Sex Disabil (2017) 35:261–273

DOI 10.1007/s11195-017-9477-9

COMMENTARY

Autism Spectrum Disorder, Adolescence, and Sexuality

Education: Suggested Interventions for Mental Health
Professionals

Michelle S. Ballan1 • Molly Burke Freyer2

Published online: 4 February 2017

 Springer Science+Business Media New York 2017

Abstract Physical and emotional changes occurring during adolescence can present
serious challenges to individuals with autism spectrum disorder (ASD). Social skills def-
icits may become more pronounced and the awakening of sexual urges and behaviors may
not be understood by youth with ASD and their families. Mental health providers can help
to address these changes, primarily in the area of sexuality education. However the extant
literature on ASD and sexuality is limited. This article highlights issues inherent in the
sexuality education of adolescents with ASD, and presents three methods for intervention:
Applied Behavior Analysis, Social Stories, and Social Behavior Mapping. Examples of
each intervention are provided to promote collaboration among clinicians, families and
adolescents with ASD to address sexuality and to ensure adequate preparation for transition
to adulthood.

Keywords Autism
Sexuality education
Social skills
Social stories
Applied behavior
analysis
Social behavior mapping
United States

Emerging sexuality issues among adolescents with autism spectrum disorder (ASD) can
provide an opportunity for mental health providers to make meaningful interventions
during a potentially difficult transitional phase. However, given the dearth of extant lit-
erature on this topic, working with adolescents with ASD on issues of sexuality can present
a challenge. Research on sexuality and individuals with ASD has been limited by the
misconception that autism is a childhood syndrome, with sexuality considered of minimal
consequence, and general societal discomfort addressing sexual issues among this

& Michelle S. Ballan

michelle.ballan@stonybrook.edu
1
School of Social Welfare and Stony Brook School of Medicine, Stony Brook University, 101
Nicolls Road, Health Sciences Center, Level 2, Stony Brook, NY 11794-8231, USA
2
Silver School of Social Work, New York University, New York, NY, USA

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population [1]. The nominal literature on individuals with disabilities and sexuality has not
been directly applicable to those with ASD, tending to focus on intellectual and devel-
opmental disabilities more generally [2]. Within the limited literature on sexuality and
ASD, emphasis is placed on sexual behaviors, with little attention given to emotional and
social aspects of sexual development and sexual identity [3]. Individuals with ASD may be
perceived as unaffected by issues related to sexuality and intimacy, due to the commonly
held belief that this population is either uninterested in intimate relationships or sex, or
incapable of engaging in appropriate sexual conduct [4].
These assumptions may lead some to conclude that individuals with ASD are not
interested in intimate relationships, do not have sexual desires similar to those found in the
general population, and do not engage in sexual behavior [5]; however, research has
provided evidence to the contrary [6, 7]. Despite this research, individuals with ASD
receive less sexuality education than typically developing individuals, leaving a large
information gap and denying them an important developmental opportunity [8, 9]. A
comprehensive review of literature on sexual education curricula found that formal,
individualized, and specific sexual education is lacking for individuals with intellectual
disabilities, leaving them at heightened risk of sexual abuse and STDs [10]. Thus, it is
prudent to provide education on the appropriate expression of sexual feelings. Given their
routine contacts with adolescents with ASD, mental health providers1 are uniquely posi-
tioned to play an integral role in promoting comprehensive sexuality education to this
population.

Adolescence and ASD

Adolescence is a time of great change for all youth, marked by major physical, psycho-
logical, and social transitions. For the child with ASD adolescence may be further com-
plicated by the impact of disability. Individuals with ASD physically mature at the same
rate as their typically developing peers, but may not experience the same social and
psychological gains, which can create confusion and marked distress [4]. These gains
include concepts such as interpreting subtle social cues among one’s peers, understanding
the significance of personal boundaries and space, and understanding the difference
between public and private behaviors [11]. Some may consider the adolescent with ASD as
a perpetual child, failing to acknowledge emerging sexual needs and issues [12]. Con-
versely, parents and others may view adolescents with ASD as young adults, assuming they
are progressing socially and psychologically at the same rate as their peers, and may assign
expectations and responsibilities to the child that have not been fully explained or explored
[13].
Differences between adolescents with ASD and their typically developing peers become
more obvious during this time, as the discrepancy between physical and socio-emotional
development may widen [14]. For example, a child’s public displays of affection may seem
appropriate for his developmental age, but could be disturbing to others based on his
mature physical appearance [15]. Non-sexual behaviors could be misconstrued as being
sexual in nature [1], or normative sexual behavior could be misinterpreted as aggressive or
negative [16]. This is not to say that the behavior in itself is deviant or problematic; rather,

1
The term ‘‘mental health providers/professionals’’ will be used in this article to refer to psychologists,
social workers, behavior specialists, and related professionals concerned with the mental health of ado-
lescents with ASD.

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that others’ perceptions of the behavior could lead the individual with ASD to be ostracized
and socially excluded, causing distress for the individual [6].
Increases in sexual behavior and interest in intimate relationships accompany matura-
tional and physical changes of adolescence. Individuals with ASD experience similar urges
as their typically developing peers, but may have difficulty expressing these feelings in a
socially appropriate manner [7] or gauging peers’ reaction or interest in their reaction.
Without guidance in areas of sexuality, adolescents with ASD may experience consider-
able difficulty coping with the physical, social, and psychological transitions of puberty
[17].

Emerging Sexuality Issues in Adolescence

Normative issues such as masturbation, menstruation, and related sexual matters present
rich opportunities for mental health professionals to support youth with ASD. Sensitive and
comprehensive work with this population may buffer the health and safety risks that
accompany physical maturation [18]. Gougeon [8] makes note of the ‘‘ignored curriculum
of sexuality’’ in which sexuality education fails to account for the informal sexual
knowledge that is gained through social channels among typically developing peers (p.
277). Sexual abuse, inappropriate sexual contact with others, and sexual behavior in public
places are among the risks inherent in failure to provide proper sexuality education and
training to individuals with ASD [19]. Likewise, if individuals with ASD are not provided
with positive sexuality education, they may internalize negative societal stereotypes
regarding their sexuality [20].
Frustration in regard to sexual expression and the physical changes experienced during
puberty can lead to aggressive or self-injurious behaviors in adolescents with ASD. For
instance, staff in a community-based residential program for individuals with ASD
observed anxiety, agitation, and aggression toward self or others among residents when
their masturbation was interrupted or they were unable to masturbate to orgasm [21].
Puberty can also mark a regression in some behaviors for adolescents with ASD [22]. For
young women with ASD, hormonal changes and physical discomfort during menstruation
may exacerbate behavioral problems, as they may not have the communication and social
skills needed to express the anxiety caused by these natural changes [18]. Personal hygiene
and unintended pregnancy are also important concerns [23].
Public displays of sexual behavior could serve as an outlet for individuals with ASD if
alternative opportunities for sexual expression in a private setting are not provided [17].
Stokes and Kaur [24] found adolescents with ASD were more likely than typically
developing adolescents to engage in inappropriate public displays of behaviors such as
touching one’s own or others’ private parts, disrobing, and masturbating. Due to a lack of
preparation and ongoing sexuality education, adolescents with ASD may not know when
and where it is acceptable to engage in these behaviors [19, 25], how to appropriately
initiate a relationship with another person, or how to cope with the frustration of social
rejection in their attempts to do so [26]. Parents of children with ASD have expressed
concern that social deficits could hinder the ability to differentiate between public and
private behaviors, as well as misperceive the intentions of others, resulting in unsolicited
sexual contact [1]. These behaviors can lead to further social isolation or even criminal
charges for the adolescent with ASD.

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While inappropriate sexual overtures are a concern, this should not overshadow the
great risk of sexual victimization faced by individuals with ASD. Mandell et al. [27] found
that almost one in six individuals with ASD in community mental health settings expe-
rienced sexual abuse. Youth with ASD may be pursued by offenders who view them as
easy targets and their social communication difficulties may make it difficult to infer the
intentions of perpetrators. Similarly, children with ASD may lack language skills needed to
describe and report instances of abuse [28]. This is a main reason why comprehensive,
developmentally appropriate sexuality education programs are vital.

Importance of Sexuality Education

Developmental and behavioral features of individuals with ASD affect numerous aspects
of functioning, most notably one’s ability to navigate the world of unspoken social
expectations. In adolescence, one’s social world widens considerably, with peer relations
becoming a focal point [29]. Socialization and communication difficulties inherent to ASD
position adolescents at a distinct disadvantage, as they may lag behind their peers in
learning social norms regarding acceptable sexual behaviors [4]. Peers provide an
important informal resource for information regarding sexuality during adolescence. Given
difficulties with social interactions, however, adolescents with ASD may be more likely to
gain knowledge of sexuality and relationships via their own observations, from social
media or from their parents [11] who often lack training or resources to provide meaningful
education in this area.
Too often, adolescents with ASD are provided with sexuality education only after
demonstrating a problematic sexual behavior [30]. Sexuality education may be delayed due
to a concern amongst parents and caregivers that talking about sexuality will increase
sexual behavior [31]. However, when physical maturation occurs at a greater rate than
growth of emotional or cognitive skills, as it does in individuals with ASD, how well
adolescents are able to adjust to this change depends largely on the support and education
they receive from families and clinicians [32]. While healthy sexual exploration and sexual
identity development are essential precursors to adulthood [33], this requires access to
comprehensive, developmentally suitable information on sexuality. To that end, several
strategies intended to reduce inappropriate sexual behaviors and promote sexual health and
development for adolescents with ASD will be discussed. These strategies, which are based
on Applied Behavior Analysis, Social Stories and Social Behavior Mapping, are the
foundation for the Growing Up Aware with Autism Sexuality Education Curriculum. Each
technique is coupled with a case example that delineates the mental health professional’s
role, and highlights the importance of collaborating with parents, educators, and
adolescents.

Applied Behavior Analysis

Applied Behavior Analysis (ABA) is an umbrella term incorporating various techniques

aimed at altering or improving specific behaviors or skills [34]. A hallmark of the practice
is demonstration of measurable behavior changes related to interventions and manipula-
tions of one’s environment, which are monitored and reinforced to ensure the desired skill
or modification has been acquired by the individual [35]. Appropriate or desired behaviors

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are positively reinforced, while unfavorable behaviors are not, encouraging repetition of
the desired behaviors and discouraging those that are not desired [36]. ABA has been
proven effective across a number of settings, providers, and behaviors [37].
Applied behavior analysis is uniquely suited for use in socio-sexual education programs
for persons with ASD, as empirically based instruction methods support gains in skills and
reduction of inappropriate behaviors related to sexuality [38, 39]. Needed skills are broken
down into small steps, each taught using a specific cue paired with a prompt if needed.
Reinforcement should immediately follow an appropriate response, while inappropriate
responses receive no reinforcement. Prompts are systematically phased out, until, ideally,
the individual can perform the skill independently [34]. Breaking down large areas of
information into smaller, more concrete tasks facilitates positive outcomes for both the
individual learning the skills and significant others [34, 38].

Applied Behavior Analysis and Masturbation

Applied behavior analysis-based intervention strategies have been used successfully to

remedy problematic behaviors and in increasing communication, learning, and appropriate
social behavior for children with ASDs [40, 41]. This evidence-based practice could prove
similarly successful in sexuality education [39], specifically in regards to the reduction of
public masturbation. Studies in various settings have found masturbation is common
among individuals diagnosed with ASD [18, 42, 43]. It is among a wide range of sexual
behaviors used to express personal needs [44]. If expressed at an appropriate time and
place, masturbation can be an important outlet for the satisfaction of sexual needs and
positive sexual self-expression [17]. While masturbation itself is not problematic, it
becomes so when it is practiced in public places, in the presence of others, or when its
frequency interferes with other activities [44]. Instead of suppressing masturbation, which
can lead to increased frustration, techniques to support appropriate masturbation can be
taught, provided that such techniques are ‘‘legally allowed, ethically appropriate, and
intended to improve quality of life’’ [19, p. 200]. Proactive sexuality education is crucial in
ensuring that normative sexual behaviors are expressed in socially acceptable and per-
sonally safe ways. ABA is an ideal forum through which to address this and other aspects
of sexuality education.
The case of Kevin, an 11 year old boy with ASD, highlights the use of ABA to reduce
public masturbation habits. Kevin is verbal with an average IQ. He exhibits masturbatory
behavior on the school playground. The goal was for Kevin to learn how to verbalize his
need to masturbate and to find more appropriate times and places to do so. Kevin’s school
social worker led the intervention effort; techniques and strategies were reinforced by his
special education teacher and parents who collaborated with her.
The social worker began by operationally defining the target behavior ‘‘public mas-
turbation’’ as: ‘‘any self-touching of the genital area either over or under clothing or
stimulating with objects on the school playground during recess in the presence of others.’’
The social worker collected baseline data by noting the frequency of Kevin’s masturbation
on the playground during a 1-week period; it was established as once daily during recess.
Additionally, the social worker conducted systematically observed antecedents and con-
sequences to Kevin’s masturbatory behavior during this baseline period. She noted that
upon entering the playground during recess, Kevin walked quickly towards the swing set.
If the swings were occupied, Kevin watched the back and forth motion of the swings. After

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watching the swinging for about 5 min, Kevin began to masturbate first by touching
himself over his clothing and then putting his hand into his pants. Thus, full occupancy of
the swings was determined to be the antecedent to this masturbatory behavior, which the
social worker concluded was purely self-stimulatory and not directed at others. The con-
sequences observed by the social worker included children screaming, laughing, pointing,
or running to tell a teacher. Typical consequences for Kevin included verbal reprimands by
staff and removal from the playground to the boy’s restroom, which were ineffective in
reducing the target behavior.
The social worker’s functional assessment also helped identify a condition under which
Kevin would not emit the target behavior: The condition of Kevin receiving designated
time on the swing set. Kevin was also taught to verbally express his urge to masturbate.
Together with Kevin’s parents and teacher, the social worker developed a special phrase
(i.e., ‘‘private time’’) that Kevin could use to let them know when he had a desire to
masturbate. Visual strategies, including diagrams of male anatomy and line drawings of
figures exhibiting masturbatory behavior, were utilized to teach Kevin the concept of
‘‘private time’’ in a manner that was not shaming. A photograph of Kevin’s bedroom was
used to highlight the distinction between public and private and to delineate where he was
permitted to masturbate.
The intervention plan allowed Kevin 10 min on the swing at the beginning of recess
every day. After this swing time, if Kevin engaged in masturbatory behavior before the end
of recess, he would be prompted to ask for ‘‘private time’’ and then be redirected to other
activities involving tactile movement such as a see-saw or spinning carousel. Kevin was
also shown the picture of his bedroom and his teacher would explain, ‘‘Not in school, only
in your bedroom at home.’’ To avoid reinforcing his public masturbation, Kevin would not
be allowed to return to the swings.

Social Stories

Social Stories, a technique created to enhance the social cognition of individuals with ASD
[45], is another approach for teaching skills. A Social Story describes a situation, concept,
or social skill from the perspective and comprehension level of a child with ASD [46].
Social Stories have been associated with increased socially appropriate behaviors [47] and
decreased problem behaviors [40]. In the context of sexuality education, Social Stories
could be used to prepare individuals for puberty-related changes or to help them find
solutions to difficult situations that have already occurred [48].
Six basic sentence types are utilized in Social Stories: descriptive, directive, perspec-
tive, affirmative, control, and cooperative. Descriptive sentences describe the target situ-
ation and the social rules governing it, including subjects and actions. Directive sentences
explain appropriate behavioral responses for that situation. Perspective sentences depict the
feelings and responses of the subject or others. Affirmative sentences express commonly
shared values or opinions fitting with the target situation. Control sentences indicate how
and when one would use learned strategies and skills. Finally, cooperative sentences
describe what others will do to help the subject [48]. Social Stories follow a format of five
to ten sentences, utilizing two to five descriptive sentences, one directive sentence, one
perspective sentence, one control sentence, and an optional affirmative sentence [46].
Social Stories have been successful in teaching children with ASD the social skills
needed to interact with others appropriately [49]. Although there is little information

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regarding the use of Social Stories in sexuality education [48], it seems likely that they can
be a useful tool to help individuals with ASD navigate this natural developmental
transition.

Using Social Stories for Teaching Menstruation Hygiene

For females, one of the most significant occurrences in puberty is the onset of menstrua-
tion. Major physiological changes occur with menstruation, including abdominal cramp-
ing, disturbances of the bowel, breast tenderness, headaches, vaginal discharge, blood, and
perspiration [50]. While menstruation itself is not a sexual behavior, its onset is seen by
many as physically, emotionally, and culturally marking the beginning of a young
woman’s sexual maturation. Personal hygiene is an important skill accompanying sexual
maturation, with menstruation requiring new skills in a private domain of one’s body [23].
Menstruation can be a source of great distress for adolescent girls, and may be especially
challenging for those with intellectual disabilities given their limited receptive language
and communication skills [51]. In a study of adolescent females with developmental
disabilities, Burke et al. [52] found that girls with ASD were more likely to experience
behavioral issues related to the onset of menstruation than girls with Cerebral Palsy or
Down syndrome. Teaching young women with ASD how to cope with menstruation,
including developing necessary hygiene skills, can likewise be difficult due to issues with
language and communication [18].
Girls with ASD should be prepared for menstruation well before it occurs; education
and feedback about other bodily changes should continue throughout puberty. Koegel and
LaZebnick [53] suggest, ‘‘Tell [your child] that she will find blood in her underpants and
what she should do about it, whether it is going to the nurse, calling home, or opening up
her personal hygiene kit. Give her this information before her first period starts’’ (p. 161).
Gabriels and Van Bourgondien [18] also advocate early intervention, noting that teaching
proper hygiene prior to the onset of menstruation may be helpful as the girl will be less
distracted and distressed than during the actual cycle.
Proper menstrual hygiene skills include how and how often to change sanitary napkins
and tampons, and washing the genital organs [17]. Henault [50] recommends the use of
physical demonstrations of sanitary napkin and tampon changes as well as models or
drawings of female genitalia to teach these skills to girls with ASD. Learning the days of
the week, months of the year, number of days in a month, and how to count to 31, are skills
that could help girls better anticipate, and thus feel more prepared for, the monthly cycle;
exercises and certain postures can be taught as a way to alleviate pain associated with
menstruation [17, 18]. Creating Social Stories around these skills could provide an
effective teaching tool for adolescent girls with ASD. The following Social Story
demonstrates the skill of changing a sanitary napkin during one’s menstrual cycle:
My name is Susan and I am a 12 year old girl. Some girls begin to menstruate, or have a
period, when they turn 12 years old. I had my first period this month. It was a new feeling
for me, but having a period is normal and okay. When I have my period, it is important for
me to use a sanitary napkin to keep my underwear clean. I will try to go to the bathroom to
check my underwear every 3 h to look at my sanitary napkin. If it is soaked with blood, I
will do my best to throw out the old napkin and put on a new, clean one. Then, I will wash
my hands with warm water and soap to make sure that I am clean before leaving the

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bathroom. It is a good thing to stay clean and fresh when I have my period. This is a normal
part of growing up.
Social Stories can be useful across a range of situations. They can be used proactively
(i.e., to prepare adolescents for future sexuality issues), or in response to emerging
behaviors [48]. In this sense, they provide a relevant tool that can be tailored to each
individual’s unique issues regarding sexuality education.

Social Behavior Mapping

Similar to Social Stories, Social Behavior Mapping is a practice derived from Cognitive
Behavior Therapy (CBT), which focuses on behavior modification through internal self-
regulation [54]. Internal processing involves thinking about the motivations behind one’s
behaviors, as opposed to the more externally focused techniques utilized in most behav-
ioral approaches, for example, rewarding a child with a sticker for sitting quietly during
class. A review of fifteen empirical research articles on the use of CBT with individuals
with autism published between 2003 and 2008 determined that such interventions were
effective, with studies showing evidence of increased socially appropriate behaviors and
decreased inappropriate behaviors in this population [55]. Crooke et al. [56] note that
social skills training for individuals with ASD tends to utilize behavioral techniques
focusing on specific, concrete skills. While this approach may be useful for reducing
overtly aggressive behaviors, social skills training is less effective in teaching the subtle
nuances behind everyday social interactions; it may teach a child to execute a certain
behavior appropriately, but may not help the child understand why it is important to do so
[57]. This comprehension is necessary for generalizing appropriate conduct to other social
contexts.
The social competence required to explore the world of sexual behavior and relation-
ships is complex and often confusing. Individuals must learn social rules and norms that
guide initiation and maintenance of intimate relationships, including how to determine if
another is interested in reciprocating [42], discerning between reality and fantasy, and
acceptable public and private behaviors [38].
Problematic sexual behavior can be a real possibility for adolescents with ASD, due to
limited empathy and social reciprocity, failure to seek age-appropriate relationships, dif-
ficulty interpreting others’ reactions and behaviors, and regulating one’s own affect [26].
Misinterpretation of social cues may culminate in behaviors such as forcing oneself on
another without consent [24], touching one’s genitals in public, obsessing over sexual
behaviors [50], or initiating a relationship with a much older or younger person [58].
Individuals who engage in these behaviors reveal lapses in social skill development; they
neither recognize the behaviors as socially inappropriate nor see how their behavior affects
the way others perceive and feel about them [59].
Mental health providers must remember that individuals with ASD who are more
advanced developmentally and are able to express feelings and thoughts on a more
complex level will still lag behind their typically developing peers in social skills. As noted
by Koegel and LaZebnick [53], ‘‘As our interventions improve and kids on the spectrum
become more and more included and more and more successful academically, the chal-
lenge will be to fill the social gaps, so that they can pursue and enjoy relationships and sex
as much as their typical peers—and without risk of offending someone or violating any
laws’’ (pp. 157–158). Social cognitive teaching methods such as Social Behavior Mapping

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are thought to be most useful for this ‘‘higher functioning’’ subset of individuals on the
autism spectrum [57].
Social Behavior Mapping goes beyond merely labeling behaviors as appropriate or
inappropriate and correcting them. This technique requires the individual to consider the
difference between ‘‘expected’’ and ‘‘unexpected’’ behaviors, which is useful language for
examining what are actually ‘‘appropriate’’ and ‘‘inappropriate’’ behaviors [59]. Shifting
the language in this way helps place the focus on the impact the behavior has on one’s
peers, as it asks the individual to consider whether his actions were expected by those
around him, and how this, in turn, influences the reactions of one’s peers. To practice this
technique with an adolescent, begin by exploring specific behaviors, and how these
behaviors may be perceived by others as expected or unexpected. Next, map out how these
behaviors could make those around the adolescent feel, followed by possible reactions and
consequences based on these feelings. Finally, consider how these consequences would
make the adolescent feel [54]. A concrete example of Social Behavior Mapping in ref-
erence to inappropriate touching in provided below.

Social Behavior Mapping and Inappropriate Touching

Consider a situation in which an adolescent male with ASD has been spontaneously
hugging girls in his class at school. This student most likely lacks the social understanding
that such behavior is no longer appropriate for his age; the idea that such behavior is
‘‘inappropriate’’ may be foreign. A Social Map for this situation would establish hugging
others without their permission as ‘‘unexpected,’’ and assist the individual in compre-
hending how others feel and, consequently, may impact others’ reactions to him in this
context. Appropriate behavioral alternatives are provided in the ‘‘expected’’ behaviors
component of the Social Map. As shown, expected behaviors lead to pleasant outcomes for
the individual, while unexpected behaviors may bring about outcomes that cause the
individual distress. The Social Map assists the individual in seeing the differing outcomes
to the various behaviors. A Social Map for use in this scenario might look like the
following (see Tables 1 and 2).
Appropriate behaviors can be tracked by circling them as they occur on the map; the
objective being to have more ‘expected’ than ‘unexpected’ behaviors [54]. Social Behavior
Mapping can be used alone or in conjunction with other interventions across a variety of
situations and contexts. Given its versatility, mental health providers may adapt the method
to fit into their own unique professional repertoire.

Table 1 Hugging my classmates: behaviors that are expected

Expected behaviors How they make Consequences you How you feel
others feel experience about yourself

Keep my hands at my sides or on my Comfortable People feel okay being Happy

desk during class around me
Not touching others sitting near me or Relaxed People want to sit next Calm
in the classroom to me
Only hugging other people when they Friendly People respond to me Accepted
tell me it’s okay to positively

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Table 2 Hugging my classmates: behaviors that are unexpected

Unexpected behaviors How they Consequences you How you feel
make others experience about yourself
feel

Touching others when I am supposed to be Annoyed Others get angry at Unhappy

sitting at my desk with my hands to myself me
Hugging other students during class Uncomfortable Students tell me to Embarrassed
leave them alone
Hugging students without them asking me to Disgusted Students tell me I’m Ashamed
weird

Discussion

Mental health professionals can play a critical role in the sexuality education of individuals
with ASD by completing the partial and often inaccurate information imparted by other
service providers, parents and the media. Clinicians with expertise in the field of ASD are
often asked by organizations and parents to provide advice on sexual behavior and
problems [44]. The demand for resources and individuals with expertise to address the
socio-emotional needs of adults with ASD, including sexuality, outstrips the supply [60].
Unfortunately, mental health providers who work with individuals with ASD may not have
the knowledge and skills to address the natural changes and concerns that come with
emerging sexual maturity. Moreover, typical sexuality education programs lack needed
elements and modifications necessary to make them relevant to individuals with ASD [48].
This includes approaching sexuality as a normative, positive aspect of development, as
opposed to the problem-focused approach that has dominated literature on ASD and
sexuality to date [61].
Furthermore, adolescents with ASD have demonstrated a desire to understand the nature
of their autism. This includes how it impacts their behavior and their relationships with
others [62]. Understanding autism is part of promoting a sense of self for adolescents with
ASD, and is a critical component of developing one’s sexual identity. Sexuality education
programs should help adolescents with ASD cultivate this knowledge, which in turn allows
the adolescent to more readily communicate to others what he or she needs to feel
effectively supported [62].
This article reviewed three techniques for application in social skills components of
sexuality education programs: Applied Behavior Analysis, Social Stories, and Social
Behavior Mapping. Each technique can be generalized to different topics and situations,
and are as relevant in the classroom as they are in the home or practitioner’s office. Issues
pertaining to sexuality are not limited to one’s private life. Rather, they present themselves
at school, at parties, at the grocery store; in short, they are everywhere. Sexuality education
should not be limited to one environment and the skills learned must be transferable to
multiple contexts. Mental health providers can strengthen sexuality education efforts by
collaborating with parents and educators to encourage reinforcement of positive techniques
in all aspects of an adolescent’s life. Teachable moments occur within various everyday
contexts, such as witnessing a public display of affection between a couple and using the
opportunity to explore how this made the adolescent feel, or seeing a TV commercial for a
sanitary napkin and using it as an opening to discuss personal hygiene. Communicating this

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information in a brief and simple manner in concert with incidental behaviorally based
interventions helps to reinforce the skills taught in sexuality education programs. Often,
adults or peers provide unwitting reinforcement by their reactions or disapprovals that in
turn function as reinforcement or punishment. This instruction helps to mitigate such
actions.
Most sexuality education programs and curricula developed for children and adults with
ASD have not been evaluated to determine effectiveness [12]. Moreover, most research on
ASD and sexuality excludes adolescents with ASD, and fails to examine the issues faced
by individuals with ASD as they enter adolescence and adulthood [61]. Finally, research on
sexuality and ASD largely focuses on males, with limited exploration of the needs of
young women [63].
Applied Behavior Analysis has an empirical research base supporting its effectiveness
for teaching individuals with ASD in general [19], but has not been extensively evaluated
in the context of sexuality education. Similarly, Social Stories and Social Behavior
Mapping have not been subject to empirical validation for use in sexuality education
[48, 57]. Research to determine the effectiveness of these intervention strategies is a logical
next step. The professional community is responsible to establish empirical foundations for
the work being carried out in clinics, schools, and homes. As children with ASD grow to be
adults, it is important that sound, evidence-based practice is utilized to ensure the transition
is a safe and healthy one.

Acknowledgements This research was supported by a Grant from the Organization for Autism Research
awarded to Michelle S. Ballan.

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