Skip to main content

Remediating Serious Inappropriate Sexual Behavior in a Male with Severe Acquired Brain Injury

Abstract

Inappropriate sexual behaviors such as sexual talk, non-genital and genital touching (non-consensual), exhibitionism and coercive sexual behavior are consistently reported sequelae of severe Acquired Brain Injury (ABI). A single-case experimental design was employed to evaluate the relative effectiveness of environmental controls and facilitated access to a sex worker in the management of inappropriate sexual behavior displayed by a male with ABI. Environmental controls comprised behavioral strategies commonly employed to manage disinhibited behavior secondary to ABI such as redirection, cueing appropriate behavior, and verbal feedback. An additional component, facilitated visits to a sex worker, provided a comparison treatment. The introduction of a sex worker contributed to the reduction and eventual extinction of inappropriate behaviors. Improvements were maintained at follow-up probes 1 and 2 years later. The social validity of the intervention is evaluated, and the legal, safety and ethical issues raised by facilitating access to a sex worker are carefully addressed.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    Australian Institute of Health and Welfare: Disability in Australia: acquired brain injury. Bulletin no. 55. Cat no. AUS 96. AIHW, Canberra (2007)

  2. 2.

    Aloni, R., Katz, S.: Sexuality difficulties after traumatic brain injury and ways to deal with it. Charles C Thomas Pub, Springfield, Illinois (2003)

    Google Scholar 

  3. 3.

    Aloni, R., Keren, O., Katz, S.: Sex therapy surrogate partners for individuals with very limited functional ability following traumatic brain injury. Sex. Disabil. 25, 125–134 (2007)

    Article  Google Scholar 

  4. 4.

    Kreutzer, J.S., Zasler, N.D.: Psychosexual consequences of traumatic brain injury: methodology and preliminary findings. Brain Inj. 3, 177–186 (1989)

    PubMed  Article  Google Scholar 

  5. 5.

    Ponsford, J.: Sexual changes associated with traumatic brain injury. Neuropsychol. Rehabil. 13, 275–289 (2003)

    PubMed  Article  Google Scholar 

  6. 6.

    Simpson, G., Blaszczynski, A., Hodgkinson, A.: Sex offending as a psychosocial sequela of traumatic brain injury. J. Head Trauma Rehabil. 14, 567–580 (1999)

    PubMed  Article  Google Scholar 

  7. 7.

    Johnson, C., Knight, C., Alderman, N.: Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment. Brain Inj. 20, 687–693 (2006)

    PubMed  Article  Google Scholar 

  8. 8.

    Simpson, G., Tate, R., Ferry, K., Hodgkinson, A., Blaszczynski, A.: Social, neuroradiologic, medical, and neuropsychologic correlates of sexually aberrant behavior after traumatic brain injury: a controlled study. J. Head Trauma Rehabil. 16, 556–572 (2001)

    PubMed  Article  Google Scholar 

  9. 9.

    Kelly, G., Brown, S., Todd, J., Kremer, P.: Challenging behaviour profiles of people with acquired brain injury living in community settings. Brain Inj. 22, 457–470 (2008)

    PubMed  Article  Google Scholar 

  10. 10.

    Wood, R.L., McMillan, T.M.: Neurobehavioural disability and social handicap following traumatic brain injury. Psychology Press, Hove, East Sussex (2001)

    Google Scholar 

  11. 11.

    Emory, L.E., Cole, C.M., Meyer, W.J.: Use of depo-provera to contral sexual aggression in persons with traumatic brain injury. J. Head Trauma Rehabil. 10, 47–58 (1995)

    Google Scholar 

  12. 12.

    Guercio, J.M., McMorrow, M.J.: Proactive protocols for severe unwanted behavior after acquired brain injury. Case Manager 13, 55–58 (2002)

    PubMed  Article  Google Scholar 

  13. 13.

    Schlund, M.W., Pace, G.: Relations between traumatic brain injury and the environment: feedback reduces maladaptive behaviour exhibited by three persons with traumatic brain injury. Brain Inj. 13, 889–897 (1999)

    PubMed  Article  Google Scholar 

  14. 14.

    Wesolowski, M.D., Zencius, A., Burke, W.H.: Effects of feedback and behavior contracting on head trauma persons’ inappropriate sexual behavior. Behav. Resid. Treat. 8, 89–96 (1993)

    Google Scholar 

  15. 15.

    Zencius, A., Wesolowski, M.D., Burke, W.H., Hough, S.: Managing hypersexual disorders in brain-injured clients. Brain Inj. 4, 175–181 (1990)

    PubMed  Article  Google Scholar 

  16. 16.

    McMillan, T.M., Papadopoulos, H., Cornall, C., Greenwood, R.J.: Modification of severe behaviour problems following herpes simplex encephalitis. Brain Inj. 4, 399–406 (1990)

    PubMed  Article  Google Scholar 

  17. 17.

    Turner, J.M., Green, G., Braunling-McMorrow, D.: Differential reinforcement of low rates of responding (DRL) to reduce dysfunctional social behaviors of a head injured man. Behav. Resid. Treat. 5, 15–27 (1990)

    Google Scholar 

  18. 18.

    Tarnai, B.: Review of effective interventions for socially inappropriate masturbation in persons with cognitive disabilities. Sex. Disabil. 24, 151–168 (2006)

    Article  Google Scholar 

  19. 19.

    Kelly, G., Parry, A.: Managing challenging behaviour of people with acquired brain injury in community settings: the first 7 years of a specialist clinical service. Brain Imp. 9, 293–304 (2008)

    Article  Google Scholar 

  20. 20.

    Todd, J., Loewy, J., Kelly, G., Simpson, G.: Managing challenging behaviours: getting interventions to work in nonspecialised community settings. Brain Imp. 5, 42–52 (2004)

    Article  Google Scholar 

  21. 21.

    Ylvisaker, M., Turkstra, L., Coehlo, C., Yorkston, K., Kennedy, M., Sohlberg, M.M., et al.: Behavioural interventions for children and adults with behaviour disorders after TBI: a systematic review of the evidence. Brain Inj. 21, 769–805 (2007)

    PubMed  Article  Google Scholar 

  22. 22.

    Horn, L.J., Zasler, N.D.: Neuroanatomy and neurophysiology of sexual function. J. Head Trauma Rehabil. 5, 1–13 (1990)

    Article  Google Scholar 

  23. 23.

    Earle, S.: Disability, facilitated sex and the role of the nurse. J. Adv. Nurs. 36, 433–440 (2001)

    PubMed  Article  Google Scholar 

  24. 24.

    Earle, S.: Facilitated sex and the concept of sexual need: disabled students and their personal assistants. Disabil. Soc. 14, 309–323 (1999)

    Article  Google Scholar 

  25. 25.

    Browne, J., Russell, S.: My home, your workplace: people with physical disability negotiate their sexual health without crossing professional boundaries. Disabil. Soc. 20, 375–388 (2005)

    Article  Google Scholar 

  26. 26.

    Tepper, M.: Facilitated sex: the next frontier in sexuality? New Mob. 11, 21–24 (2000)

    Google Scholar 

  27. 27.

    Mona, L.R.: Sexual options for people with disabilities. Women Ther. 26, 211–221 (2003)

    Article  Google Scholar 

  28. 28.

    Prostitution Control Act: [On-line]. Available: http://www.legislation.vic.gov.au (1994)

  29. 29.

    Shildrick, M.: Contested pleasures: the sociopolitical economy of disability and sexuality. Sex Res. Soc. Policy 4, 53–66 (2007)

    Article  Google Scholar 

  30. 30.

    Consumer Affairs Victoria: Regulatory impact statement, prostitution control regulations (2006)

  31. 31.

    Simpson, G.K.: You and me. An education program about sex and sexuality after traumatic brain injury, 2nd edn. South Western Sydney Area Health Service, Sydney (2003)

    Google Scholar 

  32. 32.

    Touching Base: Client’s guide. [On-line]. Available: http://www.touchingbase.org/clients_guide.html (2007)

  33. 33.

    Everett, B.: Ethically managing sexual activity in long-term care. Sex. Disabil. 25, 21–27 (2007)

    Article  Google Scholar 

  34. 34.

    Hanson, S., Kerkhoff, T.: The implications of bioethical principles in traumatic brain injury rehabilitation. In: Ashley, M.J. (ed.) Traumatic brain injury. Rehabilitative treatment and case management, 2nd edn, pp. 685–726. CRC Press, Boca Raton, USA (2004)

    Google Scholar 

  35. 35.

    Sanders, T.: The politics of sexual citizenship: commercial sex and disability. Disabil. Soc. 22, 439–455 (2007)

    Article  Google Scholar 

  36. 36.

    Shuttleworth, R.: Introduction to special issue: critical research and policy debates in disability and sexuality studies. Sex Res. Soc. Policy 4, 1–14 (2007)

    Article  Google Scholar 

  37. 37.

    Sanders, T.: Female sex workers as health educators with men who buy sex: utilising narratives of rationalisations. Soc. Sci. Med. 62, 2434–2444 (2007)

    Article  Google Scholar 

  38. 38.

    Abramson, P.R., Parker, T., Weisberg, S.R.: Sexual expression of mentally retarded people: educational and legal implications. Am. J. Ment. Retard. 93, 328–334 (1988)

    PubMed  Google Scholar 

  39. 39.

    Kazdin, A.E.: Single-case research designs: methods for clinical and applied settings. Oxford University Press, New York (1982)

    Google Scholar 

  40. 40.

    Kelly, G., Todd, J., Simpson, G., Kremer, P., Martin, C.: The Overt Behaviour Scale (OBS): a tool for measuring challenging behaviours following ABI in community settings. Brain Inj. 20, 307–319 (2006)

    PubMed  Article  Google Scholar 

  41. 41.

    Alderman, N.: The treatment of avoidance behaviour following severe brain injury by satiation through negative practice. Brain Inj. 5, 77–86 (1991)

    PubMed  Article  Google Scholar 

  42. 42.

    Youngson, H.A., Alderman, N.: Fear of incontinence and its effects on a community-based rehabilitation programme after severe brain injury: successful remediation of escape behaviour using behaviour modification. Brain Inj. 8, 23–36 (1994)

    PubMed  Article  Google Scholar 

  43. 43.

    Wolf, M.M.: Social validity: the case for subjective measurement or how applied behavior analysis is finding its heart. J. Appl. Behav. Anal. 11, 203–214 (1978)

    PubMed  Article  Google Scholar 

  44. 44.

    Davies, D.: Sex and relationship facilitation project for people with disabilities. Sex. Disabil. 18, 187–194 (2000)

    Article  Google Scholar 

  45. 45.

    Comfort, A. (ed.): Sexual consequences of disability. George F. Stickley & Co., Philadelphia, USA (1978)

  46. 46.

    World Health Organization: HIV/AIDS sex work toolkit. [On-line]. Available: http://www.who.int/hiv/topics/vct/sw_toolkit/context/en/index.html (2011)

  47. 47.

    Lindsay, W.R., Marshall, I., Neilson, C., Quinn, K., Smith, A.H.: The treatment of men with a learning disability convicted of exhibitionism. Res. Dev. Disabil. 19, 295–316 (1998)

    PubMed  Article  Google Scholar 

Download references

Acknowledgments

Special thanks to the client’s support team for persisting under difficult circumstances. Thanks also to Dr. Lucius Arco and Jenny Todd for comments on an early version of the paper, and to Dr. Michael Perdices for advice with data analysis.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Glenn Kelly.

 

 

Appendix The Overt Behaviour Scale: item descriptions for the inappropriate sexual behaviour (SEX), verbal aggression (VA), and physical aggression against other people (PA people) subscales

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Kelly, G., Simpson, G. Remediating Serious Inappropriate Sexual Behavior in a Male with Severe Acquired Brain Injury. Sex Disabil 29, 313–327 (2011). https://doi.org/10.1007/s11195-011-9213-9

Download citation

Keywords

  • Acquired brain injury
  • Inappropriate sexual behavior
  • Facilitated sex
  • Aggression
  • Australia