his parents?

31. “almost everything he knew about sex he had learnt from explicit websites. Perhaps unsurprisingly, when it came to making love to a real person, someone he cared about, he had no idea how to behave. “ I also had very high expectations of what a girl would be like from all the porn I’d watched.”

32. Issues of development -Henault Sexual behaviours: self-stimulation, exploring sexuality ‘I want to get married because I would not have to masturbate anymore and I would have someone to do the laundry.’ Frustrations and inappropriate behaviours ‘Infatuation with a woman at work got me fired.’ Gender identity & role definition: « My way » flexibility, conflict, confusion ‘Why do you love her? Because she’s clever, organised and good at filling in forms.’ Social imitation: context, consent She seemed interested in me. I got married because I thought that’s what people are supposed to do’.

33. Issues of development Interpretation of emotions: black & white. ‘Sex is physical and does not require emotional feelings for a person.’ Interpersonal relationships: couples, empathy, intimacy. ‘For most of my life I didn’t realise what the word intimacy means: now I have learned, I have to admit it sounds most unpleasant and unnatural.’ Confusion & anxiety, deception I had an affair…which almost broke up my marriage. I enjoy attention from all ladies and my wife gets mad about this.’ Sexual drive, desire, curiosity ‘On my first time I would be curious to compare the parts of the breasts and vulva with what I have had to teach myself on Wikipedia’

34. Sensory issues • I don’t like somebody trying to hold me. I’ll kiss her but only because she wants me to (AS male) • Could never come close to a smoker or drinker (AS male) • Smell – love it (AS male) • I can’t come close to a partner with ant real defects. I don’t like the nitty gritty contact with the others body (AS male)

35. Inappropriate or deviant behaviour? • Hypermasturbation: Haracopos & Pedersen (1992); Hellemans (2001) • Wing (1975): masturbation in public occurs. • DeMyer (1979): masturbation in public; inappropriate touching. • Gillberg (1983): undressing and masturbation in public, inappropriate touching. • Talking inappropriately about sex, inappropriate person-oriented behaviour) occurs quite often. • Little data on prevalence of deviant behaviours in normal population or population with other developmental disorders.

36. Reasons for Masturbation Pleasure. Obsessive or compulsive behaviour. Boredom. Lack of alternative activity. Stress. Considerations Is it masturbation? Do they know the appropriate place to masturbate in each environment? Do they know when the appropriate time is to masturbate? Will redirection work? Can distraction work? Is the person bored? Look at physical exercise programmes Check medication

37. Gender identity • Gender dysphoria is a condition where a person feels that they are trapped within a body of the wrong sex • Prof Ina Van Berckeloer-Onnes – over representation in ASD • 7.8% in her client group with ASD have Gender ID 7x more than general pop. Netherlands. • I was born in the wrong body – change it.

38. Fetish behaviour • Sexual fetishism is the sexual arousal brought on by any object, situation or body part not conventionally viewed as being sexual in nature. • The use of objects and specific stimuli could be related to a lack of imagination (Haracopos & Pedersen, 1992). • Use of objects in some cases meets criteria for DSM-IV diagnosis of fetishism.

40. Inappropriate behaviours might be a sexual expression of the restricted, repetitive and stereotyped pattern of behaviour (Hellemans, 1996). • -preoccupation with objects • -sexual themes as stereotyped pattern of interest • -ritual sexual behaviour

42. Relationships • Early social experiences play a critical role in the psychosexual development of children and adolescents and will be limited or qualitatively different when an autism spectrum disorder is present. • How can you move onto intimate relationships if you have never had a friend?

43. CASE STUDY • A 13 year old female student with AS follows male mainstream students at lunchtimes, to engage in social interaction. (She is of a fairly large build and can be quite flirtatious). Depending on the nature of interaction, she can present with a verbal and physical manner. She believes that she has quite a few admirers, unaware that the male students purposely goad her believing her reactions are funny.

44. Theory of Mind “ But they laughed, it means they enjoyed it.” “ She didn’t say anything so I can’t have upset her”

45. CASE STUDY • Students with AS have benefitted from assigned Peer Support ‘buddies’, who support the students in classroom and social situations. Some female ‘buddies’ kindly offered for the male students with AS to be their chaperons at the school Prom (all aged 16 years). Difficulties arising from this act of kindness include one male student with AS then believed this female ‘buddy’ to be his girlfriend, whilst another male student with AS said that if anyone tried to dance with his female ‘buddy’, he would hit him.

46. Summary • ‘Normal’ behaviour tends to be transient and responsive to parental redirection or admonishment. • Sexual behaviour problems include behaviours that are coercive, persistently intrusive, injurious, and frequent; such behaviour usually requires assessment of familial and situational factors and treatment beyond parent redirection.

47. Promoting development • It is important to encourage the development of self esteem • All children feel better about themselves and are more readily accepted by peers when provided with stylish and age-appropriate clothing • Social development is largely experiential, and children with ASD generally have fewer opportunities for social interactions than their typically developing peers.

48. Promoting typical teenage activities, such as going shopping or the cinema with peers or participating in social activities at school, may require extra parental planning but afford invaluable opportunities to develop social skills. • It is difficult to develop an intimate relationship if you have never had a friend.

49. By mastering appropriate greetings, eye contact, body language, issues of personal space, self-advocacy skills, and telephone and computer skills, children build a strong foundation for the development of more complex social skills.

50. All individuals need to learn as a minimum the basics of body parts, how they work and safety (Gill and Hough, 2007) • If their autism is severe, the content may need to centre on masturbation and establishing a sexual identity in a solo manner (Cambridge et al., 2003).