Aspects of Sexuality in Adolescents and Adults Diagnosed with Autism Spectrum Disorders in Childhood

Psychological and Developmental Correlates of Paraphilic and Normophilic Sexual Interests

The classification of sexual fantasies and behaviors (here referred to as 'sexual interests') has historically been divided into 'paraphilic' and 'normophilic'. However, studies on paraphilic interests are often limited to clinical or forensic samples and normophilic interests are rarely assessed in tandem. Previous research has found mixed results for psychological and other correlates of sexual interests, potentially due to inconsistency in operationalism and measurement of fantasies and behaviors. The aim of the current study was to quantify correlates of sexual interests via the Sexual Fantasies and Behaviors Inventory, containing factors related to general fantasies/behaviors, normophilia, power dynamics, sadomasochism, and courtship paraphilias, using a large (N = 4280) non-clinical sample. Psychological, developmental, sexual, and demographic correlates were investigated via bivariate correlations, mean difference testing, and multiple regression. Sexual interest domains were largely unrelated to psychopathology and developmental factors. Sociosexuality and more accepting attitudes towards sadomasochism was generally related to more arousal to/engagement in normophilic and paraphilic domains. More autism spectrum disorder traits were related to decreased normophilic interests. Psychopathic traits, sexual sensation seeking, and sexual compulsivity were related to paraphilia dimensions, especially courtship paraphilias and domination/sadism; the former was also associated with negative attitudes about establishing consent. Men, non-monogamous, and non-heterosexual participants indicated greater sexual fantasies and behaviors compared to women (except in the case of submission and masochism), monogamous, and heterosexual participants, respectively.

Complementing or Congruent? Desired Characteristics in a Friend and Romantic Partner in Autistic versus Typically Developing Male Adolescents

Ideal friend and romantic partner characteristics related to self-perceived characteristics have been investigated in typically developing (TD) individuals, but not in individuals with autism spectrum disorder (ASD). Considering the autistic symptoms and challenges, investigating these concepts in autistic individuals is relevant. Given the lack of consensus, identity-first ("autistic person") and person-first ("person with autism") language are mixed throughout, to cover all preferences. This study explored (1) the association between self-perceived characteristics and desires in a friend/romantic partner, as well as (2) compare two groups (ASD and TD) in their desires for a friend/romantic partner. Two matched groups (ASD and TD) of 38 male adolescents (age 14-19 years) reported on the desire for nine characteristics (i.e., funny, popular, nice, cool, smart, trustworthy, good looking, similar interests, and being rich) in a friend/partner, and to what extent they felt they themselves possessed seven characteristics (i.e., funny, popular, nice, cool, smart, trustworthy, and good looking). Results showed both groups sought a friend and partner similar to themselves on intrinsic characteristics (e.g., trustworthiness), but less similar on extrinsic and social status characteristics (e.g., being less cool and popular). Particularly intrinsic characteristics, more than extrinsic and social status characteristics, were valued in both partners and friends, regardless of group. No significant differences were found between groups concerning to what extent characteristics were desired. Overall, adolescents with ASD desire similar characteristics as TD adolescents in their potential romantic partners and friends. There is some indication that the match between self-perception and desired characteristics is different.

Sexual and reproductive health services for autistic young people in the United States: A conceptual model of utilization

BACKGROUND

Sexual and reproductive health services promote the ability of people to have safe, satisfying, non-coercive sexual experiences and make informed decisions about pregnancy. Stakeholder input is needed to understand barriers or facilitators to service access for autistic people, who report unmet needs.

METHODS

We recruited 18 autistic people, 15 parents, and 15 service providers in the United States to participate in an interview and two surveys. Using their input, we created a conceptual model of sexual and reproductive health service needs, access barriers, and facilitators.

RESULTS

Stakeholders rated a variety of sexual and reproductive health services as important for autistic people, including those with intellectual disability or minimal verbal language. Stakeholders identified barriers to sexual and reproductive health service utilization including lack of service availability, lack of service providers with autism or neurodiversity training, lack of accurate information about autism and sexuality, verbal and communication differences that are not accommodated by service providers, and socio-cultural attitudes about sexuality. Stakeholders identified facilitators to service access including person-centered, trauma-informed care, service accommodations such as clear and detailed expectations, and long-enough appointments. We created a conceptual model based on the social ecological model of health to organize these utilization factors and support future research, provider, and policy action. Stakeholders provided feedback and responded favorably on the model's accuracy, utility for spurring research, practice, and policy improvements, and application to diverse groups of autistic people.

CONCLUSIONS

The model shows the many feasible ways to support equitable access to services for autistic people.

Sex and Sexuality in Autism Spectrum Disorders: A Scoping Review on a Neglected but Fundamental Issue

ASD consists of a set of permanent neurodevelopmental conditions, which are studded with social and communication differences, limited interests, and repetitive behaviors. Individuals with ASD have difficulty reading eye gestures and expressions, and may also have stereotyped or repetitive language, excessive adherence to routines, fixed interests, and rigid thinking. However, sexuality in adolescents and young adults with ASD is still a poorly studied and neglected issue. This review aims to evaluate sexual function and behavior in individuals with ASD to foster a greater understanding of this important, although often overlooked, issue. This review was conducted by searching peer-reviewed articles published between 01 June 2000 and 31 May 2022 using the following databases: PubMed, Embase, Cochrane Database, and Web of Science. A comprehensive search was conducted using the terms: "Autism" OR "ASD" AND "Sexuality" OR "Romantic relation" OR "sexual behavior" AND/OR "sexual awareness". After an accurate revision of 214 full manuscripts, 11 articles satisfied the inclusion/exclusion criteria. This review found that, although individuals with ASD may have sexual functioning, their sexuality is characterized by higher prevalence rates of gender dysphoria and inappropriate sexual behavior. Furthermore, sexual awareness is reduced in this patient population, and the prevalence of other variants of sexual orientation (i.e., homosexuality, asexuality, bisexuality, etc.) is higher in adolescents with ASD than in non-autistic peers. Sexual health and education should be included in the care path of patients with ASD in order to improve their quality of life and avoid/reduce inappropriate and risky behaviors.

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.

Risk Factors for Sexual Offenses Committed by Men With or Without a Low IQ: An Exploratory Study

Although risk factors associated with offending and recidivism are relatively well-established for mainstream sexual offenses, much less is known about men with a low IQ who have sexually offended (MIQSO), let alone those with forensic involvement. In this exploratory study, 137 convicted for the commission of at least one sexual offense and found not criminally responsible because a mental disorder were recruited in a maximum-security hospital. They were all assessed with the SORAG (static risk factors) and the RSVP (dynamic risk factors). Compared with MIQSO (N = 76), men with an average or higher IQ who have sexually offended (MSO, N = 61) obtained significantly higher scores on static factors related with general delinquency (histories of alcohol abuse, non-violent criminality, violent criminality, and sexual offense) and dynamic factors related with sexual delinquency, paraphilia, and recidivism (chronicity, psychological coercion, escalation, sexual deviance, and substance abuse). In contrast, MIQSO obtained significantly higher scores on major mental illness, problems with planning and problems with self-awareness. Logistic regressions revealed that both the SORAG and RSVP were useful to predict group membership. It is concluded that risk factors related with general and sexual delinquency better describe offenses committed by MSO, whereas risk factors related with mental disorder, lack of insight and contextual impulsivity better describe offenses committed by MIQSO.

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.

Sexuality and Gender Issues in Individuals with Autism Spectrum Disorder

This article reviews relevant literature on sexuality in individuals with autism spectrum disorder (ASD). Findings reveal a growing awareness of desire for sexual and intimate relationships in individuals with ASD. However, core impairments of ASD lead to difficulties establishing requisite knowledge and skills necessary to attain a healthy sexuality and facilitate relationships. Consequently, individuals with ASD present with increased risk of engaging in inappropriate sexual behaviors and sexual victimization than their typically developing peers. The literature asserts the need to implement effective sexual education programs to assist in development of healthy sexual identity and relationships that meet each individual's needs.

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.

"Straight Sex is Complicated Enough!": The Lived Experiences of Autistics Who are Gay, Lesbian, Bisexual, Asexual, or Other Sexual Orientations

Autistics are more likely than neurotypicals to be gay, lesbian, bisexual, asexual, and other sexual orientations. Autistics and sexual minorities represent populations at high risk for depression, anxiety, and suicidality. Little is known about the experiences of individuals living at this intersection. In this phenomenology, 67 individuals who identified as autistic sexual minorities participated in online interviews to describe the meaning of their experiences. Six themes emerged, including: self-acceptance is a journey; autistic traits complicate self-identification of sexual orientation; social and sensory stressors affect sexual expression; feeling misunderstood and isolated; challenges finding mutually satisfying relationships; and difficulty recognizing and communicating sexual needs. Autistic sexual minorities experience a "double minority" status that complicates identity formation and increases vulnerability in sexual relationships.

Sexuality and Gender Issues in Individuals with Autism Spectrum Disorder

This article reviews relevant literature on sexuality in individuals with autism spectrum disorder (ASD). Findings reveal a growing awareness of desire for sexual and intimate relationships in individuals with ASD. However, core impairments of ASD lead to difficulties establishing requisite knowledge and skills necessary to attain a healthy sexuality and facilitate relationships. Consequently, individuals with ASD present with increased risk of engaging in inappropriate sexual behaviors and sexual victimization than their typically developing peers. The literature asserts the need to implement effective sexual education programs to assist in development of healthy sexual identity and relationships that meet each individual's needs.

Autism and Adult Sex Education: A Literature Review using the Information-Motivation-Behavioral Skills Framework

Adults on the autism spectrum report comparable levels of desire for sex and sexual satisfaction as adults who are not on the spectrum. However, there has been little empirical focus on the need for sexual and relationship-oriented education for youth on the spectrum as they transition to adulthood. In this review, we use the Information-Motivation-Behavioral Skills Model of sexual health behavior change as a lens through which to understand the experiences of adults on the autism spectrum. We present those insights infused with emerging data and best practices in the field. Overall, it appears clear from the extant literature that providers need to recognize the specific characteristics of autism when developing sexual education curricula. Specifically, the social communication and sensory profile of people on the autism spectrum appears to interact with access to information, motivation to engage in healthy sexual activities, and the development of skills needed to engage in healthy sexual behavior. Finally, the voice of adults on the spectrum is essential to guide the emerging understanding of healthy sexuality.

Autism Spectrum Disorder and Transition-Aged Youth

PURPOSE OF REVIEW

This article discusses common issues surrounding transition to adulthood in youth with autism spectrum disorder (ASD). We review recent evidence on co-occurring medical and mental health conditions and topics of education and employment, sexuality and relationships, independent living, and financial support.

RECENT FINDINGS

Transitioning individuals with ASD have increased risk for several medical and behavioral health comorbidities and should be routinely screened for co-occurring conditions. Evidence on interventions for mental health disorders is limited but emerging, particularly with respect to mindfulness training and cognitive behavioral therapy. Many autistic adults or their families express a desire for independent living, participation in education/employment, and intimacy and social relationships, but they often lack skills and/or resources to successfully achieve these outcomes. The time of transition to adulthood for adolescents with ASD is an opportunity for physicians to provide anticipatory guidance and necessary supports around issues of community participation. To allow time for planning, these discussions should occur well before the child reaches adulthood. Clinicians should also routinely screen for and address medical and/or behavioral health comorbidities.

Sexuality in autism: hypersexual and paraphilic behavior in women and men with high-functioning autism spectrum disorder

Like nonaffected adults, individuals with autism spectrum disorders (ASDs) show the entire range of sexual behaviors. However, due to the core symptoms of the disorder spectrum, including deficits in social skills, sensory hypo- and hypersensitivities, and repetitive behaviors, some ASD individuals might develop quantitatively above-average or nonnormative sexual behaviors and interests. After reviewing the relevant literature on sexuality in high-functioning ASD individuals, we present novel findings on the frequency of normal sexual behaviors and those about the assessment of hypersexual and paraphilic fantasies and behaviors in ASD individuals from our own study. Individuals with ASD seem to have more hypersexual and paraphilic fantasies and behaviors than general-population studies suggest. However, this inconsistency is mainly driven by the observations for male participants with ASD. This could be due to the fact that women with ASD are usually more socially adapted and show less ASD symptomatology. The peculiarities in sexual behaviors in ASD patients should be considered both for sexual education and in therapeutic approaches.

Sexual Orientation, Gender Identity, and Romantic Relationships in Adolescents and Adults with Autism Spectrum Disorder

This study compared sexual orientation and romantic relationship experience in a large sample of adolescents and adults with autism spectrum disorder (ASD) (n = 675) and general population peers (n = 8064). Gender identity was explored in the ASD group in relation to assigned gender at birth. Compared to general population peers, more people with ASD, especially women, reported sexual attraction to both same- and opposite-sex partners. About half of the participants with ASD was in a relationship (heterosexual in most cases) and most of them lived with their partner. A notable number of autistic participants, again more women than men, reported gender non-conforming feelings. Attention to gender identity and sexual diversity in education and clinical work with people with ASD is advised.

Autism-spectrum disorders in adolescence and adulthood: focus on sexuality

PURPOSE OF REVIEW

The combination of the core symptoms, characterizing individuals with autism-spectrum disorder (ASD), can lead to problems in romantic relationships and sexual functioning. The purpose of this article is to review studies on sexuality in individuals with ASD published since January 2016.

RECENT FINDINGS

Individuals with ASD and especially women show a higher diversity in sexual orientation in comparison with the non-ASD population. Furthermore, ASD women are more frequently in a relationship and usually report more previous sexual experiences. Up to now, sexual education programs specifically addressing the needs of the ASD population were scarce, which was criticized by patients, their parents, and caregivers. With the development of the Tackling Teenage Training program, a psychoeducational intervention designed specifically for ASD individuals was introduced, leading to significant improvements in psychosexual functioning and knowledge. Such programs are needed because a considerable rate of problematic sexual behaviors, including public masturbation and paraphilic sexual interests were found in the ASD population.

SUMMARY

Just like their typically developing counterparts, individuals with ASD show the whole range of normal-to-problematic sexual behaviors. Improving sexual knowledge could lead to less inappropriate sexual behaviors and could improve sexual health as part of a healthy and satisfying life.

Zoophilia in an adolescent with high-functioning autism from Sri Lanka

OBJECTIVE

Zoophilia is a rare paraphilic disorder with intense sexual urges involving animals. Autism is characterised by impairments in social communication and repetitive, restricted behaviours (RRB). Reported cases of zoophilia are limited worldwide, and zoophilia in autism is rarer.

METHOD

This is a case report describing this unique and relatively unrecognised association in a male adolescent from Sri Lanka.

RESULTS

A 17-year-old boy diagnosed with autism has average intelligence and academic capabilities. He had spent increasing time at his grandparents' cattle house. First, he was found masturbating near the cows and later having penetrative intercourse with a heifer. The shocked parents first sought traditional healing in the form of 'thovil', a demonic ritual of exorcist nature. Later, clinical evaluation found intense sexual urges towards cattle, which had led to marked distress and academic impairment. Sex hormone profile was normal. The adolescent was treated with a combination of cognitive-behaviour therapy and a selective serotonin reuptake inhibitor.

CONCLUSION

We postulate that his persistent social difficulties contributed to the development of a paraphilic disorder. Unlike with his RRBs, he was markedly distressed about this sexual behaviour. Further research is required to explore this rarely reported, potential association.

A randomized controlled trial to examine the effects of the Tackling Teenage psychosexual training program for adolescents with autism spectrum disorder

BACKGROUND

Previous research underscores the importance of psychosexual guidance for adolescents with autism spectrum disorder (ASD). Such guidance is provided in the Tackling Teenage Training (TTT) program, in which adolescents with ASD receive psycho-education and practice communicative skills regarding topics related to puberty, sexuality, and intimate relationships. This randomized controlled trial investigated the effects of the TTT program on (a) cognitive outcomes (i.e. psychosexual knowledge, and insight in interpersonal boundaries) and (b) behavioral outcomes (i.e. skills needed for romantic relationships and problematic sexual behavior).

METHODS

A total of 189 cognitively able adolescents with ASD, aged 12-18 years old, were randomized to an intervention condition (n = 95) or a waiting-list control condition (n = 94). We assessed outcomes using self-reported as well as parent-reported questionnaires at baseline (T1), posttreatment (T2; after 6 months), and follow-up (T3; after 12 months).

RESULTS

Linear mixed model analyses showed significant treatment effects for psychosexual knowledge and adequate insight in boundaries, both posttreatment and at follow-up. All adolescents increased significantly over time in their social responsiveness and decreased their problematic sexual behavior, irrespectively of condition. The TTT program was most effective for younger adolescents with ASD; following the TTT program resulted in higher psychosexual knowledge, and higher social functioning for these adolescents.

CONCLUSIONS

The results of this study indicate that the TTT program is effective as a psycho-educational program to provide adolescents with ASD with the knowledge and insight they need to prepare themselves for a healthy psychosexual development. Further research is needed to investigate how this increased knowledge and insight can subsequently ameliorate improvements in romantic skills and prevent the development of problematic sexual behavior and victimization.

Autism Spectrum Disorders: Challenges and Opportunities for Transition to Adulthood

Improved outcomes for individuals with autism spectrum disorder (ASD) have opened a range of potential pathways during the transition to adulthood. These include attending college, entering the labor force, and achieving a degree of independent living. Less cognitively able individuals may be eligible for state benefits and may enter supported employment programs. Those attending college require careful support and planning. Practitioners need to be familiar with the unique needs of young adults with ASD. Further research should attempt to define the priorities of individuals and families with ASD making this transition and clarify the value of existing supports and interventions.