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When problematic sexual concerns plague your teen.

By Stephen C. Schultz

My hope is that this information can be helpful to parents, allied health professionals, educational consultants and clinicians.

I have been asked numerous times; “How do we know when Oxbow Academy is appropriate for a student?” and the next question is inevitably “How do we discuss these issues with families?” Please feel free to use this document as a resource and foundation for discussion with families as well as colleagues.

I recently had the opportunity to speak with an educational consultant. He called to see if there was anyway we could figure out a way to admit a 19 year old to Oxbow. He went on to share with me that this boy was adopted, had some LD issues and was functioning emotionally on a 15 year old level. The current residential treatment facility, where this young man was receiving treatment, was in a cycle of “cops and robbers” with this boy because of his sneaky and manipulative sexualized behavior. This particular educational consultant was brought into the situation to try and salvage this very clinically complicated case. This students sexually acting out had progressed to a point where the treatment program felt the boy had received maximum benefit from them and he needed to be moved to a more intense level of care. Unfortunately, Oxbow Academy cannot admit a student that is 19 years old.

The educational consultant mentioned that in the beginning, prior to his involvement, the parents were hesitant to address the sexual issues head on. The treatment center that the boy was admitted to claimed they dealt with these types of issues. The educational consultant expressed sadness in the outcome of this case and mentioned that he would be willing to use this example as a learning experience for others. It is true, parents and educational consultants don’t always know the seriousness of the sexual issues when they start looking into treatment. However, upon the first signs of sexual issues, serious notice should be taken.

What we have noticed is that referring treatment centers often have an unofficial policy of “three strikes”. This means that the first time there is an incident; the program will provide additional structure, hoping the behavior will subside. Therapists will contact families and educational consultants and assure them that the issues will be addressed in therapy. In fact, other than the sexual issues, the student seems to be doing well in treatment. The treatment team will often request a Sexual Risk Assessment be done on the student, but in the mean time, the student is often kept apart from others and supervision is increased. This only fosters shame and guilt while decreasing any opportunity to build trust towards disclosure. Hence, the accuracy of the Sexual Risk Assessment becomes suspect. When the sexualized behaviors eventually continue, they are now more sneaky and sophisticated. Then, the decision to transition a student to a higher level of care is often made hastily; with the liability of the program being of the highest concern.

If you find yourself in a situation where you have a student enrolled in a program, who has acted out sexually, please contact us. We will be happy to consult with you without any pressure.

Research presented at an ATSA Conferences a few years ago showed that the most effective way to work with students demonstrating problematic sexual behaviors was in a homogeneous population. There are many programs, hospitals and residential settings that have a “tract” or a “wing” where the students who struggle with these issues work on their problems. This is not the most effective clinical arrangement. This does not mean there aren’t good intentions, caring staff and clinicians who may have worked with “Sex Offenders” (language we don’t use by the way). Often treatment teams, academic departments, residential staff and clinicians simply don’t know what they don’t know about these issues.

Because of the shame and guilt associated with sexual issues, these boys are great at playing “information poker”; only laying down the cards that people already know about. The rest of the “cards” they are determined to keep close to the vest. It’s this “game” that makes adolescents with problematic sexual behaviors so hard to work with. As previously mentioned, by the time we are contacted, behaviors have escalated to a crisis situation and financial resources for treatment have generally run thin.

Many may look at the model of treating students in a homogeneous population and think of treatment that focuses on addiction. While there are some very important similarities, such as emotional support, safety in discussing the issues in group and even some bio-chemical aspects of addiction that are relevant, these are not the main reasons. The number one benefit of a homogeneous population is the opportunity it affords us as a treatment program to establish a culture that disrupts patterns and assists the student in developing a relationship with honesty. These maladaptive and manipulative patterns are patterns of behavior as well as thought.

Let me share an example; Todd Spaulding, the clinical director at Oxbow Academy mentioned an experience he recently had with a student on his caseload. This student was previously at another residential program where he sexually acted out. A couple of weeks after admission to oxbow, this student wrote the proverbial “pull me” letter to his parents, stating that “I hate it here. The other students don’t like me! They treat me like a monster! This isn’t where I belong! I’m not fitting in,” etc.

As Todd was discussing this in a family session, it was mentioned, based on reports from Oxbows residential as well as academic departments, that this student was testing his surroundings and the willingness of the other students to not “follow the rules”. Anytime he broke a physical or emotional boundary, he was reminded by peers. He was asked not to sit so close to another student…by peers! He passed a note…and peers called a group to discuss it! His patterns were being disrupted and it’s a very uncomfortable, but necessary, process for the students to work through. It is imperative for these patterns of manipulation to be disrupted before “treatment” can begin.

So, how is an educational consultant or clinician to know when a student reaches the threshold of needing further specialized evaluation? How can educational consultants and clinicians speak with the family in a way that is not “scary” for the family? We know from the above examples, it is better to intervene early and rule out any problematic or risky behavior. I have found that speaking with families in terms of risk is the most effective way to communicate with them.

“Risk” is determined by the manifested efforts of the student to avoid any “Benevolent Structure” implemented by the parents to extinguish the behavior. For example, a student may be looking at pornography on the family computer. Parents put a block on the computer and the student “hacks” through the block to continue access. That is considered “Risk”. Some kids are actually embarrassed by being caught; they value the relationship with their parents and stop the behavior. Let’s say the “hacker student” continues and the parents take away the Internet service. The student is then caught in the neighbor’s home accessing porn on the neighbor’s computer. The bottom line is that the student is willing to take “Risk” associated with continuing the behavior even after it has caused them some familial and/or social consequences.

As we look at students who are demonstrating problematic sexual behaviors, we need to make sure we look at the specific behaviors and any patterns that exist. We also need to look at the risk the student is willing to take to continue the behaviors, even when parents or authority figures have placed some structure around these behaviors. It is important to understand that what parents, educational consultants and clinicians know about is usually just the tip of the iceberg. We also need to recognize that there are some sexual behaviors that are common and “normal” among adolescent peer groups.

I hope this next section is helpful in providing a context for discussing sexual behavioral problems.

Common Adolescent Sexual Behavior
There may be some emotional consequences associated with some of these behaviors. There may also be family values and religious concerns. If needed, outpatient treatment should be sufficient.

• Sexually explicit conversations with peers
• Obscenities and jokes within cultural norm
• Sexual innuendo, flirting and courtship
• Interest in erotica
• Solitary masturbation
• Hugging, kissing, holding hands
• Foreplay, (petting, making out, fondling) and mutual masturbation. There may be moral, social, religious or familial rules that discourage this behavior, but these behaviors are not abnormal or illegal when private, consensual, equal, and non-coercive.
• Monogamist intercourse: Stable monogamy is defined as a single sexual partner throughout adolescence. Serial monogamy indicates long-term (several months or years) involvement with a single partner which ends and is then followed by another. Once again, there may be moral, social, religious or familial rules that discourage this behavior, but these behaviors are not abnormal or illegal when private, consensual, equal, and non-coercive.

Although some of these “Yellow Flag” behaviors are not necessarily outside the range of behavior exhibited in teen peer groups, there should be a serious assessment made in order to rule out any “Red Flag” and/or illegal behaviors when they are in the context of more than one issue that is listed below, or specific patterns.

• Sexual preoccupation/anxiety (interfering in daily functioning)
• Pornographic interest (Type is a factor i.e.; Bestiality, Child, Violent etc.)
• Sexual intercourse/promiscuity (indiscriminate sexual contact with more than one partner during the same period of time.)
• Sexually aggressive themes/obscenities
• Sexual graffiti (especially chronic and impacting individuals)
• Embarrassment of others with sexual themes
• Violation of others' body space
• Pulling skirts up/pants down
• Single occurrence of peeping, exposing with known peers
• Mooning and obscene gestures
• Masturbation to underwear (very common)

Red Flag behaviors need further specialized evaluation. It would be extremely rare to have a student involved in a single Red Flag behavior. There will always be additional Yellow or Red Flag behaviors. Often, if more questions are asked, a pattern starts to appear.

• Compulsive masturbation (especially chronic or public)
• Degradation/humiliation of self or others with sexual themes
• Attempting to expose others' genitals
• Chronic preoccupation with sexually aggressive pornography
• Sexually explicit conversation with significantly younger children
• Obscene phone calls, voyeurism, frottage, exhibitionism, sexual harassment
• Touching genitals without permission (i.e. grabbing, goosing)
• Sexually explicit threats (verbal or written)
• Sexual contact with significant age difference (sibling, neighbor, relative)
• Coerced sexual contact
• Coerced penetration
• Sexual contact with animals (bestiality)
• Sexting (The use of cell phone or other electronic devise to send pictures of oneself or others.)


We have recently refined our first phase of treatment to provide a consolidated evaluation. This first phase is 90 days. Students will integrate into academics, residential living and therapy. They will work with their therapist in providing a full sexual disclosure as well as non-sexual disclosure. This disclosure process takes some time and is done with the help of the student’s therapist and paperwork assignments. Once the student has completed their disclosure and shared everything with the therapist and their family, a polygraph is scheduled. This is simply to validate the student’s honesty. Then, summaries of the students efforts in academics, residential and therapy are combined with the results of the polygraph and are sent to the psychologist to do the Psychosexual Evaluation. This gives the parents and referring professionals an integrated functional assessment, Psychological testing and Sexual Risk Assessment all within the first 90 days. At this point, parents and allied professionals know what level of continued care is required.


• Parents only commit to first 90 days
• Referring treatment programs can have students return if clinically appropriate.
• Allied professionals have a clinically sophisticated option to discuss with families.
• Students are fully engaged in academics, residential activities and therapy prior to and during testing.
• Clinical use of the polygraph encourages the student to “lay all the cards on the table”, thus allowing the development of a complete and accurate treatment plan.

Again, please don’t hesitate to contact me or Dan Jensen with any questions. Dan is a therapist and also our Director of Admissions. You can read more about this clinically complicated issue here. I hope this has been helpful.


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