What is facilitated sex? This brief video explains what facilitated sexual activity is and some of the considerations.
Dr. Mitchel Tepper is an expert in the area of sexual health, disabilities, and medical conditions with a specific focus on physical disabilities. His website can connect you with a lot of great information (I especially like his blog).
Some things to keep in mind about facilitated sex…
- Facilitated sex is a continuum. Dr. Sarah Earle suggests it might include providing sex education, fostering an environment that allows intimacy, the procurement of sexual goods, and arranging for paid-for sexual services.
- Many individuals with disabilities would be unable to participate in many parts of sexual expression without some level of facilitation.
- It’s not that abuse and victimization aren’t concerns- they are! It is also important to consider how to support individuals with exploring sexual pleasure and sexual facilitation is part of that picture.
Many women with development disabilities are under anesthesia during pelvic exams or don’t get them at all (or as recommended). However, educating about pelvic exams may be an important part of teaching sexual health. I’ve included the link to a video that may help.
This is a brief video that goes through the basic procedure of a woman having a pelvic exam. This could also be a good video for teaching about female anatomy. It has a lot of technical terminology but it also moves nice and slow.
This week, we focused on body image. This was probably the most difficult concept for students to grasp so far. In other weeks we’ve focused more on content but this week was more about self expression and they could connect the expression components, however, they really struggled with what exactly body image is and their own self awareness. For some of the students thinking about body image melted into feelings of self worth. The strategy we introduced, positive self talk, was also difficult for them to understand.
Activities this week…
What is Body Image? We’re used a pretty simple definition of body image: how you think and feel about your body and appearance. This definition highlights the cognitive and affective components of body image.
How I Feel About My Body For this activity we asked students to write down how they feel about their body. We then collected all the responses, redistributed them, and read them out loud. This activity allowed students to express their feelings about body image. It also exposed them to the thoughts and feelings of others. For the most part students in our group expressed feeling good about their bodies.
Positive Self-Talk We introduced positive self-talk as a strategy for managing negative ideations about body image. Each member of the group practiced positive self-talk by using affirmation statements in the mirror. This was very difficult for some students, even with the scripts. This may be because they didn’t understand the “why” behind the activity. This activity exposed them to a strategy for promoting a healthy body image and gave students an opportunity to practice that strategy.
Role Play Because we know that often, negative thoughts and feelings about body image occur while we are with groups of people, we role played using positive self-talk when in a group. This was essentially an extension of the previous activity but we made the task slightly more difficult.
Self-Portraits Body image is one of those topics that is not just about learning facts but mostly about self-awareness and self-expression. In addition to teaching some concrete strategies for promoting positive body image, we also wanted to provide opportunities to explore thoughts and feelings about appearance. The self-portraits were another strategy for helping students explore their thoughts and feelings about body image. For the most part, the kids were really excited about this activity. We promoted trying to reflect a positive self image, but this didn’t come naturally to all the students. We also wanted to make sure we respected the right for students to express their genuine emotions.
Just a note on classroom management. Distractions were down with the implementation of our simple rights and responsibilities, more firm “nos” and the stop sign. We did have one student who had a hard time because they had to wait until next week to take the pictures home so the paint could dry. This is something to anticipate for the future.
Materials for this week…
Hygiene is not on the SEICUS guidelines for what to teach in a human sexuality class, but we find that it can be a hard topic for students. It also is strongly connected to puberty because it is during puberty that hygiene needs change at the same time young people have more autonomy and responsibility for their hygiene. We tackled hygiene with a series of activities we called hygiene Olympics. In small groups, students moved throughout the stations to practice and contemplate hygiene tasks.
- Hand washing: Students rubbed glitter mixed with lotion on their hands and then had to wash their hands until the glitter came off. This will helped students to recognize that hand washing is more than just rinsing hands lightly with water.
- Body washing: We will had life-size body outlines, loofas, and paint. Students used the paint like it was soap. This helped students recognize the importance of washing their entire body.
- Laundry: Students saw a pile of laundry. They then sorted the clean from the dirty clothing (the dirty clothing are just tee shirts that have been dampened and wrinkled). The helped students identify clean clothing.
- Shaving: Students used an orange to practice shaving with a razor and shaving cream. The teacher in the group explained that boys often shave their face and that girls often shave their legs and underarms. Students had an opportunity to practice shaving.
- Deodorant testing: We had several deodorants with the brands blocked out. Students smelled and voted on their favorite scent. At this station, teachers pointed out the importance of wearing deodorant each day and reapplying after activities that cause sweat. This station emphasized the importance of deodorant use.
- My Hygiene Routine: Students saw pictures of different hygiene tasks. They also had a worksheet that said “My Hygiene Routine.” Students chose what order they would prefer to complete the hygiene tasks. This activity provided students with control and choice while also committing them to completing the necessary tasks.
Materials for this week
In preparing for the puberty section of Human Sexuality 101 I was looking at research on methods for teaching young girls with ASD about menstruation and came across an article using Social Stories (only a preview of the article is available for free).
In short, here’s the Four P Plan for Period Support
1. Prepare a period kit
2. Preinstruct (perhaps using social stories)
4. Plan for pain relief
Klett & Turan used a combination of three Social Stories adapted from Mary Warbol’s “Taking Care of Myself: A Hygiene, Puberty, and Personal Curriculum for Young People with Autism” (this book is not just for girls). They implemented the social stories before menarche (first period) and then planed to revisit them after menses began. These stories focused on growing up, what a period is, and how to take care of a period (I would reprint them but you have to be careful about Social Stories and their copy rights). They also used simulations with the girls using red syrup so they could practice changing a “used” menstrual pad. They reviewed the social stories over several days and completed simulations over several days. They also used different types of menstrual pads in case the girls did not always have access to the same type. They also asked the children questions about menstruation to check for comprehension (such as “What is the blood from your vagina called?” and “Do you need to wear a pad when you don’t have your period?”). This method proved effective in these case studies and the parents who implemented the plans where happy with it.
I have a good friend who made a menstrual kit for his daughter to start keeping in her book bag around age 11. In a zip lock bag he placed a change of underwear, menstrual pads, Tylenol, a change of shorts, and bathroom wipes. That way, if her first period was at school, she had everything she needed and wouldn’t need to ask for support unless she wanted to. I personally think this is a wonderful idea and wish my mom had thought of it when I was middle school! This idea has caught on because you can buy premade kits. Also, they make underwear that help keep menstrual pads in place.
I have heard that some families also preemptively use pain relief to support with discomfort and PMS. Not all girls associate the physical discomfort with their period or are able to communicate “I feel bloated” or “I have cramps.” Although these are phrases that you can teach and prompt, some families just start using an over the counter painkiller two or three days before they anticipate the start of the period. This isn’t foolproof because, especially when girls first start getting their period, they may have irregular cycles.
During the workshop we talk a little bit about gender identity and gender fluidity but I thought it might make sense to talk about this topic more in depth. Parks, Hall, and Taylor* looked at gender dysphoria (discontent with with biological sex) with individuals with cognitive disabilities and suggest “Developing a gender dysphoria or wanting to cross-dress usually has ramifications for the person’s family and social network, perhaps more so with people with intellectual disability, who may be more dependent on family and paid caregivers and have less choice about who is in their network. They may experience more hostility and gain less appropriate support from their network.” But there is still very little information about how common it is, why for some individuals gender is more fluid (have a wide flexible range of gender expression), and how best to support individuals with disabilities with issues related to gender. This topic also raises issues related to guardianship and self determination. Some individuals start going on puberty suppressants and hormone replacement starting in adolescence so their bodies can match the gender they express and the gender they identify with. For people with disabilities, who gets to make that choice?
Could having a developmental disability lead to difficulties with gender identity?
This is a little difficult to answer. There are very few studies ask this question. In Holland they looked at co-morbidity of ASD and gender disorders * and did find more individuals with ASD coming to their clinic then you would expect. However individuals with ASD may be tapped into to services which might account for this difference. When individuals with disabilities seek support they may be unable to give an accurate history and professionals in this area may be unfamiliar with working with people with disabilities which could lead to false impressions.
Given how little is known, where can I go for more information?
There are new clinical guidelines that address how clinicians should assess and support individuals with autism and persistent gender dysphoria. The new clinical guidelines (there haven’t been any in the past) affirm the right of individuals with autism to obtain gender realignment. It also affirms that many individuals with autism experience gender outside the male-female binary. Check out a reader friendly overview of the guidelines on Spectrum News.
Gender Spectrum is a great place to start looking for more information. This is a website that can link families with medical, mental health, social, and legal services. The have great definitions of all the different terminology and a great overview of gender development.
Here is also a This American Life podcast that features interviews with two little girls who were born as biological males and their families. For me, it was really eye opening and helped me connect this topic to real people.
On May 19th the Washington Post published an article on this topic (which I thought was really well done) featuring a little boy named Tyler. The story had almost 2,500 comments 5 days later. They published a follow up article about the response on May 21st, “I heard from transgendered senior citizens who lamented their decades living a lie. I got e-mails from confused parents who had their aha moment when they read Tyler’s story. And sure, I heard from the haters”. This article not only has nice information but also speaks to the relevance and controversy surrounding this topic.
*This links to the abstract of the article. Unfortunately, the full text of the article is not available for free online.
Below is a “Hierarchy: Masturbation Training” by Lisa Mitchell, LCSW-R at Penn State. Her plan for what she calls, “private touching”, was specifically developed for individuals with Autism Spectrum Disorders, but I think it is a good general framework. The hierarchy goes from lowest level of support to highest level of support. Across the board, masturbation is a topic people want more information about. I think this is a nice way to think about what kind of education or training is available as well as what you might want to try before moving on to something more intensive. I have also included a link to her entire powerpoint. She covers other topics/tips you may find interesting (relationship checklist, key concepts for topic areas, teaching techniques, problem behaviors).
- When appropriate, work with families and/or residence to establish a visual “private time schedule.”
- When appropriate, supply individual with lubricant, explaining that it is for use during “private time.”
- Meet with individual. Present illustrations of same sex persons masturbating, in conjunction with verbal explanation regarding technique.
- Meet with individual. Use illustrations and anatomical model in conjunction with verbal explanation of technique.
- Meet with individual. Use anatomically correct dolls to demonstrate appropriate masturbatory technique, in conjunction with verbal explanation.
- When appropriate, supply masturbatory aids such as body pillows, magazines, collages of stimulating pictures, vibrating pillows, masturbation sleeves, masturbation pumps, or vibrators. Explain safe usage of such aids.
- Meet with individual. Arrange for multiple viewings (when necessary) of instructional masturbation movies “Handmade Love” for males, or “Fingertips” for females. Viewings should occur in the individual’s bedroom or the private location where masturbation will be allowed to occur. Trainer may need to supply a verbal explanation while simultaneously viewing the tape to reinforce principles. (I would have the person watch on their own before feeling the need to view with another present. In general I think the videos are very good but very explicit. You could use the video in place of the verbal instructions indicated in the hierarchy).
- For individuals with more significant challenges, consider use of ABA type
approach (preferably done with relatively unfamiliar trainer) to teach more
successful masturbatory technique. Shape up steps one at a time (e.g. “Pull pants
and underwear down”, “Lay on belly”, “Put pillow between legs”, “Rock from side to
side”. Or “Pull pants down”, “Sit on bed”. “Put fingers around penis”, “Rub up and
down, up and down.”) – I have heard of this method, but I do not know anyone personally who has ever instructed on masturbation at this level. I would want to have a very comprehensive plan on how this would be implemented, full team support, and special attention paid to protecting the individual being instructed and the person doing the instruction.