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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. 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 2. 3. 4. 5. 6. 7. 8. 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: intensive supervision teaching appropriate boundaries enforcing boundaries providing specific consequences for 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. 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”) 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 HIPAA -Health Insurance Portability and Accountability Act; a federal law regulating confidentiality of patient and client records. HIPAA is a federal law. Each state also has laws regarding privacy. If there is a conflict between state and federal privacy laws, the law that applies is whichever provides the greater protection to the client. Individual - a patient or client; a person who receives services from Zumbro House. Individual Record Set - information Zumbro House maintains on a client, which the client is entitled to see, 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. 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: The client or his legal representative has signed a valid, current release of information form. 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: Progress notes Risk management plans Medication administration records Behavioral data records Treatment records from other providers Records used to make decisions about a client Admission and/or discharge information Records from which the Individual can be Billing and payment information Treatment records identified. Does not include such things as: Shift communication logs Psychotherapy notes prepared by a psychotherapist Internal investigation information Employee personnel records 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: To report abuse or neglect of a child or In response to a court order vulnerable adult For health oversight activities For certain law enforcement purposes Government audit To identify or locate a missing person Certification inspection To report a crime Licensure For grand jury proceedings Others as identified in Zumbro House's HIPAA 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.