Autism and normative sexual development: a narrative review

Investigation of Menstrual Hygiene and Self-Care Skills of Adolescent Girls with Autism Spectrum Disorder: Mother Views

PURPOSE

Puberty a period of transition from childhood to adulthood, poses problems that are difficult to manage for typically developing adolescents, but even more difficult for adolescents with autism. It is vital that girls with autism spectrum disorder (ASD), like their typically developing peers, are able to manage these physiological processes in a healthy way and learn self-care and hygiene behaviours without being dependent on others. Given the contribution of mothers to the menstrual hygiene and self-care skills of adolescent girls, this study aims to explore the views of mothers.

METHODS

The study is a case study designed in the qualitative research model. The research was carried out with the participation of 10 mothers met the necessary criteria and agreed to take part in the study voluntarily. The data obtained were subjected to descriptive and thematic analysis. Codes, sub-themes and main themes were created.

RESULTS

The research identifies the themes of self-care and menstrual hygiene, preparations made during menstruation, behavioral problems in adolescents, the person who carries out hygiene and self-care, and situations that tire/strain mothers during menstruation.

CONCLUSION

At the end of the research, it was concluded that the adolescent girls with ASD are mostly unable to perform their self-care and hygiene adequately, and that the mothers do nothing to prepare their daughters for adolescence. It was also concluded that the most stressful situation for mothers during adolescence is usually the difficulty their daughters have in using sanitary pads, cleaning armpits and genital hair, and bathing.

Perceptions of Individuals with Autism Spectrum Disorder on How Health Care Providers Address Sexual Health

OBJECTIVE

Medical providers report barriers that prevent them from discussing sexual health with patients with autism spectrum disorder (ASD). No investigations have examined the perspectives of adults with ASD about their sexual health care experiences.

METHODS

Twenty-five verbal young adults diagnosed with ASD and 40 young adults without ASD participated. An 8-item self-report survey assessed frequency of health care visits, age when sexual health was first discussed, and frequency/content of discussions with providers.

RESULTS

The likelihood of discussing sexual health topics did not differ by group, χ2s < 3.25; ps > 0.07, except sexual victimization, which the ASD group reported having discussed less than the non-ASD group (32 vs 9%), χ2 (1, N = 57) = 4.36, p = 0.04. Groups did not differ in their reported comfort level discussing sex/sexual health, having a primary care provider, or frequency of visits. The non-ASD group was significantly more likely to have received sexual health counseling (81%) than ASD group (52%), χ2 (1, N = 58) = 5.33, p = 0.02. Participants in both groups reported having received sexual health information from similar sources except the ASD group was more likely to receive information from parents than the non-ASD group (68% vs 30%), χ2 (1, N = 65) = 8.99, p = 0.003.

CONCLUSION

Participants in the ASD and non-ASD groups reported similar comfort levels with sexual health discussions and access to health providers. Yet, the ASD group received less counseling related to sexual health-particularly sexual victimization screening-suggesting that critical information may be missing. Future studies should determine how to help providers overcome barriers to providing young adults with ASD sexual health aligned with their needs.

Short report: Recommendations for education, clinical practice, research, and policy on promoting well-being in autistic youth and adults through a positive focus on sexuality and gender diversity

LAY ABSTRACT

In this article, we propose recommendations on what we can do to promote that autistic people can enjoy their sexuality and gender identity, because that contributes to overall well-being.First, we briefly summarize the existing research on sexuality and gender diversity in autistic individuals.Next, we propose recommendations for how to promote sexual and gender diversity-related health and well-being. Based on what is known about sexuality, gender diversity, and relationships in autistic adolescents and adults, we convened an international group of autistic and non-autistic researchers, advocates, parents, and professionals to develop recommendations to promote sexual and gender health in autistic people.The resulting recommendations were checked through an online survey distributed to autistic people across the world. The online participants endorsed the importance of eight final recommendations related to:1. Providing education and information on sexuality, relationships, and gender diversity to autistic individuals and their families;2. Improving expertise in and accessibility to healthcare for sexuality, relationships, and gender-related questions, with specific attention to prevention of and support after sexual victimization; and3. Meaningfully including the autism community in future research that addresses well-being relating to sexuality, relationships, and gender diversity.These community-driven recommendations aim to promote sexual health and well-being in autistic individuals internationally.

Examining maternal unmet needs and perception about autism-related services in Saudi Arabia

BACKGROUND

This study aimed to explore maternal experiences about autism services in Saudi Arabia. The main focus of the study was to gather maternal perceptions and needs about current services used for their autistic children in Saudi Arabia. The outcomes from this study will be an important source of information for service providers as parental experiences are considered as a reliable source of information about their children.

METHOD AND PROCEDURE

Data were gathered from seven focus groups with a total of twenty-nine mothers from different geographical areas in Saudi Arabia. Background data about the mothers and their family' were also collected and considered within the framework.

RESULTS

Three master themes were generated; i) maternal experiences of daily home/school provisions, ii) maternal suggestions to enhance existing services, and iii) maternal suggestions for future services. The findings from study provide with an understanding of Saudi mothers of autistic children's perception of autism provision services. This study provides data from maternal lived experiences about their needs for services, barriers and their suggestions for better services. It also provides a direction for parental and community support which ought to be initiated in Saudi Arabia to provide better family outcomes.

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.

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.

Talking About Sexuality With Youth: A Taboo in Psychiatry?

BACKGROUND

Young people who have psychiatric problems are more likely than their peers to endure difficulties during their sexual and gender identity development.

AIM

This study aims to examine the communication between mental health care providers and their patients about the topics of relations, sexuality and gender identity, including a description of professionals' attitudes toward these topics and the factors that contribute to and inhibit communication.

METHODS

Study participants (n = 242, response rate = 31%) were a representative sample of a large multicenter cohort of 768 mental health care professionals (eg, medical doctors, psychiatrists, psychologists, group counselors, parent counselors) of 7 institutions and 5 solo practices in the Netherlands, who completed a survey on communication about sexuality and gender identity with their young patients (age 12-21 years).

OUTCOMES

Sexuality and gender identity are infrequently discussed by mental health care providers with their young patients or their patients' parents.

RESULTS

Of the study sample, 99.5 % valued sexuality as an important topic to discuss with their patients. However, only 17.1% of the professionals reported that they discussed sexuality-related issues with the majority (>75%) of their patients (adolescents: 19.9%, parents: 14.4%) Additionally, only 2.3 % of the participants discussed gender nonconformity regularly with patients. Information about sexual side effects of prescribed medication was infrequently (20.3%) provided: antidepressants (40.0%), antipsychotics (34.0%), benzodiazepines (5.1%) and stimulants (2.4%). The most frequently cited reasons for not discussing these topics were a lack of awareness, own feelings of discomfort, and the patients' supposed feelings of shame. There was no gender differences observed.

CLINICAL IMPLICATIONS

Recommendations for professionals include to be aware of these topics, initiating age-appropriate conversation and use inclusive language.

STRENGTHS AND LIMITATIONS

The present study included a diverse and representative group of mental health care professionals. Frequency of sexual communication was based on self-report, which brings a risk of bias.

CONCLUSION

Despite a recognized need to engage in age-appropriate communication about sexuality and gender identity in youth mental health care, mental health providers seem to remain hesitant to discuss such topics. Bungener SL, Post L, Berends I, et al. Talking About Sexuality With Youth: A Taboo in Psychiatry?. J Sex Med 2022;19:421-429.

The sexual health, orientation, and activity of autistic adolescents and adults

Small studies suggest significant differences between autistic and nonautistic individuals regarding sexual orientation and behavior. We administered an anonymized, online survey to n = 2386 adults (n = 1183 autistic) aged 16-90 years to describe sexual activity, risk of sexually transmitted infections (STIs), and sexual orientation. Autistic individuals are less likely to report sexually activity or heterosexuality compared to nonautistic individuals, but more likely to self-report asexuality or an 'other' sexuality. Overall, autistic, and nonautistic groups did not differ in age of sexual activity onset or contraction of STIs. When evaluating sex differences, autistic males are uniquely more likely to be bisexual (compared to nonautistic males); conversely, autistic females are uniquely more likely to be homosexual (compared to nonautistic females). Thus, both autistic males and females may express a wider range of sexual orientations in different sex-specific patterns than general population peers. When comparing autistic males and females directly, females are more likely to have diverse sexual orientations (except for homosexuality) and engage in sexual activity, are less likely to identify as heterosexual, and have a lower mean age at which they first begin engaging in sexual activity. This is the largest study of sexual orientation of autistic adults. Sexual education and sexual health screenings of all children, adolescents, and adults (including autistic individuals) must remain priorities; healthcare professionals should use language that affirms a diversity of sexual orientations and supports autistic individuals who may have increased risks (affecting mental health, physical health, and healthcare quality) due to stress and discrimination from this intersectionality. LAY SUMMARY: This is the largest study on the sexual activity, orientation, and health of autistic adults. This study reaffirms that the majority of autistic adults are interested in sexual relationships and engage in sexual activity. Sexual education and sexual health screenings must remain a priority for all individuals, including those with autism; healthcare professionals should be aware that autistic patients may be more likely to identify as Lesbian, Gay, Bisexual, Trans, Queer, Asexual, and other identities not listed here (LGBTQA+) which may put them at greater risk of mental and physical health difficulties due to discrimination.

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.

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.

'Conflict versus Congruence': A Qualitative Study Exploring the Experience of Gender Dysphoria for Adults with Autism Spectrum Disorder

An emergent evidence base indicates a higher prevalence of autism exists amongst people attending gender identity clinics. This qualitative study explored adults' with autism experiences of coming to understand and address their gender dysphoria (GD). Data were collected and analysed using Grounded Theory. Ten adults with autism and GD undertook semi-structured interviews. A tentative theoretical framework of common processes involved in understanding and addressing GD for individuals with autism was developed. The experience is captured in the core category-Conflict versus Congruence. A key finding was the impact of autism as a barrier but sometimes a protective factor in participants' understanding and addressing GD. Participants appeared to achieve greater personal congruence and wellbeing upon transition. Nevertheless, conflicts remained as they navigated the social world with a continuing fear of hostility and sense of difference due to having two stigmatised identities.

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.

Insight into Informant Discrepancies Regarding Psychosexual Functioning of Adolescents with and without Autism Spectrum Disorder

The private nature of psychosexual functioning leads adolescents and their parents to have different perspectives, which highlights studying parent-child informant discrepancies in this domain. We investigated informant discrepancy in psychosexual functioning, using the self-report and parent report versions of the Teen Transition Inventory (TTI), of adolescents with autism spectrum disorder (ASD; 136 parent-child dyads) compared to adolescents from the general population (GP; 70 parent-child dyads). Significantly larger informant discrepancies exist in ASD dyads than GP dyads in most domains of psychosexual functioning, except for Body image, Sexual behavior, and Confidence in the future. It is important to use and pay attention to both informants, as discrepancies are relevant for both research and clinical practice regarding psychosexual functioning.

The Friendship Questionnaire, autism, and gender differences: a study revisited

Background

The Friendship Questionnaire (FQ) is a widely used measure of friendships in autism research and beyond. This study sought to revisit the original paper where the measure was presented, using a larger sample of both autistic and non-autistic participants to examine gender differences in scoring. It also sought to expand upon the original paper by comparing FQ results to those of the Unidimensional Relationship Closeness Scale (URCS), to examine whether there are differences in how autistic people report on their general friendships in contrast to their most significant relationships.

Methods

Participants were recruited for an online study, and 949 people (532 autistic, 417 non-autistic) aged between 18 and 81 took part. Participants completed a demographic questionnaire, the Autism Quotient-28, the Friendship Questionnaire, and the Unidimensional Relationship Closeness Scale.

Results

We used robust regressions and Pearson's correlational analyses, conducted in R. Autistic people scored lower than non-autistic people on the FQ, and similar gender differences in the pattern of FQ scores were seen in both groups. There was a significant negative correlation between AQ and FQ scores in both groups. On the URCS, we took the data from those who rated specific close relationships and found that autistic people scored this relationship more highly than non-autistic adults did. There was a significant negative correlation between AQ and URCS scores in both groups. Also, in both groups, there was a significant positive correlation between FQ and URCS scores.

Limitations

The data is entirely self-report, and diagnoses could not be verified with a clinician, although AQ scores support self-identification as autistic. Also, the groups were not evenly matched on age and other demographic variables, although this was controlled for in analyses. It is also the case that more autistic than non-autistic people were unable to specify a close relationship to score on the URCS, meaning that a certain set of experiences are not represented in this data.

Conclusions

We conclude that our data replicates the core finding of the original FQ paper that autistic people score lower on the FQ. In contrast to that paper, however, we found that there were gender differences among the autistic population. Also, our inclusion of the URCS suggests that the intimate romantic relationships and best-friendships of autistic people can be of similar quality to those of non-autistic people, suggesting that there may be important differences in autistic people's relations with friends in general versus close friends and romantic partners.

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.

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.

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.

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.

Sexual Orientation in Autism Spectrum Disorder

Clinical impressions suggest a different sexual profile between individuals with and without Autism Spectrum Disorder (ASD). Little is presently known about the demographics of sexual orientation in ASD. Sexual Orientation was surveyed using the Sell Scale of Sexual Orientation in an international online sample of individuals with ASD (N = 309, M = 90, F= 219), aged (M = 32.30 years, SD = 11.93) and this was compared to sexual orientation of typically-developing individuals (N = 310, M = 84, F= 226), aged (M = 29.82 years, SD = 11.85). Findings suggested that sexual orientation was contingent on diagnosis (N = 570, χ²₍₉₎ =104.05, P < 0.001, φ = 0.43). In the group with ASD, 69.7% of the sample reported being non-heterosexual, while in the TD group, 30.3% reported being non-heterosexual. The group with ASD reported higher rates of homosexuality, bisexuality and asexuality, but lower rates of heterosexuality. The results support the impression that non-heterosexuality is more prevalent in the autistic population. Increased non-heterosexuality in ASD has important clinical implications to target unique concerns of this population, and suggests a need for specialized sex education programs for autistic populations for increased support and awareness. Autism Res 2018, 11: 133-141. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

Research suggests that individuals with Autism Spectrum Disorder (ASD) report increased homosexuality, bisexuality, and asexuality, but decreased heterosexuality. It is important to increase awareness about increased non-heterosexuality in ASD among autistic populations, medical professionals and care-takers, so as to provide specialized care, if needed and increase support and inclusion for non-heterosexual autistic individuals.

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.

Sexuality and Autistic-Like Symptoms in Juvenile Sex Offenders: A Follow-Up After 8 Years

Juveniles who have committed a sexual offense (JSOs) are thought to have abnormal sexual development, as well as increased ASD symptoms. In the current study, sexual development and behavior, as well as stability of ASD-like symptoms were assessed in a sample of 44 male JSOs (mean age 24.7 ± 1.5 years) 8 years after their sexual offence. JSOs exhibited less knowledge of sexuality, less positive attitudes towards pornography and more often reported having been a victim of verbal sexual intimidation than a matched normal population sample. ASD symptoms were relatively stable over the 8 years follow-up, indicating that social difficulties in JSOs may be part of life-long autistic-like traits. However, ASD symptoms were not related to alterations in sexual development or behavior.

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.

Gender dysphoria and autism spectrum disorder: A narrative review

The current literature shows growing evidence of a link between gender dysphoria (GD) and autism spectrum disorder (ASD). This study reviews the available clinical and empirical data. A systematic search of the literature was conducted using the following databases: PubMed, Web of Science, PsycINFO and Scopus; utilizing different combinations of the following search terms: autism, autism spectrum disorder (ASD), Asperger's disorder (AD), co-morbidity, gender dysphoria (GD), gender identity disorder (GID), transgenderism and transsexualism. In total, 25 articles and reports were selected and discussed. Information was grouped by found co-occurrence rates, underlying hypotheses and implications for diagnosis and treatment. GD and ASD were found to co-occur frequently - sometimes characterized by atypical presentation of GD, which makes a correct diagnosis and determination of treatment options for GD difficult. Despite these challenges there are several case reports describing gender affirming treatment of co-occurring GD in adolescents and adults with ASD. Various underlying hypotheses for the link between GD and ASD were suggested, but almost all of them lack evidence.

Inappropriate sexual behaviour in adolescents with autism spectrum disorder: what education is recommended and why

AIM

Autism spectrum disorder (ASD) is a neurodevelopmental disorder impairing social skills and communication. Adolescents with ASD have sexual needs, but may not understand their physical and emotional development resulting in inappropriate sexual behaviour. The aim of this review is to describe the type of inappropriate behaviour that presents in these adolescents, explain why such behaviours occur, suggest what education is suitable and identify current gaps in research.

METHOD

The databases EMBASE, OVID MEDLINE and PSYCINFO were searched for relevant articles. In total, 5241 articles were found, with an additional 15 sources found via soft searches, of which 42 met inclusion criteria and were subsequently reviewed.

RESULTS

Sexual behaviours that occur in these adolescents with ASD include hypermasturbation, public masturbation, inappropriate romantic gestures, inappropriate arousal and exhibitionism. Such behaviours are thought to be caused via a lack of understanding of normal puberty, the absence of appropriate sex education, the severity of their ASD and other associated problems. It is suggested that individualized, repetitive education should be started from an early age in an accessible form. Social skills development is also important before more technical aspects of sex education are taught.

CONCLUSION

Despite being such a common problem for schools, institutions and families to manage, it is surprising how sparse literature is particularly regarding why inappropriate behaviour occurs and what education is effective.

Developing the DESCARTE Model: The Design of Case Study Research in Health Care

Case study is a long-established research tradition which predates the recent surge in mixed-methods research. Although a myriad of nuanced definitions of case study exist, seminal case study authors agree that the use of multiple data sources typify this research approach. The expansive case study literature demonstrates a lack of clarity and guidance in designing and reporting this approach to research. Informed by two reviews of the current health care literature, we posit that methodological description in case studies principally focuses on description of case study typology, which impedes the construction of methodologically clear and rigorous case studies. We draw from the case study and mixed-methods literature to develop the DESCARTE model as an innovative approach to the design, conduct, and reporting of case studies in health care. We examine how case study fits within the overall enterprise of qualitatively driven mixed-methods research, and the potential strengths of the model are considered.

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.

Parental romantic expectations and parent–child sexuality communication in autism spectrum disorders

This study examined the relationship between core symptoms of autism spectrum disorder, parental romantic expectations, and parental provision of sexuality and relationship education in an online sample of 190 parents of youth 12–18 years of age with a parent-reported diagnosis of autism spectrum disorder. Regression analyses were conducted separately for youth with autism spectrum disorder + parent-reported average or above IQ and youth with autism spectrum disorder + parent-reported below average IQ. For youth with autism spectrum disorder + parent-reported average or above IQ, autism spectrum disorder severity predicted parental romantic expectations, but not parental provision of sexuality and relationship education. For youth with autism spectrum disorder + parent-reported below average IQ, parental romantic expectations mediated the relationship between autism spectrum disorder severity and parent provision of sexuality and relationship education. This supports the importance of carefully considering intellectual functioning in autism spectrum disorder sexuality research and suggests that acknowledging and addressing parent expectations may be important for parent-focused sexuality and relationship education interventions.

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.

Sexuality in adolescent boys with autism spectrum disorder: self-reported behaviours and attitudes

Differences in sexual functioning of adolescents with and without autism spectrum disorder (ASD) are understudied. In the current study, self-reported sexual behaviours, interests and attitudes of 50 adolescent boys, aged 15-18, with at least average intelligence and diagnosed with ASD, were compared with a matched general population control group of 90 boys. Results demonstrated substantial similarity between the groups in terms of sexual behaviours. The only significant difference was that boys with ASD reacted more tolerant towards homosexuality compared to the control group. Results reveal that sexuality is a normative part of adolescent development in high-functioning boys with ASD. Hence, attention should be given to this topic in education and mental health care.

Common and distinct impacts of autistic traits and alexithymia on social reward

According to the social motivation hypothesis of autism, individuals with high levels of autistic traits experience reduced levels of reward from social interactions. However, empirical evidence to date has been mixed, with some studies reporting lower levels of social reward in individuals with Autism Spectrum Disorder (ASD), and others finding no difference when compared to typically developing controls. Alexithymia, a subclinical condition associated with the reduced ability to identify and describe one’s own emotions, has been found to account for other affective difficulties observed inconsistently in individuals with ASD. The current study used a nonclinical sample (N = 472) to explore the associations between autistic traits and the value of six types of social reward, as measured by the Social Reward Questionnaire. In addition, we measured alexithymia to assess if this accounted for associations between autistic traits and social reward. There were three main findings. Firstly, higher levels of autistic traits were associated with significantly less enjoyment of admiration and sociability, and adding alexithymia to these models did not account for any additional variance. Secondly, both autistic traits and alexithymia were uniquely associated with reduced levels of enjoyment of prosocial interactions and sexual relationships. Thirdly, autistic traits were associated with higher levels of enjoyment of passivity and negative social potency, but these associations were no longer significant once alexithymia was taken into account, suggesting that co-occurring alexithymia accounted for these apparent associations. Overall, the current findings provide a novel and more nuanced picture of the relationship between autistic traits and social reward.

Sexual behavior and autism spectrum disorders: an update and discussion

In the last few years, we have gained a deeper understanding about sexuality among individuals with autism spectrum disorder (ASD). Greater interest in this subject and improvements in the empirical study of ASD populations are driving this enlightenment. The data is dispelling antiquated notions that ASD individuals are asexual, sexually unknowledgeable and inexperienced, and/or disinterested in relationships. We still have a ways to go in examining paraphilic or deviant arousal sexual behaviors among ASD individuals. This manuscript provides an update on sexuality research in ASD in the last few years. This is accompanied by a discussion of the paraphilic type sexual behaviors observed among some ASD individuals.

Brain activation by an olfactory stimulus paired with juvenile play in female rats

We have previously shown that reward experienced during social play at juvenile age can be paired with artificial odors, and later in adulthood facilitate olfactory conditioned partner preferences (PP) in female rats. Herein, we examined the expression of FOS immunoreactivity (FOS-IR) following exposure to the odor paired with juvenile play (CS+). Starting at day P31 females received daily 30-min periods of social play with lemon-scented (paired group) or unscented females (unpaired group). At day P42, they were tested for play-PP with two juvenile males, one bearing the CS+ (lemon) and one bearing a novel odor (almond). Females were ovariectomized, hormone-primed and at day P55 tested for sexual-PP between two adult stud males scented with lemon or almond. In both tests, females from the paired group displayed conditioned PP (play or sexual) toward males bearing the CS+. In the present experiments females were exposed at day P59 to the CS+ during 60 min and their brains processed for FOS-IR. One group of female rats (Play+Sex) underwent play-PP and sexual-PP, whereas a second group of females (Play-only) underwent exclusively play-PP but not sexual-PP. Results showed that in the Play-only experiment exposure to the CS+ induced more FOS-IR in the medial prefrontal cortex, orbitofrontal cortex, dorsal striatum, and ventral tegmental area as compared to females from the unpaired group. In the Play+Sex experiment, more FOS-IR was observed in the piriform cortex, dorsal striatum, lateral septum, nucleus accumbens shell, bed nucleus of the stria terminalis and medial amygdala as compared to females from the unpaired group. Taken together, these results indicate mesocorticolimbic brain areas direct the expectation and/or choice of conditioned partners in female rats. In addition, transferring the meaning of play to sex preference requires different brain areas.