ASD and Inappropriate (as perceived) Sexualised Behaviour
The ideas and information summarised in these notes concerning the meaning and motives of behaviours, of an apparently over-sexualised nature among teenagers diagnosed with ASD, were collated to provide some background guidance to inform the review of a student at a specialist and residential school whose behaviour has become the source of concern.
One major principle concerns exploring the stimulus for, and the likely function of, the behaviours.
The context is that of determining how to ensure that the sexual needs and interests of young people with ASD are allowed appropriate recognition and expression despite the core characteristics of social communication weaknesses and undeveloped theory of mind which can lead to uncertainties among the individuals concerned about initiating and maintaining relationships, and to anxieties among peers and significant others about the observable actions and the attributed underlying motives.
M.J.Connor March 2007
In the foreword to a recent book concerned with Asperger Syndrome (AS) and sexuality (Henault 2006), Tony Attwood makes the point that people with this condition have sexual interests, issues, and diversity that are no different to those which apply to the population as a whole.
However, what matters is that adolescents and older individuals with AS (or with ASD) may experience significant problems both in regard to recognising and understanding the thoughts and feelings and actions of others, which may be both subtle and complex (especially with regard to relationships, one might say), and in expressing their own feelings. There are the further complications that the adolescent peer group may not be the best source of role models or information and that the gullibility and uncertainty of the individual with AS or ASD (referred to simply as “ASD” henceforward) may be mischievously exploited by some peers.
This point is taken up by Henault in her initial comments to the effect that the experience of sexuality may turn out to be challenging for these young people (and their carers) given the intervening issues of the interpersonal and communication anomalies, circumscribed interests, anxiety, and sensory sensitivity that make up the very nature of ASD.
The risk is that the sexual nature of the individual concerned may be underestimated, repressed or glossed over … or mis-understood and over-estimated !
Henault is further concerned lest the matter of sexuality may be an issue too far for some parents and carers, and any tendency to deny the legitimacy or normality of the sexuality of children and young people with ASD (or to avoid discussion thereof for fear lest this may stimulate potentially disturbing exploratory behaviours) may only set up resistance to their gaining of guidance and information.
Accordingly, she sets out 5 basic philosophical principles :
The basic theme is that the young people with ASD have the same socio-sexual interests and needs as any other young people, but that the communication and social deficits impact negatively upon their ability to engage in social and sexual interactions and increase the probability of inappropriate sexual behaviours.
The Problem and the Context
Any children approaching puberty, or young people who have already entered adolescence, will benefit from information and advice about sexual development and relationships It is even more apposite in the case of individuals with ASD who may not be able to learn incidentally, or who may misinterpret behaviours observed among others, if misunderstandings or negative reactions and anxiety are to be avoided.
The problem is that adolescents are usually keen to follow the current trends in fashion or music, or clothes, and to remain conscious of what their peers do and like, but individuals with ASD may perceive the social norms or rules differently.
Two common reactions are described by Henault … there is either no apparent interest in, or influence from, peer pressures; or there is an exaggerated influence where the individual with ASD conforms quite literally. There will be a complete following of behaviour, such as in the wearing of a particular type of clothing, but this lack of true personal choice and simple imitation may not equate to becoming accepted by peers.
The implication is that the same may apply to behaviours, including those relating to
(intimate) behaviours where the observed actions may be copied without an appreciation of the context, their meaning, or the stage of the relationship that the observed young people have reached.
This links to self esteem in that difficulties in establishing true friendships in a setting such as a school, where other young people are seen to be part of groups of peers and to do things together, may be distressing. The risk is that the distress and the associated feelings of difference plus lowered self esteem may lead on to anger and aggressive actions towards others.
The risk of rejection, and of associated behaviours (which could be translated into ether aggressive behaviour or to withdrawal into their own private world), is greater in the case of young people with ASD because of the difficulty in recognising emotions and of interpreting social signals.
These social disadvantages and misunderstandings are part of the context in which sexual misunderstandings or what may be perceived as inappropriate sexual behaviour can arise.
It is recognised that adolescence is a time when individuals are driven by sexual interest and want to explore behaviours, but it is noted (eg by Griffiths 1999) that there are additional factors which impact specifically upon those adolescents with ASD.
This line of thought is continued by Hellemans and Deboutte (2002) who argue that young people with ASD are like any others in experiencing a need to meet a partner and to enjoy a close relationship, but the social difficulties may interfere with the fulfilment of the quest for intimacy leading to frustration and to what may be seen as inappropriate sexualised activity.
Converging evidence highlights the frequency of inappropriate sexual behaviours, and the virtual universality of masturbation among individuals with ASD.
Henault reviews and summarises the data to highlight the fact that masturbation is the most common sexual behaviour reported by male adolescents with ASD (and those without ASD). Self stimulation is not at all a problem in itself if the context is appropriate (private). However, public masturbation is the most frequently reported form of inappropriate sexual behaviour.
Such behaviour can become compulsive or a source of distraction (engaged in when the level of stimulation is low).
A further problem can arise in respect of reactions to masturbation which can be misleading or contradictory such that the individual is uncertain whether it is or is not part of typical and normal behaviour (in the appropriate context), and may even develop feelings of guilt if the message is received that the behaviour is bad or improper.
Inappropriate masturbation could be defined as that which is constant, is maintained regularly but associated with feelings of shame, or is carried out in front of other people.
The implication (Hingsburger 1995) is to help these young people to learn that masturbation is a normal and healthy behaviour, but to recognise when and where it is appropriate (private versus public settings), while also dispelling myths and introducing the idea that masturbation can be accompanied by sexual images or fantasies (thus to be cathartic and reduce frustration or tensions).
Clear and consistent information is the key.
The When and Why of Inapproriate Sexualised Behaviour
The particular needs or circumstances associated with ASD will play a further part in all this, notably the difficulty in recognising when, and in which circumstances, certain actions or utterances are acceptable and when they are not. What one might say privately to a friend can be quite inappropriate in a public context.
Further, it is noted that inappropriate behaviours can be triggered by specific factors which can be anxiety arousing or which indicate the individual’s need to achieve something, or to escape from a situation that he or she finds stressful.
The general view is that children and young people with ASD do not set out to shock or embarrass other people, but may be reacting to some anxiety or stressful situation, which could involve some unexpected change in routine, negative interaction with a group of peers, excessive demands or uncertainty over what is expected …etc (or even the anticipation, rightly or wrongly of some stressful event).
The problem for the observing adult is that of appreciating the source of any such anxiety. One may believe that the precipitating factor has been identified, but the postulated antecedents of the target behaviour may not match those perceived in the mind of the individual with ASD.
(The implication drawn by the present writer – MJC – is for a careful functional assessment as far as practicable. What are the circumstances associated with the behaviour? When and where were the first instances? What was the context? Where and when is the target behaviour most evident? Is there a particular occasion or setting or activity or peer grouping which appears to give rise more than any other to the target behaviour? What is the individual seeking to achieve, or to say, via the behaviour? Is there some stress or unhappiness associated with the current arrangements?
What evidence can be cited for any developing hypothesis?
In other words, while there may be a directly sexual motive, including self stimulation as a kind of faute de mieux, the behaviour could also be a means of comfort or a means of distraction, or a call for assistance in the face of some stressful circumstance.
Is the behaviour chosen because it is of a kind that is not and cannot be ignored by the adults around; it does command attention?
Perhaps it started as a kind of displacement activity, but has become a problem in its own right given the associated pleasure, or the power that it engenders in respect of the reactions of significant others …. ie is there a double problem in respect of some initial and precipitating anxiety and the effect of the subsequent behaviour upon the sensitivities and routines of these significant others whose reactions interact with the individual’s very feelings and behaviour?)
Reference is made by Aquilla (2003) to the potential significance of hyposensitivity which may apply to some individuals with ASD … a weak sensory response to stimuli.
There is a possibility that this could increase the observedly inappropriate behaviours so that, for example, masturbation does become a prolonged and frequent form of behaviour, not because of some sexual compulsion but as a result of this particular sensory phenomenon.
Griffiths (op.cit) refers also to the simple issue of reaction to medication in terms of side effects impacting upon sexual function or upon levels of agitation or anxiety generally.
This author also refers to the risk of repressing sexual feelings and cites the example of a young man who was censured every time he tried to make contact with a young woman, even if his attempts were within the bounds of acceptable behaviour. His reaction was to force his attentions upon a resistant young woman given his belief that censure would be less likely if the action was rapid … ie he thought his behaviour was appropriate in the circumstances and was not a deliberately provocative act.
Similarly, Griffiths continues, exhibitionism can reflect a lack of discrimination rather than deliberately sexualised behaviour. The example is cited of a girl who did not close the bathroom door, and tended to put her clothes back on only during the walk from the bathroom to wherever she was going next.
Again the issue was about a failure to discriminate between what is acceptable in private and what is not acceptable in public. An associated difficulty may be that the individuals concerned have been accustomed to support and help at a younger age for bathing or other personal needs, and have some consequent difficulty in recognising when and with whom they can be casual about exposing themselves.
Distinction between public, private, and intimate behaviours is also relevant in the case of imitation behaviour of peers or of somewhat older people without recognising the context and nature of the relationship concerning the behaviour imitated. The example is given of a young man with ASD seeing a couple kissing in the street, who then kisses the first girl he meets !
Similarly, behaviours which were acceptable, even reinforced during a younger stage, such as sitting on a carer’s lap, and showing affection to a range of other people, may be seen as quite unacceptable in an adolescent.
The implication is for clear education and advice, and for drawing clear boundaries as early as possible between what is acceptable and unacceptable. Individuals with ASD may not have a natural tendency to look for and to interpret social signals, or to develop incidentally an awareness of how to interact with others, but can often respond to direct cues and clues and consistently reinforced behavioural rules.
Frustration is common among
individuals with ASD who may not be able to cope with the complex and subtle
rules, and variability in rules, associated with relationships. There will be communication difficulties and
some interpersonal anxiety along with a fear of rejection (even if this fear is
not easily identified or verbalised).
A reaction to this frustration might include aggressive feelings and action towards those who do seem able to enjoy acceptance and relationships, or a withdrawal into a private world which may well include self harm or a dependence upon masturbatory behaviour (which, interestingly, is sometimes described as self abuse).
The implication, set out by Henault, is for an exploration of the circumstances and the associated emotions behind observable behaviour before forming attributions and conclusions.
For example, the issue may be about impulsiveness and a lack of appreciation of how others may feel or react to a given behaviour; or, in the case of behaviours associated with relationships or sexuality, the issue may include the notions of mutuality and implicit or explicit consent.
Sheehan (2002) gives the example of an 11 year old boy (with ASD) who was as interested as any boy in the female body. However, his response to such interest was intimately to touch a girl in his school without any prior warning or the obtaining of her consent. What might be construed as a sexual assault was actually more about a deficient theory of mind, an impulsiveness, and a failure to consider the issue of consent and the feelings of the other person(s) … ie a social assault rather than a sexual assault, one might say.
What matters is direct and explicit teaching of rules and boundary-recognition.
Further, and in respect of imitation, it is recognised that individuals with ASD are more subject to sexual exploitation or abuse than typically developing peers because of their social vulnerability. If they have been exploited in any such way, by older students, for example or anyone else, it is likely that certain behaviours which could be described as inappropriately sexualised will be observed.
There is no recognition of the inappropriate or over-intimate nature of some actions; it is simply a matter of imitating what has been experienced.
Where the observed behaviour is described as a kind of obsessive or compulsive sexuality, the analysis would usefully include such questions as ….
Hypotheses that could be explored include :
Masturbation warrants a further discussion in its own right in Henault’s various publications.
It is repeated that masturbation is the most common form of sexual activity in adolescence, and that it is a normal and an entirely acceptable way of releasing sexual tensions.
However. masturbation becomes problematic when it occurs in an inappropriate
(public or over-lookable) place, or when it is accompanied by feelings of guilt, shame, or anxiety.
The recommendation is that teenagers with ASD need to be given specific advice/instruction about the difference between public (school, shop, friend’s house, playground, etc) and private places (bedroom, home bathroom), and about when masturbation is acceptable (ie alone, door shut). The message needs to be unequivocal so that no misunderstandings, or behaviour seen as inappropriate, are likely to occur.
If this behaviour becomes the major activity for any individual, it would be reasonable to explore the motivations and possible underlying issues … is it associated with some anxiety, a change in routine, a general sense of being unsettled or unhappy, or simply a matter of sexual gratification (and, in the latter case, the advice is for toleration if the rules about privacy are followed, although one might encourage the reduction of frequency to a couple of occasions each day).
Where the masturbatory behaviour starts to take over and to inhibit day to day routines, one might explore the usefulness of creating new opportunities for stimulating and interesting pursuits involving, ideally, access to new groups of peers, and a range of creative, physical, and sporting activities. This is not to attempt some sublimation of the sexual feelings but simply to increase the amount and type of stimulation.
Further, the issue of social skill and social perception is emphasised when it comes to a discussion of actions that might be interpreted as sexual delinquency.
The underlying problem in what might appear to be some kind of sexual assault perpetrated by boys or young men may actually be a matter of difficulties in knowing how to approach females and to initiate /develop relationships. There may be insufficient awareness of their feelings, and limited empathy towards any initial reserve or actual anxiety.
Kohn et al (1998) are quoted as describing a boy (16 years old) who repeatedly and sexually touched women whom he found attractive. Subsequent assessments revealed no remorse (or, perhaps, no reasons for remorse) on his part; and he simply repeated that he liked a given woman and wanted to show her, in his way, that he liked her.
The example may be an extreme one, but Kohn et al emphasise the factors of social maladjustment or lack of social awareness as significant.
Such actions are associated with the core features of ASD so that sexual delinquency is not actually more prevalent among an ASD population, but may appear to be so because the behaviours are a function of the deficits in theory of mind, limited experience of relationships (including intimate relationships), impulsiveness, and difficulty in expressing emotion.
Further, when staff in a specialist school or centre tend to include more females than males, especially among the care staff, it is possible that males with ASD may wish to identify with those who are most accepting towards them, namely females, and may wish to be closer to them or to imitate them.
This could involve a kind of pseudo-transvestism (seeking to be similar to the women with whom they share a positive relationship) or an over-closeness, a quest after a more intimate involvement, without regard to the rules applying to roles and to social norms and boundaries.
It is worth repeating that the need is for constant advice and direct teaching about social rules, proximity, and the need to seek an understanding of the feelings and likely reactions of others which may be interpretable from their verbal and nonverbal communications.
It may also be helpful to link the direct teaching and reminders about appropriate behaviour, such as how to avoid embarrassment or alarm from masturbation in public, with behavioural strategies …. such as a series of visual signals, red or green, to be located around the house or school to indicate where it is acceptable and where not, and much positive feedback or reinforcement for shifts of behaviour in the targeted direction.
Adams (2001) describes the potential value of visual cues and prompts, while also conducting an analysis of the circumstances in which the target behaviour is most prevalent … does masturbation occur, for example, when the child appears anxious, or bored, or following some difficult situation (such as a confrontation with peers)?
The point about recognising the feelings and needs of adolescents with ASD and the provision of education and guidelines was also taken up by Adams whose experience includes the frequency with which families or educators believe that the developmental delay associated with ASD means that sexual issues will not be relevant or any source of concern. On the contrary, Adams highlights that sexual interest and drives are universal and the only real variation is concerned with timing or with the style of expression of the sexual awakening.
She, too, stressed the need for guidance, including the need to focus upon the time and the place (public versus private), and the desirability of initiating education as early as possible, thus to avoid a situation where behaviours acceptable among young children, such as indiscriminate hugging of other people, is continued beyond puberty and well into adolescence when it is not acceptable and a potential source of anxiety to other people.
Such behaviours may appear sexually inappropriate when they are actually more age-inappropriate, but their effect may well be to increase the risk of limited social interaction for the young people concerned, or even outright rejection by peers.
(Adams cites the case-example of a young man who caused concern by his tendency to follow younger girls, but who was found simply to have no appropriate same-age peers with whom to associate.)
Meanwhile, and relevant to the frequent use of the description of behaviour as either appropriate or inappropriate, one notes the views expressed by Benson (2005) who points out that it is usually non-ASD individuals who decide when something is inappropriate. The constant need is to remember that a core issue of autism and ASD is social communication difficulty which will limit an individual’s capacity to recognise and understand the rules of social behaviour and of relationships. Behaviours may have a particular function which does not involve being provocative or reflecting sexual motives.
She uses the example of an individual with ASD who brushes up against female staff (or other females) when they meet which could be a matter of seeking to determine their mood or patience, etc … via their observable reaction … in the absence of a capacity to appreciate or read body language or facial expressions.
Alternatively, the individual may enjoy the power to evoke a reaction or may be seeking attention (with negative attention more reassuring than no attention).
Benson also agrees that certain behaviours perceived as challenging or sexually inappropriate could simply be a matter of the imitation of behaviours observed in other people (or in a film or TV programme or magazine) but without any appreciation of the context and without any consideration of the feelings of the other person (or a kind of tacit assumption that the other person feels perfectly comfortable with the approach).
As also suggested in the information sheet from OAASIS (2007), kissing someone met in the classroom or even in the street may not be an example of “forward” sexual behaviour but a reflection of what the individual considers to be friendly behaviour, a way to initiate an interaction, and a copy of what others have been seen to do.
The notes emphasise the principle that “ if you have Asperger syndrome, you do not always know what you know ” …. hence the importance of regular prompts and reminders, of clear and specific directions, and consistent praise and reinforcement of the alternative and appropriate behaviours.
It has been argued by Bullock (2005), too, that, when the behaviour of young people with ASD is investigated, insufficient consideration has been given to the question whether a desire for companionship and friendship is seen as the same as a desire for a sexual relationship. Do the young people themselves confuse friendship with relationship, and seek the sexual element because they see this pattern among other young people and try to do the same?
The example is given of a 13 year old boy attending a unit for students with ASD attached to a mainstream secondary school. He is said to be interested in girls and to want to have a girl friend, and is fascinated by their appearance (their hair, for example), but he is distressed by an inability to form or maintain friendships, and is described as vulnerable to censure or more active peer rejection as a result of his tendency to try to touch the girls’ hair (or other parts of their bodies following what he has seen other boys do).
Work with this boy demonstrated that his wish was simply to be friends with some or many of the girls around him, but that there was a failure to appreciate the significant difference between “ friend” and “ girlfriend”, and to determine how to establish a friendship. The outcome involved the closer analysis of the areas of social difficulty such as entry skills in conversation, pragmatics, etc., and the initiation of a programme by which to teach and practise such skills, to build confidence, to reduce the inappropriate touching, and generally to make sense of what relationships involve.
(The author referred to the boy’s likely confusion in watching other students enjoying holding or kissing each other, without any reprimand, and the reaction in the form of screaming - to indicate anger or distress - when he sought to do the same thing with a girl with whom he wanted to be friends.
The boy’s mother summarised the frustration by describing him as if he were stuck behind a sheet of glass, seeing everything going on, but not quite able to join in, or joining in but getting it wrong.)
A common theme among the advice available concerns the potential usefulness of social stories by which to deliver clear and consistent messages about what is appropriate and what is unacceptable; and for a constant “refreshing” of such advice to match new or different contingencies as they are encountered.
The overall principle is that of taking nothing for granted, including no assumption that a given and learned element of social behaviour will generalise to different contexts and situations.
(This could be illustrated by a consistent procedure [ Koller 2000 ], agreed by all staff and carers, to deal with public incidents of masturbation whereby the same steps are applied ….
In assessing behaviours, thought to reflect inappropriate sexualisation, among children and young people with ASD, it is important constantly to keep in mind the context in respect of limited social communication, and delayed or disordered theory of mind involving difficulty in understanding the feelings of others and their likely reactions to given situations or approaches.
However, this is not to belittle at all the significance of behaviours which appear motivated by sexual curiosity etc. and one needs to keep in mind the current public fears about the apparent incidence of sexual misbehaviour and the very hostile attitudes to anyone suspected or accused of sexual offences.
This suggests the need to take concerns very seriously, especially given the “hidden” nature of the ASD condition, in order to protect the individuals with ASD as much as or as well as anyone else.
The implication is for a clear (functional) assessment of the behaviours which have become the source of concern.
What is the purpose of the behaviours? What outcome is sought?
Do they reflect some sexual motive, or confused attempts to be like peers in respect of observable interpersonal (including intimate) relationships, or attempts to establish simple attachments without an understanding of the appropriate means?
Do they reflect a sexual curiosity and interest of a kind experienced by any adolescent male but with insufficient awareness of how one might pursue such interest without the risk of rejection or of causing alarm and anger?
Are the behaviours (such as masturbation) pursued at a relatively high intensity because there is no other means of expressing and satisfying sexual feelings (with the additional complication of minimal appreciation of issues about time and place and privacy)?
Do the behaviours reflect a general anxiety? Or a specific anxiety about some particular event or about current peer interactions? Or a wish to escape from a setting or set of demands and expectations which the individual dislikes or cannot readily tolerate? Do they reflect a defiance towards authority? Are the particular behaviours chosen because of the attention and reaction they generate? Are they designed to provide some comfort and a sense of security or some distraction from environmental pressures and worries? What other (concern-arousing) behaviours co-exist?
What, then, are the precise behaviours giving rise to the concern?
Where? When? (and when did they start?) Under what circumstances? With whom? What have been the apparent antecedents? What have been the typical consequences? Are there times and settings where the behaviours do not occur, or when they are particularly intense? Are the observations and the focus of concerns the same for school staff and for parents?
What does the individual himself say? What are his perspectives? What are the feelings and attitudes of peers?
What is the target for any intervention? Who will be involved and how will communication be managed? What are the steps and strategies?
* * * * * *
M.J.Connor March 2007
Adams J. 2001 Puberty and the awakening of sexuality. Guidance Notes : Autism Today
Aquilla P. 2003 Sensory issues in individuals with Asperger syndrome. Presentation to the 2nd National Conference on Asperger Syndrome. Toronto : Asperger Society of Ontario
Aston M. 2001 The Other Half of Asperger Syndrome. London : National Autistic Society
Benson S. 2005 Sex education and children and young people with autistic spectrum disorders. Information sheet. London : National Autistic Society
Bullock C. 2005 Enhancing the understanding of relationships and sexuality of a 14 year old boy with autism. Good Autism Practice 6(2) 39-44
Griffiths D. 1999 The sexuality of people presenting a pervasive developmental disorder. Presentation to the Conference for Services for Persons with Pervasive Developmental disorder. Montreal.
Hellemans H. and Deboutte D. 2002 Autism spectrum disorders and sexuality. Presentation to the World Autism Congress : Melbourne.
Henault I. 2006 Asperger Syndrome and Sexuality. London : Jessica Kingsley
Hingsburger D. 1993 I Openers : Parents ask Questions about Sexuality and Children with Developmental Disabilities. Vancouver : Family Support Institute Press
Hingsburger D. 1995 Hand Made Love. Newmarket : Diverse City Press
Koller R. 2000 Sexuality and adolescents with autism. Sexuality and Disability 18(2) 125-135
OAASIS 2007 Inappropriate sexual behaviour and the child with Asperger syndrome and similar conditions. Information sheet. Brockenhurst : OAASIS
Sheehan S. 2002 Consent for sexual relations. In D. Griffiths et al (Eds) Ethical Dilemmas : Sexuality and Developmental Disability. New York : NADD Press
© Mike Connor 2007.
Back to NAS Surrey Branch Welcome Page