As clinicians, we are morally and ethically charged to be available to speak to a variety of topics related to our clients’ developmental and psychological growth. This duty often feels more akin to a privilege, as we are able to bear witness to the emerging consciousness and identity development of our clients in this co-created therapeutic space. In exchange for this sacred position, we are charged with supporting our clients along their journeys of discovery and listening intently about important topics of conversation that typically are considered too sensitive to discuss fully and wholeheartedly with peers.
Through our providing a safe place for discussions of topics like these, clients are able to formulate healthy methods of coping with stressors and gain access to important information that can help inform educated decision making. As psychotherapists, we too must be brave to engage in these difficult dialogues, as our own anxieties and biases may prevent us from full immersion in these critical moments. We must not forget that we are also human and are susceptible to the same blind spots that impact our clients and the rest of the community. Similarly, we must also take into account our own history and life circumstances, such as religion, race, and gender when listening to our clients so that we can better understand and appreciate their experiences. Sex is an often difficult but critical topic for many to discuss, both outside in the public sphere and inside the safety of a therapeutic space.
A Human Rights Perspective
Some view the topics of sex and sexuality as tawdry or overly-personal, perhaps better left for conversations behind closed doors. Psychotherapists can be instrumental in cultivating productive public and private conversations about sex and sexuality, addressing individual and collective needs for discussion of these important dynamics within our community. Like many, I believe sex to be a human right in that individuals should be able to seek as much or as little healthy consensual sex as they desire. The idea of viewing sex through a human rights lens involves transitioning from a misogynistic or chauvinistic view of sexual participation (as a privilege or an obligation) to incorporating more rights and liberties into the concept of sex and sexual liberation. This view of sex as a human right is not only shared by many in the clinical community, but this topic has gained tremendous popularity in the international community as the topic of sex as a human right has been adopted by organizations fighting for women’s reproductive and civil rights. For example, at the 2013 Montevideo Consensus on Population and Development in Latin America and the Caribbean, a conference organized by the Economic Commission for Latin America and the Caribbean (ECLAC), Uruguay, and the United Nations Population Fund, members supported a resolution to:
Promote policies that enable persons to exercise their sexual rights, which embrace the right to a safe and full sex life, as well as the right to take free, informed, voluntary and responsible decisions on their sexuality, sexual orientation and gender identity, without coercion, discrimination or violence. (United Nations Population Fund, 2013).
This aforementioned resolution provides a great guideline for clinicians on how to begin to incorporate the concept of sex as a human right into clinical conversations with clients and their families when necessary or appropriate. The resolution highlights not only the need for individuals to have sex that is healthy from a medical standpoint, but also enjoyable. This added context to the resolution is important because it speaks to an understanding of the great physiological and psychological benefits that can arise from safe and fulfilling sex if people chose to engage in sexual behavior either by themselves or with others. Additionally, this resolution does not specifically speak to one gender, but rather encourages all genders to seek out safe and enjoyable sex while also advocating for these individuals to be free from harassment or harm when exploring their sexuality and sexual experiences.
Clinical Importance for Individuals Impacted by Autism
Sex as a human right becomes an even more meaningful topic when discussed with those individuals and families impacted by autism. Although there is limited research specifically on the sexual lives of people diagnosed with Autism Spectrum Disorder, research on the sexual lives of people with intellectual disabilities may provide a window into some shared experiences.
Recent research by Kijak (2013) illustrated that many people diagnosed with intellectual disability (72%) report having had sex by age 20 or older. Additionally, a high proportion of these individuals engaged in sex either due to curiosity (39%) or to “feel like an adult” (33%) (Kijak, 2013, p. 118). These reasons for initiating sexual contact or behavior are important because these results underscore the idea that individuals may engage in sexual behavior in part because they perceive that sex is developmentally expected of them at a given age. Individuals with diagnoses in the intellectual disability or autism spectrum are, like others, flooded with sexually suggestive media representations and messages. These stimuli appear to have a significant impact on the decision to engage in sexual behavior, regardless, at times, of the individual’s psychosocial maturity to do so.
Additionally, there is a high instance of masturbation reported in the intellectual disability community (Kijak, 2013); anecdotally, this is consistent with the reports of clients and caregivers during my clinical work with members of the autism spectrum community. Although medical professionals and others commonly see masturbation as a healthy sexual outlet, it can present challenges, including safety risks, to clients who masturbate in inappropriate locations or with inappropriate objects (see, e.g., Kijak, 2013). Having a place to ask questions, explore concerns, and discuss sexual interests and behavior with a knowledgeable, supportive, and ethical provider can assist clients and important others in addressing both needs and challenges.
Even though individuals diagnosed with autism or intellectual disability are engaging in and interested in sex, society is still often biased about their participation in sexual activities. Research by Franco, Cardoso, and Neto (2012) suggested that, despite believing that sexuality is a human right afforded to all, many respondents were less encouraging of displays of sexual interest by individuals with intellectual disabilities and were similarly discouraging of people with intellectual disabilities being able to marry or have children.
It is possible that this prejudice stems from and is supported by the absence of sexual representations of people with disabilities, especially intellectual or developmental disabilities, in popular media. The absence of these sexual role models can cause shame, especially as other groups in society are afforded various degrees of sexualized status in media. Not being able to look into a magazine or watch a television show in which characters are attracted to someone who looks like or behaves like you can be an isolating experience and is something that several of my clients with autism have vocalized in treatment. This seemingly popular prejudice against people with autism being “sexy” can have a tremendous impact on the ways in which attraction, sex, and sexuality are incorporated into the identities of those with intellectual or developmental disabilities.
Speaking about this potential prejudice and being aware of it in conversations with patients with autism is helpful to continue to support appropriate identity formation in these individuals, encourage them to be curious about themselves, and assist them in building holistic representations of self. In these moments, clinicians can listen for internalized stereotypes or self-deprecating comments that speak to these negative societal views and can assist clients in analyzing the formation of these ideas and in constructing healthier core identities. Individuals prone to receiving negative reactions to public or private conversations or displays of sexuality may particularly benefit from having a therapeutic space in which to speak about sexually related topics. As I have seen in my own clinical work, teens and young adults with diagnoses on the spectrum are interested in having these conversations, but the negative feedback that they often receive from others can be intentionally or unintentionally shaming and harsh. This negative feedback and lack of communication has the potential to further “closet” individuals with autism spectrum diagnoses and reduce their willingness to seek out support to navigate important social or medical circumstances related to their sexual lives.
For example, in the study of adults with intellectual disability diagnoses cited earlier, Kijack (2013) found that only one out of ten participants could recite forms of contraception and prophylactics accurately. As one can imagine, such knowledge gaps can have serious repercussions, including sexually transmitted infections and unintended pregnancies. In addition, sexual exploitation is a serious risk for both males and females with autism-related diagnoses (Mandell, Walrath, Manteuffel, Sgro, & Pino-Martin, 2005), with women with these diagnoses at greatest risk when compared to other females in the community without autism or intellectual disabilities (Casteel, Martin, Smith, Gurka, & Kupper, 2008).
Implications for Psychotherapy
In order to continue to act as psychotherapists who believe in sex as a human right, it is important for us to provide appropriate sexual health information to our clients when warranted, while also referring them to relevant professionals for more in-depth delivery of information outside of our range of competent practice. In conjunction with this information, it is also important for clinicians to be vigilant to evidence of potential sexual assault, abuse, or exploitation in the lives of our clients with autism spectrum diagnoses. When in conversations with individuals with autism spectrum, intellectual, or other developmental concerns, it is also important to listen for misconceptions or misinformation about dating or sex and be prepared to supportively correct these thoughts with compassion.
Additionally, with appropriate permission, it may be helpful to communicate some of these misconceptions to trusted allies by whom our clients are comfortable being supported in their sexual wellbeing. It is also important to acknowledge that caregivers may similarly benefit from clinically informed conversations regarding sex and sexuality, again with appropriate permission, in order to better support individuals with autism spectrum diagnoses. Research from Swango-Wilson (2008) highlighted how caregivers often do not know how to handle conversations surrounding sex and sexuality with individuals with autism or intellectual disability diagnoses, and psychologists and other clinical caregivers may be the only avenue for gaining this type of support or knowledge.
Caregivers’ lack of knowledge or unwillingness to have these conversations could foster unintended shame or embarrassment about sexual urges or fantasies; in addition, ignoring this topic could result in individuals missing out on key psychosocial or medical information related to dating, sex, consent, and sexual healthcare practices. When working with caregivers, it might be helpful to acknowledge the necessity to speak to the identified client about sexually related issues while simultaneously acknowledging the discomfort inherent in speaking to someone else about sexual themes and behaviors. In these moments, the clinician can help caregivers rehearse appropriate or gentle ways to broach various topics, increasing the caregivers’ level of comfort, familiarity, and confidence.
Healthy sex is happy sex, and individuals diagnosed with autism are looking for pleasurable experiences similar to many of those without a comparable diagnosis. By making therapeutic space to speak about sexuality in an informative and open manner, a clinician can spark significant personal growth within clients, assisting them with continued identity development and supporting self-advocacy and the healthy exploration of personal preferences regarding their bodies and sexual needs.
Cite This Article
Jenkins, J. (2017, April). The birds and the bees (and autism): Difficult dialogues about sex and sexuality. Psychotherapy Bulletin, 52(1), 10-13.
Casteel C., Martin S. L., Smith J. B., Gurka K. K., & Kupper L. L. (2008). National study of physical and sexual assault among women with disabilities. Injury Prevention, 14(2), 87-90. doi:10.1136/ip.2007.016451
Franco, D. G., Cardoso, J., & Neto, I. (2012). Attitudes towards affectivity and sexuality of people with intellectual disability. Sexuality and Disability, 30(3), 261-287. doi:10.1007/s11195-012-9260-x
Kijak, R. (2013). The sexuality of adults with intellectual disability in Poland. Sexuality and Disability, 31(2), 109-123. doi:10.1007/s11195-013-9294-8
Mandell, D. S., Walrath, C. M., Manteuffel, B., Sgro, G., & Pino-Martin, J. (2005).Characteristics of children with autistic spectrum disorders served incomprehensive community-based mental health settings. Journal of Autism and Developmental Disorders, 35(3), 313–321. doi: 10.1007/s10803-005-3296-z
Swango-Wilson, A. (2008). Caregiver perceptions and implications for sex education for individuals with intellectual and developmental disabilities. Sexuality andDisability, 26(3), 167-174. doi:10.1007/s11195-008-9081-0
United Nations Population Fund (2013, August 15). Population conference adopts Montevideo Consensus of wide-ranging priority actions on reproductive health,gender equality, young people [press release]. Retrieved from http://www.unfpa.org/press/population-conference-adopts-montevideo-consensus-wide-ranging-priority-actions-reproductive