Sexual behavior and autism spectrum disorders: an update and discussion

Influence of environmental enrichment on sexual behavior and the process of learning and memory in a rat model of autism with valproic acid

Autism spectrum disorder (ASD) is a psychiatric disorder with severe behavioral consequences and no specific therapy. Its etiology is multifactorial, as it is caused by a complex interaction of genetic and environmental factors. In rats, prenatal exposure to the antiepileptic drug valproic acid (VPA) has been associated with an increased risk of autistic-like behaviors in offspring, including social behavior deficits, increased repetitive behaviors, and cognitive impairments. In addition, VPA-treated rats have shown altered sociosexual behaviors. However, the mechanisms underlying these alterations in reproductive processes in VPA-treated rats are not fully understood. Interestingly some abnormal behaviors in VPA autism models are improved by an enriched environment (EE). In the present study, we examined the effects of EE on memory performance and sexual behavior in male rats. We found that on postnatal day 90, EE reduced the time it took for both control and VPA-treated groups to find a hidden platform in the Morris water maze. On PND 100, prenatal exposure to VPA reduced total exploring time in object recognition tests. On PND 110, EE reduced mount and intromission latency and increased ejaculatory frequency in VPA-treated male rats. These results suggest that environmental stimuli significantly influence the onset of sexual behavior in VPA-treated male rats and that EE may be a potential tool for improving a variety of behavioral deficiencies in rodent models of autism.

"Comforting, Reassuring, and…Hot": A Qualitative Exploration of Engaging in Bondage, Discipline, Domination, Submission, Sadism and (Sado)masochism and Kink from the Perspective of Autistic Adults

Background

There is a lack of research on autistic intimacy; however, a small body of research suggests that bondage, discipline, domination, submission, sadism and (sado)masochism (BDSM)/kink may be appealing to autistic people. We aimed at exploring how engagement in BDSM/kink related to autistic identity, using a phenomenological approach.

Methods

We recruited six autistic adults through purposive sampling on social media. All participants took part in a one-to-one spoken interview about their engagement in BDSM/kink and how it related to their sense of identity.

Results

We used interpretative phenomenological analysis to analyze the data and found three key themes. Theme 1, "Practicing safe 'sex'" highlighted how the clear communication and explicit focus on consent present in BDSM/kink facilitated a feeling of safety. Theme 2, "So many ways to touch and be touched" was focused on the sensory draw of BDSM/kink, and how it provided exciting ways to explore sensory joy (and sometimes revulsion). Theme 3, "Subverting (neuro)normativity" showed how autistic people can find pleasure in intimate practices that transgress normative expectations.

Conclusion

Our findings highlighted the importance of exploring the perceptions of autistic adults in relation to their own intimate practices. Autistic intimacy is an emerging area of research, with very little focus on lived experience. Although engagement in BDSM/kink may appear niche, our findings suggest that there are aspects which are inherently appealing to autistic people. These findings can be used to destigmatize both autistic intimacy and engagement in alternative intimate practices more broadly.

The Novel Somatosensory Nose-Poke Adapted Paradigm (SNAP) Is an Effective Tool to Assess Differences in Tactile Sensory Preferences in Autistic-Like Mice

One of the most prevalent deficits in autism spectrum disorder (ASD) are sensitivities to sensory stimuli. Despite the prevalence of sensory deficits in autism, there are few paradigms capable of easily assessing sensory behaviors in ASD-like mouse models. We addressed this need by creating the Somatosensory Nose-poke Adapted Paradigm (SNAP), which consists of an elevated platform with 6 holes in the center, half of which are lined with sandpaper and half are smooth, requiring mice to use their whiskers to sense the texture. The SNAP paradigm assesses tactile sensory preferences as well as stereotypy, anxiety, and locomotion. We used two wild-type (neurotypical) mouse strains, C57BL/6J (C57) inbred and CD-1 outbred mice, and two ASD mouse models, BTBR (a model of idiopathic ASD) and Cntnap2 -/- mice (a model of syndromic ASD). We found that both ASD models produced more nose pokes into the rough condition than the smooth condition, suggesting an increased preference for complex tactile stimulation when compared with the neurotypical groups, wherein no differences were observed. Furthermore, we found increased stereotypy and time spent in the center, suggestive of decreased anxiety, only for BTBR mice compared with the other mouse strains. Overall, SNAP is an easy to implement task to assess the degree of preference for complex tactile stimulation in ASD mouse models that can be further modified to exclude possible confounding effects of novelty or anxiety on the sensory preferences.

Mapping the Physical Language of Children Diagnosed with Autism: A Preliminary Study

Children diagnosed with autism spectrum disorder have a unique motor profile, characterized by, for example, unusual posture or compulsive use of the body. However, not much is known about specific characteristics of their physical language, such as their movement direction, their self-touch pattern, etc., and even less is known about these characteristics with regard to their typically developing siblings. In this first of its kind study, we attempted to map the physical language of children diagnosed with autism spectrum disorder and to compare it to their typically developing siblings. To this end, we recruited 12 pairs of siblings, comprising one sibling with a diagnosis of autism and one sibling who is typically developing. The siblings were asked to play for 10 min and were videotaped throughout the interaction. We evaluated the siblings' physical language using Laban's movement analysis. We found significant and substantial differences between the physical language of the children diagnosed with autism and their typically developing siblings. The results are discussed in terms of the implications of the differences in physical language between the two populations and how movement analysis could be important for interventions in order to improve the communication and social abilities of ASD children.

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.

Flexibility of neural circuits regulating mating behaviors in mice and flies

Mating is essential for the reproduction of animal species. As mating behaviors are high-risk and energy-consuming processes, it is critical for animals to make adaptive mating decisions. This includes not only finding a suitable mate, but also adapting mating behaviors to the animal's needs and environmental conditions. Internal needs include physical states (e.g., hunger) and emotional states (e.g., fear), while external conditions include both social cues (e.g., the existence of predators or rivals) and non-social factors (e.g., food availability). With recent advances in behavioral neuroscience, we are now beginning to understand the neural basis of mating behaviors, particularly in genetic model organisms such as mice and flies. However, how internal and external factors are integrated by the nervous system to enable adaptive mating-related decision-making in a state- and context-dependent manner is less well understood. In this article, we review recent knowledge regarding the neural basis of flexible mating behaviors from studies of flies and mice. By contrasting the knowledge derived from these two evolutionarily distant model organisms, we discuss potential conserved and divergent neural mechanisms involved in the control of flexible mating behaviors in invertebrate and vertebrate brains.

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.

The Mental Capacity Act 2005 and autoerotic asphyxiation: pleasure versus the risk of harm

There has been a series of judgments in recent years emanating from the Court of Protection in England and Wales involving sexual relations. One such judgment is unique in that it is the first time the court has assessed capacity in the sexual practice of autoerotic asphyxiation in a person with a diagnosis of autism spectrum disorder. This article reviews the judgment and specifically the key section of the Mental Capacity Act 2005, section 27, which applies to capacity decisions in the context of family relationships, including sexual relationships. The practice of autoerotic asphyxia can be a complex and emotive subject and dangerous to individuals undertaking it. The judgment provides guidance and a framework for applying the Act to assess the capacity of someone practising autoerotic asphyxia that can be used in clinical practice for people with any mental disorder.

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.

Therapy outcomes for neurodiverse couples: Exploring a solution-focused approach

The need for clinical approaches that address romantic relationship concerns of adults with autism spectrum disorder (ASD) has been essentially overlooked. There are a growing number of recommendations in the available literature to increase the availability and evaluation of treatment approaches that are appropriate for couples that include an adult with ASD. The aim of the present study was to explore clinical outcomes of a neurodiverse couple who participated in twelve sessions of solution-focused brief therapy. Our findings indicated both partners experienced improvement in the target complaints, communication and emotional awareness. On the other hand, each partner had a different trajectory of change in relationship satisfaction over the course of treatment. Directions for future research and implications for couple therapy with adults diagnosed with ASD are discussed.

Autistic Narratives of Sensory Features, Sexuality, and Relationships

Background

Research about the experience of sexuality and intimacy for autistic people has largely excluded the potential influences of autistic sensory features, which are highly common. The aim of this study was to explore how autistic sensory features influence autistic people's experiences of sexuality and relationships, including the impact of low and high neurological threshold sensory patterns and regarding specific sensory modalities.

Methods

Utilizing a qualitative approach, we explored autistic people's perspectives about the influences of sensory features on their experiences of sexuality and relationships through existing publicly available narratives (5 books and 13 online forums containing messages from 72 unique usernames) and responses to an open-ended survey question (N = 49). We used deductive coding based on Dunn's model of sensory processing, as well as inductive coding to identify additional themes about autistic sensory features and sexuality.

Results

Our findings indicated that sexual and relationship experiences were related to both sensory sensitivity and sensation seeking (i.e., low and high threshold sensory patterns) across several sensory modalities, including touch, sight, sound, and smell. Sensory features influenced autistic people's sexual and relationship experiences in both positive and negative ways. Examined narratives revealed adaptations and strategies used by autistic people to enhance or enable engagement in sexual activity as well as implications for their sexual identity.

Conclusions

Sensory features and their impact on the sexuality and relationship experiences of autistic people should be considered in clinical practice and educational programming. More research is needed to further understand the impact of autistic sensory features on experiences of sexuality and relationships, and to develop effective strategies to promote safe and satisfying engagement, when desired.

Lay summary

Why was this study done?: Autistic people often respond to sensations differently than other people, including being more sensitive to sensations and/or wanting more intense sensations (called "autistic sensory features" in this study). Many aspects of sexuality and relationships involve sensory input. However, we do not know much about how autistic sensory features influence sexuality and relationships for autistic people.What was the purpose of this study?: The purpose of this study was to explore how autistic sensory features influence autistic people's experiences of sexuality and relationships.What did the researchers do?: For this study, we used two different sources of data. The first was existing publicly available things written by autistic people, including books and posts on online forums. The second was answers provided on a survey question asking about autistic sensory features and sexuality. Overall, we looked at things written by over 120 autistic people. We reviewed all the information to explore what kinds of sensory responses (e.g., sensitivities and sensation seeking) and sensory modalities (e.g., touches, sights, sounds, and smells) they wrote about. We also looked more generally to see how autistic people described the ways that autistic sensory features influenced their sexuality and relationship experiences.What were the results of the study?: Our findings show that in the information we accessed, autistic people did write about how sensory features influence their sexual and relationship experiences. Some people who have sensory sensitivities described confusion, distress, and frustration with sexual experiences. Despite wanting to participate, people with sensitivities described negative reactions to many of the sights, sounds, smells, and textures that were involved in dating and sexual activities. Other people indicated that they avoided sexual activity because of their sensory features. However, we also found that some autistic people seek out more intense sensations in their sexual activities, and others that enjoy intimacy that promotes calming and self-regulation. People wrote about strategies they use in response to their autistic sensory features, such as communication with partners and the use of substances to dull sensations.What do these findings add to what was already known?: There has not been much published research on this topic, so this study is a starting place. In books, as well as in online discussion boards, autistic people have been discussing the importance of sensory features to their sexuality and relationships. We accessed that information, and used theory and clinical experience to analyze their writings and help identify what other research is needed.What are potential weaknesses in the study?: We used text already written by autistic people and responses on one survey question for this study. Therefore, we may not have gained a complete understanding of the ways that autistic sensory features influence sexuality and relationship experiences.How will these findings help autistic adults now or in the future?: This study contributes to greater understanding of how autistic traits affect sexuality and relationships for autistic people. That information can be used to develop effective education and resources for autistic people, families, and service providers.

Health-related risky behaviors in Chinese adolescents with autism: a cross-sectional study

BACKGROUND

Health-related risky behaviors (HRB) generally refer to behaviors that have a negative influence on health and quality of life. HRB in adolescents with autism have not been well understood so far. We aim to explore health-related risky behaviors and their risk factors with autistic adolescents.

METHODS

In this study, 150 adolescents with autism and 150 neurotypical adolescents were enrolled. Participants in both groups completed the Adolescent Health-Related Risky Behavior Inventory (AHRBI). Autism Spectrum Screening Questionnaire (ASSQ), Wechsler Intelligence Scale, Theory of Mind (ToM) Test, Zung Self-rating Anxiety Scale (SAS), Zung Self-rating Depression Scale (SDS), and Self-Esteem Scale (SES) were also assessed in the autism group to explore risk factors.

RESULTS

The results showed that the total score of AHRBI and scores of "aggression and violence (AV)", "suicide or self-injury (SS)", "health-compromising behavior (HCB)", and "unprotected sex (US)" subscales in the autism group were significantly higher than those in the control group (Z value = - 4.58 ~ - 2.26, all P < 0.05). Anxiety, depression, low self-esteem, low IQ score, low ToM test score, increasing age, and communication disorder were found as risk factors for health-related risky behaviors in autistic adolescents.

CONCLUSIONS

Adolescents with autism have more health-related risky behaviors than neurotypical adolescents. We should pay attention to the emotional state, self-esteem, cognitive function, and verbal communication levels of autistic adolescent with health-related risky 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.

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.

Social Capital and Autism in Young Adulthood: Applying Social Network Methods to Measure the Social Capital of Autistic Young Adults

Social isolation is a core challenge associated with autism. Interpersonal relationships and the resources and support embedded in the social networks of autistic young adults could impact key adult outcomes, including quality of life, mental health, employment, and independence. However, little research systematically measures the networks of autistic young adults and network impact on key adult outcomes. This article demonstrates how social network analysis can be adapted for the field of autism to measure young adult networks. We provide examples as to how this approach could be implemented to yield key insights into the amount and quality of interpersonal relationships and the types of resources embedded in the networks of autistic young adults. The network protocol was feasibility tested with autistic adults during the posthigh school transition period (n = 17, 19–27 years). The parents of three of the recruited young adults also successfully completed a complementary network survey, allowing for the inclusion of the parent-reported network using duocentric network analysis, never before applied to parent–child networks. The implementation data collected from the study suggest feasibility of egocentric and duocentric approaches, with several important modifications to adapt the measure for the field of autism. The future potential of social network research for understanding autism in adulthood is discussed.

What was the purpose of this study?

Many autistic young adults are disconnected from people, communities, and organizations that could provide them with valuable social resources to support their transition to adulthood. This study tests the feasibility of using social network methods to measure the resources that autistic young adults gain from their social connections. Future studies using our social network measure might provide valuable information about possible interventions that could help autistic youth acquire the social resources needed for successful adult outcomes.

What did the researchers do?

To test the feasibility of our social network measure, 17 autistic adults, between the ages of 19 and 27 years, were recruited to complete a survey about their social connections and the resources provided to them by their social connections. The parents of three of the autistic adults were also surveyed to provide information about the social connections that they relied on to help their autistic young adult to transition successfully.

What were the results of the study?

All participants successfully completed our survey online. We analyzed the network data to illustrate what types of information the survey produced. We demonstrated how the survey captures different types of support that people gained from their networks. We also used network pictures to show how network measures characterize connections among supporters of autistic young adults. This research successfully lays the groundwork for future studies to test whether the social resources young adults on the autism spectrum receive from their networks impact their adult outcomes.

What do these findings add to what is already known?

We know very little about the social networks for young adults on the autism spectrum. Also, no studies have used duocentric network analysis to measure the social capital of youth and their parents together. This project produced new useful ways of collecting social network data from young autistic adults that will produce knowledge about how to help young adults on the autism spectrum build networks that will yield the social resources needed to support positive adult outcomes.

What are potential weaknesses of this study?

The study was only designed to test the feasibility of the social network measure and does not provide generalizable information about how networks might impact outcomes. Also, the social network measure only allowed participants to identify five people, possibly under-reporting the actual size and composition of autistic young adult networks.

How will these findings help young adults on the autism spectrum now or in the future?

If future research suggests that social network factors help young adults on the autism spectrum to improve outcomes, then network interventions, guided by social network data, can be created.

Parent-Child Concordance on the Pubertal Development Scale in Typically Developing and Autistic Youth

BACKGROUND

Characterizing puberty in autism spectrum disorder (ASD) is critical given the direct impacts of pubertal progression on neural, cognitive, and physical maturation. Limited information is available about the utility and parent-child concordance of the self-report and parent-report Pubertal Development Scale (PDS) in ASD, an economical and easily administered measure.

METHOD

The primary aim of this study was to examine the concordance between self-report and parent-report PDS ratings in autistic males and females ages 8-17y compared to typically developing (TD) youth, including using the PDS to derive informant-based estimates of adrenal and gonadal development. We hypothesized that there would be greater parent-youth discrepancies in pubertal ratings among autistic males. Our second aim was exploratory; we examined whether individual characteristics impact PDS concordance and hypothesized that lower intellectual and adaptive skills, higher autistic traits, and reduced self-awareness/monitoring would correlate with lower concordance.

RESULTS

There were no significant diagnostic group differences in parent-youth concordance for overall PDS scores among males and females. Autistic males had significantly lower inter-item agreement with their parents than TD males and had lower agreement for both adrenal and gonadal aspects of pubertal maturation (adrenal κ=.48; gonadal κ=.55).

CONCLUSIONS

The PDS is a feasible measure in ASD. Greater parent-youth discrepancies in autistic males may be due to reduced parental awareness or reduced insight into pubertal maturation among autistic males. Future research is needed to further elucidate individual and/or environmental characteristics that influence youth- and parent-reported PDS scores, including differences in self-perception and insight.

Family Sexuality Communication: Parent Report for Autistic Young Adults Versus a Comparison Group

Families are a critical context for healthy sexuality development. This study characterized family sexuality communication for autistic adults (age 18-30) without intellectual disability (n = 117) versus a neurotypical comparison group (n = 319). Parent-reported number of sexuality topics covered did not significantly differ by gender or autism/comparison group. Parents of autistic adults who covered few or no topics (31%) reported higher religiosity, lower comfort and self-efficacy, and were less likely to say that the adult expressed attraction or desire for relationships. Parents of autistic adults were more likely than comparison parents to perceive their young person as being uninterested or not ready to learn about sexuality topics. These results suggest that families of autistic people require support to convey sexuality-related knowledge and values.

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.

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.

The prevalence of mental disorders and patterns of comorbidity within a large sample of mentally ill prisoners: A network analysis

BACKGROUND

Comorbidity has profound implications in both the clinical field and research, yet little is known about the prevalence and structure of comorbid mental disorders. This article aims not only to present data on the prevalence of mental disorders and comorbidity, but also to explore relationships between comorbid mental disorders by using a network approach.

METHODS

Data used in this cross-sectional study are part of a prospective cohort study within penitentiary psychiatric centers (PPCs) in the Netherlands. It includes DSM diagnoses of 5,257 unique male patients incarcerated in one of the PPC's. Prevalence rates of mental disorders and comorbidity were calculated, the network of comorbid DSM diagnoses was constructed using regression coefficients.

RESULTS

Schizophrenia spectrum and substance-related disorders were most prevalent within this sample (56.7 and 43.1%, respectively), and over half of all patients were diagnosed with a comorbid disorder (56.9%). Four distinctive groups of disorders emerged from the network analysis of DSM diagnoses: substance use, impulsivity, poor social skills, and disruptive behaviors. Psychotic disorders were considered as a separate group as it was unconnected to other disorders.

CONCLUSIONS

Comorbid mental disorders can be described, at least in part, as connected networks. Underlying attributes as well as direct influences of mental disorders on one another seem to be affecting the presence of comorbidity. Results could contribute to the understanding of a possible causal relation between psychopathology and criminal behavior and the development of treatment programs targeting groups of disorders.

Sexual and Relationship Interest, Knowledge, and Experiences Among Adolescents and Young Adults with Autism Spectrum Disorder

Little research exists to describe sexual and romantic relationships among adolescents and young adults with autism spectrum disorder (ASD) from their perspectives. Sexuality and intimacy are developmentally important and influence health and quality of life for all adolescents and young adults, including those with ASD. This study explored and compared the sex and relationship experiences of 27 adolescents and young adults with ASD (males = 20). Adolescents and young adults participated in semi-structured interviews to explore this topic. Using theme analysis, we uncovered four thematic categories: (1) interest in relationships, (2) ideal partners, (3) realities of adolescent and young adult relationships, and (4) advice about sex and relationships. Although many adolescents and young adults expressed wanting a relationship, few reported having partners. Among those that did, their actual relationships rarely met ideals. Most adolescents and young adults talked with parents and friends but not healthcare providers about sex and relationships. All adolescents and young adults described the need for additional education. Adolescents and young adults express the need for education that covers basic safety and sexual health topics as well as social/relationship skills building and courtship modeling. These findings can inform the design of tailored sexual health intervention. Future research should examine specific issues related to sexuality from the adolescents' and young adults' perspectives.

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.

Feasibility and preliminary efficacy of a parent-mediated sexual education curriculum for youth with autism spectrum disorders

Youth with autism spectrum disorder can face social-communication challenges related to sexuality, dating, and friendships. The purpose of this study was to assess the feasibility, acceptability, and preliminary efficacy of the Supporting Teens with Autism on Relationships program. In total, 84 youth with autism spectrum disorder aged 9 to 18 and their parents participated in this study; two groups received the Supporting Teens with Autism on Relationships program (interventionist-led parent group vs parent self-guided), while an attentional control group received a substance abuse prevention program that included instruction in problem-solving and social skills. Feasibility and acceptability of the Supporting Teens with Autism on Relationships program was high overall. The Supporting Teens with Autism on Relationships program was effective in increasing parent and youth knowledge of sexuality, while the attentional control was not. There was preliminary support for improvement in parenting efficacy related to discussing sexuality with their children. Gains were seen among completers regardless of whether the parent received support from a facilitator. Implications and future directions are discussed.

A Qualitative Comparison of Caregiver and Youth with Autism Perceptions of Sexuality and Relationship Experiences

OBJECTIVES

Caregivers play a critical role in educating their youth with autism about sex and relationships; yet, we know little about caregivers' ability to deliver this support, youth's perspectives, or the congruence of youth and caregiver experiences. To help fill this gap, we explored and compared the perspectives of caregivers and their youth with autism spectrum disorder about and interactions regarding sex and relationships.

METHODS

We conducted qualitative one-on-one interviews with youth (n = 27) and focus groups with their caregivers (n = 29). A semi-structured guide elicited information from both the groups about the youth's physical, emotional, and social transition to adulthood. Thematic analysis, including coding and analytical memos, identified key themes within and across youth and caregiver discussions about sex and relationships.

RESULTS

Thematic analysis of interviews revealed overarching themes about companionship, interest and experience, and access to sexual information across both the groups. Themes included different nuances among caregivers and youth, however. Caregivers expressed more future-oriented concerns than youth and overestimated their knowledge of their youth's interest and experience with sex and comfort confiding in caregivers. Youth described relationships and information sources of which their caregivers were unaware.

CONCLUSION

Interventions for both caregivers and youth can support healthy and safe intimate relationships among youth with autism spectrum disorder. By comparing youth and caregiver dialogues, this study adds to what we know, and it can be used to develop a blueprint for improving communication patterns that not only include but also extend well beyond sexual health.

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.

Psychosexual Functioning of Cognitively-able Adolescents with Autism Spectrum Disorder Compared to Typically Developing Peers: The Development and Testing of the Teen Transition Inventory- a Self- and Parent Report Questionnaire on Psychosexual Functioning

To gain further insight into psychosexual functioning, including behaviors, intrapersonal and interpersonal aspects, in adolescents with Autism Spectrum Disorder (ASD), comprehensive, multi-informant measures are needed. This study describes (1) the development of a new measure of psychosexual functioning in both parent- and self-reports (Teen Transition Inventory; TTI) covering all three domains of psychosexual functioning (i.e. psychosexual socialization, psychosexual selfhood, and sexual/intimate behavior). And (2) the initial testing of this instrument, comparing adolescents with ASD (n = 79 parent-report; n = 58 self-report) to Typically Developing (TD) adolescents (n = 131 parent-report; n = 91 self-report) while taking into account gender as a covariate. Results from both informants indicate more difficulties regarding psychosexual socialization and psychosexual selfhood in the ASD group. With regard to sexual/intimate behavior, only parents reported significantly more problems in adolescents with ASD.

A psycho-legal perspective on sexual offending in individuals with autism Spectrum disorder

It is important to consider whether there are innate vulnerabilities that increase the risk of an individual with an autistic spectrum disorder (ASD), predominantly those defendants with a diagnosis of Asperger's Syndrome, being charged and convicted of a sexual offence. The significance of such can be readily seen in recent English case law, with judgments on appeal finding convictions unsafe where there have been a number of failings in the Judge's summing up. In this article, we will consider the gravity of Judges omitting to highlight a defendant's diagnosis of autism spectrum disorder and the necessity of detailed explanations to jury members regarding the condition and its effect upon thoughts and behaviour. Consideration will be specifically given to the necessity to prove sexual motivation in such offences and the judicial direction required in relation to whether the appellant's actions had been sexually motivated. Recognition of the social impairments inherent in ASDs are vital to this work and we shall consider whether the difficulty with the capacity to develop appropriate, consenting sexual relationships as a result of impaired social cognition may be one of the factors which increases the risk of sexual offending in individuals with ASD (Higgs & Carter, 2015).

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.

Childhood animal cruelty, bestiality, and the link to adult interpersonal violence

Animal cruelty has been a concern of the legal and psychiatric communities for many years. Beginning in the early 1800s, state legislatures in the United States established laws to protect the basic safety and security of animals in their jurisdictions. Legislatures have differed in opinion on the animals to receive protection under the law and have instituted differing penalties for infractions of anti-cruelty measures. In the 1960s, the psychiatric community took notice of childhood animal cruelty as a potential risk factor for violent acts against humans. Since that time there has been increasing evidence that children who engage in animal cruelty may be at increased risk of interpersonal offenses in adulthood. Less is known about children and adults who engage in bestiality and the potential risk that these individuals may pose for interpersonal sexual or nonsexual violent acts. We review the legal status of animal cruelty in the United States, summarize the history of psychiatric interest in and research of animal cruelty, describe current knowledge regarding the link between animal cruelty and violence, and propose a novel classification scheme for individuals who engage in bestiality to assist forensic psychiatric examiners in determining the risk that such behavior poses for future interpersonal offending.

Medical Therapy for Inappropriate Sexual Behaviors in a Teen With Autism Spectrum Disorder

Teens with autism spectrum disorder often exhibit sexual behaviors in public that are disturbing to parents, teachers, and peers. Some have proposed that such behaviors can be curtailed with hormonal suppression. There is information on the Internet suggesting that such medications work, and some reports in the peer-reviewed medical literature support these claims. Such medications can have serious side effects. In this paper, we present a case in which parents requested such treatment of their teenage son with autism spectrum disorder.

Adolescent boys with an autism spectrum disorder and their experience of sexuality: An interpretative phenomenological analysis

This qualitative study explored how adolescent boys with autism spectrum disorder experience their sexuality. Previous research has demonstrated that sexuality is a developmental task for boys with autism spectrum disorder, as it is for their peers. Case studies have suggested a relation between autism spectrum disorder and atypical sexual development; empirical studies on this subject, however, are scant and inconsistent. This study is based on interviews with eight boys, aged 16-20 years, with Asperger's disorder or autistic disorder. Interpretative phenomenological analysis of the data revealed three major themes relating to (a) how they experience sexual feelings, think about sexuality and think about themselves as sexual beings; (b) how they perceive messages relating to sexuality in their surroundings; and (c) how they experience finding and having a partner and partnered sex. We believe that attention to these themes is needed in assessment, education and further research.

Adolescent boys with autism spectrum disorder growing up: follow-up of self-reported sexual experience

Systematic research on sexual development in adolescents with autism spectrum disorder (ASD) remains scant, notwithstanding the often-suggested relation between ASD, atypical, and even sexually offensive behaviours. This study compared follow-up data related to lifetime sexual experience (LTSE) in a homogeneous group of adolescent boys with ASD (n = 30), aged 16-20, with a matched group of boys in the general population (n = 60). Most boys in the ASD and control groups reported masturbation and having experienced an orgasm. The proportion of boys with ASD that had no partnered sexual experience was larger than in the control group. This difference was mostly explained by significantly fewer boys with ASD, compared with controls, who reported experience with kissing and petting; no significant differences emerged relating to more intimate partnered sexual experiences. The results suggest the existence of a subgroup of boys who have not (yet) entered the arena of partnered sexual experiences-a finding in line with research in adult samples. There were no differences relating to sexual abuse or coercion. Exploration of the partnered experiences revealed a variety of types of partners, mostly of comparable age. Several boys with ASD had not anticipated their sexual debut. Although they felt ready for it, some boys reported regret afterward. The hypothesised sexual developmental trajectories are subject to further research, but the sexual experience in this sample and the assumed developmental differences indicate the need for early, attuned, and comprehensive sexuality-related education and communication.

Study protocol: a randomized controlled trial investigating the effects of a psychosexual training program for adolescents with autism spectrum disorder

BACKGROUND

Previous research shows that adolescents with autism spectrum disorder (ASD) run several risks in their psychosexual development and that these adolescents can have limited access to reliable information on puberty and sexuality, emphasizing the need for specific guidance of adolescents with ASD in their psychosexual development. Few studies have investigated the effects of psychosexual training programs for adolescents with ASD and to date no randomized controlled trials are available to study the effects of psychosexual interventions for this target group.

METHODS/DESIGN

The randomized controlled trial (RCT) described in this study protocol aims to investigate the effects of the Tackling Teenage Training (TTT) program on the psychosexual development of adolescents with ASD. This parallel clinical trial, conducted in the South-West of the Netherlands, has a simple equal randomization design with an intervention and a waiting-list control condition. Two hundred adolescents and their parents participate in this study. We assess the participants in both conditions using self-report as well as parent-report questionnaires at three time points during 1 year: at baseline (T1), post-treatment (T2), and for follow-up (T3).

DISCUSSION

To our knowledge, the current study is the first that uses a randomized controlled design to study the effects of a psychosexual training program for adolescents with ASD. It has a number of methodological strengths, namely a large sample size, a wide range of functionally relevant outcome measures, the use of multiple informants, and a standardized research and intervention protocol. Also some limitations of the described study are identified, for instance not making a comparison between two treatment conditions, and no use of blinded observational measures to investigate the ecological validity of the research results.

TRIAL REGISTRATION

Dutch Trial Register NTR2860. Registered on 20 April 2011.