Socio-sexual functioning in autism spectrum disorder: A systematic review and meta-analyses of existing literature

Psychometric Properties of Psychosexual Functioning Survey Among Autistic and Non-autistic Adults: Adapting the Self-Report Teen Transition Inventory to the U.S. Context

Psychosexual functioning is an important aspect of human development and relationships. A previous study investigated psychosexual functioning of autistic adolescents using the Teen Transition Inventory (TTI), but there is a lack of comprehensive measurement of psychosexual functioning among autistic and non-autistic (NA) adults. To address this gap, the current study adapted the self-report TTI to the Psychosexual Functioning Survey (PSFS) and presented it to 131 autistic (n = 59) and NA adults (n = 72) in the U.S. Comparisons of psychometric properties between the original TTI and the PSFS are shared; the developmental relevancy among some items was changed, and the alphas indicated a difference in the content of certain scales. Differences emerged between autistic and NA adults in both the intra- and interpersonal domains of psychosexual functioning, but not in sexual and intimate behaviors. The findings suggest the persistence of differences from adolescence to adulthood between autistic and NA people and highlight the importance of understanding the unique experiences of adults in psychosexual functioning relative to diagnostic status.

"I Don't Care if it Would Kill the Mood. I'm Going to Use My Words": Perceptions and Use of Explicit Verbal Sexual Consent in Neurodiverse Undergraduate Students

Adults entering college, especially autistic individuals, may have a higher likelihood of unwanted or distressing sexual experiences. Additionally, autistic adults appear to endorse dissatisfying sexual education experiences and difficulties with consent cues. The current mixed-methods study examined the types of consent cues college students rely on and potential barriers to seeking sexual consent. We combined data from two studies of undergraduate students: 1) an in-person cross-sectional study exploring conceptualizations and interpretations of consent in autistic and non-autistic young adults (n = 30), and 2) an online, short-term longitudinal study examining predictors of mood concerns in neurodiverse students transitioning into their first semester at 4 northeastern United States university systems in Fall 2022 and 2023 (n = 230). In-person participants completed a semi-structured interview asking about consent expression and interpretation. Participants from both studies completed self-report surveys measuring autistic traits, attitudes and perceptions toward sexual consent, and sexual education history. Qualitative analysis suggested students preferred to rely on explicit verbal consent, but felt they were unusual for doing so. In contrast, quantitatively, students across both studies expressed comfort with explicit verbal consent, to a high and similar degree. Further research may benefit from investigating differences between young adults' perceived and actual sexual consent preferences of peers, with attention to neurodivergent individuals.

A Systematic Review of the Relationship Between Neurodiversity and Psychosexual Functioning in Individuals with Autism Spectrum Disorder (ASD) or Attention-Deficit/Hyperactivity Disorder (ADHD)

The scientific literature on psychosexual functioning shows a range of outcomes for individuals with neurodiversity. The aim of this article was to synthesize and critically evaluate evidence regarding psychosexual selfhood (orientation), behaviors and experiences in individuals with autism spectrum disorder (ASD) or attention-deficit/hyperactivity disorder (ADHD) to prioritize further research and identify interventions to reduce risk. A systematic review of the literature that compared sexual orientation, behavior and experiences of individuals with ASD or ADHD with those of neurotypical peers was performed in AMED, CINAHL, MEDLINE, PsycARTICLES and PsycINFO, Psychology and Behavioural Sciences Collection, Child Development and Adolescent Studies databases (supplemented by hand-searching of reference lists). Seventeen ASD and nineteen ADHD studies met inclusion criteria. Overall, the studies reviewed suggest poorer psychosexual functioning for individuals with ASD or ADHD compared to neurotypical peers, including a lack of satisfaction in their sexual relationships, sexual dysfunction, risky sexual behaviors, and victimization. This appears to be more marked for females. Individuals with ASD were more likely to identify with a non-heterosexual orientation compared with neurotypical peers. The study identifies gaps in our knowledge relating to risky sexual behaviors (in particular, those relating to sexual health and vulnerability to sexual victimization and perpetration). The public health implications of the findings are discussed. Future research is needed to clarify the mechanisms by which individuals with neurodevelopmental disorders may be at increased risk of adverse psychosexual outcomes and identify interventions that may mediate outcomes.

BARRIERS TO REPORTING AND LACK OF EQUITABLE SUPPORT: ABORTION ACCESS FOR ADULTS WITH AUTISM EXPERIENCING RAPE-RELATED PREGNANCY POST-ROE

Following the overturning of Roe v. Wade, individuals with autism experience unique barriers to accessing abortion for rape-related pregnancies in states restricting reproductive health care. Barriers to reporting rape include inadequate sex education which contributes to a lack of information about sexual violence (SV), difficulties labeling and recognizing SV, and potential difficulties navigating the role of a caregiver or conservator when reporting SV. Individuals with autism often experience a lack of equitable support from formal SV support services. Both barriers to reporting and lack of equitable support from formal SV support services reflect that individuals with autism are marginalized and often overlooked when receiving sexual and reproductive health care. Suggestions are provided for sexuality educators, SV support services, police, healthcare providers and policymakers, for better supporting individuals with autism experiencing rape-related pregnancy in states with abortion restrictions.

Are Autism Spectrum Disorder and Asexuality Connected?

Asexuality is a lack of sexual attraction to any gender. There is some evidence to suggest that many self-identified asexuals have a formal diagnosis of autism spectrum disorder which is characterized by deficits in social interaction and communication, as well as by restricted and repetitive interests and behaviors. Additionally, the literature shows that asexuality and lack of sexual attraction or low sexual interest is overrepresented in people with autism spectrum disorder compared with neurotypical samples. Nevertheless, no studies have been conducted to investigate the relationship between autism and asexuality in depth. We conducted a systematic review of the literature to examine whether asexuality and autism spectrum disorder are connected. We conclude that asexuality and autism share various aspects, such as a possible role of prenatal factors, reference to romantic dimensions of sexual attraction and sexual orientation, and non-partner-oriented sexual desire, but future research should explore and clarify this link.

Prenatal exposure to valproic acid and treatment with intranasal oxytocin have sex-specific effects on behavior in Long Evans rats

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social behaviors and communication. In rodents and humans, prenatal exposure to antiepileptic valproic acid is associated with an increased risk for autistic-like characteristics. One potential treatment is oxytocin, a prosocial neuropeptide that can be delivered intranasally. However, the sex-specific effects of valproic acid exposure and intranasal oxytocin treatment on behavior have not been fully explored. Pregnant Long Evans rats were administered valproic acid (500 mg/kg) or saline midday on gestational day 12, and after weaning, male and female pups were assigned to control (saline-saline), valproic acid-saline, or valproic acid-oxytocin groups. Oxytocin (0.8 IU/kg) or saline was delivered intranasally 30-60 min before tests for anxiety-like behaviors (elevated plus maze), social interactions (sociability) and sociosexual behaviors (partner preference, 50 kHz vocalizations and scent marking). Prenatal exposure to valproic acid resulted in sex-specific differences in behavior. When compared to controls, valproic acid males showed enhanced anxiety-like behaviors in adolescence and fewer scent marks in adulthood, while valproic acid females showed reduced sexual (partner) preference as adults. Intranasal oxytocin was anxiolytic for valproic acid males, but moderately anxiogenic for valproic acid females, and in both sexes it surprisingly impaired social interactions in the sociability test. Furthermore, intranasal oxytocin failed to improve sociosexual deficits in valproic acid rats. These findings highlight the importance of conducting preclinical studies in both sexes, and suggest that oxytocin may be an effective treatment in animal models with heightened anxiety-like behaviors.

Promoting Healthy Sexuality for Children and Adolescents With Disabilities

This clinical report updates a 2006 report from the American Academy of Pediatrics titled "Sexuality of Children and Adolescents With Developmental Disabilities." The development of a healthy sexuality best occurs through appropriate education, absence of coercion and violence, and developmental acquisition of skills to navigate feelings, desires, relationships, and social pressures. Pediatric health care providers are important resources for anticipatory guidance and education for all children and youth as they understand their changing bodies, feelings, and behaviors. Yet, youth with disabilities and their families report inadequate education and guidance from pediatricians regarding sexual health development. In the decade since the original clinical report was published, there have been many advancements in the understanding and care of children and youth with disabilities, in part because of an increased prevalence and breadth of autism spectrum disorder as well as an increased longevity of individuals with medically complex and severely disabling conditions. During this same time frame, sexual education in US public schools has diminished, and there is emerging evidence that the attitudes and beliefs of all youth (with and without disability) about sex and sexuality are being formed through media rather than formal education or parent and/or health care provider sources. This report aims to provide the pediatric health care provider with resources and tools for clinical practice to address the sexual development of children and youth with disabilities. The report emphasizes strategies to promote competence in achieving a healthy sexuality regardless of physical, cognitive, or socioemotional limitations.

Sexual Knowledge, Desires, and Experience of Adolescents and Young Adults With an Autism Spectrum Disorder: An Exploratory Study

Although most persons with an Autism Spectrum Disorder (ASD) wish to have romantic and/or sexual relationships, little is known about self-report sexuality of adolescents/young adults with ASD. In this exploratory study, 172 male and female adolescents/young adults (68 with ASD and 104 without ASD) completed an online version of the Sexual Behavior Scale-Third edition. Although many more similarities than differences were observed between the groups for views and desires about romantic relationships (e.g., wishing to have a girlfriend/boyfriend), fewer participants with ASD (mostly boys) had experience with a variety of sexual/dyadic behaviors, and approximately half of girls with ASD reported negative sexual experiences. Significantly higher rates of participants with ASD felt their knowledge about sexuality was limited and found it difficult to understand sexual education compared with typically developing (TD) participants. Significantly lower rates of participants with ASD reported that they identify to their assigned gender compared with TD participants. Multiple regressions revealed that being older at first diagnosis and possessing better knowledge about sexuality were significant predictors of both positive and negative sexual experience. This study explores strengths and challenges related with the sexual health of adolescents/young adults with ASD and implications for clinical and educational practice are discussed.

Exploring Three Core Psychological Elements When Treating Adolescents on the Autism Spectrum: Self-Awareness, Gender Identity, and Sexuality

For those growing up on the autism spectrum, adolescence is associated with unique challenges. This narrative review explores three core psychological elements for clinicians to consider when treating adolescents on the autism spectrum: self-awareness, gender identity, and sexuality. Developmental tasks of adolescence include adaptation to a maturing mind and body, increased expectations for independence, and the ability to establish satisfying interpersonal relationships. What are welcome opportunities for non-autistic peers can become nearly insurmountable hurdles for autistic teens, which, in turn, could lead to crisis, particularly if skills needed for success in managing these tasks have not yet been acquired.

Romantic Intimacy in Autism: A Qualitative Analysis

Although autistic people have difficulties with social-emotional reciprocity, most still desire intimate romantic relationships. This study sought to identify enablers and barriers to emotional and physical intimacy for Autistic (n = 31) and non-autistic (n = 26) individuals. All participants completed an online survey including demographic information, the Autism Spectrum Quotient and questions on intimacy which were subject to thematic analysis. Enablers of intimacy for both groups included communication, sharing and similarity, respect and safety for self and other, and working on the relationship. Barriers for both groups included intra- and interpersonal conflicts; autistic people specifically highlighted uncertainty about relationships and communication. These findings suggest autistic and non-autistic people have similar notions of intimacy, yet have different challenges in experiencing it.

Sexual and Reproductive Health Service Utilization and Sexuality for Teens on the Autism Spectrum

OBJECTIVES

Health care providers and educators play critical roles in supporting healthy sexuality development for youth with autism spectrum disorder. There is limited information about the sexual behavior of these youth, especially girls, and about their access to sexuality education or health care services.

METHODS

This study addressed these gaps by surveying parents of youth with autism aged 12-18 years (N = 298, 52.7% boys) with a range of intellectual functioning.

RESULTS

According to parent report, most youth experienced sexual attraction and were interested in relationships, including same-sex attraction or relationships (13.2%). Girls were more likely than boys to have had a romantic relationship and less likely to have experienced school or legal consequences for sexual behavior. Around one-fifth of youth had engaged in a socially inappropriate sexual behavior, whereas 6.4% had a known sexual abuse history and 14.5% were bullied by peers for lack of sexual knowledge. Almost 40% received no sex education in school or in the community, including 60.9% of youth with parent-reported intelligence quotient under 70. Some parents consulted with school personnel (36.4%) or health care providers (55.9%) about sexuality issues, whereas 19.5% reported taking no action aside from talking to their child about sexuality. Utilization models including predisposing, enabling, and needs-related factors were applied to parent consultation with providers and use of school-based sexuality education programming.

CONCLUSION

The results suggest unmet needs for sexual and reproductive health services, particularly among youth who are younger, those who have co-occurring intellectual disability, or those who are homeschooled or who attend private, charter, or therapeutic versus public schools.

INSAR Special Interest Group Report: Stakeholder Perspectives on Priorities for Future Research on Autism, Sexuality, and Intimate Relationships

The number of empirical studies on sexuality and intimate relationships in autistic people has grown over the last years with the increasing awareness that sexuality and intimate relationships are an important part of life and well-being for autistic people. Further, expression and enjoyment of sexuality is a fundamental, basic human right. This paper reports on needs for future research in this area based on the input of autistic adults, researchers, and other stakeholders (e.g., parents and professionals). Utilizing the nominal group technique, 65 individuals participated in eight groups in which they brainstormed on research questions they deemed most important. Responses were categorized into themes and ranked according to importance based on the level of priority attributed by participants. Findings suggest that future research should focus on developing ways to support sexual and relationship well-being and getting a better understanding of sexuality and relationships in autistic people. Also, attention was drawn to the need for studying the influence of stereotypical societal views, and stigma. Finally, the importance of participatory research to include perspectives of autistic people in research and practice was stressed. LAY SUMMARY: Sexuality and romantic relationships are part of daily life for most people, including autistic people. For this study, groups of autistic people, professionals, and autism researchers discussed which research on autism, sexuality, and relationships is needed and can help autistic adolescents and adults. The group discussions revealed that more research is needed on how to support well-being relating to romantic relationships and sexuality in autistic people and how the people around them can contribute to this. Therefore, we also need to learn more about how autistic people of all ages and throughout their lives experience sexuality and relationships. Finally, the need for attention to the role of stereotypical ideas and stigma about autism, sexuality, and relationships was pointed out. Attention to the experiences of autistic people can help professionals, researchers, and policy makers to offer and organize attuned support and do relevant research. Autism Res 2020, 13: 1248-1257. © 2020 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals LLC.

Gender identity, sexual orientation and adverse sexual experiences in autistic females

BACKGROUND

There is growing recognition that autistic females present with more diverse gender and sexual identities than their non-autistic counterparts. Likewise, autistic females are also at an increased risk of adverse sexual experiences. As higher rates of sexual victimisation are observed in individuals with diverse sexual identities in the broader population, rates of negative sexual experiences among autistic females remain unclear. This study aimed to investigate the representation of gender and sexual diversity within autistic females and examine their rates of regretted, and unwanted, sexual encounters among females with a transgender gender identity and non-heterosexual sexual orientation.

METHODS

Two hundred and ninety-five females completed the Sexual Behaviour Scale-III (SBS-III) online. Self-reported gender identity and sexual orientation were compared between 134 autistic (M_age= 26.2 years, SD = 8.7) and 161 non-autistic females (M_age = 22.0 years, SD = 4.6). Differences in the prevalence of negative sexual experiences were compared across diagnosis and each gender identity and sexual orientation label.

RESULTS

Autistic females were more likely to identify with a transgender gender identity (p < .05) and non-heterosexual sexual orientation (p < .007) compared to non-autistic females. Autistic homosexual females were more likely to have experienced a range of negative sexual experiences than autistic heterosexual females (OR ≥ 3.29; p < .01) and were more likely to have experienced unwanted sexual experiences than non-autistic females regardless of sexual orientation (OR ≥ 2.38; p < .05). There were no differences in rates of negative sexual experiences between autistic bisexual and both autistic heterosexual and non-autistic bisexual females. Non-autistic bisexual females (OR = 0.24; p = .018) presented with a reduced risk of regretted sexual experiences than non-autistic heterosexual peers. There were no differences in negative sexual experiences across gender identity in the autistic sample.

LIMITATIONS

The use of fixed format response items may have restricted participants' abilities to provide rich responses pertaining to their sexual identities and nature of negative sexual experiences. The small number of participants who identified as transgender (n = 40) limits the reliability of results pertaining to sexual experiences across gender identity. Moreover, although multiple recruitment methods were used in this study, non-representative may bias estimates of prevalence rates. Thus, the data may not be representative of the broader population.

CONCLUSIONS

Results indicate that autistic females present with greater diversity in their sexual identities than individuals without autism, with those with a homosexual sexual orientation being at greater risk of experiencing adverse sexual encounters. Findings suggest the importance of increased clinical attention to this diversity and the need to provide support to facilitate the development of a healthy sexual identity and reduce the risks identified in this study.

Intuitive Moral Reasoning in High-Functioning Autism Spectrum Disorder: A Matter of Social Schemas?

Using a schema-theoretical perspective in the field of moral cognition, we assessed response behavior of adolescent (n = 15) and adult (n = 22) individuals with Autism Spectrum Disorder (ASD) in comparison with adolescent (n = 22) and adult (n = 22) neurotypically developed controls. We conceptualized the Intuitive Moral Reasoning Test-in five moral dilemmas, participants had to choose between two alternative actions and assess their decision with respect to emotional valence, arousal, moral acceptability and permissibility from both the perspective of the acting person and then of the victim. Patients with ASD displayed a different decision and response behavior, particularly when the dilemmas were based on extreme life situations in combination with a social schema involving close social relationships.