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

Exploring social touch in autistic and non-autistic adults via a self-report body-painting task: The role of sex, social context and body area

LAY ABSTRACT

What is already known about the topic?At least in neurotypical individuals, social touch represents an important channel for emotional communication associated with social bonding and pain/anxiety modulation. Autistic adults report to avoid social touch more and to have different tactile sensitivity than their non-autistic comparisons.What this paper adds?Few studies specifically investigated social touch in autistic individuals, and none of them examined the role of participants' sex, social context in which social touch occurs, and specific body areas being touched. In our study, adult participants reported how pleasant, erogenous and appropriate they would consider touches delivered by another person over their entire body in intimate (date), friendly (dance class) and professional (physiotherapy-massage session) social contexts. Autistic adults reported social touch to be less pleasant, erogenous and appropriate specifically in intimate and friendly social contexts and in body areas typically touched in these situations. Importantly, autistic females seem more at risk to experience unpleasant social touch as, although they considered it more unpleasant than non-autistic females and autistic males, they did consider it similarly appropriate in professional social contexts where touch is normed to be socially appropriate.Implications for practice, research or policyOur results might improve awareness and understanding about autistic adults' different, and often more discomforting, experience of social touch and thus help consider and respect it during everyday social interactions. Our results might also benefit future research investigating, for instance, the neural underpinnings of social touch differences in autism or aiming at developing support for autistic individuals seeking help in the diverse spheres of social touch.

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.

Research methods at the intersection of gender diversity and autism: A scoping review

LAY ABSTRACT

Research has increasingly focused on the intersection between gender diversity and autism. To better understand this literature, this scoping review systematically searched five databases for peer-reviewed literature on gender diversity and autism published between 2018 and 2023. Included studies (N = 84) were of English language, featured original qualitative or quantitative findings, and examined a psychosocial connection between autism and gender spectra variables. Most studies focused on measuring prevalence of autism among gender-diverse individuals. While the overall study rigor was acceptable, weaknesses in measurement, sample selection, and definition of key terms were noted. Promisingly, studies in this area appear to be shifting away from a pathologizing lens and towards research methods that engage in meaningful collaboration with the autistic, gender-diverse community to investigate how to best enhance the quality of life and wellbeing of this population.

Perspectives of autistic adolescent girls and women on the determinants of their mental health and social and emotional well-being: A systematic review and thematic synthesis of lived experience

LAY ABSTRACT

Difficulties with mental health and low levels of well-being are more common among autistic girls and women than non-autistic people, but we do not fully understand why. Research does not focus enough on what autistic girls and women could tell us about this. This review aims to summarise the studies where autistic girls and women explain things that affect their mental health and well-being to help us understand how to prevent these difficulties from developing. Three research databases were searched to find possibly relevant studies. There were 877 studies found, which two researchers screened according to particular criteria. They found 52 studies that could be included in this review. One researcher evaluated the quality of these studies and extracted the key information from them. This review summarises the views of 973 autistic girls and women aged between 13 and 70+. The findings from the 52 studies were analysed, and we found many factors that affect the mental health and well-being of autistic girls and women. These factors fall into two categories: (1) difficulties living in a world not designed for autistic people and (2) the impact of stigma due to being autistic.

Theoretical-Methodological Foundations for the Global Integration Method (Método de Integração Global-MIG) in the Treatment of Autism Spectrum Disorder

Currently, there is no intervention model for autism spectrum disorder (ASD) that addresses all levels and factors of the International Classification of Functioning, Disability and Health (ICF, WHO). The most researched programs focus on naturalistic, developmental and behavioral approaches to socio-communication. Less attention has been paid to motor and environmental reactivity aspects (behavior/interest restriction and sensory reactivity). The evidence rationale for the Global Integration Method (MIG, "Método de Integração Global"), a model addressing sensorimotor reactivity in addition to socio-communication, is presented. MIG is an integrative, interdisciplinary, family-oriented intervention and naturalistic program that addresses all levels and moderating factors of ASD's impact. MIG's theoretical rationale is based on the predictive coding impairment and embodied cognition hypotheses. MIG incorporates both bottom-up (flexible therapeutic suit, social-motor synchronization) and top-down (schematic social information processing, narratives, imagery) strategies to promote the building and use of accurate, flexible and context-sensitive internal predictive models. MIG is based on the premises that predictive coding improves both socio-communication and environmental reactivity, and that the postural stabilization provided by the flexible therapeutic suit frees information processing resources for socio-cognitive learning. MIG builds on interdisciplinary, professionally and parentally mediated work based on behavioral principles of intensive training in a situated environment.

Social Validity of Pivotal Response Treatment for Young Autistic Children: Perspectives of Autistic Adults

The social validity of autism behavioral intervention has been questioned. Naturalistic Developmental Behavioral Interventions (NDBIs) attempt to address some concerns, but it is unclear whether autistic people consider NDBIs socially valid. Social validity of an NDBI, Pivotal Response Treatment (PRT), was investigated through autistic adults commenting on videos of autistic children receiving PRT. Qualitative coding of responses generated three themes: respect for individuals; assessment of intervention implementation; and socioemotional considerations. Although video brevity limits the scope of the present study's conclusions, participants highlighted PRT components that appeared socially valid (e.g., reinforcing attempts, following the child's lead) and aspects appearing invalid (e.g., overemphasis on spoken language). Therefore, adjustments appear necessary for PRT to be fully acceptable to the autistic community.

Affectivity, sexuality, and autism spectrum disorder: qualitative analysis of the experiences of autistic young adults and their families

BACKGROUND

Autistic people have communication, sensorial, and social difficulties, which on many occasions, make their adaptation on the sexual and affective levels difficult. For this reason, it is important to know the opinion of individuals with autism spectrum disorders (ASD) and their families, to offer this perspective to professionals to facilitate adapted health education programs in mental health units.

METHODS

This qualitative descriptive design presents the experiences of autistic individuals and their families in relation to the affective-sexual experiences from individual, family, and social perspectives. Two focus group sessions were held with eight family members and seven individual semi-structured interviews with autistic young adults. The transcripts were qualitatively analysed using content analysis.

RESULTS

Four themes (Family and social dynamic; Social behaviour of the autistic individual; Affective-sexual relationships; Addressing affective and sex education) and 13 related categories emerged from these results. Communication and social interaction problems act as barriers for young adults when developing affective-sexual relationships, leading to the emergence of negative feelings and experiences that reinforce avoidance behaviours, further intensifying their difficulties in interacting with others. Families, especially mothers, exhibit a poor perception of their ability to provide affective-sexual guidance, leading to anxiety and frustration. There are also reports of poor sex education and lack of support systems.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The experiences of young people and their families are sometimes conflicting when it comes to affectivity and sexuality, but the parental role emerges as relevant in the sex education process. Families play a pivotal role in sex education, which is why professionals should provide them with support and information through health education programmes, foster empathetic communication and promote sexual and emotional development that is adapted to the characteristics and interests of autistic people.

Measuring the prevalence of autistic traits in a cohort of adults living with HIV or taking HIV pre-exposure prophylaxis and mapping safer-sex barriers and facilitators: a study protocol

INTRODUCTION

Autistic individuals identify with a wider range of sexual orientations than non-autistic individuals, including higher rates of bisexual orientation in autistic men. Gay, bisexual and other men who have sex with men are at greater risk for HIV. Prevalence data of autistic traits in people living with HIV or using Pre-Exposure Prophylaxis (PrEP) for HIV are lacking so far. Such data, combined with insights in barriers and facilitators for safer sex in autistic people living with HIV or using PrEP, are a first step to improve health support for autistic people in HIV clinics. This support is crucial since autistic individuals have worse physical and mental health outcomes. The objective of this research is to determine the prevalence of autistic traits within the group of people living with HIV or using PrEP in Belgium and to describe specific facilitators and barriers for sexual safer behaviour in people living with HIV and PrEP users with autistic traits.

METHODS AND ANALYSIS

The research is a cross-sectional, observational and multicentre study with recruitment of individual participants. The research consists of two phases. In phase 1, adults coming for HIV/AIDS care or HIV PrEP in participating Belgian HIV Reference Centres will be invited to fill in the validated Autism Spectrum Quotient questionnaire. In phase 2, participants with a score above the predefined cut-off for autistic traits (>26), who agreed to be informed about this score, will be invited to complete an additional survey, inquiring facilitators and barriers for sexual safer behaviour.

ETHICS AND DISSEMINATION OF RESULTS

Institutional Review Board Institute of Tropical Medicine Antwerp, 25 July 2022, REF 1601/22 and University Hospital of Antwerp, 12 September 2022, Project ID 3679: BUN B3002022000111. Study results will be published in peer-reviewed journals and presented to Belgian HIV Reference Centres and at conferences.

The Extent and Nature of Autistic People's Violence Experiences During Adulthood: A Cross-sectional Study of Victimisation

This study investigated the extent and nature of violence experiences reported by autistic adults. Autistic (n = 118) and non-autistic (n = 110) adults completed a questionnaire about their experiences of sexual harassment, stalking and harassment, sexual violence and physical violence since the age of 15. Autistic adults reported higher rates of all violence types, multiple forms of violence and repeated instances of the same type of violence. Typical gender differences in the patterns of violence (more physical violence reported by men and more sexual violence reported by women) were apparent in the non-autistic but not the autistic group. Findings add to the limited research in this area and highlight the need to identify risk and protective factors. Policy and practice implications are also discussed.

Predictors of Sexual Victimization Among Autistic and Non-Autistic College Students

PURPOSE

This study examined predictors of sexual victimization among autistic and non-autistic college students. Specifically, we aimed to determine whether autistic students are more likely than non-autistic students to experience unwanted sexual contact and sexual assault, controlling for co-occurring diagnoses. We also aimed to determine whether students with other disabilities, specifically ADHD, learning disability (LD), and psychological disorders, are more likely than students without these disabilities to experience unwanted sexual contact and sexual assault.

METHODS

Autistic students (n=270) and non-autistic students (n=270) who had participated in a nationwide survey were matched on demographic characteristics and co-occurring diagnoses. Logistic regression analyses were conducted to address the research questions and evaluate predictors of unwanted sexual contact and sexual assault.

RESULTS

Autistic students were as likely as non-autistic students to have experienced unwanted sexual contact and sexual assault, controlling for co-occurring diagnoses. Regardless of autism diagnostic status, students with ADHD were more likely than students without ADHD to have experienced unwanted sexual contact and sexual assault.

CONCLUSIONS

Although autism diagnostic status was not a significant predictor of unwanted sexual contact or sexual assault, other factors associated with increased risk of sexual victimization, such as co-occurring ADHD, are likely to be found in autistic populations. This study highlights the importance of educational, social, and institutional supports to decrease sexual victimization among college students with neurodevelopmental disabilities.

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

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

Transidentities and autism spectrum disorder: A systematic review

Transidentity and autism frequently co-occur. Previous reviews have focused mainly on frequencies. Here, we conducted a systematic review to condense all the studies and themes on this co-occurrence and to offer a global view. We followed the PRISMA method and selected 77 articles (including 59 clinical studies) in April 2022. We found 5 main themes (sex ratio, theories, sexual orientation, clinical and social consequences, and care implications) in addition to frequencies. Many theories have been proposed to explain the co-occurrence. One posits that social difficulties related to autism would lead to less identification with gender norms and less pressure to conform to these norms, allowing for greater gender diversity in people with autism. Given their difficulties with social interactions and communication, the announcement of one's transidentity to one's social group is often discredited, increasing the risk of suffering and delayed care. Many reports reaffirm the importance of providing specialised care for transgender people with autism. Autism is not a contraindication for gender-affirming treatment. However, some cognitive specificities can affect the planning of care, and transgender people with autism are at high risk of discrimination and harassment. We conclude that there is a need to raise awareness about gender and autism.

Affectivity and Sexuality in Adolescents with Autism Spectrum Disorder from the Perspective of Education and Healthcare Professionals: A Qualitative Study

People with autism spectrum disorder (ASD) present several different characteristics that predispose them to greater difficulties with intimate emotional and sexual relationships. This qualitative study uncovers the perspective of education and healthcare professionals on the affective and sexual needs of young people with ASD by analysing their narratives in semi-structured focus group sessions. Professionals highlight the inadequate training they receive in this aspect of health. They consider it should be commonplace for professionals working with autistic people as it would aid their collaborative efforts when treating children and adolescents with ASD. They show that, by working together with the families to establish joint objectives, these professionals can appropriately address sex and affective education, preventing risky behaviours among young people with ASD, and improving the interactions these individuals have with others. Sex and affective education is described as an indispensable tool at this stage of development and should be specially adapted for those with ASD.

Impacts of psychological wellbeing with HIV/AIDS and cancer among sexual and gender minorities: A systematic review and meta-analysis

Background

The agony and economic strain of cancer and HIV/AIDS therapies severely impact patients' psychological wellbeing. Meanwhile, sexual minorities experience discrimination and mental illness. LGBT individuals with cancer and HIV/AIDS play two roles. It is important to understand and examine this groups mental wellbeing.

Objective

The purpose of this study is to synthesize current studies on the impact of HIV/AIDS and cancer on LGBT patients' psychological wellbeing.

Methods

This research uses a systematic literature review at first and later stage a meta-analysis was run on the same review. In this study, data from Google academic and Web of Science has been used to filter literature. PRISMA 2020 Flow Diagram seeks research on LGBT cancer and HIV/AIDS patients. The above sites yielded 370 related papers, some of which were removed due to age or inaccuracy. Finally, meta-analyses was done on 27 HIV/AIDS and 33 cancer patients's analyse.

Results

The research included 9,898 LGBT cancer sufferers with AIDS and 14,465 cancer sufferers with HIV/AIDS. Using meta-analysis, we discovered the gap in psychological wellbeing scores between HIV/AIDS LGBT and non-LGBT groups ranged from -10.86 to 15.63. The overall score disparity between the HIV/AIDS LGBT and non-LGBT groups was 1.270 (95% CI = 0.990-1.560, Z = 86.58, P < 0.1). The disparity in psychological wellbeing scores between cancer LGBT group and general group varies from -8.77 to 20.94 in the 34 papers examined in this study. Overall, the psychological wellbeing score disparity between the cancer LGBT subset and the general group was 12.48 (95% CI was 10.05-14.92, Test Z-value was 268.40, P-value was <0.1).

Conclusion

Inflammation and fibrosis in HIV/AIDS and cancer sufferers adversely affect their psychological wellbeing.

Implicit and Explicit Gender-Related Cognition, Gender Dysphoria, Autistic-Like Traits, and Mentalizing: Differences Between Autistic and Non-Autistic Cisgender and Transgender Adults

Evidence indicates a link between autism spectrum disorder (ASD) and gender diversity, yet this intersection remains insufficiently understood. Here, we investigated whether (1) ASD affects gender-related cognition (i.e., mental processes of perceiving and interpreting one's own gender self-concept), (2) autistic people have increased gender dysphoria and recall limited gender-typed behavior from childhood, and (3) transgender individuals have increased ASD-like traits and difficulties in mentalizing. A total of 106 non-autistic cisgender (51 birth-assigned female), 107 autistic cisgender (57 birth-assigned female), 78 non-autistic transgender (41 birth-assigned female), and 56 autistic transgender adults (27 birth-assigned female) participated in the study. The mean age of participants was 31.01 years (range = 18 to 70). Using an explicit as well as an implicit measure, for the first time, we found that ASD affected gender-related cognition only in autistic cisgender people. Sex differences were also observed in this group. Whereas autistic cisgender birth-assigned males showed a stronger implicit gender-group identification than non-autistic cisgender birth-assigned males, autistic cisgender birth-assigned females showed a weaker gender-group identification than non-autistic cisgender birth-assigned females. Furthermore, autistic cisgender people reported significantly more gender dysphoric feelings and recalled significantly less gender-typed behavior from childhood than non-autistic cisgender individuals. No difference was observed between non-autistic and autistic transgender people. We also found that relative to non-autistic cisgender individuals, both non-autistic transgender and autistic transgender people reported significantly more ASD-like traits. However, mentalizing difficulties were observed only in the latter group. This research enhances our understanding of the link between ASD and gender diversity.

Theories on the Link Between Autism Spectrum Conditions and Trans Gender Modality: a Systematic Review

While research on the prevalence of co-occurring autism spectrum conditions (ASC) and trans gender modality (TGM) is available, less is known about the underlying mechanism of this association. Insight is needed to improve treatment of trans autistic people. This review provides an overview of theories on the ASC-TGM link and the available evidence for/against them published between January 2016 and October 2020. A systematic search was performed in PubMed, PsycINFO, Web of Science, and Scopus. This resulted in 36 studies, in which 15 theories were identified. Results indicate all theories lack substantial empirical support. Unlikely and promising theories were identified. The most promising theories were those on resistance to social norms and weakened sex differences. Future directions are provided.

Sexual Coach in High-Functioning Autism: A Growing Need

When individuals with autism spectrum disorders (ASD) reach adulthood, they may experience a set of challenges related to sexual health, dating and romantic relationships [...]

Autism Spectrum Disorder and Gender Dysphoria/Incongruence. A systematic Literature Review and Meta-Analysis

The suggested overlap between autism spectrum disorder (ASD) and gender dysphoria/incongruence (GD/GI) has been much disputed. This review showed a relationship between ASD traits and GD feelings in the general population and a high prevalence of GD/GI in ASD. Our meta-analyses revealed that the pooled estimate of the prevalence of ASD diagnoses in GD/GI people was 11% (p < .001) and the overall effect size of the difference in ASD traits between GD/GI and control people was significant (g = 0.67, p < .001). Heterogeneity was high in both meta-analyses. We demonstrated that the chances that there is not a link between ASD and GD/GI are negligible, yet the size of it needs further investigation.

Evidence That Nine Autistic Women Out of Ten Have Been Victims of Sexual Violence

Background

Research indicates that sexual violence affects about 30% of women in the general population and between two to three times as much for autistic women.

Materials and Methods

We investigated prevalence of sexual abuse, autistic traits and a range of symptoms, using an online survey addressed to the women of the French autistic community (n = 225). We assessed victimization through an open question and through a specific questionnaire, derived from the Sexual Experiences Survey-Short Form Victimization.

Results

Both case identification methods yielded high figures: 68.9% victimization (open question) compared to 88.4% (standardized questionnaire). Two thirds of the victims were very young when they were first assaulted: among 199 victims, 135 were aged 18 or below and 112 participants were aged 15 or below. 75% of participants included in our study reported several aggressions. Analyses indicate that primo-victimization was highly correlated to revictimization and that being young increased that risk. Young victims were also at higher risk of developing post-traumatic stress disorder. A third of the victims reported the assault. 25% of those were able to file a complaint (n = 12) and/or receive care (n = 13). For the remainder 75%, reporting did not lead to action.

Discussion

Those findings indicate a very large proportion of victims of sexual assault among autistic women, consistently with previous research. The World Health Organization states unambiguously that sexual violence is systemic and that vulnerable individuals are preferably targeted by offenders. We therefore postulate that it would be erroneous to consider that victimization of autistic women is mainly due to autism. On the contrary, autism seems to be just a vulnerability factor. Some authors propose that educating potential victims to better protect themselves would help preventing abuse. We reviewed this proposition in the light of our results and found it to be impossible to apply since more than half of the victims were below or at the age of consent. Literature about sexual violence is discussed. Large-scale prevention programs proposed by World Health Organization and the Center for Disease Control aim at cultural changes in order to diminish gender inequality, that they identify as the very root of sexual violence.

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.

Gender Differences in Misdiagnosis and Delayed Diagnosis among Adults with Autism Spectrum Disorder with No Language or Intellectual Disability

Autism Spectrum Disorder (ASD) is often unrecognized, especially in mild forms and in women. Studies evaluating features associated with missed/misdiagnosis in men and women with ASD are warranted. 61 subjects (22 females, 39 males, age 28.5 ± 10.8 years) with ASD with no language/intellectual deficit were enrolled in the service for the treatment of psychiatric comorbidities in adults with ASD of the ASST Fatebenefratelli-Sacco in Milan (Italy). A detailed clinical history was gathered, and two self-report questionnaires (Autism Spectrum Quotient-AQ and Adult Autism Subthreshold Spectrum-AdAS Spectrum) were administered. 75.4% received their ASD diagnosis average eight years later than the first evaluation by mental health services. Compared to males, females showed a significantly greater delay in referral to mental health services and a significantly higher age at diagnosis of ASD. Among men, diagnostic delay inversely correlated with scores on the AdAS Spectrum total, Verbal communication, Empathy and Inflexibility and adherence to routine domains. Among women, diagnostic delay positively correlated with the Attention to detail score while the age at diagnosis of ASD positively correlated with the AdAS Spectrum Verbal communication and Restricted interests and rumination domain scores. Females were less likely to be correctly diagnosed and more likely to be misdiagnosed at first evaluation than men. Females reported significantly higher scores than men in the Hyper/Hyporeactivity to sensory input domain only among subjects who were misdiagnosed. Our findings provide gender-specific information about ASD patients seeking help for comorbid conditions and might be a primary ground for future research.

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

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

#Bias: The Opportunities and Challenges of Surveys That Recruit and Collect Data of Autistic Adults Online

Internet-based online surveys are a crucial tool for researchers to learn about the understudied and often overlooked population of autistic adults. The recruitment and administration of online surveys can be cheaper, quicker, and have a wider reach compared with more traditional in-person methods. As online surveys become more prevalent, it is important to place strengths in the context of limitations and biases that can arise when recruiting and administering surveys online. In this perspective, we discuss two common issues that often appear in studies that use online tools to recruit and administer surveys to autistic adults and nonautistic volunteers: selection bias and sample identifiability. Selection bias is the distortion in effect estimates (e.g., relative risk, risk ratio, incidence rate) resulting from the factors that influence why a person chose to participate or how the researcher recruits and selects participants in a study. Sampling identifiability is the ability (or inability) to quantify and define the population of interest. We use a case example of an online survey study of suicidal ideation in autistic adults and describe how issues in selection bias and sample identifiability arise and may lead to challenges unique to studying autistic adults. We conclude with recommendations to improve the quality and utility of online survey research in autistic adults. Using online resources to recruit and collect data on autistic adults is an incredible tool with great potential; yet, authors need to consider the limitations, potential biases, and tools to overcome systematic error at each stage of the study.

LAY SUMMARY

What is the purpose of this article?: Our purpose was to describe challenges in conducting and analyzing data from surveys of autistic adults, recruited and completed online.What is already known on the topic?: Health outcomes for autistic adults are understudied by crucial areas of autism research. While researchers are interested in the outcomes of autistic adults, this type of research is difficult because many autistic adults are not formally diagnosed, so not available to recruit for studies through clinic registries. Furthermore, study participation can be a long, inconvenient, and stressful process. It is not surprising then that we are seeing internet surveys of autistic adults become a popular tool to reach this population. We wanted to offer an overview and recommendations of these issues to researchers and people who read research about topics pertaining to autistic adults.What are the perspectives of the authors?: We are epidemiologists at Boston University and the University of Wisconsin-Madison. We both conduct research centered in improving health and well-being for autistic people across the life span. As people who study research methods, we have seen a lot of new research using survey methods. This research is intriguing, but all too often the articles need more information so we can be sure that the research is high quality. We want to share ways to improve this type of research and to help people in understanding the strengths and limitations of online survey research.What do the authors recommend?: We offer a few considerations for researchers working in this area. (1) Make the steps you took to do the research as clear as possible. (2) Be specific about who you intend to study and who you ended up studying. (3) Present the demographics and characteristics of the participants. (4) If possible, consider using data analysis methods to account for selection bias and sample identifiability issues. (5) Do not make statements that are not supported for your study results. (6) Acknowledge that we are at the beginning of studying autistic adults. (7) Advocate for more funding for research in autistic adults.How will these recommendations help autistic adults now or in the future?: Online surveys are an important tool for researchers to generate hypotheses and connect with a wider range of participants. However, online surveys have unique methodological challenges. We hope that this perspective raises the topic of bias and misinterpretation in online surveys and researchers continue to produce valid and meaningful work that is crucial to improving lives of autistic adults.

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

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

Sexuality and Gender Issues in Individuals with Autism Spectrum Disorder

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

Toward a Gender-Sensitive Approach of Psychiatric Rehabilitation in Autism Spectrum Disorder (ASD): A Systematic Review of Women Needs in the Domains of Romantic Relationships and Reproductive Health

Later age of diagnosis, better expressive behaviors, increased use of camouflage strategies but also increased psychiatric symptoms, more unmet needs, and a general lower quality of life are characteristics often associated with female gender in autism spectrum disorder (ASD). Psychiatric rehabilitation has shown small to moderate effectiveness in improving patients' outcomes in ASD. Few gender differences have been found in the response to psychiatric rehabilitation. This might be related to the predominance of males in research samples, but also to the lack of programs directly addressing women's unmet needs. The objectives of the present paper were: (i) to review the needs for care of autistic women in romantic relationships and reproductive health; (ii) to review the existing psychosocial treatments in these domains; and (iii) to evaluate the strengths and limitations of the current body of evidence to guide future research. A systematic electronic database search (PubMed and PsycINFO), following PRISMA guidelines, was conducted on autistic women's needs for care relating to psychiatric rehabilitation in romantic relationships and reproductive health. Out of 27 articles, 22 reported on romantic relationships and 16 used a quantitative design. Most studies were cross-sectional (n = 21) and conducted in North America or Europe. Eight studies reported on interventions addressing romantic relationships; no published study reported on interventions on reproductive health or parenting. Most interventions did not include gender-sensitive content (i.e., gender variance and gender-related social norms, roles, and expectations). Autistic women and autistic gender-diverse individuals may face unique challenges in the domains of romantic relationships and reproductive health (high levels of stigma, high risk of sexual abuse, increased psychiatric symptoms, and more unmet needs). We discussed the potential implications for improving women's access to psychiatric and psychosocial treatment, for designing gender-sensitive recovery-oriented interventions, and for future research.

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.