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. 2024 Sep 5;32(6):918–930. doi: 10.1080/13218719.2024.2372763

Characteristics of harmful sexual behaviour in autistic adolescent males as compared to controls

Lawrence Leung a,✉, Charlotte L Mentzel a, Linda Hobbs a, Tess Patterson a,b
PMCID: PMC12642891  PMID: 41293216

Abstract

There is limited published data on how harmful sexual behaviour (HSB) by male adolescents diagnosed with Autism Spectrum Disorder (ASD) may differ from their neurotypical peers. This study examines a population of male adolescents who had engaged in HSB and were referred for assessment to a New Zealand (NZ) regional treatment centre. Autistic individuals were compared to a control group who had no mental health or neurodivergent diagnosis or presented with only depression or anxiety on characteristics of the HSB. It was found that the autistic adolescents performed HSB against a greater mean number of victims. Although the two groups harmed similar mean numbers of victims by engaging in contact HSB, the ASD group harmed a significantly greater mean number of victims by engaging in non-contact HSB. This study provides novel findings and highlights the need for further research relating to autistic male adolescents who have engaged in HSB.

Keywords: adolescent males, autism spectrum disorder, harmful sexual behaviour

Introduction

Child sexual abuse (CSA) is a pervasive and detrimental issue worldwide (Barth et al., 2013). It is estimated that 2–62% of girls and 3–16% of boys have been harmed, although underreporting of CSA is a recognised problem (Johnson, 2004). The physical, emotional, and psychological impacts of CSA can have lasting negative consequences that persist through to adulthood (Cashmore & Shackel, 2013; Johnson, 2004). Efforts to prevent CSA have focused on two primary strategies: (a) offender management initiatives (such as registering sex offenders and notifying communities of their presence) and (b) school-based educational programmes (teaching children how to identify and avoid dangerous situations) (Finkelhor, 2009). However, these two strategies are seen to have limited efficacy. For example, a recent meta-analysis with 25 years of data showed that sex offender registration and notification did not have a statistically significant impact on recidivism rates (Zgoba & Mitchell, 2023). Furthermore, while school-based programmes have been effective at outcomes such as increasing certain knowledge in children (Davis & Gidycz, 2000; Fryda & Hulme, 2015), such interventions can be resource-intensive (Sutton et al., 2019), and an observable reduction of CSA has not been reliably or validly measured (Topping & Barron, 2009). It has been suggested that potential offenders, instead of victims, are more appropriate targets for intervention and prevention programmes (Bolen, 2003). This requires an understanding of which individuals are at risk of committing CSA.

There is increasing awareness that a substantial portion of CSA is committed by male adolescents, with a worldwide estimation of 15–50% of reported sexual offences being committed by male adolescents (Leroux et al., 2016; Vizard et al., 1995; Zolondek et al., 2001). Similarly in New Zealand (NZ), it is estimated that 25–42% of sexual offences are committed by adolescents (Anderson et al., 1993; Lambie et al., 2002). Furthermore, approximately 50% of adult sex offenders report that they first engaged in harmful sexual behaviour (HSB) when they were in their adolescence (Davis & Leitenberg, 1987; Lussier, 2017). Concerning and harmful sexual behaviour (HSB) is a term used to describe sexual behaviours that are inappropriate, problematic, and potentially abusive to the person engaging in the behaviour and others (Oranga Tamariki, NZ Ministry for Children, 2021). This definition allows inclusion of a breadth of sexual behaviours beyond those that have been formally charged and sentenced through a judicial system. While the rate of recidivism of sexual offences is not as high as that of recidivism for other types of offending in adolescents (Leroux et al., 2016; Vitacco et al., 2009), longitudinal studies have shown that some adolescents who commit sexual offences do recidivate and continue their sexual offending into adulthood (Lussier et al., 2024; Schnitzer et al., 2020). Estimates suggest that 8% (7%–9%) of adolescents will recidivate while still an adolescent or young adult (Lussier et al., 2024). Additionally, 8–12% of adolescents will recidivate in adulthood (Lussier, 2017).

A subset of male adolescents who have engaged in HSB are persons diagnosed with Autism Spectrum Disorder (ASD) (i.e. autistic individuals)1 (Allely & Creaby-Attwood, 2016; Sala et al., 2020). ASD is a neurodevelopmental disorder with core features of persistent impairments in social communication and interactions across multiple contexts and restricted, repetitive, and inflexible patterns of behaviours and interests (American Psychiatric Association, 2022). Autistic individuals exhibit a wide range of sexual behaviours from developmentally typical to problematic or HSB (Turner et al., 2017). While the large majority of autistic individuals are found to show sexual interest and other sexual developmental behaviours similar to their neurotypical peers (Dewinter et al., 2015), a quarter of autistic individuals are noted to have inappropriate sexual behaviours and paraphilias (Fernandes et al., 2016; Payne et al., 2020). Given that most autistic individuals are reported as being ‘scrupulously law-abiding’ (Murrie et al., 2002, p. 66), the characteristic of being law-abiding may be seen as a protective factor that may reduce the likelihood of engaging in HSBs. However, other factors faced by autistic individuals are hypothesised as potential risk factors for engaging in HSB, such as lack of social understanding, limited intimate relationships, a higher level of sexual frustration, fixed or obsessional interests, and reduced empathy and impulse control (Schnitzer et al., 2020; Sevlever et al., 2013; Trew & Russell, 2024). In fact, research on persons who commit sexual offences (i.e. non-autistic persons) has noted the presence of many traits that are common with ASD, such as poor peer relations, lower empathy, obsessive self-absorption, and having few emotional bonds as risk factors that increase the likelihood of sexual offending (Mogavero, 2016).

Existing evidence does not substantiate claims that autistic individuals are more likely to commit offences of all types when compared to the wider population (de la Cuesta, 2010; Mouridsen, 2012; Rutten et al., 2017). In relation to sexual offences, the literature examining associations between ASD and engagement in HSB is limited and has mixed findings. While it is suggested that the rates of sexual offending are lower among autistic offenders (Dein & Woodbury-Smith, 2010) and ASD alone does not increase the risk of HSB (Higgs & Carter, 2015), several studies suggest ASD-related symptoms and diagnoses are over-represented among juvenile sex offenders (‘t Hart-Kerkhoffs et al., 2009; Kumagami & Matsuura, 2009). Of note, one study found that 60% of male adolescents who were convicted of sexual offences and were sentenced to treatment met the diagnostic criteria for ASD (Sutton et al., 2013). In addition, a study of juvenile sex offenders found that ASD symptoms were relatively stable on follow-up 8 years later (Baarsma et al., 2016), indicating that these difficulties are likely life-long autistic traits instead of transient developmental or behavioural issues.

Research on autistic adolescents who have engaged in HSB is an area of emerging research interest, but there is a paucity of research examining this area (Allely & Creaby-Attwood, 2016; Trew & Russell, 2024). In particular, to our knowledge, there have been no published data examining whether HSBs differ between autistic and non-autistic adolescents.

Using data collected as part of a broader study examining a population of adolescent males who have engaged in HSB for which they received a referral for assessment at NZ regional community-based treatment centres (Patterson et al., 2022), this study aims to compare HSB performed by autistic adolescent males (ASD group) with HSB performed by non-autistic adolescent males (control group). We compared groups (ASD; control) on: (a) mean number of victims harmed; (b) the mean number of penetrative, fondling, or non-contact HSB performed; and (c) the age at which the adolescent male engaged in their first HSB and age at referral for assessment.

Method

Ethical approval was granted by the New Zealand Health and Disability Ethics Committee (LRS/11/EXP/018). Researchers extracted data from comprehensive assessment reports of a NZ population of adolescents who had engaged in HSB and who had been referred for assessment. The multimodal assessments from which the data were extracted were conducted by clinicians at four NZ regional community-based adolescent treatment programmes between January 2003 and May 2013. Most clients were referred by Child, Youth and Family, the NZ Government agency responsible for supporting children and families (now Oranga Tamariki, Ministry for Children). Other sources of referral were child adolescent and family mental health services, non-governmental community agencies, and individuals/family members. The assessment included interviews with the individual, family members, and other professional’s involved, psychometric assessment, and additional information from other support agencies. The objective of these assessments is to inform treatment and is independent of legal proceedings. After assessment are completed recommendations regarding the most suitable course of intervention, support, and treatment is provided for the adolescent and their family.

Selection of ASD and control groups

As a part of a wider study on adolescent males who had engaged in HSB, data were extracted systematically and independently from assessment reports, by two researchers. See Patterson et al., (2022) for details.

Patterson et al., (2022) examined a total of 277 assessment reports (mean age at assessment: 14 years 10 months; age range: 11 years 9 months to 18 years 11 months). Descriptions of mental health and neurodivergent diagnoses were extracted from the assessment reports and categorised as follows: ASD, Intellectual Disability (ID), Depression, Anxiety, Obsessive Compulsive Disorder (OCD), Attention-Deficit/Hyperactivity Disorder (ADHD), Bipolar Disorder, Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and other mental health difficulties. In some instances, the assessment report documented suspected (but not diagnosed) mental health or neurodivergent difficulties; these are not coded here.

Here, we examine the data from the 13 male clients who had a diagnosis of ASD (ASD group) (i.e. all autistic male clients from the referral period January 2023 to May 2013). The control group (n = 140) included 134 (48.38%) male clients who had no reported mental health or neurodivergent difficulties diagnosed and 6 (2.17%) clients who were recorded as having only co-morbid depression or anxiety. Clients excluded from the control group include those with neuroatypical disorders (ADHD and ID) due to possible genetic links and overlap with ASD (Reiersen & Todd, 2008), and those with ODD and CD, as there is evidence that these conditions predict future psychopathology and enduring functional impairments, with some individuals progressing to having antisocial personality disorder, and their offending tends to present differently than other clients (Burke et al., 2010). A total of 124 individuals were excluded from the control group (77 clients with ADHD, 22 clients with ID, 21 clients with ODD and 24 clients with CD, some of whom had more than one of the diagnoses). It is possible that the control group included individuals with suspected ASD, as neurodiversity or mental health difficulties were not coded unless described by the clinician report writer as a confirmed diagnosis. (See Table 1 for description of comorbidities for ASD and control groups.)

Table 1.

Comorbidities for those included in the ASD and controls groups.

Comorbidities ASD group
(n = 13)
 Control group
(n = 140)
n%   n%  
Alcohol and drug use 7.69 1 32.86 46
Depression 0 0 3.57 5
Anxiety 0 0 0.71 1
ADHD 46.15 6 0 (excluded) 0
ODD 7.69 1 0 (excluded) 0
Conduct disorder 0 0 0 (excluded) 0
Intellectual disability 15.38 2 0 (excluded) 0
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Reports of HSB performed2

For each client, the Assessment Report writer identified instances of HSB and the victim of each instance. Details of the HSB committed were extracted from the reports and categorised according to acts against a discrete victim. In this way, the total number of HSBs performed by the clients equals the total number of victims harmed.

Each incident of HSB was classified as one of three categories: (a) penetrative, (b) fondling/touching, or (c) non-contact (e.g. exhibitionism, inappropriate sexual talk or thoughts, stealing underwear, peeping, asking others to get naked, verbally forcing others to do sexual acts, showing pornography to children, and accessing sexual material online). If the HSB could fit into more than one of these three categories, the HSB was categorised according to the most intrusive category. The age of the client when they performed each HSB act was recorded, and the age of the client at the time of referral for assessment was also noted.

In summary, we report here on the number of victims harmed, intrusiveness of that harm, and the age at which the client performed their first HSB, and the time of referral for assessment.

Data analysis

Independent t test analysis was used to compare groups (ASD; control) for (a) mean number of victims harmed, (b) mean number of victims harmed by penetrative, fondling, or non-contact HSB performed, and (c) the client age when they engaged in their first recorded HSB and were referred for assessment. Cohen’s d measures were included to present the effect size. Analyses were conducted using SPSS (Version 28). Statistical significance was determined by (two-sided when appropriate) p < .05.

Results

Mean number of victims

There was a significant difference in the mean number of discrete victims harmed by the ASD group (M = 4.08, SE = 1.08) compared to the control group (M = 2.53, SE = 0.17), t(151) = −2.41, p < .001, d = 2.22. The ASD group harmed a greater mean number of discrete victims than did the control group. (See Table 2.)

Table 2.

Characteristics of HSB engaged in and age at first HSB for ASD compared to control groups.

  ASD group
(n = 13)
 Control group
(n = 140)
 Test (Cohen’s d)
M Range SE % M Range SE %
Number of discrete victims 4.08   1.08   2.53   0.17   t(151) = −2.41, p < .001 (d = 2.22)**
Mean number of victims harmed by intrusiveness of HSB                  
 Penetrative 1.08       0.93       t(151) = −0.48, p = .41
 Fondling 1.01       0.66       t(151) = −1.01, p = .27
 Non-contact 1.92       0.86       t(151) −2.42, p = .02 (d = 1.51)**
Percentage of group that engaged in 1 or more acts by intrusiveness of act                  
 Penetrative       61.54       62.14  
 Fondling       46.15       36.43  
 Non-contact       61.54       38.57  
Age at first HSB (years) 11.31 5–15 0.99   11.89 5–17 0.25   t(151) = 0.66, p = .61
Age at referral for assessment (years) 15.05 12–18 1.42   14.93 11–18 1.58   t(151) = −0.26, p = .19
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**p < .05.

Intrusiveness of the HSB

Given that the ASD group harmed a greater mean number of victims than the control group, we would assume that the ASD group would harm a greater mean number of victims by engaging in each type (penetrative, fondling, and non-contact) of HSB—that is, the greater number of victims harmed would be reflected in equally greater numbers of victims harmed across all three categories of intrusiveness. However, there was no significant difference in the mean number of victims harmed by penetrative acts (ASD M = 1.08, control M = 0.93), t(151) = −0.48, p = .41; presented with 1 or more penetrative act (ASD 61.54%, control 62.14%) or fondling acts (ASD M = 1.01, control M = 0.66), t(151) = −1.01, p = .27; or presented with 1 or more fondling act (ASD 46.15%, control 36.43%) performed by the ASD compared to the control group. The ASD group, however, did harm a significantly greater mean number of victims by engaging in non-contact HSB compared to the control group (ASD M = 1.92, SE = 0.57; control M = 0.86, SE = 0.12), t(151) −2.42, p = .02, d = 1.51; presented with 1 or more non-contact act (ASD 61.54%, control 38.57%). (See Table 2.)

Client age when engaged in their first HSB and when referred for assessment

There was no significant difference in mean age (years) for the first performed HSB between the ASD group (Mage = 11.31, SE = 0.99 ) and the control group (Mage = 11.89, SE = 0.25), t(151) = 0.66, p = .61. There was also no significant difference in the mean age at which the clients were referred for assessment between the ASD group (Mage = 15.05, SE = 1.42) and the control group (Mage = 14.93, SE = 1.58), t(151) = −0.26, p = .19. (See Table 2.)

Discussion

There is increasing interest in autistic adolescent males who engage in HSB. Current literature suggests that while ASD alone does not correlate with higher sexual offending rates (Higgs & Carter, 2015), ASD and ASD symptoms are overrepresented in adolescent males who have committed sexual offences (‘t Hart-Kerkhoffs et al., 2009; Kumagami & Matsuura, 2009; Sutton et al., 2013). Although there are a number of case reports on individual characteristics and HSB of autistic male adolescents, there is a paucity of research examining the pattern of HSB of these autistic individuals compared to neurotypical individuals.

The data presented here identified that autistic adolescent males harmed a greater mean number of victims during a similar time period, compared to a non-autistic control group. They did not start engaging in HSB any earlier, performing their first HSB at around the same age as controls, nor were they referred for assessment any later than the controls. The present study found that the ASD group harmed a greater mean number of victims by engaging in non-contact type HSBs, but had similar numbers of victims as did the control group in relation to acts of penetrative or fondling HSB. Non-contact type HSBs included acts such as exhibitionism, inappropriate sexual talk or thoughts, stealing underwear, peeping, asking others to get naked, verbally forcing others to do sexual acts, showing pornography to children, or accessing sexual material online. The data presented here do not provide evidence of motivation for the non-contact harmful sexual behaviour. However, as discussed by Trew and Russell (2024), the autistic individuals may engage in more behaviours that ignore social constraints or boundaries. These inappropriate and intrusive behaviours may lead to problematic or harmful sexual behaviours that are unintentionally sexual in nature or that are not purely sexually motivated. This data was collected from assessment reports conducted before the prolific availability of sexual material online and before mainstream use of online social media as a communication tool. As this type of material and technology continues to develop and becomes increasingly available to young people, research will need to closely examine the type of HSB being engaged in by autistic and non-autistic adolescents.

This is the first study within a NZ context to examine the differences in HSB engaged in between autistic and non-autistic male adolescents and demonstrates novel findings that directly contribute to the much-needed research base that examines HSBs in autistic adolescent males compared to their neurotypical controls. The data examined here is from pre-treatment assessment reports from a population of adolescents who have been referred for assessment after engaging in HSB, capturing a wider sample than only individuals who have been formally charged and sentenced for sexual offending through a judicial system.

From an intervention perspective, there has been a suggestion for the development of tailored sex and relationship education packages that suits the specific needs of autistic individuals who have already engaged in HSB (Dredge & Rose, 2023; Payne et al., 2020; Sevlever et al., 2013; Trew & Russell, 2024). Our study showed that the ASD group performed HSB on a greater number of victims than did the control group. Further, as they did not start their HSB at an earlier age, this implies that the ASD group is more prolific with their HSB across a similar time period, and that they therefore carry a higher risk in terms of number of victims harmed. Secondary prevention interventions (i.e. targeting groups carrying higher risk) directed at this group may be a relevant area for further study. In particular, with proactive sexual education being shown to be beneficial to the long-term quality of life for autistic individuals (Tullis & Zangrillo, 2013) and misunderstanding the seriousness of their behaviours being a self-reported theme for autistic individuals who have committed sexual offences (Payne et al., 2020), an educational programme specifically designed for autistic individuals may be helpful. An educational programme that includes explicit and clear advice regarding normal and HSBs, delivered to young autistic adolescents, may reduce the likelihood of autistic adolescents engaging in HSB. Further, as autistic individuals are more likely to experience victimisation, including sexual abuse, when compared to those without disabilities (Fisher et al., 2013), and sexually abused autistic children are more likely to engage in sexually abusive behaviour themselves (Mandell et al., 2005), these educational programmes may also offer protection to autistic individuals from becoming a victim of HSB themselves. This may also then reduce the potential for the victim repeating the cycle of HSB on others. While engaging in HSB is likely a rare event among the general population of autistic individuals, broader screening among autistic adolescent males to include identification of those who may have engaged in or be at risk of engaging in HSB would provide opportunity to offer early intervention that could benefit community safety (Trew & Russell, 2024).

It has been suggested that childhood sexual abuse tertiary prevention efforts should be concentrated on intensive management for those at the highest risk to re-offend (Finkelhor, 2009). While there are studies that propose early onset of sexual offending in adolescence does not appear to predict a trajectory of life-long sexual offending (Caldwell et al., 2008; Parks & Bard, 2006), there is also evidence that untreated youth who have committed sexual abuse have higher rates of sexual and non-sexual recidivism when compared to those who have received treatment (Fortune & Lambie, 2006). In support of the benefits of tertiary prevention, a previous NZ study examining a community treatment programme that involved group therapy for a small group of adolescents who had committed sexual offences showed positive results, with no recorded reoffending (Lambie et al., 2000). As usual group-based interventions require participants to be able to introspect, share personal information, and interact in a group, a group-based intervention would be inherently challenging for autistic individuals (Higgs & Carter, 2015). Because of this, an adapted group- or individual-based approach for autistic adolescents is likely needed (Broadstock, 2018; Trew & Russell, 2024). Without follow-up data, it is not known whether the ASD group in our study will have a higher rate of recidivism of HSB as they move into adulthood, but given the apparent potential risk (i.e. a higher number of victims harmed and similar rates of contact, penetrative, or fondling HSB performed), tertiary prevention interventions for this ASD group should be considered a priority.

In the present study, the finding that autistic adolescent males harmed a higher number of victims by engaging in non-contact HSBs compared to non-autistic individuals but harmed similar number of victims by engaging in contact (i.e. penetrative or fondling) HSB is in keeping with previous research. Specifically, Lindsay and colleagues, who examined autistic and non-autistic individuals referred to a forensic intellectual disability service, also found that the ASD group had more non-contact sexual offences (42.6% vs 33.7%, p = .26) and similar rates of contact sexual offences (27.7% vs 30.7%, p = .74) (Lindsay et al., 2014). From a justice perspective, the findings of the present study and the Lindsay et al., study may suggest implications around legal consequences, such as the potential difference in the severity of the sentence if the individual is charged for their HSB (e.g. less severe sentencing due to non-contact rather than contact behaviours). Prior research, however, does not necessarily support less severe sentencing for autistic persons. For example, although a NZ study on autistic young adults showed lower rates of being charged or convicted for all types of crimes (i.e. including sexual crimes), those autistic individuals who were charged were significantly more likely to be charged with a serious offence (Bowden et al., 2022). Also, a recent study of the Australian criminal justice system by Foster and Young reported significantly higher sentencing outcomes for autistic individuals of all ages who had engaged in sexual assaults compared to non-autistic individuals, while no significant difference in sentences was found for other offending including murder, manslaughter, and assaults (Foster & Young, 2022). While this may appear to be at odds with our finding that the ASD group harmed more victims with non-contact HSB, it may be consistent with our finding that the ASD group overall sexually harmed a greater number of victims (i.e. the potential for higher sentencing outcome due to a greater number of victims). There are a number of confounding factors in untangling judicial implications for autistic individuals who engage in HSB. Autistic people face additional challenges when engaging with the criminal justice system—‘A court setting is a complex social event. A person with ASD may well have difficulties’ (Bathgate, 2017, p. 94). The complication and confusion of the court process are easily amplified with ASD, and sexualised behaviour can be misinterpreted and misconceived in view of legal requirements for conviction (Creaby-Attwood & Allely, 2017). Autistic individuals may be unaware of the gravity of their offence or may appear dismissive of their victims, which may be perceived as aloof, unapologetic, and lacking in remorse or empathy, which, in turn, may negatively affect sentencing outcomes (Foster & Young, 2022; Mogavero, 2016). As autistic individuals are known to be vulnerable to bullying and social isolation in prison (de la Cuesta, 2010), there is a need for the various parties in the criminal justice system to understand the typology and patterns around autistic individuals and their engagement in HSB, so that reasonable and informed adjustments can be offered to autistic individuals who engage with the criminal justice system (Freckelton, 2013; Slavny‐Cross et al., 2022).

Limitations

There are several limitations to this study. As a small exploratory study, the sample size in the ASD group is small (n = 13), which affects the power of the study to detect certain findings, and data from small samples are more prone to the effects of having outliers. Replication is required to demonstrate the validity of the findings. This study also relies on extracted file information from reports conducted for the purpose of assessment for further treatment. These assessments are done by various clinicians with some degree of variability; full information may not always have been available, which limits the array of variables that we could report on. Further research could investigate variables such as the relationship and age differentiation between the victim and the adolescent who engaged in the HBS, the degree of planning, or the use of alcohol or drugs. For this study, assessment reports between 2003 and 2013 were examined, a period prior to widespread and easy access to online material. The recent prolific availability of sexual material online and the increase in use of social media as a communication tool suggests a need for replication of this study. Additionally, individuals with suspected but not diagnosed mental health or neurodivergent conditions, including ASD, are not coded; it is possible that individuals with undiagnosed ASD may instead have been included in the control group. Finally, as an observational study, one cannot determine the causality of the findings.

Conclusion

Research on ASD and HSB is in its infancy. We found that autistic individuals performed HSB against a greater mean number of victims during the same period and that they engaged in similar amounts of penetrative and fondling-type acts compared to the control group but in significantly more non-contact type acts. It is important that HSB in autistic individuals is given attention in terms of typology, patterns, and useful interventions.

Acknowledgements

The authors would like to thank the STOP organisation of New Zealand for allowing access to their file information.

Funding Statement

This work was funded by a James Hume Bequest Fund, Dunedin School of Medicine, and by a Marsden Grant [grant 15-UOO-061] from the Royal Society of New Zealand.

Footnotes

1

We have chosen to use identify first language (i.e., autistic person) in reflection of autistic preference (Kenny et al., 2016; Whaikaha – NZ Ministry of Disabled People, 2022).

2

Generally, harmful sexual behaviour (HSB) is defined as developmentally inappropriate sexual behaviour displayed by children and young people that may be harmful, abusive, or coercive (Hackett et al., 2019). Problematic sexual behaviour (PSB) is defined as behaviours displayed by young children (under the age of 12 years) that involve sexual body parts, and that are developmentally inappropriate or potentially harmful to themselves or others (El-Murr, 2017). Some adolescents assessed may have engaged in prior PSB; for this paper, we do not specifically distinguish between PSB and HSB; rather, we treat both PSBs and HSBs as a range of concerning sexual behaviours and refer to them as HSB.

Ethical standards

Declaration of conflicts of interest

Lawrence Leung has declared no conflicts of interest.

Charlotte L. Mentzel has declared no conflicts of interest.

Linda Hobbs has declared no conflicts of interest.

Tess Patterson has declared no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Ethical approval was granted by the New Zealand Health and Disability Ethics Committee, LRS/11/EXP/018) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was not obtained from all individual participants included in the study, as clients and their guardians give signed consent that information gathered during assessment and treatment at the STOP organisation may be used for research purposes, and additional consent will only be sought if research involves direct contact with the client. Direct contact with the client did not occur in this study. This procedure was approved by the New Zealand Health and Disability Ethics Committee (LRS/11/EXP/018).

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