SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Sexual Behavior in Male Adolescents and Young Adults

with Autism Spectrum Disorder and borderline/mild mental retardation.

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Abstract

Group home caregivers of 20 institutionalized, male adolescents and young adults with

Autistic Disorder (AD) and borderline/mild mental retardation (MR) and of 19

institutionalized, male adolescents and young adults with borderline/mild MR, without AD

were interviewed with the Interview Sexuality Autism-Revised (ISA-R). Overall the

individuals with AD were not significantly less sexually active than the individuals with

MR. Masturbation was common in both groups. Individuals with MR had significantly

more experience with relationships. No difference was found in the presence of

inappropriate behavior. No difference was found in sexual orientation. Some deviant

sexual behaviors (stereotyped sexual interests; sensory fascinations with a sexual

connotation; paraphilia) were present in the group with AD, but not in the group with MR.

A difference seemed to exist in the nature of sexual problems in the individuals with AD

and MR, problems in individuals with AD being more related to an obsessive quality of

the sexual behavior.

Keywords

Autism – Sexuality – Mild mental retardation - Belgium

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Sexual Behavior in Male Adolescents and Young Adults

with Autistic Disorder and borderline/mild mental retardation

Research on sexual behavior of individuals with Autism Spectrum Disorders (ASD) has

demonstrated that persons with ASD are sexual beings: they display sexual interest and a

wide range of sexual behaviors (1-9). Most studies have reported masturbation as the main

sexual expression. Two recent studies (2, 3) have dealt with the sexuality of “high-

functioning” persons with autistic disorder (AD) and Asperger’s disorder (AS). Both

studies have reported that some persons with ASD have experienced sexual intercourse,

although their sexual experience is limited compared to typically developing persons.

Several studies (1–3, 6, 8, 9) reported that some persons with ASD do develop sexual

problems, including deviant forms of masturbation with the use of unusual objects,

“hypermasturbation” (repeated, unsuccessful attempts to masturbate) that could be related

to an inability to reach orgasm, undressing or masturbation in the presence of other people

and the initiation of unwanted physical contact (1). The occurrence of paraphilia has been

reported by Hellemans et al. (2) in 2 individuals of a group of 24 institutionalized male

high-functioning adolescents and young adults with Autism Spectrum Disorder (ASD).

Some case reports of paraphilia in individuals with ASD (10-14 ) and of Gender Identity

Disorder in individuals with ASD (14-18) have been published.

The present study is the second in a series of studies on autism and sexuality at

Antwerp University. Hellemans et al. (2) have studied a group of 24 high-functioning male

adolescents and young adults with ASD living in an institution by means of a semi-

structured, investigator-based interview. Most individuals were reported to express sexual

interest and to display some kind of sexual behavior. Socio-sexual skills were fairly well

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

known in theory, but application in practice was moderate. Masturbation was common.

Many individuals were seeking physical contact with others. Half of the sample had

already had a relationship, while three individuals were reported to have had sexual

intercourse. The number of indefinite sexual and bisexual orientations appeared to be high.

Ritual-sexual use of objects and sensory fascinations with a sexual connotation were

sometimes present. A paraphilia was present in two individuals. About one third of the

group needed some kind of intervention regarding sexual development or behavior.

The purpose of the present study was to examine the theoretical knowledge and

application in practice of self-care and socio-sexual skills, the range of sexual behavior and

the presence of sexual problems in a group of institutionalized male adolescents and young

adults with borderline/mild mental retardation and autistic disorder in comparison with a

group of institutionalized male adolescents and young adults with borderline/mild mental

retardation without autistic disorder. The objective was to observe the impact of the

independent variable, autistic disorder on the dependent variable, sexual behavior. Based

on the literature and the first Antwerp study it was hypothesized that when compared with

the individuals without AD, individuals with AD would:

1. experience more problems with the physical changes of puberty;

2. have less knowledge of self-care and socio-sexual skills and show more problems with

application in practice of these skills;

3. be as interested in sexuality;

4. be less experienced in sexual relationships;

5. present more inappropriate sexual behavior such as masturbation in public or unwanted

touching;

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

6. display more deviant sexual behavior such as hypermasturbation, use of objects in

masturbation and paraphilia;

7. have more often an indefinite or bisexual orientation;

8. exhibit overall more sexual problems and need more interventions to manage these

problems such as the use of medication.

Method

Subjects

Two groups of male institutionalized adolescents and young adults (age 15,0 to 21,11

years) were recruited for this research: persons with borderline/mild mental retardation

(Full Scale IQ 51-80) and Autistic Disorder (AD) and persons with borderline/mild mental

retardation (MR) without AD. A total of 20 persons with AD were recruited from eleven

institutions in Flanders (the Dutch-speaking part of Belgium) offering residential care for

persons with ASD. Psychologists of institutions known to have students with ASD were

contacted by phone to explain the study. Informed consent-letters were sent to the

psychologists to be given to the parents of possible candidates. The participating

individuals had been diagnosed autistic by independent psychiatrists. The diagnosis was

confirmed using DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth

Edition) criteria (19) on the basis of an examination of the individual medical records and

information from caregivers, by the first author (H.H.), a child psychiatrist who has

extensive experience with diagnosing autism spectrum disorders. A total of 19 persons

with borderline/mild MR without AD were recruited from ten residential institutions for

persons with borderline/mild MR following the same procedure as for the group with AD.

Absence of autistic symptoms was confirmed by the first author on the basis of an

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

examination of the individual medical records and information from caregivers. Exclusion

criteria for both groups were a history of sexual abuse and the existence of other handicaps

(motor, sensory) besides AD and MR. Information on exclusion criteria was obtained from

the medical records and an interview of the caregivers. One person with MR was excluded

because a history of sexual abuse was suspected. The two groups were matched according

to age and full-scale IQ.

As in the first Antwerp study (2), information about the individuals was obtained

from the caregivers who supervised them. For ethical and practical reasons, it was decided

to interview caregivers instead of a direct interview of the individuals. Parents were

expected to be reluctant to approve a direct interview of their child. Konstantareas and

Lunsky (4) who interviewed individuals with autistic disorder and developmental delay

reported a 40 % decline in participation rate. A frequently given reason was the fear that

vulnerable people were to be exposed to information of a sexual nature (4). It was also

easier to design an interview of caregivers, than an interview of persons with ASD, which

would require specific interviewing methods because of the communication deficits related

to the diagnosis of ASD. Questions would have to be simplified and supported by visual

means to facilitate comprehension (4). Thirty-five caregivers (AD group: 12 female, 5

male; mean age 35 years, range 27-52; MR group: 6 female, 12 male; mean age 38 years,

range 21-50) were involved, with a diversity of professional training, mainly educational

staff but also some psychologists. The caregivers of the persons with AD knew the

individuals for 9 months in one case and for at least one year in all other cases (mean 38

months; range 9- 84). The caregivers of the MR group knew the individuals for about 6

months in 4 cases and for at least one year in all other cases (mean 28 months; range 6- 60

months).

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

The parents and participants signed an informed consent for the interviews. The

study design was approved by the local ethical committee.

Instrument

An investigator-based, semi-structured interview, the Interview about Sexuality in Autism

that was developed for the first Antwerp study was revised for the present study. The first

part of the Interview about Sexuality in Autism-Revised (ISA-R) covers the theoretical

knowledge, the amount of training received and the actual practice of self-care skills

(washing the genitals; changing underwear; proper use of the toilet; hygiene after visiting

the toilet) and socio-sexual skills (knowing whom one is allowed to touch or kiss; knowing

where one can walk around naked and where not; knowing with whom and when one is

allowed to talk about sex; knowing that it’s not appropriate to touch the genitals in the

presence of others; knowing where one can masturbate). One question was included on the

adaptation to the physical changes of puberty (Did X show difficulties related to the

physical changes of the body during puberty e.g. morning erections, breast development,

menstruation?). The second part of the ISA-R covers the actual sexual behavior. The third

part asks about the presence of specific autistic features in the sexual behavior. Finally

some questions cover sexual problems. Some questions (e.g. theoretical knowledge and

actual practice of self-care and socio-sexual skills) had a five point rating scale (1: very

poor, 2: poor, 3: moderate, 4: good, 5: very good). The question on adaptation to the

physical changes of puberty and some of the questions on sexual behavior and sexual

problems had a five point frequency rating scale (1: never, 2: once, 3: sometimes, 4: often,

5: always). Other questions about sexual behavior and sexual problems (e.g. “Does N.

masturbate?”) were dichotomized (behavior present/not present). When appropriate, the

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

answers were also qualitatively explored. In the revised version some minor changes were

carried out. The scoring of the rating scales was more precisely defined. A section on the

knowledge of sexual terms was omitted. Three questions on sexual problems were added

(Do you think X has sexual problems? Do you think X should get help for these problems?

Does X already get help for these problems?). The first question had a five point rating

scale and the next questions were dichotomized. The answers were qualitatively explored.

Statistical analysis

Fisher’s Exact tests were used for univariate analysis of discrete variables. T-tests were

employed to compare both groups on continuous variables when Levene’s test assumed

equal variances. Otherwise Mann-Whitney U-test was calculated. An alpha level of 0.05

(two-tailed) was used to indicate significance for all statistical analyses.

Results

Sample characteristics

There was no significant age difference between the AD and the MR group (AD: mean age

= 17.6 years, Standard Deviation = 1.53, range: 15.0-20.3; MR, mean age = 17.8 years, SD

= 1.74, range: 15.6-21.3). Prior Wechsler Intelligence Scale for Children-Revised (AD: 18,

MR: 18) or Terman (AD: 2, MR: 1) results of all individuals of both groups were known.

There was no significant Full Scale IQ difference between both groups (AD, mean IQ =

67.95, SD = 7.22, range: 54-78; MR, mean IQ = 67.89, SD = 6.97, range: 55-78).

Dealing with physical changes during puberty

Individuals with AD were reported to show significantly more difficulties with the external

changes of the body during puberty (e.g. growth spurt, morning erections, appearance of

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

pubic hair) than individuals with MR (p= .005). E.g. one individual with AD could not

stop scratching his pubic region after the appearance of pubic hair.

Self-care and Socio-sexual Skills

The theoretical knowledge (Table 1) and actual practice (Table 2) of self-care and socio-

sexual skills was usually rated adequate for both groups. No significant differences were

found between the AD and the MR groups. In both groups a lot of attention was being

given to the training of socio-sexual skills (Table 3). No significant difference in the

amount of training being given was found between both groups.

Sexual behavior (Table 4)

Sexual interest

As reported by the caregivers, most of the individuals with AD and with MR showed

definite signs of interest in sexuality. Three of the individuals with AD showed “no interest

at all” in sexuality and one individual was only “a little” interested. One person with MR

was only “a little” interested in sexuality. None of the individuals with MR showed “no

interest at all”. No significant difference existed between both groups.

Masturbation

As reported by the caregivers, the proportion of individuals of whom it was not known

whether they masturbated was high in both groups (AD: 55 %; MR: 53 %). Eight (40 %)

individuals with AD and 9 individuals with MR (47 %) were definitely known to

masturbate. One individual with AD was definitely known not to masturbate, since he told

so to his mentor. Masturbation usually took place in the bedroom or in the bathroom for

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

both groups. Two individuals with AD and 4 individuals with MR occasionally

masturbated in the presence of others. One adolescent with AD had a compulsion to

masturbate every day regardless of the circumstances: he would also masturbate in the

presence of others when staying with several group members in a room on holidays. The

proportion of subjects with AD that had been taught how to masturbate was higher than in

the group with MR (AD: 40%; MR: 10%), although the difference was not significant

(p=.065, Fisher’s Exact test ). One adolescent with AD had to be taught how to

masturbate with the aid of verbal and visual instruction because he did not spontaneously

discover how to reach orgasm which lead to frustration. Although 4 individuals with AD

had a particular interest in a certain object, it was not definitely clear to the caregivers

whether they used this object during masturbation. No case of hypermasturbation was

reported. One individual with AD was reported to have bizarre fantasies during

masturbation about sweating feet of girls and of having sex with a horse.

Person-oriented behavior

Eleven individuals with AD (55 %) caressed or cuddled other persons (sometimes to often)

compared to 9 individuals with MR (47 %). Six individuals with AD (32 %) did not care

whether or not the other person enjoyed this compared to 3 individuals with MR (16 %).

Eight (40 %) individuals with AD sometimes kissed others (kissing of family members and

at birthday parties not included) compared to 8 persons with MR (42 %). Three (15 %)

individuals with AD did not care whether the “partner” liked the contact or not, compared

to 2 (11 %) persons with MR. Sexually intended touching occurred in 5 individuals with

AD (25 %) and in 7 individuals (37 %) with MR. Unwanted sexual touching occurred in

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

both groups: in 4 persons with AD (20 %) and 3 persons with MR (16 %). None of these

findings were significantly different.

Three individuals with AD (15 %) and 5 individuals with MR (26 %) talked with

the caregivers about the need for a close affective and/or sexual relationship. As reported

by the caregivers, two individuals with AD (10 %) and eleven individuals with MR (59 %)

had already had a relationship (defined as a mutual involvement with a partner lasting

longer than 24 hours to exclude a onetime flirt) at least once before (p=.005, Fisher’s Exact

test).

As reported by caregivers two individuals with AD (10%) had experienced

intercourse compared to seven (37%) of the individuals with MR (p=.052, Fisher’s Exact

test). The two individuals with AD had homosexual intercourse consisting of mutual

masturbation with another resident of the institution. In both cases the initiative had been

taken by the other person. Although the intercourse had taken place repeatedly and both

persons with AD were consenting, according to the caregivers none of them was

homosexually oriented. Five of the individuals with MR had sexual intercourse with

penetration with one or more girls usually also staying in the institution. One bisexually

oriented individual with MR had several male sexual partners. One individual with MR

had once had homosexual intercourse without being considered by caregivers as being

homosexually oriented.

Six individuals with AD (30 %) and 2 individuals with MR (10 %) expressed their

frustration about having difficulties in establishing a relationship.

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Sexual orientation

As reported by the caregivers, fourteen individuals with AD (70%) had a definite sexual

orientation: twelve heterosexual, one bisexual and one homosexual orientation (Table 5).

The bisexually oriented individual was primarily interested in prepubescent boys and girls.

Six individuals had an indefinite sexual orientation including the four persons with no or

little interest in sexuality. Eighteen individuals with MR had a pronounced sexual

orientation: seventeen heterosexual and one bisexual. As expected the one individual with

little interest in sexuality had also an indefinite sexual orientation. Although a higher

proportion of individuals with AD had an indefinite sexual orientation than the individuals

with MR, the difference was not significant (p=.065, Fisher’s Exact test).

Specific autistic features: influence of repetitive patterns and sensory fascinations on

sexual behavior

A specific interest in particular objects was noted for four individuals with AD. For two of

them these objects (pictures of brightly colored trucks for one, “Fanny”, a strip character,

for the other) were clearly sexually arousing. For the two others the nature of the objects

(lingerie and soft tissues) had an obvious sexual connotation. Partialism (a sexual interest

in body parts) was common in the AD group: four individuals got sexually aroused by

body parts (three by feet, one by bellies) compared to none of the MR group. This

difference was not significant (p=.106, Fisher’s Exact test). Three other individuals with

AD also were interested in body parts (one in earlobes and hair, one in hands and hair, one

in long hair) but without obvious signs of sexual arousal. Two more individuals were

fascinated by body parts of their own (one by his muscles, the other by his fingers) also

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

without clear signs of sexual arousal. Two individuals with AD got sexually excited by

olfactory fascinations. One of them had a bizarre fascination for stinking feet of girls and

women. Taken together six individuals with AD had a sexual fascination in objects and/or

body parts and/or sensory stimuli. None of the controls had such a fascination.

Individuals with MR were significantly more aroused by “usual” sexual stimuli

such as pictures of naked women ( p= .011).

Paraphilia

Two of the individuals with AD were primarily attracted to prepubescent children. One

had a sexual interest in young girls but without actual sexual behavior towards children.

The other one had an intense sexual desire for young boys and girls and had already tried

to contact children. He met the criteria for a DSM-IV-diagnosis of pedophilia and was

being treated for this disorder. One person with AD had several paraphilias including

olfactophilia, podophilia and zoophilia. One individual with AD was reported to wear

panties of his mother but it was not yet clear whether he got sexually aroused by this act.

None of the individuals with MR had a paraphilia.

Sexual problems

Sexual problems were described as severe for 5 (25 %) individuals with AD and 1 (10 %)

individual with MR (not significant: p=.187, Fisher’s Exact test). Three individuals with

AD were described as being obsessed by sexuality, including the two individuals with a

paraphilia. One individual with AD was reported to have an anxious attitude towards

sexuality e.g. having guilt feelings after masturbating. The sexual problems in the

individual with MR had to do with a lack of norms leading to a risk of abuse of girls. Most

of these problems were dealt with within the institution by means of coaching by the

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

mentor. The individual with pedophilia was receiving therapy in a specialized centre for

sexual perpetrators.

Psychopharmalogical treatment

Seven of the individuals with AD (35 %) were on psychoactive medication: 5 on an

atypical neuroleptic (risperidone), 3 on neuroleptics (pimozide, benperidol, pipamperon),

and 2 on a selective serotonin reuptake inhibitor (SSRI; fluvoxamine, citalopram). Two of

the individuals were on medication because of their sexual problems, one taking a

neuroleptic drug, the other an atypical neuroleptic drug and an SSRI. The neuroleptics

were being given to diminish the libido. The SSRI was being given to diminish sexual

preoccupations. In both cases the drugs seemed to have little effect on these behaviors. Six

individuals of the MR group (31.5 %) were taking drugs: 2 methylphenidate to treat

Attention Deficit/Hyperactivity Disorder (ADHD), 1 an atypical neuroleptic (risperidone)

and 3 a neuroleptic (pipamperon) because of aggressive behavior. None of the persons

with MR was mentioned to be taking medication for sexual problems.

Discussion

The present study expands our knowledge about sexual issues in individuals with AD.

Some of the hypotheses are supported by the results, some partially supported and some

rejected.

Individuals with AD were reported to show significantly more difficulties with the

external changes of the body during puberty. This could be due to the resistance to change

that is often associated with AD.

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

The present study confirms the findings of previous studies (1, 2, 4-6, 8, 9) that the

majority of adolescents and young adults with ASD express sexual interest and display a

variety of sexual behaviors. Overall the individuals with AD were not significantly less

sexually active than the individuals with MR. Masturbation occurred frequently in both

groups, as it does in normal male adolescents. The number of persons of whom it was not

known whether they masturbated was high in both groups. For the group with AD this

number was comparable to the study of Hellemans et al. (2) but higher than in other

studies (1, 6, 8). This could be related to the presence of many individuals with more

severe degrees of mental retardation in these last studies which could lead to a more public

expression of sexual behavior. Another reason could be that the majority of the individuals

in this study had single bedrooms so that masturbation could take place in the privacy of

the bedroom and bathroom. It is not obvious why more individuals with AD had been

taught how to masturbate than individuals with MR. This could be due either to the

expectation or to the actual experience that individuals with AD had more difficulties in

discovering an adequate masturbation technique. No research exists neither on the

advantages and disadvantages of teaching an adequate masturbation technique nor on the

best way of teaching this skill.

Person-oriented sexual behavior occurred frequently in both groups but the sexual

developmental level reached by individuals with AD tended to be limited. Individuals with

MR had significantly more experience with relationships. The greater experience with

sexual intercourse in individuals with MR was nearly significant. The two individuals with

AD, who had experienced sexual intercourse, probably did so in the course of

experimenting with sexuality: both had homosexual intercourse without being considered

by caregivers as being homosexual.

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

In comparison with previous studies (1, 2, 6, 8, 9) less inappropriate behavior was

reported, although touching the genitals in public and masturbation in the presence of

others occurred in some individuals of both groups. No significant difference was found

between the group with AD and with MR.

The number of homo- and bisexual oriented persons in both groups falls within the

normal range of prevalence of homo- and bisexuality in male adolescents and young adults

(20: 6% homosexual and 7,7% bisexuals in a random community survey of men aged 18 to

27; 21: 2% of adult men are exclusively homosexual, 3% are bisexual). The possibility of a

higher prevalence of bisexuality in individuals with ASD suggested by Haracopos and

Pedersen (1) and Hellemans et al. (2) was not observed in the present study. More

individuals with AD were reported to have an indefinite sexual orientation than individuals

with MR but this difference was not significant. In the first Antwerp study an indefinite

orientation was found in 25 % of the individuals.

As in previous studies (1, 2) some of the individuals with AD had stereotyped

interests and sensory fascinations with a sexual connotation, e.g. sexual arousal by specific

objects, partialism, and sexual arousal by specific sensory stimuli. A DSM-IV-diagnosis of

paraphilia was present in two individuals (one pedophilia, one multiple paraphilias). This

appears to be a high number, but the prevalence of paraphilias in the normal population of

male adolescents and young adults is unknown (22, 23). None of these deviant sexual

behaviors was reported in the MR group. Hypermasturbation or the use of objects in

masturbation was not found in either of the groups.

More individuals with AD were reported to have sexual problems than individuals

with MR, but the difference was not statistically significant. A difference seemed to exist

in the nature of sexual problems in the individuals with AD and MR. Problems in

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

individuals with AD usually were related to an obsessive quality of sexuality which was

not reported in individuals with MR.

The present study again confirms that sexual issues are important in persons with

ASD, and that sexual behavior in some persons with ASD shows specific autistic features.

The assessment of individuals with ASD should include an assessment of the sexual

development and of specific sexual problems that could be related to ASD such as the

presence of a paraphilia. The results also stress the importance of sex education in persons

with ASD and of dealing with sexual problems.

This study has some limitations: small samples of institutionalized individuals with

AD and MR, which does not allow to draw conclusions about the general non-

institutionalized population of both groups; an exclusively male study group; the indirect

approach of an interview with caregivers which could result in an underestimate of the

frequency of sexual behavior; an interview of only residential caregivers and not of the

parents; the methodological problem of the indirect approach so that only caregivers who

discussed these issues with the individuals could reliably answer the questions; different

proportions of male and female caregivers in both groups could bring differences to the

results. Due to the small samples the present study lacks power to find significant

differences in behaviors that could be relevant but that have a low frequency such as an

indefinite sexual orientation or the presence of sexual problems. Future research should

address these issues by directly interviewing larger samples of male and female individuals

with ASD, both institutionalized and non-institutionalized, in comparison with controls.

Some topics certainly need more research e.g. the prevalence of paraphilia in persons with

ASD and the sexual orientation of individuals with ASD.

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Acknowledgments

We thank the participants and their parents who gave their consent to this study,

and the caregivers for their commitment.

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

References

1. Haracopos, D., Pedersen, L. Sexuality and autism, a nationwide survey in Denmark,

Preliminary Report. http://www.autismuk.com/index9sub.htm (1992)

2. Hellemans, H., Colson, K., Verbraeken, C., Vermeiren, R., Deboutte, D. :Sexual

behavior in high-functioning male adolescents and young adults with autism spectrum

disorder. Journal of Autism and Developmental Disorders, 37, 260-269 (2007)

3. Hénault, I., Attwood, T.: Het seksualiteitsprofiel van volwassenen met het Asperger

syndroom. De noodzaak voor begrip, ondersteuning en educatie (The sexual profile of

adults with Asperger’s syndrome. The need for understanding, support and education).

Wetenschappelijk Tijdschrift Autisme, 2, 54-58 (2003)

4. Konstantareas, M., Lunsky, Y.: Sociosexual knowledge, experience, attitudes and

interests of individuals with autistic disorder and developmental delay. Journal of Autism

and Developmental Disorders, 27, 397-413 (1997)

5. Ousley, O.Y., Mesibov, G.B.: Sexual attitudes and knowledge of high-functioning

adolescents and adults with autism. Journal of Autism and Developmental Disorders, 21,

471-481 (1991)

6. Ruble, L., Dalrymple, N.: Social/sexual awareness of persons with autism: A parental

perspective. Archives of Sexual Behavior, 22, 229-240 (1993)

7. Stokes, M.A., Kaur, A.: High-functioning autism and sexuality: a parental perspective.

Autism, 9, 266-289 (2005)

8. van Bourgondien, M., Reichle N., Palmer, A.: Sexual behavior in adults with autism.

Journal of Autism and Developmental Disorders, 27, 113-125 (1997)

19
SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

9. van Son-Schoones, N., van Bilsen, P.: Sexuality and autism. A pilot-study of parents,

health care workers and autistic persons. International Journal of Adolescent Medicine and

Health, 8, 87-101 (1995)

10. Bowler, C., Collacott, R.A.: Cross-dressing in men with learning disabilities. British

Journal of Psychiatry, 162, 556-558 (1993)

11. Kobayashi, R.: Psychosexual development of autistic children in adolescence. Japanese

Journal of Child and Adolescent Psychiatry, 32, 3, 1-14 (1991)

12. Kobayashi, R.: Psychosexual development of autistic children during adolescence. In:

M. Shimizu (Ed.), Recent progress in child and adolescent psychiatry (pp. 12-20).

Springer, Tokyo (1996)

13. Realmuto, G.M., Ruble, L.A.: Sexual behaviors in autism: problems of definition and

management. Journal of Autism and Developmental Disorders, 29, 121-127 (1999)

14. Williams, P.G., Allard, A., Sears, L.: Case study: cross-gender preoccupations in two

male children with autism. Journal of Autism and Developmental Disorders, 26, 635-642

(1996)

15. Kraemer, B., Delsignore, A., Gundelfinger, R., Schnyder, U., Hepp, U.: Comorbidity

of Asperger syndrome and gender identity disorder. European Child and Adolescent

Psychiatry,14, 292-296 (2005)

16. Landén, M., Rasmussen, P.: Gender identity disorder in a girl with autism - a case

report. European Child & Adolescent Psychiatry, 6, 170-173 (1997)

17. Mukkades, N.M.: Gender identity problems in autistic children. Child: Care, Health

and Development, 28, 529-532 (2002)

20
SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

18. Perera, H., Gadambanathan, T., Weerasiri, S.: Gender identity disorder presenting in a

girl with Asperger's disorder and obsessive compulsive disorder. Ceylon Medical Journal,

48, 57-58 (2003)

19. American Psychiatric Association: Diagnostic and statistical manual of mental

disorders (4th Ed.). APA, Washington (1994).

20. Bagley, C., Tremblay, P.: On the prevalence of homosexuality and bisexuality, in a

random community survey of 750 men aged 18 to 27. Journal of Homosexuality, 36, 1-18

(1998)

21. Seidman, S.N., Reider, R.O.: A review of sexual behavior in the United States.

American Journal of Psychiatry, 151, 330-341(1994).

22. Frenken, J.: Strafbare seksualiteit en seksueel deviant gedrag: definities en prevalenties

(Punishable sexuality and sexual deviancy: definitions and prevalence). Tijdschrift

Klinische Psychologie, 32, 6-12 (2002)

23. Maletzky, B.M. : The paraphilias: research and treatment. In: P.E. Nathan & J.M.

Gorman (Eds.), A guide to treatments that work (pp. 525-557). Oxford University Press,

Oxford (1998)

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Table 1. Theoretical knowledge of self-care and socio-sexual skills

AD group MR group

S O M SD Range S O M SD Range P

Self-care skills

Washing the genitals 16 4 4.88 .342 4-5 14 5 5.00 .000 5-5 .178

Changing underwear 19 1 4.95 .229 4-5 19 0 5.00 .000 5-5 .317

Hygiene after using the toilet 18 2 4.78 .732 4-5 15 4 4.87 .516 3-5 .664

Socio-sexual skills

Knowing whom it is 20 0 4.80 .410 4-5 18 1 5.00 .000 5-5 .148

Knowing whom it is 20 0 4.80 .523 3-5 16 3 4.88 .500 3-5 .448

Suitable clothing 20 0 5.00 .000 5-5 19 0 5.00 .000 5-5 .1

Talking about sex appropriately 15 5 4.40 1.404 1-5 18 1 5.00 .000 5-5 .050

Touching the genitals in public 16 4 4.75 1.000 1-5 19 0 5.00 .000 5-5 .276

Knowing where it’s allowed 15 5 5.00 .000 5-5 16 3 5.00 .000 5-5 .1
to masturbate
(AD=Autistic Disorder; MR=Mental Retardation; S=sample analyzed; O=unknown; M=mean; SD=Standard Deviation;

1: very poor, 2: poor, 3: moderate, 4: good, 5: very good).

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Table 2. Application of self-care and socio-sexual skills

AD group MR group

S O M SD Range S O M SD Range P

Self-care skills

Washing the genitals 12 8 4.92 .289 4-5 9 10 4.67 1.000 2-5 .780

Changing underwear 19 1 4.84 .688 2-5 19 0 4.89 .459 3-5 .970

Hygiene after using the toilet 19 1 4.63 .955 2-5 18 1 4.67 .970 2-5 .720

Socio-sexual skills

Knowing whom it is 19 1 3.741 .368 1-5 19 0 4.47 .964 2-5 .096

allowed to touch

Knowing whom it is 18 2 4.391 .420 1-5 18 1 4.89 .471 3-5 .258

Suitable clothing 20 0 4.65 .745 3-5 19 0 4.84 .501 3-5 .395

Talking about sex appropriately 15 5 3.93 1.534 1-5 18 1 4.28 .895 3-5 .793

Touching the genitals in public 17 3 4.12 1.364 1-5 19 0 4.63 .684 3-5 .271

Knowing where it’s allowed 13 7 4.69 .751 3-5 16 3 5.00 .000 5-5 .110
to masturbate
(S=sample analyzed; O=unknown; 1: very poor, 2: poor, 3: moderate, 4: good, 5: very good).

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Table 3. Instruction received on self-care and socio-sexual skills

AD group MR group

S O 0 1 2 S O 0 1 2 P

Self-care skills

Washing the genitals 19 1 5 0 14 17 2 7 2 8 .160

Changing underwear 20 0 2 2 16 18 1 5 3 10 .104

Proper use of the toilet 17 3 8 1 8 18 1 11 3 4 .245

Socio-sexual skills

Knowing whom it is 19 1 4 7 8 18 1 0 18 0 .074

Knowing whom it is 18 2 8 3 7 18 1 9 5 4 .369

Suitable clothing 18 2 6 3 9 19 0 8 7 4 .190

Talking about sex appropriately 17 3 4 5 8 18 1 3 8 7 .887

Touching the genitals in public 16 4 6 6 4 18 1 9 5 4 .553

Knowing where it’s allowed 18 2 5 1 12 18 1 10 1 7 .089

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Table 4 Sexual Behavior

AD group MR group

No Yes Unknown NA No Yes Unknown NA P

Masturbates 1 8 11 0 0 9 10 0 1

Masturbation technique has been instructed 12 8 0 0 10 2 5 0 .128

Masturbates in a compulsive way 7 1 0 12 2 0 7 10 1

Caresses other persons 9 11 0 0 8 9 2 0 .630

Lacks reciprocity in caressing 5 6 0 9 6 3 0 10 .501

Kisses other persons 11 8 1 0 10 8 1 0 .796

Lacks reciprocity in kissing 5 3 0 12 2 2 4 11 .596

Displays sexually intended touching 15 5 0 0 12 7 0 0 .399

Lacks reciprocity in sexual touching 1 4 0 15 4 3 0 12 .922

Talks about need for relationship 17 3 0 0 14 5 0 0 .978

Has had a close relationship 16 2 2 0 7 11 1 0 .005

Has had sexual intercourse 16 2 2 0 9 7 3 0 .052

Has expressed frustration about not being 10 6 4 0 3 2 14 0 .929

able to establish or maintain a relationship

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SEXUAL BEHAVIOR IN AUTISM SPECTRUM DISORDERS

Table 5. Sexual orientation

AD group MR group

Indefinite sexual orientation 6 1

Heterosexual 12 17

Homosexual 1 0

Bisexual 1 1

26