Download Sexual Offending Behavior in Adults with Developmental Disabilities

January 2014 Training
Sexual Offending Behavior and HIPAA
**Please read through all of the training material and then complete the quiz located on the Staff Training page of the
website. The quiz must be completed during the month of May.
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Sexual Disorders: Paraphilias
Sexual Offending Behavior in Adults with Developmental Disabilities
HIPAA- Confidentiality of Private Records
Sexual Disorders
Paraphilias are a group of sexual disorders defined in the DSM-IV-TR as:
 intense, recurring sexual fantasies, sexual urges or behaviors
that involve
 non-human objects, children or non-consenting adults, suffering or humiliation (to self or to others)
Two additional criteria from the DSM-IV are used in the diagnosis of a paraphilia:
 The behavior has lasted at least 6 months
 It causes clinically significant distress or impairment in social, occupational or other important areas of life.
In addition, these objects, activities, or situations are often necessary for the person's sexual functioning. With a
paraphilia, the individual's urges and behaviors cause significant distress and/or personal, social, or career problems.
Such behaviors may have serious social and legal consequences.
NOTE: The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) is a manual published by the American
Psychiatric Association (APA) that includes all currently recognized mental health disorders. The DSM-IV codes are thus
used by mental health professionals to describe the features of a given mental disorders and indicate how the disorder
can be distinguished from other, similar problems.
What Behaviors Are Considered Paraphilias?
Exhibitionism ("Flashing")
Exhibitionism is characterized by intense, sexually arousing fantasies, urges, or behaviors involving exposure of the
individual's genitals to an unsuspecting stranger. The individual with this problem may feel a need to surprise, shock, or
impress his victims. The condition usually is limited to the exposure, with no other harmful advances made, although
"indecent exposure" is illegal. Actual sexual contact with the victim is rare. However, the person may masturbate while
exposing himself or while fantasizing about exposing himself.
Fetishism
People with fetishes have sexual urges associated with non-living objects. The person becomes sexually aroused by
wearing or touching the object. For example, the object of a fetish could be an article of clothing, such as underwear,
rubber clothing, women's shoes, women's underwear, or lingerie. The fetish may replace sexual activity with a partner
or may be integrated into sexual activity with a willing partner. When the fetish becomes the sole object of sexual
desire, sexual relationships often are avoided.
Frotteurism
With this problem, the focus of the person's sexual urges is related to touching or rubbing his genitals against the body
of a non-consenting, unfamiliar person. In most cases of frotteurism, a male rubs his genital area against a female, often
in a crowded public location. This disorder also is a problem because the contact made with the other person is illegal.
Pedophilia
Pedophilia, one of the more common paraphilias, is a psychosexual disorder in which the fantasy or actual act of
engaging in sexual activity with children is the preferred or exclusive means of achieving sexual excitement and
gratification. People with pedophilia have fantasies, urges, or behaviors that involve illegal sexual activity with a
prepubescent child or children (generally age 13 years or younger). Some pedophiles are sexually attracted to children
only (exclusive pedophiles) and are not attracted to adults at all. Some pedophiles limit their activity to their own
children or close relatives (incest), while others victimize other children. The frequency of behavior associated with
pedophilia may vary with psychosocial stress. As the individual’s stress levels increase, the frequency of his or her acting
out generally increases. One difficulty with diagnosing pedophilia is that individuals rarely seek help voluntarily from
mental health professionals. Instead, counseling and treatment is often the result of a court order.
Most experts regard pedophilia as resulting from psychosocial factors rather than biological characteristics. Some think
that pedophilia is the result of having been sexually abused as a child. Others think that it derives from the person’s
interactions with parents during their early years of life. Some researchers attribute pedophilia to arrested emotional
development; that is, the individual is attracted to children because he or she has never matured psychologically. Some
regard pedophilia as the result of a distorted need to dominate a sexual partner.
Voyeurism ("Peeping Tom")
This disorder involves achieving sexual arousal by observing an unsuspecting and non-consenting person who is
undressing or unclothed, and/or engaged in sexual activity. This behavior may conclude with masturbation by the
voyeur. The voyeur does not seek sexual contact with the person they are observing.
How Common Are Paraphilias?
Most paraphilias are rare and are more common among males than among females (about 20 to 1 of males to females).
The reason for this disparity is not clearly understood; however, some researches attribute paraphilias being more
common in men to biology. They hold that testosterone, one of the male sex hormones, predisposes men to develop
deviant sexual behaviors. While several of these disorders are associated with aggressive behavior, others are not
aggressive or harmful. Some paraphilias -- such as pedophilia, exhibitionism, voyeurism, sadism, and frotteurism -- are
criminal offenses. Pedophilia, voyeurism, and exhibitionism are the three paraphilias most commonly leading to arrest
by the police.
What Causes Paraphilia?
It is not known for certain what causes paraphilia. Most experts regard paraphilias as resulting from psychosocial factors
rather than biological characteristics. Some experts believe it is caused by a childhood trauma, such as sexual abuse.
Others suggest that objects or situations can become sexually arousing if they are frequently and repeatedly associated
with a pleasurable sexual activity. In most cases, the individual with a paraphilia has difficulty developing personal and
sexual relationships with others.
Many paraphilias begin during adolescence and continue into adulthood. The intensity and occurrence of the fantasies
associated with paraphilia vary with the individual, but usually decrease as the person ages.
How Is Paraphilia Treated?
Most cases of paraphilia are treated with counseling and therapy to help these people modify their behavior.
Medications may help to decrease the compulsiveness associated with paraphilia and reduce the number of deviant
sexual fantasies and behaviors. In some cases, hormones are prescribed for individuals who experience frequent
occurrences of abnormal or dangerous sexual behavior. Many of these medications work by reducing the individual's sex
drive.
The three classes of medications most often used to treat paraphilias are: female hormones, particularly
medroxyprogesterone acetate, or MPA; luteinizing hormone-releasing hormone (LHRH) agonists, which include such
drugs as triptorelin (Trelstar), leuprolide acetate, and goserelin acetate; and anti-androgens, which block the uptake and
metabolism of testosterone as well as reducing blood levels of this hormone. The anti-androgens in particular have been
shown to be effective in reducing the rate of recidivism.
How Successful Is Treatment for Paraphilia?
To be most effective, treatment for paraphilia must be provided on a long-term basis. Unwillingness to comply with
treatment can hinder its success. It is imperative that people with paraphilias of an illegal nature receive professional
help before they harm others or create legal problems for themselves.
Information adapted from WedMD and Encyclopedia of Mental Health Disorders
Sexual Offending Behavior in Adults with Developmental Disabilities
Introduction
There are a number of reason adults with developmental disabilities commit sexual offenses against others.
There are a variety of offenses they may commit. Sexually inappropriate behavior may include such things as
sexual comments, revealing one’s genitals, sexually touching other people, sexual assault, and rape. Sexual
offenses may be committed against children, adolescents, adults, or disabled peers. Either males or females
may be victims of sexual offenses. Non-disabled adults who commit sexual offenses often do so in an attempt
to gain power or control over their victims. This is less likely to be true of adolescents or developmentally
disabled adults. In many cases, sexually inappropriate behavior appears to be the result of an inappropriate
attempt to meet a need for love and affection rather than the result of a malicious attempt to harm the other
person.
Many people who commit sexual offenses have been traumatized in the past. They may have been sexually
abused themselves. They may have experienced isolation, lack of intimacy, difficulty forming attachments,
feelings of inadequacy, errors in thinking or judgement, or modeling of sexually inappropriate behavior by
others. People with developmental disabilities may experience isolation, difficulty with relationships, and
problems with thinking as a result of their disabling conditions. If they have also been sexually abused
themselves, or witnessed inappropriate sexual behavior by others, they may be even more likely to commit
sexual offenses themselves.
Cycle of Abuse
1. Trigger
Typically, some current event or experience acts as a trigger that begins the cycle. Sometimes the
trigger is something that reminds the person of a negative experience in the past. The triggering
experience may cause the person to feel angry, sad, helpless, powerless, afraid, or humiliated. The cycle
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of abuse can be interrupted at this point by encouraging the person to focus on more positive
experiences or beliefs or by helping the person to find a healthy outlet for the unpleasant feelings.
Dysfunctional Response
The person responds to the feelings generated by the triggering experience in a dysfunctional or
unhealthy manner. He may dwell on the negative experience or on the unpleasant feelings. He may
focus on feelings of victimization or experiences of being victimized. He may anticipate rejection,
failure, or mistreatment. He may isolate himself from others. The cycle may be perpetuated by
negative self-talk or redirected by positive self-talk. Other people can help by encouraging the person to
stop and think, to talk about the negative feelings or beliefs, and to choose to move in a more positive
direction.
Anger/Power/Control
The individual attempts to relieve the feelings of victimization, helplessness, or injustice, and to regain a
sense of power and control using blame, manipulation, or anger. The person may argue with others,
pick fights, or engage in power struggles. He may try to control or manipulate others. He may ignore or
resist offers of assistance. The individual may tell himself, “I can do whatever I want.” He may believe,
“He/she/it made me feel/think/act this way.” It may be possible to redirect the person by reminding
him of how his attitudes and actions impact those around him. Activities that help the person to stop
and think or calm down may be helpful.
Fantasies/Planning
The person may engage in fantasies about sexual activity. He may consider ways to act on his fantasies.
He may begin looking for a potential victim or even choose a victim. Faulty self-talk that may
perpetuate the cycle includes “I can’t help myself” or “I’m not really going to do it”. Techniques that
may be useful in disrupting the cycle include providing increased supervision, encouraging the person to
record fantasies so they can be discussed in treatment, and helping the person the choose “safe”
activities, outlets, or forms or expression.
Preparatory Behavior (Antecedent Behavior)
The person begins finding ways to be around a potential victim. He may take steps to set up or “groom”
a potential victim. He may begin planning a time and/or place to act on his fantasies. He may tell
himself, “I’m in control”; “they want it”; or “they deserve this”.
Sexual Offense
Eventually, the individual acts on his fantasies and plans. He may begin with non-sexual contact with his
chosen victim, or with minimally sexual contact. Success in any encounter often leads to an increased
level of contact. The individual may believe, “I can’t help it.” He may convince himself, “He/she wants
me to do it.”
Aftereffects
After the offense has been committed, the person usually experiences a period of relief from the
tension, anxiety, and negative emotions that triggered or perpetuated the cycle. Within a short time,
the person may begin to feel anxious about the consequences of his actions. He may take steps to
minimize the risk of getting caught. He may blame or threaten the victim. He may experience transitory
feelings of guilt. He may believe, “I can’t tell anyone” or “I’ve got to hide this”.
Reframing
Finally, the individual resolves the fear or guilt associated with his inappropriate behavior. He may
apologize profusely. He may rationalize or excuse his behavior. He may reassure himself – and
sometimes others – “I’ll never do it again”; “that was the last time”; or “I’ve learned my lesson”.
Treatment Strategies
Treatment programs for sexual offenders with developmental disabilities vary widely. The goal is to assist the
person to prevent a repeat of their sexual offending behavior. Some of the techniques that are commonly used
include:
 Identifying and reporting fantasies
 Recognizing the offense cycle
 Developing healthy self-esteem
 Learning anger management techniques
 Learning appropriate social or relationship skills
 Developing a safety plan
 Developing a relapse prevention plan
Relapse Prevention
Preventing recurrence of sexual offending behavior involves both managing behavior and cognitive training or
teaching new ways of thinking.
Behavior management may involve:
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intensive supervision
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teaching appropriate boundaries
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enforcing boundaries
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providing specific consequences for
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teaching more appropriate behaviors or
skills
specific behavior
Assisting Clients with Relapse Prevention
Staff can assist clients with relapse prevention in a number of ways. One of the most important things staff can
do to prevent recurrence of sexual offending behavior is to provide the appropriate level of supervision at all
times.
Staff can also help by assisting with safety planning. If a formal safety plan is part of an individual’s treatment
program, it is essential that any staff member who works with that individual be familiar with the plan and how
it is to be utilized.
Staff needs to be aware of which people are likely to be seen as potential victims. Potential victims may be
chosen because of their age, size, gender, race, mental capacity, or degree of vulnerability. The two most
important factors in the choice of a victim are availability and vulnerability.
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Staff should be aware of what kinds of situations or experiences serve as triggers or red flags for the individual.
Examples may include:
seeing or being around certain people (i.e. children, women, specific individuals)
being in certain places (i.e. playgrounds, locker rooms, bedrooms, bathrooms)
experiencing certain feelings (i.e. sad, angry, scared, hopeless)
having certain thoughts (i.e. “It doesn’t matter what happens; it’s worth the risk”)
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engaging in certain behaviors (i.e. staring at potential victims, masturbating while thinking about potential victims)
being in certain circumstances (i.e. being alone with potential victims)
Staff can also help by encouraging the person to talk about what they are thinking, feeling, or experiencing. Doing this
may make it easier to notice triggering events or faulty thinking the person may be experiencing. Staff can then
encourage the person to choose healthy ways of responding to stressors or can redirect faulty thinking into more
appropriate directions.
HIPAA – Confidentiality of Client Records
Definitions
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HIPAA -Health Insurance Portability and Accountability Act; a federal law regulating confidentiality of patient
and client records.
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HIPAA is a federal law. Each state also has laws regarding privacy.
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If there is a conflict between state and federal privacy laws, the law that applies is whichever provides the
greater protection to the client.
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Individual - a patient or client; a person who receives services from Zumbro House.
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Individual Record Set - information Zumbro House maintains on a client, which the client is entitled to see,
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HIPAA Compliance Officer - person who is responsible to answer questions about HIPAA privacy compliance
issues and to handle concerns or complaints about the company's HIPAA policies.
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Zumbro House's HIPAA Compliance Officer is Christopher Onken.
Confidentiality Policy
Information concerning Zumbro House clients is confidential. It may not be disclosed to anyone unless:
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The client or his legal representative has signed a valid, current release of information form.
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There is a specifically listed exception that allows disclosure without a release. (See Zumbro House's HIPAA
Policy Manual.)
Individual Record Set
Includes such things as:
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Progress notes
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Risk management plans
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Medication administration records
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Behavioral data records
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Treatment records from other providers
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Records used to make decisions about a client
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Admission and/or discharge information
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Records from which the Individual can be
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Billing and payment information
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Treatment records
identified.
Does not include such things as:
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Shift communication logs
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Psychotherapy notes prepared by a psychotherapist
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Internal investigation information
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Employee personnel records
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Information compiled in reasonable anticipation of a civil, criminal, or administrative judicial proceeding
If you are unsure whether or not specific information is included in the Individual Record Set, contact your supervisor or
the Zumbro House HIPAA Compliance Officer.
Ongoing Privacy and Security
Staff must monitor access to Individual information on an ongoing basis. This includes:
Paper records:
• Must be created, maintained, and stored in a physical location that assures other clients, unauthorized staff, or
visitors do not have access.
• This includes information in/on printers, copiers, fax machines, etc. as well as information in folders, binders, or
files.
Electronic records:
• All electronic records, including those created or used in an employee's home, must be created, used, and stored,
in a way that assures other clients, unauthorized staff, or visitors do not have access. This may involve the use
of a secure physical location, passwords, encryption, etc.
• Information must not be shared by e-mail unless the client (or his legal representative) has given written consent
to use e-mail for this purpose.
Verbal Communications:
• All verbal communications regarding clients must be conducted in a way that assures other clients, unauthorized
staff, or visitors do not overhear.
Disclosing Individual Information
Whenever information is disclosed, staff must ensure that the minimum necessary information is disclosed.
Information may be shared with current Zumbro House staff as necessary for care or treatment.
Information may not be shared with staff who have no need to know (i.e. staff from another house)
When staff respond to a request for information, they must review the type of information requested and the date of
the information requested and disclose only the minimum information necessary to respond to the request.
Zumbro House must verify the identity and authority of any person requesting Individual Information.
• Request a copy of the authorization
- Signed release of information form
- Court document
- Document appointing the person as a legal representative for the client
• Request Identification
- Driver's license
-State-issued ID card
- Government letterhead
• Copy verification information and place in client's file
Disclosing Individual Information without a Release
Under certain limited circumstances, information may be disclosed without a release from the client. These include:
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To report abuse or neglect of a child or
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In response to a court order
vulnerable adult
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For health oversight activities
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For certain law enforcement purposes
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Government audit
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To identify or locate a missing person
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Certification inspection
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To report a crime
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Licensure
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For grand jury proceedings
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Others as identified in Zumbro House's HIPAA
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To avert a serious threat to health or safety
Policy Manual
Client Rights
Inspect and Copy Records
• Individual must submit a written request.
• Zumbro House must respond within 30 days.
• Permission may be denied if there is a medical or program reason, as determined by a licensed professional.
• A copy of the written request must be retained in the client's file.
Request an Amendment to Records
• Individual must submit a written request.
• The request must include the reason for the request.
• Zumbro House must respond within 30 days by:
-Amending the Individual Record Set
-Denying the request and providing a written explanation of the reason for the denial
- Requesting a 30 day extension if it is not possible to comply within 30 days
Accounting of Disclosures
• Zumbro House must keep a record of all disclosures of Individual Information.
• An Individual may request a list of disclosures for the last six years, beginning April 13, 2003.
• Zumbro House must keep a record of Accountings.
Request Restricted Use
• Individual must submit a written request, including:
-Whether request is to restrict use, restrict disclosure, or both
- What information is to be restricted
- To whom the restriction is to apply
• Zumbro House will either grant or deny the request and document both the request and the response in the
client's record.
• If the request is granted, Zumbro House will abide by the request except to provide emergency treatment.
Complaints
Zumbro House clients, their legal representatives, or Zumbro House employees may initiate a complaint.
Complaints may be in regard to Zumbro House's HIPAA policies, Zumbro House's compliance with its HIPAA policies and
procedures, or Zumbro House's compliance with HIPAA regulations.
Complaints may be made in person, by phone, by e-mail, or in writing by contacting:
Christopher Onken
1103 Weir Drive Suite 100
Woodbury, MN 55125
651-264-1000
[email protected]
Zumbro House will not retaliate against anyone who initiates a complaint or participates in an investigation into such a
complaint.
Zumbro House will keep a record of all HIPAA complaints and how they are resolved.
Okay – go ahead and complete your quiz! Take your time and refer back to this training material if needed.