NDIA Accountability Project

This project is in DRAFT

Sexual services and sexualised behaviours of concern

‹ PrevPage 1 of 9 · Source p. 77Next ›

Sexual services and sexualised behaviours of concern

The content of this document is OFFICIAL.

Please note: The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making. Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice. The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research question: Can sexual services delivered by a sex worker reduce the frequency or severity of sexualised behaviours of concern (including aggressive, inappropriate or offensive sexual behaviour, sexual assault, sexual harassment or other criminal behaviour of a sexual nature) for people with disability?

Date: 09/12/2022 Requestor: Steve redacted Endorsed by: Katrin redacted: s22(1)(a)(ii) - irrelevant Researcher: Aaron redacted: s22(1)(a)(ii) - irrelevant Cleared by: Stephanie

Sex work and BOC OFFICIAL Page 1 of 9 Page 77 of 96

Research paper

OFFICIAL For Internal Use Only

Contents

Sexual services and sexualised behaviours of concern ……………………………………………………. 1

  • Contents ………………………………………………………………………………………………………….. 2
  • Summary …………………………………………………………………………………………………………. 2
  • Case study – sex work used to reduce sexualised behaviours of concern …………………. 2
  • Facilitated sex ………………………………………………………………………………………………….. 4
  • Other interventions for sexualised behaviours of concern ……………………………………….. 6
  • References ………………………………………………………………………………………………………. 7

Summary

This paper discusses evidence for sexual services as an intervention to reduce sexualised behaviours of concern. There is little evidence in the literature supporting a specific strategy to reduce sexualised behaviours of concern. Much of the evidence is derived from single subject case studies which do not generalise.

There is one study that explicitly identifies sex work as an intervention that can reduce behaviours of concern. In this study, utilisation of a sex worker coincided with near complete reduction in instances of sexualised behaviours of concern. However, since the study was a single subject case study, it is not possible to generalise the results (3. Case study).

There is some further evidence, mostly theoretical and anecdotal, that assisting people with disabilities to engage in intimate relationships or otherwise exercise their sexual expression might lead to a reduction in behaviours of concern (4. Facilitated sex).

This paper also discusses other ways of managing inappropriate sexualised behaviours. The weight of evidence is in favour of behaviour analytic methods, especially interventions using differential reinforcement or multi-component behaviour modification (5. Other interventions).

Case study – sex work used to reduce sexualised

behaviours of concern There is a single study which examines the use of sex work as an intervention intended to manage sexualised behaviours of concern (Kelly & Simpson, 2011). The subject was a single man in his 40s who experienced a hypoxic brain injury 5 years prior. The subject showed behaviours of concern including inappropriate sexual talk, genital and non-genital touching, public masturbation and exhibitionism. The authors note that the initial preference for their intervention was sexual surrogacy (refer to 4. Facilitated Sex). No surrogate partners were

Research paper

OFFICIAL For Internal Use Only

available in the subject’s location and so the treating team investigated accessing a sex worker instead.

The study employed a BCBC design in which the baseline condition and comparison condition were alternated over a period of months. The baseline condition involved consistent behaviour management including avoiding triggers, redirection, prompting to act appropriately or removing subject or target from the situation. The comparison condition involved consistent behaviour management plus weekly or fortnightly visits to a sex worker. Numbers of incidents of sexualised behaviours of concern began to reduce from the second half of the first baseline phase. Incidents of inappropriate sexual talk occurred over 49 times in the first baseline phase. This reduced to 16 times in the first comparison phase, remained steady in the second baseline phase (17 times) and then reduced to 2 times in the last comparison phase.

The first comparison phase saw dramatic reductions in inappropriate sexual touching and exhibition. Incidents of exhibitionism and public masturbation occurred 14 times in the first baseline phase, twice in the second baseline phase and did not occur at all in the either of the comparison phases. Incidents of inappropriate touch occurred 23 times in the first baseline phase, twice in the first comparison phase, 3 times in the second baseline phase and did not occur at all in the last comparison phase (refer to Figure 1 - Incidents of sexualised behaviours of concern by shift).

Reduction in behaviours may have been due to the combination of consistent behaviour management and visits to a sex worker. As the reduction was seen from the second half of the first phase, the main therapeutic effect may be due to the behaviour management techniques. In a related study, Kelly et al (2022) reflect on this case study and suggest that the effects are likely due to the ongoing value of behaviour supports implemented for the duration of the study. Also, the reduction may be partially due to the support workers becoming more comfortable and skilled at employing behaviour management techniques over time.

While this case study suggests a strong effect of the intervention, it examined only a single person and so results cannot be generalised beyond this study. Unfortunately, no further studies have re-examined the hypothesis. It should also be noted that systematic reviews which included Kelly and Simpson (2011) rate the study of moderate to high quality (Clay et al 2018; Verberne et al 2019).

Sex work and BOC Page 3 of 9

OFFICIAL

Page 79 of 96

Facilitated sex

The intervention used in Kelly and Simpson is a type of facilitated sex. Facilitated sex refers to a variety of activities that address the sexual needs of people with disabilities (Kelly & Simpson, 2011). This can include sexual health education, assistance to attend social events, assistance obtaining services of a sex worker, obtaining or acting as a surrogate partner, set up, preparation or physical assistance to initiate masturbation or sex (Earle, 2001; Bahner, 2016). There is some lack of consensus around terminology. For example, Benoit et al (2022) reproduce a distinction in the literature between sexual assistance and facilitated sexual assistance. The latter term is broader and covers all the activities described as sexual assistance.

There are theoretical reasons for thinking that facilitated sex might lead to a reduction in behaviours of concern. One approach suggests that some inappropriate sexual behaviour could be a result of a lack of skills or opportunity to form functional intimate relationships (Grace et al, 2020). There is some support for this in a study of self-reported motivations for criminal sexual behaviour among people with ASD. Subjects in this study reported some motivations for inappropriate sexual behaviour to be lack of understanding of appropriate relationships, lack of social skills to aid in forming relationships, lack of any intimate relationships or simply wanting to have sex (Payne et al, 2020).

Reyes et al (2011; Falligrant & Pence, 2020) describe a study in which inappropriate sexual behaviours are replaced with appropriate sexual behaviours:

Sex work and BOC OFFICIAL Page 4 of 9 OFFICIAL Page 80 of 96

Research paper

OFFICIAL For Internal Use Only

Masturbation decreased subsequent arousal to deviant stimuli, suggesting masturbation may decrease arousal levels in situations where an establishing operation for inappropriate sexual behavior is typically present. Self-management procedures may be enhanced by teaching individuals with IDDs to masturbate prior to engaging in activities or entering situations that are typically arousing. That is, just as these individuals may learn to inhibit or manage their arousal by counting backwards, they may also learn to engage in appropriate sexual behavior as an antecedent strategy to reduce subsequent arousal. (Faligrant and Pence, 2020, p.3)

Victorian state government guidelines support this approach for young people with intellectual disability or ASD. They suggest providing the young person with “time alone with privacy” and encouraging behaviour change “through safe and fulfilling sexual exploration” (Department of Health and Human Services, 2016, p.10).

Besides Kelly and Simpson (2011) and Reyes et al (2011) no other studies were found that explicitly aim to investigate the effect of facilitated sex on inappropriate sexualised behaviours. However, some studies mention an observed effect. These observations are largely anecdotal. For example, in an interview study of nurses and clinicians in an aged care setting, Watershoot et al note that participants described a reduction in inappropriate sexualised behaviours for a person with dementia after introducing a specialised sex worker:

some participants described how their team learned how to facilitate the residents in a pro-active manner over time. N5 described this a “win/win” situation, for example, because hiring a specialized sex worker let a resident “bloom” and decreased a resident’s inappropriate touches toward staff as well (Watershoot et al, 2022, p.840).

Torrisi et al (2017) and De Geogi and Series (2016) agree that facilitating sex for people with dementia and reinterpreting sexualised behaviours as the expression of a need for intimacy might help reduce behaviours of concern:

The need for normal sexual expression while preventing inappropriate sexual behaviors should be emphasized. In nursing homes, single rooms and provision for conjugal or home visits could help reduce the frequency of such behaviors by satisfying the patient’s normal sexual drive (Torrisi et al, 2016, p.5).

Similarly, Aloni et al (2007) present a case study of surrogate partner therapy in which a 22-year-old man with a TBI was assisted to access a surrogate partner. Surrogate partner therapy is a form of therapy in which a client works with both a therapist and a surrogate partner to practice social and relationship skills in a controlled environment. This can include exercises in relaxation, communication, sensual and sexual touching (IPSA, n.d; Benoit et al, 2022). The intervention was motivated, in part, by inappropriate sexualised behaviours of concern. Aloni et al report that the subject’s “inappropriate way of talking and sexual behaviour was reduced and at times was almost eradicated” (Aloni et al, 2007, p.132). However they did not report any other relevant details of this change nor does the study appear to have an experimental design. Also of note, while surrogate partner therapy is intended to treat a variety of issues

Sex work and BOC Page 5 of 9

OFFICIAL

                              Page 81 of 96

Other interventions for sexualised behaviours of concern

It can be difficult to structure experimental studies with adequate sample sizes which examine the effects of treatments on sexualised behaviours of concern. This can be due to ethical considerations or lack of available participants (Casey et al, 2018). Much of the research is structured around single participant case studies. This is true of research focussing on young people and adults.

In their systematic review, Casey et al (2018) conclude that there is insufficient evidence to determine which specific technique is most effective at reducing inappropriate sexualised behaviours for people with acquired brain injury, intellectual or developmental disability. However, the strongest evidence was for behaviour analytic techniques using either a punishment component or a differential reinforcement component or both.

A narrative review from Warner et al (2022) suggests that Applied Behaviour Analysis (ABA) can assist with the management of sexualised behaviours of concern in people with Autism Spectrum Disorder. However, due to the format of the review, the quality and levels of evidence of included studies was not considered. Also, recommendations were largely based on the generalisation of ABA techniques to sexualised behaviours rather than direct evidence of efficacy. For further information on ABA used to manage behaviours of concern please refer to TAB research paper RES 246 ABA and positive behaviour support.docx.

Pritchard et al (2016) describe a case of reducing significant and problematic sexual behaviours of concern in a 17 year old with ASD using an individualised multi-component behavioural intervention. Intervention included cognitive behavioural therapy, sexuality and relationship education, active support and a points-and-levels behaviour modification system. At conclusion of the study the subject had not shown sexualised behaviours of concern for 3 months. The authors followed up with Pritchard et al (2021) in which they describe several cases of individualised multi-component behavioural intervention showing consistent success in reducing behaviours.

Falligrant and Pence (2020) describe different procedures of differential reinforcement of alternate behaviour or differential reinforcement of other behaviour, sometimes combined with punishment, for people with intellectual and development disability. All the interventions they canvassed were effective at reducing sexualised behaviours of concern, sometimes to near zero levels. They also describe some studies indicating people with intellectual and development disabilities may be able to learn self-management methods to reduce behaviours. However, all the studies described are either single person case studies or very low sample studies. The authors do not consider quality or levels of evidence in their review.

Research paper

OFFICIAL For Internal Use Only

In patients with dementia, Torrisi et al (2017) recommend certain behavioural interventions including redirection, distraction and avoidance of triggers. This is supported by De Georgi and Series (2016) who also note that despite lack of empirical evidence, non-pharmacological treatments for sexualised behaviours of concern are the first line treatment for inappropriate sexualised behaviours due to issues of safety and ethics.

A handful of studies have focused on inappropriate sexualised behaviours for young people with autism or developmental disabilities. McClay et al (2015) found 11 studies showing positive treatment effects of interventions for reducing inappropriate sexualised behaviour in children and adolescents with developmental disabilities. Most studies support behaviour analytic techniques such a differential reinforcement but most studies are also single subject case studies and so results are not generalisable.

Clionsky and N’Zi (2020) assert that there are no evidence-based interventions for children or adolescents with ASD showing inappropriate sexualised behaviours. They suggest that effective treatments for neuro-typical young people, such as cognitive behavioural therapy, should be adapted for children and adolescents with ASD. However, this suggestion contrasts with a 2020 Cochrane Review, which found insufficient evidence to determine whether cognitive behavioural therapy was effective for reducing harmful sexual behaviour in adolescents without disability (Sneddon et al, 2020).

References

  • Aloni, R., Keren, O., & Katz, S. (2007). Sex therapy surrogate partners for individuals with very limited functional ability following traumatic brain injury. Sexuality and Disability, 25(3), 125–134. https://doi.org/10.1007/s11195-007-9047-7

  • Bahner, J. (2016). Risky business? Organizing sexual facilitation in Swedish personal assistance services. Scandinavian Journal of Disability Research: SJDR, 18(2), 164–175. https://doi.org/10.1080/15017419.2015.1063540

  • Benoit, C., Mellor, A., & Premji, Z. (2022). Access to sexual rights for people living with disabilities: Assumptions, evidence, and policy outcomes. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-022-02372-x

  • Clay, C. J., Bloom, S. E., & Lambert, J. M. (2018). Behavioral interventions for inappropriate sexual behavior in individuals with developmental disabilities and acquired brain injury: A review. American Journal on Intellectual and Developmental Disabilities, 123(3), 254–282. https://doi.org/10.1352/1944-7558-123.3.254

  • Clionsky, L. N., & N’Zi, A. M. (2020). Addressing sexual acting out behaviors with adolescents on the autism spectrum. Adolescent Psychiatry, 9(2), 129–134. https://doi.org/10.2174/2210676609666190730091304

— PAGE TEXT START —

Research paper

OFFICIAL For Internal Use Only

In patients with dementia, Torrisi et al (2017) recommend certain behavioural interventions including redirection, distraction and avoidance of triggers. This is supported by De Georgi and Series (2016) who also note that despite lack of empirical evidence, non-pharmacological treatments for sexualised behaviours of concern are the first line treatment for inappropriate sexualised behaviours due to issues of safety and ethics.

A handful of studies have focused on inappropriate sexualised behaviours for young people with autism or developmental disabilities. McClay et al (2015) found 11 studies showing positive treatment effects of interventions for reducing inappropriate sexualised behaviour in children and adolescents with developmental disabilities. Most studies support behaviour analytic techniques such a differential reinforcement but most studies are also single subject case studies and so results are not generalisable.

Clionsky and N’Zi (2020) assert that there are no evidence-based interventions for children or adolescents with ASD showing inappropriate sexualised behaviours. They suggest that effective treatments for neuro-typical young people, such as cognitive behavioural therapy, should be adapted for children and adolescents with ASD. However, this suggestion contrasts with a 2020 Cochrane Review, which found insufficient evidence to determine whether cognitive behavioural therapy was effective for reducing harmful sexual behaviour in adolescents without disability (Sneddon et al, 2020).

References

  • Aloni, R., Keren, O., & Katz, S. (2007). Sex therapy surrogate partners for individuals with very limited functional ability following traumatic brain injury. Sexuality and Disability, 25(3), 125–134. https://doi.org/10.1007/s11195-007-9047-7

  • Bahner, J. (2016). Risky business? Organizing sexual facilitation in Swedish personal assistance services. Scandinavian Journal of Disability Research: SJDR, 18(2), 164–175. https://doi.org/10.1080/15017419.2015.1063540

  • Benoit, C., Mellor, A., & Premji, Z. (2022). Access to sexual rights for people living with disabilities: Assumptions, evidence, and policy outcomes. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-022-02372-x

  • Clay, C. J., Bloom, S. E., & Lambert, J. M. (2018). Behavioral interventions for inappropriate sexual behavior in individuals with developmental disabilities and acquired brain injury: A review. American Journal on Intellectual and Developmental Disabilities, 123(3), 254–282. https://doi.org/10.1352/1944-7558-123.3.254

  • Clionsky, L. N., & N’Zi, A. M. (2020). Addressing sexual acting out behaviors with adolescents on the autism spectrum. Adolescent Psychiatry, 9(2), 129–134. https://doi.org/10.2174/2210676609666190730091304

                           Sex work and BOC                    Page 7 of 9
                     OFFICIAL
                            Page 83 of 96

— PAGE TEXT END —

Research paper

OFFICIAL For Internal Use Only

De Giorgi, R., & Series, H. (2016). Treatment of inappropriate sexual behavior in dementia. Current Treatment Options in Neurology, 18(9), 41. https://doi.org/10.1007/s11940-016-0425-2

Department of Health and Human Services. (2016). Avoiding and responding to sexualised behaviours of concern in young people with intellectual disability and autism spectrum disorder. Victorian State Government. https://providers.dffh.vic.gov.au/avoiding-and-responding-sexualised-behaviours-concern-young-people-intellectual-disability-and

Earle, S. (2001). Disability, facilitated sex and the role of the nurse. Journal of Advanced Nursing, 36(3), 433–440. https://doi.org/10.1046/j.1365-2648.2001.01991.x

Falligant, J. M., & Pence, S. T. (2020). Interventions for inappropriate sexual behavior in individuals with intellectual and developmental disabilities: A brief review: Inappropriate Sexual Behavior. Journal of Applied Behavior Analysis, 53(3), 1316–1320. https://doi.org/10.1002/jaba.716

Freckelton, I., SC. (2013). Sexual Surrogate Partner Therapy: Legal and Ethical Issues: This paper is a revised version of the talk delivered to the Tasmanian branch of ANZAPPL in Hobart on 7 September 2013. Psychiatry, Psychology, and Law: An Interdisciplinary Journal of the Australian and New Zealand Association of Psychiatry, Psychology and Law, 20(5), 643–659. https://doi.org/10.1080/13218719.2013.831725

Grace, N., Greenhill, B., & Withers, P. (2020). “They just said inappropriate contact.” What do service users hear when staff talk about sex and relationships? Journal of Applied Research in Intellectual Disabilities: JARID, 33(1), 39–50. https://doi.org/10.1111/jar.12373

International Professional Surrogates Association. (n.d). About surrogate partner therapy. https://www.surrogatetherapy.org/what-is-surrogate-partner-therapy

Kelly, G., Brown, S., Gillett, L., Descallar, J., & Simpson, G. K. (2022). Can behaviour support interventions successfully treat inappropriate sexual behaviour after acquired brain injury in community settings? A case series (N = 24). Neuropsychological Rehabilitation, 32(3), 407–428. https://doi.org/10.1080/09602011.2020.1830807

Kelly, G., & Simpson, G. (2011). Remediating serious inappropriate sexual behavior in a male with severe acquired brain injury. Sexuality and Disability, 29(4), 313–327. https://doi.org/10.1007/s11195-011-9213-9

McLay, L., Carnett, A., Tyler-Merrick, G., & van der Meer, L. (2015). A systematic review of interventions for inappropriate sexual behavior of children and adolescents with developmental disabilities. Review Journal of Autism and Developmental Disorders, 2(4), 357–373. https://doi.org/10.1007/s40489-015-0058-5

Pritchard, D., Graham, N., Penney, H., Owen, G., Peters, S., & Mace, F. C. (2016). Multi-component behavioural intervention reduces harmful sexual behaviour in a 17-year-old

Sex work and BOC Page 8 of 9

OFFICIAL

Page 84 of 96

Research paper

OFFICIAL For Internal Use Only

male with autism spectrum disorder: a case study. The Journal of Sexual Aggression, 22(3), 368–378. https://doi.org/10.1080/13552600.2015.1130269

Pritchard, D., Penney, H., Richards, V., & Graham, N. (2021). Behavioral treatment of sexual offending. In Applied Behavior Analysis Treatment of Violence and Aggression in Persons with Neurodevelopmental Disabilities (pp. 129–152). Springer International Publishing.

Reyes, J. R., Vollmer, T. R., & Hall, A. (2011). The influence of presession factors in the assessment of deviant arousal. Journal of Applied Behavior Analysis, 44(4), 707–717. https://doi.org/10.1901/jaba.2011.44-707

Rosenbaum, T., Aloni, R., & Heruti, R. (2014). Surrogate partner therapy: ethical considerations in sexual medicine. The Journal of Sexual Medicine, 11(2), 321–329. https://doi.org/10.1111/jsm.12402

Torrisi, M., Cacciola, A., Marra, A., De Luca, R., Bramanti, P., & Calabrò, R. S. (2017). Inappropriate behaviors and hypersexuality in individuals with dementia: An overview of a neglected issue. Geriatrics & Gerontology International, 17(6), 865–874. https://doi.org/10.1111/ggi.12854

Verberne, D. P. J., Spauwen, P. J. J., & van Heugten, C. M. (2019). Psychological interventions for treating neuropsychiatric consequences of acquired brain injury: A systematic review. Neuropsychological Rehabilitation, 29(10), 1509–1542. https://doi.org/10.1080/09602011.2018.1433049

Warner, S., Barger, M., & McCary, L. M. (2022). Individualized sexuality education for people with Autism Spectrum Disorder. Education and training in Autism and Developmental Disabilities, 57(4) 359-370.

Waterschoot, K., Roelofs, T. S. M., van Boekel, L. C., & Luijkx, K. G. (2022). Care staff’s sense-making of intimate and sexual expressions of people with dementia in Dutch nursing homes. Clinical Gerontologist, 45(4), 833–843. https://doi.org/10.1080/07317115.2021.1928357

Sex work and BOC Page 9 of 9

OFFICIAL Page 85 of 96