Transcript Sexuality and Children with Disabilities: What’s OK?

Sexuality and Developmental
Disabilities: What’s OK?
Melissa L. Hoffmann, Ph.D.
University of Tennessee Health Science
Center
June 23, 2010
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When people with a developmental
disability express their sexuality it is
often seen as a “problem” – Why?
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Belief that people with disabilities aren’t
really sexual
Belief that people with disabilities should
not be sexual
Sexuality is expressed inappropriately
Other?
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Parents and caregivers often avoid educating
individuals with disabilities about sexuality. Why?
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Belief that individual will always be “child-like” and therefore
nonsexual
Fear that sexual knowledge will lead to sexual behavior
Difficulty discussing the subject in general
Difficulty discussing the subject in a way the individual can
understand
Personal values and beliefs
Other?
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People with intellectual disabilities generally have the
same range of sexual thoughts, attitudes, feelings,
desires, and fantasies as people without disabilities
Most children with a developmental disability begin
puberty at the same age as other children and
experience the same physical and hormonal changes
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However, children with neurodevelopmental disabilities are
20 times more likely to experience early pubertal changes
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Despite these similarities, an individual
with a developmental disability will
likely need more education and support
to understand and manage these
thoughts, feelings, desires, and physical
changes
Sexual Development is
Multidimensional
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Gender-role socialization
Physical maturation
Body image and self esteem
Social relationships
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Being liked and accepted
Displaying and receiving affection
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Future social aspirations
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More than just hormones and reproduction!
Benefits of Sex Education
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Increased social skills
Improved assertiveness
Greater independence
Reduced risk of abuse, pregnancy, STDs
The language to report abuse
Healthier choices in sexual behavior and
relationships
More appropriate sexual behaviors
Risks of avoiding Sex
Education
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Individuals with developmental disabilities are at higher risk for:
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Sexually Transmitted Diseases
Pregnancy
Victimization
Reasons for this:
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Lack of knowledge about sexuality
Misinformation about sex
Misplaced trust in others due to dependence on others for
assistance
A tendency to be overly compliant
Overprotection and limited social contact
Lack of strategies to protect themselves
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It is important that all individuals, with or
without a disability, are educated about
sexual development and given the chance to
explore, enjoy, and express their sexuality in
positive and healthy ways
Education about sexuality should be ongoing
and tailored to the age and ability of the
individual
How to Teach
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Provide information
in as simple and
concrete a manner
as possible
Start with simple
information, then
add to it as the child
grows older or asks
more questions
Guidelines
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Read age and developmentally appropriate
books together
Use pictures, demonstrations with dolls when
appropriate (e.g., showing where babies
come from)
Use proper terms as much as possible –
individuals with developmental disabilities will
not understand euphemisms (i.e., the birds
and the bees)
Teach proper names for body parts from the
beginning
Tips
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Try to give positive messages
Make sure you know what you’re talking
about! Don’t be afraid to check facts
first
Provide clear rules regarding which
behaviors are ok and which are not
Don’t be too serious!!
Obstacles to Learning
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Learning at a slower rate
Communication issues
Limited literary skills
Difficulty with abstract thinking and
comprehension
Trouble relating information to their
own life experience
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There is no “right way” to teach a child
(or adult) about sexuality. It is a
process that will involve success and
failure just like teaching about other
subjects. Don’t get frustrated. You
may have to address the same concepts
again and again.
What to Teach?
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Appropriate and inappropriate expressions of sexuality (sexual behaviors)
Public vs. private
Body parts
Puberty
Personal care and hygiene
Masturbation
“Mechanics” of sex
Reproduction
STDs
Contraception
Personal safety and protective behaviors
Social skills to develop and maintain appropriate relationships
Different types of relationships
Sex and relationships, including marriage and same sex attraction
Coping with relationship difficulties and rejection
Individual values, religious beliefs if applicable
Body Parts
Baxley & Zendell, 2005
Point to the picture that matches each word:
Head
Leg
Stomach
Foot
Breast Penis Testicles
Pubic Area
Public vs. Private
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Private vs. Public behaviors is an important
distinction, but it is an abstract concept so
it may be difficult to understand
Public vs. Private Worksheet
Baxley & Zendell, 2005
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House Rules:
Discuss the house rules regarding dress:
1. Where is it Ok to be without clothes on? ___________________________
2. Where is it Ok to be with just underwear on? ________________________
3. Where can I get dressed and undressed? ___________________________
Discuss the house rules regarding touch:
1. What are the rules about me touching my body? ______________________
2. What are the rules about me touching my private parts?________________
3. Where in the house can I touch my private parts? ____________________
Discuss the house rules regarding private areas:
1. Are there private areas in our house where I can touch myself? ___________
2. What are the private areas in our house?____________________________
3. What are the areas in our neighborhood?____________________________
4. What are the private places in our community?________________________
5. Are there private places in my school? _____________________________
6. What are the private places in my school?___________________________
Discuss where public places are in our house, neighborhood, community, and school:
1. What are the public places in our house? ____________________________
2. What are the public places in our neighborhood?_______________________
3. What are the public places in our community?_________________________
4. What are the public places in school?_______________________________
Discuss public and private regarding everyday activities:
1. What are our house rules about other people’s privacy? For instance knocking on
the door, using other peoples’ things without asking. _____________________
2. Where is Ok to urinate, look at a newspaper/magazine, take a bath, get dressed,
or hug a friend? (Discuss answers for each of the following locations).
A. At home? ________________________________________________
B. In the neighborhood?_______________________________________
C. In the community? _________________________________________
D. In school?________________________________________________
Discuss who are trusted individuals to talk to about personal feelings, issues and needs.
__________________________________________________________________
Relationship skills
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Discuss and help youth practice appropriate
affection, including with whom and where
Model and explain social norms
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If I hug an older child with an intellectual disability but I
don’t explain why I am hugging him, he may believe that
it’s ok to hug people without reason
Role-playing relationship/social skills may be
useful
Teach the right to refuse
Use social situations as examples – give a context
for the information presented
Masturbation
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Self-touch, or masturbation should be
discussed as a natural and healthy way to
explore and express sexuality in a private
place
Individuals who masturbate in public may
have been told to only masturbate in private,
but they have difficulty because they are not
visually stimulated. Pictures (not necessarily
pornographic) may be needed
Birth Control/Disease
Prevention
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Individuals with developmental disabilities may
have difficulty comprehending long term
consequences of pregnancy, STDs
Barrier devices (i.e. condoms, diaphragms)
require manual dexterity, motivation, and
cognitive understanding
Birth control pills require organization and
memory
Medications may impact birth control (e.g., some
antiepileptic medications are known to decrease
the effectiveness of birth control pills and
implants)
Prolonged use of injectable contraceptives has
been linked to bone density loss – problematic for
individuals already at risk due to chronic medical
conditions
Decisions regarding sterilization should be made
in the context of the individual’s capacity to make
decisions, the consequences of reproduction for
that person and the children, and applicable laws
When to Teach?
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Throughout a person’s
life – beginning in early
childhood
When a child expresses
interest or curiosity
Before and during
puberty
Don’t wait for the child
to ask! Look for
opportunities to discuss
the subject
When is Sexual Behavior
Problematic?
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It can be more difficult to determine normal
vs. problematic behaviors in children,
adolescents, and sometimes adults with
developmental disabilities due to differences
between age and cognitive ability/maturity
Concerns about the ability to consent to
sexual behaviors make this difficult as well
Normal Sexual Behavior in
Children
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Asking sexual questions
about
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Bodies (theirs and others)
Conception/reproduction
Birth
Arousal
Marriage
Intercourse
Exploring gender roles
and behaviors
Looking at their bodies
and the bodies of
others
Normal Sexual Behavior in
Children
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Touching their genitals to
explore anatomy and
sensations
Engaging in mutual touching
with similar aged friends or
cousins (same or opposite
sex friends)
Acting out sexual behaviors
with dolls, pets, and stuffed
animals in the context of
play
Telling sexual jokes and
using sexual words/”potty
words” with peers
Normal Sexual Behavior in
Children and Adolescents
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In late childhood/early adolescence, youth
may begin having romantic interests
Dating relationships may begin
Sexual fantasies begin in adolescence
Adult-like sexual activity may begin in
adolescence
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About 50% of high school aged youth are sexually
active
Problematic Sexual Behavior
Sexual Behaviors May Be Problematic When:
 They are causing complaints or are negatively affecting
other people or self
 They interfere with social or family relationships and
daily or normal functioning
 They are out of balance with other aspects of the
individual’s life and interests
 They continue in spite of consistent and clear requests
to stop
 They are done in inappropriate places, despite being
taught otherwise
Sexual Behaviors May Be Problematic
When:
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The individual appears unable to stop
him/herself from engaging in the
behaviors
They are accompanied by or followed
by aggression or verbal expressions of
anger
Fear, anxiety, deep shame, or intense
guilt is associated with the behaviors
Problematic Sexual Behaviors
The following types of sexual behaviors are almost
always a problem and require assessment and
possibly treatment:
 Sexual behaviors which cause physical or
emotional pain or discomfort to self or others
 Sexual behavior toward much younger children
 Forcing others (physically or through intimidation
or threats) to do sexual acts
 Tricking or bribing others into sexual acts
Problematic sexual behavior in individuals with
developmental disabilities may be related to:
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Poor boundaries/social skills
Lack of impulse control
Tendency toward repetitive/perseverative
behaviors
Lack of opportunity for social and romantic
relationships
Difficulty understanding abstract concepts (e.g.,
private vs. public, social cues)
What to Do?
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Acknowledge the behavior
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Discuss rules related to the behavior
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“You are touching your penis. Touching your
penis probably feels good.”
“It’s not ok to touch your penis at school. It is ok
to touch your penis in your bedroom when you are
alone.”
Use behavior management techniques as
appropriate
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Rewards and punishments
What to Do?
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Consider possible safety issues
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Where is the behavior occurring? Do others
need to be made aware of the problem?
Is increased supervision needed?
Are children and/or others in the home
safe?
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When behaviors do not decrease,
become increasingly problematic, or are
abusive or harmful, seek professional
help
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Assessment by a mental health
professional with knowledge of sexual
behavior
References
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American Academy of Pediatrics, 2006 Clinical Report –
Sexuality of Children and Adolescents with
Developmental Disabilities.
Family Planning Victoria. Better Health Channel Fact
Sheets. www.betterhealth.vic.gov.au
DiAnn L. Baxley and Anna Zendell, 2005. Sexuality Education
for Children and Adolescents with Developmental
Disabilities: An instruction manual for parents or
caregivers of and individuals with developmental
disabilities.
National Information Center for Children and Youth with
Disabilities, 1992. Sexuality Education for Children and
Youth with Disabilities.
www.sexualityandu.ca