Abstract
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.Keywords: Asperger syndrome, autism, hypersexual disorder, hypersexuality, paraphilia, paraphilic disorder, sexuality
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Introduction
Autism spectrum disorders (ASD) are neurodevelopmental disorders that comprise a heterogeneous group of conditions, which are characterized by impairments in social interaction and communication, as well as repetitive and stereotyped interests and behaviors.1 Reported prevalence rates have risen markedly in recent decades (up to 1% lifetime prevalence), with more and more adults being diagnosed with ASD.2 It is assumed that the male-to-female-ratio is between 3 and 4 to 1,3 and there exist particular gender differences in ASD.4 Although nearly half of individuals with ASD are not intellectually impaired and have normal cognitive and language skills (such as individuals with high-functioning autism or Asperger syndrome), the social interaction and communication deficits and difficulties in seeing the perspective of others and intuitively understanding nonverbal social cues constitute hidden barriers to the development of romantic and sexual relationships.5,6 Sexuality-related problems can arise, especially at the start of puberty, a time when the development of ASD individuals' social skills cannot keep up with increasing social demands, and the challenges of forming romantic and sexual relationships become particularly apparent.7Go to:
Studies on sexuality in individuals with ASD
About 10 years after the official entry of autism in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, the first systematic studies on the sexuality of patients with ASD were published.8-11 The current state of research on sexual experiences, sexual behaviors, sexual attitudes, or sexual knowledge of ASD individuals is rather mixed, with some studies finding differences from healthy controls (HCs) while others do not. However, because of the heterogeneous nature of the disorder spectrum and the diverse scientific methodology of the studies, this is not surprising. Previous studies have: (i) included female and/or male patients in residential settings with presumably more impairments and less opportunities for sexual experiences; (ii) focused on persons with intellectual impairments or other comorbid developmental disabilities, thereby leading to confounding effects; (iii) used online surveys in which only higher-functioning individuals took part; (iv) relied on reports from family members and care-givers or from the patients themselves; and (v) assessed individuals with ASD in different age ranges.These studies suggest that many individuals with ASD seek sexual and romantic relationships similar to the non-ASD population12,13 and have the entire spectrum of sexual experiences and behaviors.12-18 However, there are still many stereotypes and societal beliefs about individuals with ASD, referring to them as uninterested in social and romantic relationships and as being asexual.10,19,20 Table I presents an overview of studies assessing different aspects of sexuality in young and older adults with high-functioning autism, on the basis of self-report questionnaires.11,12,15,21-33 We specifically focused the literature review on these studies because their methodology corresponds to the research approach used in the study presented here. The studies presented in Table I confirm that sexuality does matter in ASD individuals, and it becomes clear that the whole spectrum of sexual experiences and behaviors is represented in this group.11-13,15,20-31
TABLE I.
Literature overview. Note: The following terms were used in the systematic literature search: “sexual,” “sexuality,” “sexual behavior,” “sexual disorder,” “sexual relationship,” “Asperger,” and “Autism” in different combinations. The databases PubMed, PsydNFO, and Web of Science were searched. Only studies assessing sexual behavior in individuals with high-functioning autism (HFA) and using selfreport measures were included in the table. ASD, autism spectrum disorder; HC, healthy control; SD, standard deviation.| Reference | Type of study | Autism diagnosis | Sample, age | Main results |
| Bejerot et al, 21 2014 (Sweden) | Case-control | ASD diagnosis by psychiatrist or psychologist | 50 ASD (24 women) vs 53 HCs matched for age and gender ASDmale: 31.8 years (SD=7.8 years) ASDfemale: 28.1 years (SD=6.3 years) | ASD individuals were older at first sexual intercourse ASD individuals reported fewer moments of sexual arousal and less sexual interest More female ASD individuals were homosexual |
| Brown-Lavoie et al, 22 2014 (Canada) | Case-control | Self-reported ASD diagnosis | 95 ASD (36 women) vs 117 HCs matched for age ASDmale+female: 27.8 years (SD=4.3 years) | ASD individuals had less knowledge about sexuality-related issues ASD individuals had experienced more sexual victimization |
| Byers et al,12 2013 (multiple countries) | Cross-sectional | Self-reported ASD diagnosis | 141 ASD (81 women) At least one relationship lasting for at least three months | ASD individuals with less symptomatology reported better sexual well-being, higher sexual satisfaction, sexual assertiveness, sexual arousability, lower sexual anxiety, and fewer sexual problems |
| Byers et al, 23 2013 (multiple countries) | Cross-sectional | Self-reported ASD diagnosis | 129 ASD (68 women) ASDmale+female: 35.3 years | ASD individuals without previous relationship experience reported higher sexual anxiety, lower sexual arousabiiity, lower sexual desire, and less positive sexual cognition |
| Byers and Nichols24 2014 (multiple countries) | Cross-sectional | Self-reported ASD diagnosis | 205 ASD (128 women) in a relationship for at least three months ASDmale-female: 38.6 years (SD=9.9 years) | Individuals with more ASD symptoms reported lower sexual and relationship satisfaction |
| Cottenceau et al,25 2012 (France) | Case-control | ASD diagnosis by psychiatrist | 26 ASD (2 women) vs 44 adolescents with diabetes vs 250 HCs ASDmale+female: 15.0 years (SD=2.5 years) | ASD individuals had lower scores in affective and sexual relationships than the other two groups |
| Dekker et al, 26 2017 (Netherlands) | Case-control | ASD diagnosis by trained clinicians | 58 ASD vs 91 HCs ASDmale+female:16.8 years (SD=2.1 years) | ASD individuals did not report about more problems with sexual or intimate behaviors than HCs |
| Dewinter et al,15 2014 (Netherlands) | Case-control | ASD diagnosis by mental health professional | 50 ASD (0 women) vs 90 HCs matched for age, ethnicity, and educational level ASDmale: 16.7 years (SD=0.8 years) | No difference in the number of ASD individuals and HCs who had experienced masturbation, oral sex, vaginal intercourse, anal intercourse |
| No difference in the number of ASD individuals and HCs who had made use of explicit sexual materials and online pornography during the last six months | ||||
| Dewinter et al, 27 2015 (Netherlands) | Cross-sectional | ASD diagnosis based on observation through clinician | 43 ASD adolescents (0 women) and their parents ASDmale: 16.7 years (SD = - 0.8 years) | Parents tended to underestimate sexual experiences such as masturbation or experience with orgasm |
| Dewinter et al, 28 2016 (Netherlands) | Case-control | ASD diagnosis by mental health professional | 30 ASD (0 women) vs 60 HCs matched for age and educational level | Fewer ASD individuals had experienced French kissing or petting with a partner |
| ASDmale: 18.6 years (SD=1.0 years) | No difference in the number of ASD individuals and HCs who had experienced masturbation, oral sex, vaginal intercourse, anal intercourse | |||
| No difference in the number of ASD individuals and HCs who had made use of explicit sexual materials and online pornography | ||||
| Gilmour et al, 29 2012 (multiple countries) | Case-control | Self-reported ASD diagnosis | 82 ASD (55 women) vs 282 HCs ASDmale + female: 28.9 years (SD=9.3 years) | No differences in breadth and strength of sexual behaviors Higher rate of asexuality in ASD individuals |
| Hannah and Stagg,30 2016 (United Kingdom) | Case-control | ASD diagnosis by trained clinician | 20 ASD (8 women) vs 20 HCs ASDmale+female: 18-25 years | ASD individuals showed less sexual consciousness, sexual assertiveness, and sex-appeal consciousness No differences in feelings about sexual education and need for sexual education |
| Hénault and Attwood, 20 2006 (multiple countries) | Cross-sectional | Self-reported ASD diagnosis | 28 ASD (9 women) vs population mean score ASDmale+female : 34.0 years; range: 18-64 years | ASD individuals had fewer sexual experiences during the last two months No significant differences in sexual satisfaction and sexual desire |
| May et al, 31 2017 (Australia) | Case-control | ASD diagnosis confirmed by parents | 94 ASD (21 women) vs 3454 HCs ASDmale+female: 14.8 yars (SD=0.3 years) | No difference in the percentage of ASD individuals and HCs that reported previous sexual experiences Female ASD individuals were significantly younger at time of first sexual intercourse |
| Mehzabin and Stokes, 32 2011 (Australia) | Case-control | Self-reported ASD diagnosis | 21 ASD (9 women) vs 39 HCs ASDmale: 25.3 years (SD=3.6 years) ASDfemale: 23.4 years (SD=1.9 years) | ASD individuals had fewer sexual experiences No differences in the level of public sexualized behavior |
| Ousley and Mesi-bov,11 1991 (USA) | Case-control | ASD diagnosis by psychologist | 21 ASD (10 women) vs 20 mentally retarded adults ASDmale: 27.3 years (SD=5.4 years) ASDfemale: 27.3 years (SD=5.9 years) | ASD individuals had fewer sexual experiences and less interest in sexuality No difference in sexual knowledge |
| Strunz et at, 33 2017 (Germany) | Cross-sectional | ASD diagnosis by psychiatrist and self-reported ASD diagnosis | 229 ASD (137 women) ASDmale+female : 34.9 years (SD=10.3 years) | 30% of ASD individuals indicated that sexual activities are perceived as unpleasant |
Most of the hitherto existing research has focused on men, and few studies have addressed gender-specific issues concerning social, emotional, and cognitive domains, and even fewer studies exist examining sexuality independently in men and women with ASD.12,13,20,32 The few clinical observations32 and the small set of systematic studies indicate that women with ASD might present less pronounced social and communication deficits and have special interests that are more compatible to the interests of their peer groups.33-36 Furthermore, women with ASD seem to apply coping strategies, such as imitating the social skills of their non-ASD peers, therefore being more socially unobtrusive.34 Regarding sexuality-related issues, women with ASD seem to have poorer levels of overall sexual functioning, feel less well in sexual relationships than do men with ASD, and are also at greater risk of becoming a victim of sexual assault or abuse.37 Males with ASD were found to engage more in solitary sexual activities,11-14,18,37 as well as to have a greater desire for sexual and romantic relationships20; however, there is some evidence that females with ASD, despite having lower sexual desire, more often engage in dyadic relationships.13
Although individuals with ASD seek sexual experiences and relationships, development and maintenance of romantic and sexual relationships are greatly affected by the deficits in social and communication skills and the difficulties in understanding nonverbal or subtle interactional cues and with mentalization (meaning being able to understand one's own and others' mental states, eg, emotions, desires, cognitions experienced by such individuals.6 Furthermore, many individuals with ASD do not receive sexual education that takes their behavioral peculiarities into consideration, and they are less likely to get information on sexuality from social sources.5,22,38
Another point to consider is the restricted and repetitive interests, which may be nonsexual in childhood but can transform into and result in sexualized and sexual behaviors in adulthood. Furthermore, the frequently reported sensory sensitivities can lead to an overreaction or underreaction to sensory stimuli in the context of sexual experience.39 In hypersensitive individuals, soft physical touches can be experienced as unpleasant; on the other hand, hyposensitive individuals may have problems in getting aroused and in reaching orgasm through sexual behaviors.20 Taken together, the core symptoms of ASD combined with limited sexual knowledge and a lesser facility for having romantic and sexual experiences could predispose some individuals with ASD to developing challenging or problematic sexual behaviors,22,38 such as hypersexual and paraphilic behaviors, and even sexual offending.
Different terms have been used to describe quantitatively above-average sexual behaviors including sexual addiction, sexual compulsivity, sexual preoccupation, and hypersexuality. In this article, we will use the terms hypersexual behavior or hypersexuality referring to quantitatively relatively frequent sexual fantasies, sexual desire, and behaviors.40,41 However, one should note that the mere presence of quantitatively above-average sexual behaviors does not qualify for assignment of a psychiatric diagnosis (like hypersexual disorder or compulsive sexual behavior disorder). Kafka proposed that diagnostic criteria for a hypersexual disorder diagnosis be included in DSM-5. 40 These criteria define a hypersexual disorder as recurrent and intense sexual fantasies, urges, or sexual behaviors over a period of at least 6 months, causing clinically significant distress, and that are not due to other substances or medical conditions; also, the individual has to be at least 18 years of age.40,42 Although Reid and colleagues have shown that hypersexual disorder may be validly and reliably assessed through use of these diagnostic criteria, the American Psychiatric Association nevertheless rejected such use because of the still insufficient state of research, calling for more studies about the cross-cultural assessment of the disorder, for representative epidemiological studies, and for studies on the etiology and associated biological features.43
For the proposed eleventh edition of the International Classification of Diseases (ICD-11), the following definition for diagnosis of compulsive sexual behavior disorder41 is being considered:
Compulsive sexual behavior disorder is characterized by persistent and repetitive sexual impulses or urges that are experienced as irresistible or uncontrollable, leading to repetitive sexual behaviors, along with additional indicators such as sexual activities becoming a central focus of the person's life to the point of neglecting health and personal care or other activities, unsuccessful efforts to control or reduce sexual behaviors, or continuing to engage in repetitive sexual behavior despite adverse consequences (eg, relationship disruption, occupational consequences, negative impact on health). The individual experiences increased tension or affective arousal immediately before the sexual activity, and relief or dissipation of tension afterwards. The pattern of sexual impulses and behavior causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.
With regard to paraphilias, the DSM-5 now distinguishes between paraphilias and paraphilic disorders, thereby aiming at a destigmatization of nonnormative sexual interests and behaviors that do not cause distress or impairment to the individual or harm to others.42 In the DSM-5, paraphilias are defined as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” (see Box 1 for a list of paraphilic disorders included in DSM-5). 44 Although the proposed criteria for paraphilic disorders in the ICD-11 resemble those of the DSM-5, one major difference between these two diagnostic manuals is the removal of paraphilic disorders diagnosed primarily on the basis of consenting behaviors that are not in and of themselves associated with distress or functional impairment. This led to the ICD-11 exclusion of fetishistic, sexual masochism, and transvestic disorder,41,45 behaviors that have been reported in ASD individuals.
Box 1. Overview of paraphilic disorders included in current diagnostic manuals.
Exhibitionistic disorder
• Sexual arousal through exposing one's genitals or sexual organs to a nonconsenting person.
Fetishistic disorder*
• Sexual arousal through play with nonliving objects.
Frotteuristic disorder
• Sexual arousal through rubbing one's sexual organs against a nonconsenting person.
Sexual masochism disorder*
• Sexual arousal by being bound, beaten, or otherwise made to suffer physical pain or humiliation.
Sexual sadism disorder
• Sexual arousal by inflicting psychological or physical suffering or pain on a sexual partner.
Transvestic disorder*
• Sexual arousal through dressing and acting in a style or manner traditionally associated with the opposite sex.
Voyeuristic disorder
• Sexual arousal from watching others when they are naked or engaged in sexual activity.
Pedophilic disorder
• Primary or exclusive sexual attraction to prepubescent children.
*Reflecting conditions that are based on consenting behaviors and usually do not involve nonconsenting others and are not in and of themselves associated with distress or functional impairment. The Working Group on the Classification of Sexual Disorders and Sexual Health has proposed removing these conditions from the ICD-11.
So far, only very few studies have assessed hypersexual or paraphilic behaviors in individuals with ASD, and most of them are case reports reporting about ASD individuals showing excessive masturbation,46-50 exhibitionistic behaviors,51 pedophilic fantasies or behaviors,52,53 fetishistic fantasies or behaviors,54,55 sadomasochism,50 or other forms of paraphilias.56 However, to our knowledge, all previous studies on hypersexual and paraphilic behaviors have been conducted in males and in most cases with cognitively impaired ASD individuals.
After having reviewed the literature, we aimed to investigate hypersexual behaviors as well as paraphilic fantasies and behaviors in a large sample of male and female ASD patients compared with HCs matched according to gender, age, and educational level.
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