Chapter 13

Chapter 13

Sexuality and Mental Health Issues

Dorothy M. Griffiths, Debbie Richards, Paul Fedoroff, and
Shelley L. Watson
Learning Objectives
Readers will be able to: 1. Compare the sexual wellness of persons with developmental disabilities to the sexual health of non-disabled persons. 2. Define sexual abuse of persons with developmental disabilities and apply the double-edged definition to the history and life experiences of persons labelled as disabled. 3. Identify the key mental health challenges that relate to the sexuality of persons with developmental disabili-ties and how the disability may create increased risks. 4. Identify appropriate treatment options for persons with developmental disabilities who present with sexual challenges. Introduction

The sexuality of persons with developmental disabilities raises
serious mental health issues. It is actually not the sexuality of
persons with disabilities, but how society has misunderstood
Mental Health Needs of Persons with Developmental Disabilities and responded to their sexuality, that pose challenges for their mental health. Myths regarding the sexuality of persons with developmental disabilities have contributed to more than a century of abuse and repression for persons who have been la-belled (Griffiths, 1999), and have created an increased risk that persons with developmental disabilities will develop sexuality related problems. In this chapter, the following topics related to persons labelled as developmentally disabled will be ex-plored: 1. Sexuality as a normal part of mental well-being, 2. Sexuality as a mental health risk 3. Sexual abuse: Unwanted forced sexual contact 4. Sexual abuse: Restricted sexuality 5. Mental health risk factors associated with sexually inap-
1. Sexuality as a part of mental well-being

Healthy sexuality is essential to mental wellness. The neces-
sary requirements for the development of healthy sexuality
have been identified by the World Health Organization (1975).
They are as follows: (i) the establishment of the capacity to en-
joy and control sexual and reproductive behaviour in accor-
dance with social and personal ethics; (ii) freedom from fear,
shame, guilt, false beliefs, and other psychological factors that
inhibit sexual response and the establishment of sexual rela-
tionships; and (iii) freedom from organic disorders, diseases,
and deficiencies that interfere with sexual and reproductive
functions.
In reality, the World Health Organization criteria for sexual health is not being met for most persons who are developmen- tally disabled. Facts are as follow:

1. Persons with developmental disabilities are less likely to
have control over their sexuality and reproduction. 2. They often experience restriction, punishment and recrimi- nation regarding their sexuality, and are further denied pri-vacy, opportunity, knowledge and choice regarding their sexual expression. They are more often the victims of sex-ual assault and abuse. 3. They are more likely to experience physical and medical challenges that interfere with their sexual experience and reproduction. As shown in Table 1: Syndromes and Effects on Sexuality, many conditions common among persons with developmental disabilities may have sexual implica-tions.
Thus on all three levels, the sexual well-being of persons with
developmental disabilities is jeopardized.
2. Sexuality as a mental health risk
One of the silent mental health challenges for persons with de-velopmental disabilities is sexual abuse. For the purpose of this chapter, the following definition will be adopted. Sexual abuse is defined as including unwanted or forced sexual contact, unwanted touching or displays of sexual parts, threats of harm or coer-cion in connection with sexual activity; denial of sexuality, denial of sexual education and in-formation, forced abortion or sterilisation (The Roeher Institute, 1994, p. vi). Mental Health Needs of Persons with Developmental Disabilities Effect(s) on Sexuality
Inappropriate sexual behaviour due to social skill deficits Males are generally sterile; Fertility rate in females is low Inappropriate sexual behaviour related to impulsivity Delayed development of secondary sexual characteristics Gonadal defects vary from severe deficiency to apparently normal sexual Inappropriate sexual activity due to impulsivity associated with Inappropriate touching due to complex motor tics May lack secondary sexual characteristics Inappropriate sexual behaviour due to increased sociability Gender Affected
Syndrome*
Table 1: Syndromes* and their effects on sexuality
The syndromes on this table have been selected by the authors as samples only. Other syndromes may also have * 3. Sexual Abuse: Unwanted or forced sexual contact

The sexual abuse of persons with developmental disabilities
will be explored relative to the incidence, causes, impact of
abuse on mental health, and its consequences. The relation-
ship between abuse as a serious mental health risk will be
identified.
Incidence:

In the early 1990s, researchers increased the awareness among
the developmental disability field as to the widespread sexual
abuse and exploitation of persons with developmental disabili-
ties. One study reported that 75-85% of women with develop-
mental disabilities, living in community residential pro-
grammes, had experienced sexual assault (Davis, 1989). The
majority of offences occurred in private homes (57.3%), or set-
tings where services were being received, such as group homes
(8.5%), institutions (7.7%), hospitals (1.7%), rehabilitation
services (4.3%) (Mansell, Sobsey, & Calder, 1992).
The research by Mansell and her associates indicates that per-
sons with developmental disabilities were abused at the hands
of family members, neighbours, or babysitters, just as were
non-handicapped persons. However, they were also at in-
creased risk of abuse from other persons with disabilities, es-
pecially when clustered with potential offenders in residential
programmes, and from persons in a care-giving role or those
who gain access to the person through the disability services.
The offenders were typically male, and were known to the vic-
tim (Sobsey, 1994; Mansell et al., 1992).
In a study involving 119 victims of sexual abuse, Mansell et al.
Mental Health Needs of Persons with Developmental Disabilities (1992) reported that abuse was generally repetitive (10.3%), or had occurred on many occasions (53.8%). Only 19.2% of the victims reported that the abuse had been singular, or had oc-curred 2-10 times (16.7%). Cause: The person’s disability is not the direct cause of the increased vulnerability for abuse. The social conditions and systems, in which persons with developmental disabilities must interact as a result of their disability, create the increased risk (Griffiths et al., 1996, Roeher Institute, 1988, Sobsey, 1994). Several risk factors have been associated with the social conditions in which most persons with developmental disabilities find them-selves. They include the following: • social isolation and economic disadvantage; reliance on caregivers, who may lack training and support; lack of opportunity to gain socio-sexual knowledge, or to access social interactions; lack of empowerment and concurrent emphasis on compli-ance; socialized tolerance for a breach of socio-sexual bounda-ries; and lack of credibility given to abuse reports. Recent research and theory has suggested that the socially cir-cumscribed world, within which persons with developmental disabilities usually live, and the nature of the roles and rela-tionships in such settings, may result in confusion or distortion of interactions that can reduce the natural boundaries for abuse. When the healthy boundaries between support- providers and support-recipients become blurred or breached,
there is a potential for sexual abuse to be tolerated, or even
worse, misinterpreted as appropriate social approach behaviour
(Owen, Griffiths, Sales, Feldman & Richards, 2000). In some
cases, persons with a developmental disability may be unaware
of the expected limits of support-providers’ behaviour beyond
care-giving duties, and may not know or feel they have the
right to defend themselves. Without clear policies and proce-
dures with regard to appropriate boundaries, caregivers can ra-
tionalise inappropriate behaviour, and support-recipients will
remain unclear as to appropriate and inappropriate caregiver
behaviour (Owen, et al., 2000).

Impact of Abuse on Mental Health:
Myths exist that people with developmental disabilities, espe-
cially those who are more disabled, are insensitive to pain and
are asexual (Sobsey & Mansell, 1990), and will not be affected
by sexual abuse. However, Mansell et al. (1992) reported that
most persons with developmental disabilities demonstrate
negative effects following abuse. The experience of the nega-
tive effects following sexual abuse is idiosyncratic, and often
related to pre-abuse history, the understanding of the abusive
event, the nature of the abuse, the relationship with the abuser,
and post abusive experience. Some individuals may experience
the event as abusive and even traumatic; other individuals may
experience the event with less negative overtones, or misinter-
pret it as love because of a lifetime of learned tolerance to an
institutionalized abuse or misunderstood intentions (Owen et
al, 2000). In either case, the person with a disability is likely to
demonstrate behavioural symptoms. These symptoms are often
not understood, nor treated effectively as abuse reactions.
Rather, symptoms can be poorly managed through behavioural
Mental Health Needs of Persons with Developmental Disabilities control and sedation and the reason for the symptoms may never be appropriately assessed or treated. Consequences: Crimes, including sexual crimes, against persons with develop-mental disabilities are rarely reported (Wilson & Brewer, 1992). Following abuse, persons are often removed from their home or programmes (Mansell et al., 1992). In summary, the pervasive occurrence of sexual abuse, the na-ture of the abusive relationships, the lack of intervention fol-lowing abuse, and the lack of natural consequences for abusers of persons with developmental disabilities, and the potential aftermath of disruption in their lives creates a severe mental health risk for persons with developmental disabilities. 4. Sexual Abuse: Restricted Sexuality

As stated earlier, abuse of the sexuality of persons with dis-
abilities can involve restriction of sexuality through practice,
policy, medication and denial of knowledge.
History:
At different times in history, persons with developmental dis-
abilities were treated as “the sexually innocent”, who needed
social protection. At other times in history, such as the begin-
ning of the twentieth century, the Eugenics Movement branded
persons with developmental disabilities as “sexually dangerous
or promiscuous”, and in need of sanctioning. Persons with de-
velopmental disabilities were congregated with other popula-
tions typified by crime, sexual promiscuity, mental illness and
poverty. The professional community, armed with scientific data from hereditary studies, pursued most aggressively such restrictive measures as controlled marriage, sterilization, and segregation through institutionalization" (Scheerenberger, 1983). In the later part of the 20th century, forced sterilization eventually gave way to voluntary sterilization, and sex educa-tion was introduced. However, the facts about the sexuality of persons with disabilities have been slow to emerge from the myths (Griffiths 1992, 1999). Despite the advent of massive deinstitutionalization and the expansion of community living for persons with developmen-tal disabilities, most agencies that support persons with devel-opmental disabilities do not teach about or permit sexual activ-ity, appropriate or inappropriate. Today, many agencies still hold written or unwritten policies that fail to recognize the sexuality of the persons they serve. Age-appropriate, consen-sual and private sexual activity is often restricted or punished. Hingsburger (1992) observed that the sexual experiences of individuals with developmental disabilities may have been so suppressed, controlled or punished that some individuals ex-perience a negative reaction tendency to anything sexual. This is called erotophobia. Symptoms of this erotophobic behaviour include fear of one’s own genitals, a negative reaction to any discussion, pictures or act involving sexual things, denial and anger over one’s own developing sexuality, self-punishment following sexual behaviour, and a conspiracy of denial (Hingsburger, 1992). Medication Use and Misuse: Persons with developmental disabilities often receive a variety Mental Health Needs of Persons with Developmental Disabilities of medications for conditions associated with their disability, for psychiatric treatment or behavioural control, and to control sexual behaviour. Many of the medications prescribed to persons with develop-mental disabilities have sexual side effects. Additionally, the sexual side effects are more common as the dose and number of drugs increase, as often happens with persons with develop-mental disabilities. Too often, however, persons with develop-mental disabilities are not informed of the potential side effects that a medication can have on their sexual urges, fantasies or expression. Anti-convulsant medications, neuroleptics and an-tihypertensive medications are all associated with sexual dys-function (Crenshaw and Goldberg, 1996). “Unwanted sexual activity”, as defined by health-care providers was often “treated” with sedating neuroleptic medications (Mason & Granacher, 1980). In addition to causing tiredness and altera-tions in sexual desire, neuroleptics often cause erectile dys-function, inhibited orgasm, and retrograde ejaculation in men (Lingjaerde, Ahlfors, Bech, Dencker, & Elgen, 1987). In women, neuroleptic medications have been associated with de-creased vaginal lubrication, inhibited orgasm, and dysmennor-hea (alteration in menstrual periods). Gallactorrhea (breast milk let-down) has been reported in both men and women (Lingjaerde et al., 1987). {See Table 2 for a partial list of such sexual active drugs. The medications in Table 2 have been se-lected based on the frequency with which they are prescribed for people who have a developmental disability.} Most experts now agree that neuroleptic medications should never be prescribed for the purpose of controlling sexual be-haviour (Fedoroff, 1995). This is because better pharmacologi-cal interventions are now available, and because of the poten- tially lethal side effects of neuroleptic malignant syndrome (Levenson, 1985), and the disfiguring and incurable neurolep-tic induced syndrome of tardive dyskinesia (American Psychi-atric Association, 1992). Table 2: Sexual Side Effects in Commonly Prescribed Medications
Primary Indication
Side Effect(s)
Cardiovascular
Central Nervous System
Mental Health Needs of Persons with Developmental Disabilities Primary Indication(s)
Side Effect (s)
Sleep disorders/ anxiety Decreased sex drive; delayed ejacula- Primary Indication(s)
Side Effect (s)
By the late 1970s, most facilities reported having sex educ tion to some degree, but sexual behaviours, other than mastu bation, continued to be sanctioned (Coleman & Murphy, 1980). Pioneer sexuality educators, such as Kempton (1975) and Gordon (1971) began to move away from the moralistic tion; delayed, painful, retrograde, or no approach to sex education, toward providing information, not -rearing. Even today, although the field gene ally recognizes the importance of sociosexual education for rsons with developmental disabilities, most agencies do not provide ongoing access to sociosexual training for the persons they s Chemo- upport. Generally, persons are provided sociosexual
therapeutic
after they have engaged in a sexually inappropr Loss of sex drive; erectile dysfunction i- ate behaviour, or have become overtly sexual (Griffiths, 1999). Gastrointestinal
Decreased sex drive (M & F); erectile The restricted treatment of sexuality of persons with develo mental disabilities throughout history, the use and misuse of medication, and the denial of sexual knowledge pose a threat ntal health of persons with developmental disabilities.
These, in addition to the high rates of direct sexual abuse Genitourinary
ed or unwanted sexual contact, renders sexual abuse as one of the greatest mental health risks to persons 5. Mental health risk factors associated with sexually in-
Musculoskeletal
appropriate behaviour
Mental Health Needs of Persons with Developmental Disabilities In the previous two sections, we have shown that persons with developmental disabilities are (i) less likely to have sexual ex-periences that enhance their mental health, and (ii) more likely to experience abusive sexual events which may contribute to mental health challenges. These risk factors and others contrib-ute to an increased vulnerability for persons with developmen-tal disabilities to develop more sexually inappropriate behav-iour. Statistics on Sexually Inappropriate Behaviour: Gilby, Wolf and Goldberg (1989) reported that persons with developmental disabilities often engage in more inappropriate behaviours such as public masturbation, exhibitionism and vo-yeurism, but less serious sexual violations, than do nondis-abled persons. Edgerton (1973) suggested that persons with developmental disabilities do not tend to demonstrate any more sexually inappropriate behaviour than do non-disabled persons if they are provided a normative learning experience. However, the sexual learning experience of many persons with developmental disabilities is anything but normative. Offence Statistics: Studies on population statistics have shown that individuals with developmental disabilities are over-represented in the population of convicted sexual offenders (Shapiro, 1986; Steiner, 1984, Langevin, 1992). However, these statistics have been debated. Some argue that they are overestimated because the data is based on the number of people convicted, and peo-ple with developmental disabilities are more likely to get caught, to confess and unable to mount a suitable defence (Santamour & West, 1978; Murphy et al., 1983). Although the rate of serious sexual assaults may be overesti-mated among this population, it is likely that the rate of “sexually inappropriate behaviour” may not be. It is likely that persons who commit such violations are often diverted into residential programmes rather than correctional facilities, or the charges are dropped (Day, 1994). Nature of Sexually Offensive and Inappropriate Behaviour:
Sexual behaviour, defined as offensive or inappropriate, can
take many forms. According to the the Diagnostic and Statisti-
cal Manual of Mental Disorders (4th ed.) (DSM-IV; APA,
1994), there are a number of diagnostic codes under the rubric
of paraphilia, meaning love of the unusual. Paraphilia is de-
scribed as: "recurrent sexually arousing fantasies, sexual urges
or behaviours generally involving (1) non human objects, (2)
the suffering or humiliation of oneself or one's partner, or (3)
children or other non-consenting persons, that occur over a pe-
riod of at least six months" (p. 522).

Day (1994) suggested that paraphilia does occur, but rarely
among persons with developmental disabilities. It is, however,
often misdiagnosed. Among this population, there is a higher
experience of abuse (Griffiths, Quinsey & Hingsburger, 1989;
Gilby et al., 1989), poor self-esteem (Lackey & Knopp, 1989),
lack of sociosexual knowledge and experience (Hingsburger,
1987), and poor social problem-solving skills (Hingsburger,
1987). The DSM-IV states that in persons with developmental
disabilities there may be a "decrease in judgement, social
skills, or impulse control that, in rare cases, leads to unusual
sexual behavior" distinguishable from paraphilia (APA,1994,
p. 525).
The latter behaviours can be differentiated from paraphilia
Mental Health Needs of Persons with Developmental Disabilities since these acts do not represent a person's preferred and recur-ring sexual behaviour (APA, 1994). This non-paraphilic sexual behaviour usually occurs at a later stage in development, and is often sporadic. The DSM-IV description, while accurate in some cases, does not provide diagnostic criteria for differenti-ating between paraphilia and what some authors have called “counterfeit deviance”. The term “counterfeit deviance” was used in an article by Hingsburger, Griffiths, and Quinsey in 1991. They provided case examples to demonstrate that often, the sexual misbehav-iour of persons with developmental disabilities is the product of experiential, environmental, or medical factors, rather than a paraphilia. Such misbehaviour can result from a lack of pri-vacy (structural), modeling, inappropriate partner selection or courtship, lack of sexual knowledge or moral training, or a maladaptive learning history, or medical or medication effects (Hingsburger et al., 1991). Day (1994) identified two types of sexual offenders among those with developmental disabilities. They were (a) those who committed sex offences only, and (b) those who committed a range of offences, including those of a sexual nature. He ob-served that the latter group demonstrated a higher incidence of sociopathic personality disorder, brain damage, family dys-function, and other inappropriate behaviour. This group was less sexually naïve, and more specific and persistent in sexual offending. In contrast, those who committed only sexual of-fences were generally mildly disabled and without associated psychopathology, brain damage or generalized problem behav-iours. This latter group committed less serious offences and was less specific in choice of offence behaviour or victim. Of-fenders in this group were typically shy, lacking sexual knowl- edge or experience, and often were from sexually repressive environments (Day, 1997). In contrast to non-disabled offend-ers who target mostly females, offenders with developmental disabilities offend equally against males and females (Gilby et al., 1989; Griffiths, et al., 1989). In addition, offenders with developmental disabilities appear to have far fewer victims. The presence of various biomedical, psychological and socio-environmental variables that are more likely to be present in the lives of persons with developmental disabilities, can create increased risk for the development of sexually offending or in-appropriate behaviours (Griffiths, 2002). These variables are discussed in depth in Griffiths (2002); however, they are dis-cussed briefly below. Biomedical Factors: Neurological challenges and mental illness are more often wit-nessed in the population of persons who commit sexually of-fensive or inappropriate behaviours; these conditions are more likely to coexist in persons with developmental disabilities (Nezu, Nezu, & Gill-Weiss, 1992). Persons with developmen-tal disabilities experience the same range of mental health challenges as persons without disabilities. As such, they are vulnerable to the same range of mental health challenges that may present as non-specific sexual symptoms (i.e., mania or obsessive compulsive disorder). Psychological Factors:
Psychological factors such as lack of attachment bonds, lack of prosocial inhibition, childhood sexual trauma, and deficits in skills and empathy, are risk factors for development and occur- Mental Health Needs of Persons with Developmental Disabilities rence of sexual challenges in the nondisabled population. Per-sons with developmental disabilities have been found to be as likely or more likely to experience these psychological vulner-abilities (Griffiths, 2002). Although the experience of abuse does not predict that an indi-vidual will commit a similar sexual crime, among persons with developmental disabilities who have engaged in sexually of-fensive behaviour, there is a high percentage of persons who have experienced childhood abuse (Griffiths, as cited in The Roeher Institute, 1988; Hingsburger, 1987). If early sexual abuse may condition some individuals to respond sexually to the presence of certain individuals, or when confronted with specific situations reminiscent of early experiences of abuse, then the increased sexual abuse may represent a risk for future sexual problems. Moreover, because persons with develop-mental disabilities are denied education, counselling or oppor-tunity to develop healthy sexual experiences to counter-condition the early abuse, they may be more likely to be influ-enced by that experience of abuse. For example, one man who had been abused repeatedly as a young boy within his family, then went on to abuse young boys when he became older be-cause was unaware that his behaviour was unacceptable. For the young man, age-inappropriate sexual contact was the only standard of conduct he had been taught. This man had neither cognitively nor experientially encountered any instruction or moral view contrary to his experience. Day (1997) suggested that the high rates of sexually inappro-priate behaviour attributed to persons with developmental dis-abilities reflect the generally repressive and restrictive attitudes toward the sexuality of persons with disabilities. Individuals with developmental disabilities may experience a differential
conditioning to sexuality. Persons with developmental disabili-
ties have often been punished for normal sexual behaviour.
The environments in which many persons with developmental
disabilities live may reverse the natural contingencies of rein-
forcement and punishment for sexual behaviour. Appropriate
and consenting sexual behaviours are often punished at the
same or greater rates than an inappropriate and perhaps non-
consenting sexual encounter.
Additionally, for many persons with developmental disabili-
ties, sexually inappropriate behaviour has failed to bring about
natural aversive consequences. Persons with developmental
disabilities may lack knowledge of the law, or the relevance of
the law to their sexual misbehaviour. If persons with develop-
mental disabilities are charged with sexually inappropriate be-
haviour, the charges are often dismissed and the person is
placed in settings other than correctional facilities. Thus, the
natural consequences are often not taught nor experienced.

Risk Assessment:
An important challenge for mental health professionals, charged with the assessment and treatment of people with de-velopmental delay, is the accurate assessment of risk of violent or sexual offences. Typical interviewing and testing proce-dures require adaptation and caution when used with this population (i.e., phallometric testing) (Murphy, Coleman, & Haynes, 1983). One of the most well established actuarial assessment instru-ments for the prediction of sex offences is the Sex Offender Risk Appraisal Guide (SORAG) (Quinsey, Harris, Rice, & Mental Health Needs of Persons with Developmental Disabilities Cormier, 1998). Recent research by Fedoroff, Smolewska,
Selhi, Ng, and Bradford (2001) demonstrated that persons with
developmental disabilities are more likely to score signifi-
cantly higher overall when compared to other offenders with
an equal number of victims. On two subscales, they rated sig-
nificantly higher on two scores when compared to a matched
sample of nondisabled offenders. The subscales were related
to marriage and living with natural parents up to age 16. Fe-
doroff et al. (2001) suggest it is likely that the factors that may
contribute to a man being unable to establish a romantic rela-
tionship, or to hold a job, have a different developmental path
for a man who has developmental delay than in a man without
cognitive handicaps. As we have stated before, the opportu-
nity for appropriate sociosexual interaction have been denied
in the population of persons with disabilities. Thus, the in-
creased risk may be the result of the life experience afforded
persons with disabilities in our society, such as limited options
for meaningful work, lack of opportunity to develop relation-
ships and marry, isolation from family and community.

Treatment Programmes:
In the early part of the century, sexual behaviour (appropriate
or inappropriate) resulted in castration or incarceration in seg-
regated facilities (Pringle, 1997). In the 1970’s, behavioural
control techniques were adopted to stop sexual behaviour such
as masturbation. Approaches included the use of time-out,
omission training, or punishments like response cost, over-
correction, or squirts of contingent lemon juice in the mouth
following this behaviour (Griffiths, Quinsey & Hingsburger,
1989). Informally, persons with developmental disabilities
were ridiculed, sanctioned or denied privileges.
In the early 1980’s, few programmes offered treatment for per-sons with developmental disabilities who demonstrated sexu-ally offensive behaviour (Coleman and Murphy, 1980). In the past two decades, however, an increasingly rich body of clini-cal literature on intervention programmes for sex offenders with developmental disabilities has emerged (Murphy et al., 1983; Griffiths, Hingsburger & Christian, 1985, Griffiths et al., 1989; Haaven, Little, & Petre-Miller, 1990; Lund, 1992; Ward et al., 1992). More recently, the treatment focus has shifted to-ward promotion of the development of adaptive sexual behav-iours (Griffiths, et al., 1989; Haaven, et al., 1990; Lindsay, et al., 1998; Nezu, Nezu & Dudeck, 1998; Ward et al, 1992). Based on a growing body of clinical experience, specialized treatment providers have reported that sex offenders with de-velopmental disabilities, particularly those individuals who were mild and moderately disabled, have been surprisingly re-sponsive to treatment (Lackey & Knopp, 1989). However, to date there is minimal empirical demonstration of the treatment effectiveness with this population (Griffiths, Watson, Lewis, & Stoner, in press). The recidivism rates for persons with developmental disabili-ties who commit sexual offences present contradictory data for persons in community and institutional settings. Demetral (1989, as cited in Nolley, Muccigrosso & Zigman, 1996) re-ported a recidivism rate of less than 2% within a community programme; Haaven et al. (1990) indicated a rate of recidivism of 23% for their population of institutionalized offenders. Nol-ley et al. (1996) suggested that treatment outcome in the com-munity is enhanced by the use of qualified facilitators, in-creased social opportunities for persons with developmental disabilities, the enlistment of natural support systems, and Mental Health Needs of Persons with Developmental Disabilities teaching about culturally acceptable ways of sexual expres-sion. Treatment strategies should involve: 1. Teaching and reinforcing alternative replacement behav- iours that will serve the same or similar function as the sexually aggressive behaviour by: • Providing an appropriate means for the individual to achieve the desired interaction and sensory state, which the person is now receiving through an inappropriate means, both acted out and in fantasy; Overcoming barriers to the development of appropriate socio-sexual outlets currently unavailable because of such vulnerabilities as a lack of social skills; and/or Providing an alternative and appropriate means for the individual to reduce, remove or alter the aversive inter-nal state the person is currently escaping through the sexually aggressive behaviour or fantasies. 2. Altering the maintaining consequences that have been sus- For many persons with developmental disabilities, this often means teaching the legal consequences of sexual aggression, and that as a citizen, they will be held re-sponsible for such behaviour, and Teaching individuals to use the naturally punitive con-sequences (legal, social and moral) of the behaviour, to inhibit sexual aggressive behaviour and/or fantasies through cognitive self-management methods such as covert sensitization or masturbatory reconditioning (Griffiths et al., 1989). 3. Judicious use of medication or hormonal therapy: Medication and hormonal therapy may be an important addition to treatment plans for individuals whose sex-ual interests pose a risk to themselves or others. Table 3 describes a lists of common medications used to treat sexual deviations. Apparent from the table, the poten-tial side-effects of the medications can be significant. When considering medication or hormonal therapy for the treatment of sexual problems in people with devel-opmental delay, the practice guidelines should be fol-lowed: Box 1: Practice Guidelines for Medications or Hormonal
Therapy for Sexual Offending Behaviour
(i) Medication or hormonal therapy should only be pre-scribed to patients who understand the risk and benefits of treatment with these medications, and who are able to give voluntary consent. (ii) Medication or hormonal therapy should be used as part of a comprehensive treatment plan which includes healthy sex education and psychotherapy. (iii) Medication or hormonal therapy should only be pre-scribed in cases in which their efficacy can be monitored (e.g., there is no point in prescribing medication or hormo-nal therapy to a person with sexual interests in children if that person has no contact with children, and is not other-wise distressed by their interests in children (paedophilia). (iv) Medication or hormonal therapy should only be pre-scribed by physicians who are able to assess their efficacy Mental Health Needs of Persons with Developmental Disabilities and diagnose medical contraindications to their use. (v) Other treatment options should always be considered. Table 3– Class of Medications for Sexually Inappropriate

Behaviour
How they work
Effects and side-effects
Medication
Antiandrogens
Decrease testosterone Decrease sex drive Decrease fertility Glucose intolerance Increase risk of thromboembolic disorders Alter liver function Glucose intolerance Increase risk of thromboembolic disorders Alter liver function
Summary

There is a complex interplay of biomedical, social and psycho-
logical factors, related to the experience of being a sexual per-son with a developmental disability in our society. A) Although sexuality is considered an important factor in mental health and wellness (World Health Organization, 1975), the sexuality of persons with developmental dis-abilities is often negatively affected because of the follow-ing: a) denial of opportunity to enjoy and control sexual and reproductive behaviour in accordance with social and personal ethics; b) the experience of fear, shame, guilt, false beliefs, and other psychological factors that inhibit sexual response and the establishment of sexual relationships; and c) the co-existence of organic disorders, diseases, and defi- ciencies that interfere with sexual and reproductive functions. B) Persons with developmental disabilities are more likely to be sexually abused, and to have their sexual expression re-pressed and punished. They are also less likely to receive treatment for their sexual abuse experiences. These abusive and repressive experiences represent serious behavioural and mental health risks for persons with developmental disabilities. C) The statistics show that individuals with developmental disabilities are more likely to engage in sexually inappro-priate behaviour as a result of conditioning, and are more likely to be involved in less serious sexual crimes, because they will likely get caught, confess, and not negotiate a plea bargain, or gain appropriate defence. Moreover, they are less likely to receive appropriate treatment for their challenging sexual behaviour. Mental Health Needs of Persons with Developmental Disabilities The sexuality of persons with developmental disabilities poses
significant mental health risks, not because of the disability,
but because of the societal response to the sexuality of those
who are labelled in our society. The World Health Organiza-
tion has proclaimed that we are all sexual beings, and that in-
cludes those with a disability. Failure to recognize this reality
poses a great threat to the mental health integrity of individual
with disabilities.
Resources
Sexuality and Persons with Developmental Disabilities
Fegan, L., Rauch, A., & McCarthy, W. (1993). Sexuality and
people with intellectual disability (2nd ed.). Baltimore, MD: Paul H. Brookes. Monet-Haller, R.K. (1992). Understanding and expressing sexuality: Responsible choices for individuals with devel-opmental disabilities. Baltimore, MD: Paul H. Brookes. Rowe, W., & Savage, S. (1987). Sexuality and the develop- mentally handicapped. Queenston, Ont.: Queenston, On-tario. (out of print)
Socio-sexual Education
Cowardin, N. & Stanfield J. (1986). Life facts I: Sexuality and
life facts II: Sexual abuse. Santa Monica, CA: Stanfield Publishing Kempton, W. (1988). Life Horizons I and II. Santa Barbara, Kempton, W. (1993). Sexuality and persons with disabilities that hinder learning: A comprehensive guide for teachers and professionals. Santa Barbara, CA.: James Stanfield Publishing. Watson, S., Griffiths, D., Richards, D., & Dykstra, L. (2002). Sex education for persons with developmental disabilities. In D. Griffiths, D. Richards, P. Fedoroff, & S. Watson (Eds). Ethical dilemmas: Sexuality and developmental dis-ability (pp. 175-225). Kingston, NY: NADD Do You Know?
1. What are some of the key mental health risks that face people with developmental disabilities regarding their sexuality? 2. Why are people with developmental disabilities over- represented in correctional facilities regarding sexual crimes? 3. What factors could contribute to the development of sex- ual problems in persons with developmental disabilities? 4. Can individuals with developmental disabilities benefit from sex offender treatment programmes? What should be the focus of treatment? Sociosexual Assessment
Wish, J.R., McCombs, K.F., & Edmonson, B. (1979). The
socio-sexual knowledge and attitude test. Wooddale, IL: Stoelting.
Relationship Training
Champagne, M.P. & Walker-Hirsch, L. (1993). Circles: Inti-
macy and relationships. Santa Barbara, CA: James Stanfield Publishing.
Sexual Abuse
G. Allan Roeher Institute (1988). Vulnerable. Toronto, Ont.:
Mental Health Needs of Persons with Developmental Disabilities Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities. Baltimore, MD: Paul H. Brookes.
Sexual Policies
Griffiths, D., Owen, F., Lindenbaum, L. & Arbus, K. (2002).
Sexual policies in agencies supporting persons who have developmental disabilities, Part II: Practical Issues and Procedures. In D.Griffiths, P. Fedoroff, D., Richards, & S. Watson (Eds.), Ethical dilemmas: Sexuality and develop-mental disability (pp. 77-132). Kingston, NY: NADD. Owen, F., Griffiths, D. & Arbus, K. (2002). Sexual policies in agencies supporting persons who have developmental dis-abilities, Part I: Ethical and Organizational Issues. In D. Griffiths, P. Fedoroff, D. Richards, & S. Watson (Eds.), Ethical dilemmas: Sexuality and developmental disability (pp. 53-76). Kingston, NY: NADD. Sexually Inappropriate Behaviour
Griffiths, D. (2002). Sexual aggression and persons with de-
velopmental disabilities. In W.I. Gardner (Ed.), Aggression in persons with developmental disabilities: Biomedical and psychosocial considerations in diagnosis and treatment (pp. 326-397). New York: National Association for Dual Diagnosis. Griffiths, D., Quinsey, V.L., & Hingsburger, D. (1989). Changing inappropriate sexual behavior. Baltimore, MD.: Paul H. Brookes. (out of print) Haaven, J., Little, R., Petre-Miller, D. (1990). Treating intel- lectually disabled sex offenders. Orwell, VT: Safer Soci-ety. Hingsburger, D., Griffiths, D., & Quinsey, V. (1991). Detect- ing counterfeit deviance. The Habilitative Mental Health- Ward, K.M., Heffern, S.J., Wilcox, D., McElwee, D., Dow- rick, P., Brown. T.D., Jones, M.J., & Johnson, C.L., (1992). Managing inappropriate sexual behavior: Support-ing individuals with developmental disabilities in the com-munity. Anchorage, Alaska: Alaska Specialized Education and Training Services.
Reading for Parents
Schwier, K. M. & Hingsgburger, D. (2000). Sexuality: Your
sons and daughters with intellectual disabilities. Balti-more, MD: Brookes Publishing. Hingsburger, D. (1993). I openers. Parents ask questions about sexuality and children with developmental disabili-ties. Vancouver, BC: Family Supports Institute Press. Social Skills
Griffiths, D. (1990). Teaching social competency: Part 1 Prac-
tical guidelines. Habilitative Mental Health Care Newslet-ter, 9(1), 1-5. Griffiths, D. (1990). Teaching social competency: Part 2 The Social Life Game. Habilitative Mental Health Care News-letter, 9(2), 9-13. Valenti- Hein, D. (1990) The dating skills program for adults with mental retardation. The Habilitative Mental Health-Care Newsletter, 9(6), 47-50. York Behaviour Management Services (1979). Social Life
Sociosexual Resources:
Canadian Guidelines for Sexual Health Education www.hc-sc-gc.
Mental Health Needs of Persons with Developmental Disabilities National Clearninghouse on Family Violence SIECCAN (Sex Information and Education Council of Can- SIECUS (Sex Information and Education Council of the US) Safer Society www.safersociety.org Sexual Health Network: Sexuality and Disability or Illness In- formation Help Therapy www.sexualhealth.com References

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