Journal Article Review: Autism and Sexual Development

WCF Clinical Team

How should we refer to someone with an autism diagnosis?

A study from OTARC at LaTrobe University by Bury et. Al. (2022), asked 198 adults with an ASD diagnosis about their preferred language surrounding being identified as someone with an autism diagnosis. “Person on the spectrum” was least likely to cause offence, while labels with diagnosis/ condition or “with” autism were least preferred. Identity first language, such as autistic person and autistic, was most polarizing, but also popular.

Key recommendation from the literature is to also ASK a person and their family about their preferred terminology.

Autism is now considered a high prevalence condition. It is estimated that 1 in 100 children worldwide are on the autism spectrum and approximately 1 in 70 Australians are on the autism spectrum.

Image from Mindful, showing the comorbidities related to ASD.

Why is sexual development important to consider in research and clinical spaces?

Maggio MG, Calatozzo P, Cerasa A, Pioggia G, Quartarone A, Calabrò RS. Sex and Sexuality in Autism Spectrum Disorders: A Scoping Review on a Neglected but Fundamental Issue. Brain Sci. 2022 Oct 24;12(11):1427. doi: 10.3390/brainsci12111427. PMID: 36358354; PMCID: PMC9688284.

Decades ago, people with ASD were thought to be “asexual”. This was thought to be the case as researchers saw that people with an autism diagnosis were not interested in social relationships in the same way that neurotypical people were. Due to this, they assumed that people with a diagnosis of Autism, where void of sexual feels. However, it is now known that people with a diagnosis of Autism experience the full range of sexual experiences, the same as neurotypical people do. The only substantial difference within the sexual experience lies in the completeness of the relational experience, in which people with autism may experience more challenges.

Pubertal timing (stages of puberty; Adrenarche & Gonadarche) is approximately equivalent for autistic and non-autistic adolescents. However, there is some research identifying that females on the spectrum report earlier pubertal development compared to males on the spectrum and neuro-typical females (Corbett et al., 2022).  This shows that individuals in the spectrum begin the experience sexual desires and feelings around the same time as neurotypical individuals.

Research suggests that individuals of the spectrum have higher rates of inappropriate sexual behaviour, compared to those who are not on the spectrum; however this is not completely true.

Due to the way that autism as a diagnosis has been viewed, both clinically and socially, the sexual development of individuals on the spectrum has been highly under looked at. In 2013, majority of the research conducted on autism and sexual development, was through parents of children who are on the spectrum. Researchers would interview parents, asking them to answer on behave of their child. In 2019, research shifted and moved towards asking the person who had the autism diagnosis, rather than the parents.

A Framework of Sexual Development

Tolman and McClelland, 2011

This framework was created to encouraged empirical research, and illustrates how adolescents learn about themselves, their bodies, intimate partners, and relationships within contexts where they are required to both manage risks and develop positive patterns for adulthood sexuality. 

Tolman and McCelland provide an organizing framework for understanding sexuality as normative and developmentally expected. The framework shows that children and young people’s sexual development occurs through three things; sexual behaviour, sexual selfhood, sexual socialisation.

Sexual self-hood: is how someone feels within and towards a relationship.

Sexual socialisation: is how the C/YP learns about things associated with Sex and the sexual experience. E.g. consent, kissing, how to safety have sex.

Autistic peers do not learn as much about sex education from peers, and missing out from learning through formal curriculum learning in schools.

In a 2011 study (Centre for Autism,  2011) they found that 50% of adolescents in there study with ASD have had no sex education. In a 2016 study, it suggested that feelings toward sex education did not differ between autistic and neurotypical individuals, but the groups differed significantly on measures of sexual awareness. Negative experiences of sex education and issues of vulnerability, social anxiety, and confused sexuality were prominent features of the qualitative interviews. This report suggest that mainstream sex and relationship education is not sufficient for people with ASD, specific methods and curricular are necessary to match their needs (Hannah, Stagg, 2016)

Sexual Behaviour: is the specific sexual behaviour the C/YP is engaging in e.g. masturbation, kissing, engaging in sexual intercourse.

75% of adults with autism without an intellectual disability have romantic relationship experience (Dewinter 2017).

Image taken from Mindful slides

Literature review: Beddows, N., & Brooks, R. (2016). Inappropriate sexual behaviour in adolescents with autism spectrum disorder: what education is recommended and why. Early intervention in Psychiatry, 10(4), 282-289.

There were 42 relevant articles were used within the study. What they found is below:

What sexual behaviour occurs in adolescents with ASD?

Type of behaviour	Problematic sexual behaviour
Masturbation	Hypermasturbation due to inability to reach orgasm (poor masturbation technique). Public masturbation seen in individuals who experience higher needs (articles uses language of low functioning ASD). Use of inappropriate objects for masturbation (e.g. belt).
Intimate relationships	Inappropriate romantic gestures and unaware of consequences of such behaviours. Difficulties to form intimate relationships.
Inappropriate arousal	Obsession with certain objects (e.g hands, wellington boots).
Exhibitionism	Difficulties in distinguishing appropriate behaviour from inappropriate behaviour, particularly regarding location. E.g. disrobing in public.
Offenses	Touching themselves and others, inappropriately in public.
Physical and sexual abuse	If abused themselves, it is more likely that they will display similar behaviours towards others.
Deviant obsessions	Paraphilia (arousal via unusual objects, people or situations).
Gender identify problems	Gender dysphoria/gender identify disorder (confusion between biological sex and gender identify). NOTE: This was a literature review, reviewing articles published in earlier years. This language was used within the studies. (Dewinter, 2017) studies results shows that autistic individuals have a higher rate of Gender diversity. Study of 675 adolescents and adults with ASD. 22% women and 9% off men reported gender non-conforming feelings. Males more likely to identify as bisexual, Females more likely to identify as homosexual than neurotypical individuals.
Other	Inappropriate gestures, non-consensual hugging, inappropriate comments with sexual connotations.

Reasons why inappropriate sexual behaviour occurs in individuals on the spectrum

• Normal puberty changes – Individuals on the autism spectrum experience the same hormonal changes as neurotypical individuals, but these changes can be more confusing and harder to interpret due to their unique differences. ASD adolescents may struggle with theory of mind, making it difficult to understand social behaviours. This, combined with hormonal changes, can lead to frustration and anxiety, sometimes resulting in inappropriate sexual behaviours.

• ASD level – Due to the varying symptoms of autism, individuals on the spectrum experience it differently. Those with more pronounced traits may display higher levels of inappropriate behaviour.

• Social differences – Some individuals on the spectrum may struggle with social communication and awareness, which are crucial for understanding appropriate sexual behaviours. The variability of social rules, especially in public versus private settings, can lead to confusion and inappropriate actions, even if they are innocent.

• Sensory differences – Sexual behaviours initiate pleasure, therefore satisfying their need for sensory stimulation. It is important to look at someone’s sensory sensitivities, and how they affect their sexual behaviour.  Are they low registration vs sensory sensitive, sensory seeking vs sensory avoiding.

• Differentiation of relationships – Individuals with ASD may struggle to identify when affection is appropriate and differentiate between friends, family, lovers, and strangers. This can lead to confusion about appropriate behaviour in friendships versus romantic relationships

• Curiosity – Individuals on the spectrum may be curious about the human body, leading to inappropriate sexual behaviour due to a lack of understanding or education about personal boundaries and social norms.

• Previous sexual abuse – Individuals on the spectrum are more likely to be sexual abused than neurotypical individuals due to vulnerabilities. If individuals with ASD have been abused in the past, they are more likely to act similarly towards others, demonstrating inappropriate sexual behaviour.

• Medications – side effects of medication effecting sexual desire, libido, and ability to complete masturbation, leading to hyper masturbation, masturbating in inappropriate locations, and/ or sexual aggression.

• Pornography - Exposure to the Internet and pornography can distort the views of individuals with ASD regarding sexuality, potentially leading to aggressive sexual behaviours. Some may mimic actions seen in porn, perceiving them as normal sexual behaviour.

• Poor sex education - Individuals with ASD may possess inadequate skills and knowledge to fulfil their sexual desires (e.g. may have a poor masturbation technique), so are not able to reach orgasm, leading to hyper masturbation.

Education topic	Why topic is required
Formation of friendships	ASD adults have reported that they would have preferred to have a greater understanding of their disability and how they were different to neurotypicals, and about formation of meaningful friendships and romantic relationships.  For sexuality to be understood, it appears that an individual with ASD must understand what autism is before they can make progress with their social skills and subsequently their sexuality. For this to happen, it is imperative that all those who interact with the adolescents with ASD, including parents, teachers and friends, acknowledge and accept that they are different.
Theory of mind	It is important for ASD individuals to understand ASD, what it is and how neurotypicals are different from themselves.
Social rules	Developing an understanding of what is appropriate and what is not, dependent on setting.
Social norms	To whom it is appropriate to show affection (e.g. the difference between a stranger and a friend). Explanation of personal space and the difference between private and public spaces are also important.
Interpretation of senses	Education differentiating touch associated with romantic relationships.
Formal sex education	The normal sex education curriculum should be taught; however, additional material may also need covering (e.g. masturbation technique if inadequate skills are present or the mechanics of sexual intercourse).
Parent education	Parents need to provide continuity of education, so that what is taught at school is reinforced at home.

Recommendations from the other literature and what Clinicians can be doing:

• Important for repetitive education to start from an early age. Begin in early years of adolescence, enhancing skill deficits across domains can contribute to risk reduction of sexual assault. It is important to teach social norms prior to more technique aspects of sexual education.

• This can be done through social stories of appropriate touch for friends, family, strangers. What is a private place vs what is a public place.

• People with ASD do not learn from peers to the same extent as neurotypical individuals. This needs to be compensated for through other means of social socialisation. Sexual learning should be individualised and made accessible to everyone. For individuals on the spectrum, it is important to teach what to do, rather than why not to do something – language used is important.

• One-on-one learning sessions with a trusted adult, is beneficial. This is where clinicians can come in and support school and parents.

• Appropriate sexual expression should be strived for, not repression of sexuality, and sexual desire.

• There should be different programs for those with and without intellectual disabilities.

References

Corbett BA, Muscatello RA, Kim A, Vandekar S, Duffus S, Sparks S, Tanguturi Y. Examination of pubertal timing and tempo in females and males with autism spectrum disorder compared to typically developing youth. Autism Res. 2022 Oct;15(10):1894-1908. doi: 10.1002/aur.2786. Epub 2022 Aug 1. PMID: 35912944; PMCID: PMC9561009.

 Cheak-Zamora, N. C., Teti, M., Maurer-Batjer, A., O’Connor, K. V., & Randolph, J. K. (2019). Sexual and relationship interest, knowledge, and experiences among adolescents and young adults with autism spectrum disorder. Archives of sexual Behavior, 48(8), 2605-2615.

Beddows, N., & Brooks, R. (2016). Inappropriate sexual behaviour in adolescents with autism spectrum disorder: what education is recommended and why. Early intervention in Psychiatry, 10(4), 282-289.

Dewinter, J., De Graaf, H., & Begeer, S. (2017). Sexual orientation, gender identity, and romantic relationships in adolescents and adults with autism spectrum disorder. Journal of autism and developmental disorders, 47, 2927-2934.

Hannah, L.A., Stagg, S.D. Experiences of Sex Education and Sexual Awareness in Young Adults with Autism Spectrum Disorder. J Autism Dev Disord 46, 3678–3687 (2016). https://doi.org/10.1007/s10803-016-2906-2

Maggio MG, Calatozzo P, Cerasa A, Pioggia G, Quartarone A, Calabrò RS. Sex and Sexuality in Autism Spectrum Disorders: A Scoping Review on a Neglected but Fundamental Issue. Brain Sci. 2022 Oct 24;12(11):1427. doi: 10.3390/brainsci12111427. PMID: 36358354; PMCID: PMC9688284.