Current Developmental Disorders Reports

https://doi.org/10.1007/s40474-020-00190-1

AUTISM SPECTRUM (A RICHDALE AND L LAWSON, SECTION EDITORS)

As Diverse as the Spectrum Itself: Trends in Sexuality, Gender

and Autism
Giorgia Sala 1 & Laura Pecora 1 & Merrilyn Hooley 1 & Mark A. Stokes 1

# Springer Nature Switzerland AG 2020

Abstract
Purpose of Review The goal of this paper is to provide an update on recent findings relating to sexuality and gender in autism.
The following questions were posed in the review of recent literature: What are the key emerging trends in sexuality and gender
within autism, and how might these issues have clinical significance?
Recent Findings After many years of misinformation, it is now recognised that most autistic people are interested in romance and
sexuality. There is growing awareness of reduced heterosexuality and increased diversity and dysphoria in gender identity in
autistic people, and initial clinical guidelines for the potential co-occurrence of autism and gender dysphoria are emerging. There
is a heightened risk of inappropriate sexual behaviours and victimisation in autism, and autistic women appear to be more
vulnerable in having unwanted sexual experiences than autistic males and typically developing females.
Summary Sexuality and gender are importance topics for most autistic people. Experience and expression of sexuality and
gender may differ in the autistic population compared with typically developing people, which underlies the importance of
identifying, understanding and supporting the development and maintenance of intimate relationships in autistic people. We
suggest a biopsychosocial and developmental framework be used to tailor individual support for sexuality and gender-related
issues for autistic youth.

Keywords Autism . Gender . Sexuality . Adolescence . Adulthood

Introduction The increased prevalence of ASD diagnoses [4, 5], coupled

Autism spectrum disorder (ASD) is a heterogeneous
neurodevelopmental condition persisting through the lifespan
characterised by: (1) difficulty with social communication and
interaction across multiple contexts, and (2) restricted or repet-
itive behaviours, interests or activities (RRBI) [1].
Approximately 1 in 59 individuals is diagnosed with an ASD
[2]. Many self-advocates prefer identity-first language to refer
to those diagnosed with an ASD [3]; therefore, the term ‘autistic
individuals’ is used where appropriate; those without a diagno-
sis of ASD (where neurotypicality is assumed) are referred to as
‘typically developing’ (TD) when comparisons are being made.
This article is part of the Topical Collection on Autism Spectrum
* Mark A. Stokes
mark.stokes@deakin.edu.au
with the large cohorts of those diagnosed now reaching adult-
hood, focuses empirical attention on the social transitions
across the lifespan for autistic people. Supported transition is
essential to optimise positive outcomes in adulthood, such as
equitable access to employment, housing, services to support
mental and physical health, social networks and intimate rela-
tionships [6, 7]. Sexuality and gender are core aspects of the
transition to adulthood and fundamental to the formation and
maintenance of intimate relationships and associated health
and social outcomes. This review provides a brief theoretical
perspective on sexuality and gender in autism and synthesises
results from recent meta-analyses, systematic reviews and a
sample of recent original studies focused on these areas, to
provide an update on emerging trends and key areas of re-
search and clinical interest to support this population.
Autism, Sexuality and Gender

1
School of Psychology, Faculty of Health, Deakin University, 221 Prior to the 1990s, there was minimal empirical attention on
Burwood Highway, Burwood, Victoria 3125, Australia the romantic and sexual interests of autistic people. Indeed, it

appeared that autistic people were assumed to be disinterested
in intimacy [8] and their lack of apparent/professed interest
when asked by researchers about their interest in ‘the opposite
sex’ (sic) was taken as evidence for their asexuality. As such,
there was little evidence sought on the healthy sexual and
romantic development of autistic people, their identities or
orientations. Early studies reported ‘very few’ instances of
sexual relationships amongst autistic adults [9]; used proxy
report methods from parents, or other caregivers if in residen-
tial settings [10, 11]; tended to focus on heterosexual behav-
iour [11]; and grouped participants with mixed functional ca-
pacity [12]. The limitations of proxy report were the lack of
data captured regarding subjective experiences, private behav-
iour, self-reported sexual orientation or desire for intimacy.
After recognising and addressing these methodological flaws,
it is now acknowledged within the literature and clinical com-
munity that most autistic people are interested in sexuality and
romantic relationships, especially those without cognitive im-
pairment [13–17]. A greater use of self-report and multiple
informants now is used within research to capture subjective
experiences and obtain richer data [18–20]. There is now in-
creased recognition that many autistic people have more ex-
perience in sexual and romantic relationships than was shown
in previous literature and the discourse has largely shifted to
understanding and supporting healthy sexual development in
this population [21].
Various frameworks may be applied to understand issues of
clinical significance relating to sexuality and gender in autistic
populations. For example, biopsychosocial and developmen-
tal frameworks provide an understanding of what may be oc-
curring on an individual level, while a social model of disabil-
ity [22] may help to understand contextual, external chal-
lenges for autistic people in exploring their sexuality and gen-
der identity. From a biological perspective, ASD is
conceptualised as a brain-based developmental condition
[23], and certain characteristics are considered inherent, such
as executive functioning difficulties, sensory hypo- and hy-
persensitivities, integrating verbal and non-verbal communi-
cation and motor coordination, which all vary on an individual
basis. These factors are involved in processes that relate to
individual and social functioning, such as self-awareness,
emotion-regulation, communication and adaptive functioning,
and are central to the formation and maintenance of intimate
relationships.
These biological differences result in difficulties navigating
a neurotypically dominated world with implicit social rules
and norms, and these can be framed within a social model of
disability [24]; i.e. biological differences can give rise to psy-
chological and social difficulties, which may be compounded
by a feedback loop of rejection and bullying from neurotypical
peers. Social relationships become more complex and nu-
anced during the transition to adolescence and can be partic-
ularly difficult for autistic people [25, 26]. It is therefore
Curr Dev Disord Rep
understandable that psychological difficulties such as low
mood, social anxiety and low confidence often emerge in
adolescence [27, 28], when autistic people may become more
aware of their social difficulties and internalise negative self-
perceptions, which impinge on developing relationships.
Social difficulties within ASD are not only biological. Many
autistic people describe a ‘need for solitude’ due to exhaustion
from ‘pretending to be normal’ and copying those around
them to fit in [29]. This struggle for social cohesion likely
affects autistic adolescent’s exploration and expression of their
developing sexuality and gender identity, particularly when
these do not reflect traditional social norms.
Key trends within the literature on autistic people and sex-
uality and gender include greater levels of non-heterosexual
attraction [15], a purported link between autistic traits and
gender diversity/dysphoria [30], vulnerability to both sexual
coercion—particularly amongst autistic women [31]—and to
inappropriate sexual behaviour perpetrated by autistic people
at times [32]. These trends are further outlined in the subse-
quent sections focusing on recent studies and utilising
biopsychosocial theories as relevant to contextualise this
evidence.
Sexuality and Romance
Findings of recent systematic reviews and meta-analyses com-
paring sexual functioning between autistic and TD groups
have found some consistent differences, although the number
of studies included in meta-analyses is small and largely over-
lapping (e.g. nine studies in Pecora, Mesibov and Stokes [33];
six in Hancock, Stokes and Mesibov [16]). Compared with
TD groups, autistic people demonstrated lower sexual knowl-
edge, less formal/informal sexual education, less social con-
tact with others, more inappropriate sexual behaviour, less
awareness of privacy and more concern about sexuality-
related matters [13, 22]. Additionally, compared with autistic
males, autistic females reported greater sexual anxiety, and
less sexual desire, arousability and masturbation, though, in-
terestingly, greater levels of sexual behaviour [22].
Importantly, these meta-analyses focus on autistic individuals
without comorbid intellectual disability. Recent studies focus-
ing on autistic samples without comorbid intellectual disabil-
ity also report relatively high rates of romantic relationship
experience, e.g. approximately 25–50% currently in relation-
ships (individuals aged 15–90 years across the two samples)
[32, 34] and approximately 70–80% having been in at least
one romantic relationship (individuals aged 18–73 years
across these samples) [18, 19, 35•, 36].
In terms of sexual orientation, the overwhelming consensus
of recent research suggests that autistic people demonstrate
greater levels of non-heterosexual attraction compared with
normative data [14, 15, 18, 36, 37]. Higher autistic traits in a
Swedish population-based sample (n = 47,356) were found to
Curr Dev Disord Rep
be associated with increased likelihood of self-reported bisex-
uality or nonnormative sexual orientation [38], and higher
scores on self-report measures of broader autism phenotype
traits were associated with more same-sex attraction in a sam-
ple from the USA [39]. Dewinter et al. [34] compared sexual
orientation of autistic men and women from a national autism
register (n = 675) to a large control group of normative data
(n = 8064) in the Netherlands. They measured sexual orienta-
tion in terms of attraction to ‘men only’, ‘women only’ or
‘both men and women’ and found sexual orientation amongst
autistic men and women varied significantly more than within
the general population: A smaller percentage of autistic people
expressed attraction only to the opposite sex, and a larger
percentage of autistic people did not express attraction to
any of the provided categories, resulting in a new ‘none of
the above’ category added by the researchers. It is difficult to
draw conclusions about the ‘none of the above’ group, wheth-
er they were largely comprised of asexual individuals, those
who had not decided on their orientation or those who felt
attracted to individuals outside of the gender binary.
Additionally, significantly more autistic women in their sam-
ple were in same-sex relationships compared with the control
group, while the same was not found when comparing autistic
and control group men [16].
George and Stokes [15] found similar variability in sexual
orientation with 69.7% of their autistic sample (n = 309)
reporting a non-heterosexual orientation, compared with
30.3% non-heterosexual in a TD comparison group (n =
310). Autistic individuals reported significantly more homo-
sexual, bisexual and asexual orientations and less prevalent
heterosexual orientation, compared with the comparison
group. Autistic females also were significantly more likely
to report a larger range of sexual orientations compared with
autistic males. Participants were recruited online via social
media, word of mouth and by contacting national and interna-
tional autism organisations. The authors acknowledged limi-
tations such as the majority female participants (71.9%) across
the two samples and a higher than expected rate of non-
heterosexuality in the comparison group compared with nor-
mative data, which may relate to participant self-selection by
those with more liberal sexual attitudes and practices.
However, this makes the significant group differences more
striking as recent normative data from Australia and the USA
suggests a rate of approximately 3.0–3.5% non-
heterosexuality [40, 41].
As the emphasis has shifted to self-report in recent years,
particularly as self-advocacy in autism research grows, quali-
tative research has started to fill a much-needed gap in captur-
ing previously unheard voices of autistic people elaborating
on their experiences of sexuality, gender and relationships.
There appears to be some common themes across the studies,
and as expected, many participants in these studies report
diverse sexual orientation and gender identities [35•, 42, 43].
Common themes include difficulty with aspects of courtship
and flirting, limited or inadequate sexual education and desire
for more practical and tailored support in this area, sensory
processing differences that influence physical intimacy and
sexual practices and uncertainty regarding sexual orientation
or desire to participate in romantic relationships. Previous
negative experiences such as bullying, sexual victimisation
[44] or unhealthy relationships also arise in the qualitative
literature, with autistic participants describing concerns about
being rejected and social anxiety regarding dating [20, 45].
However, there are a range of positive and adaptive behav-
iours also described by autistic participants to facilitate sexual
and romantic relationships. These include explicit communi-
cation in discussing needs, using barrier methods to reduce
sensory discomfort or engaging in non-penetrative sex, using
online dating to get ‘chit-chat’ out of the way before meeting
potential partners, identifying similarities with partners such
as shared neurodiverse identity or similar experiences of social
difficulties or identifying positive characteristics in partners
such as loyalty, kindness and understanding of autism [20,
35•, 42, 45]. Adolescent autistic males in Dewinter et al.
[46] described multiple channels of sexual education such as
peers, the Internet and parents and described sexual explora-
tion through bodily awareness and experimenting with others,
much like TD adolescents.
The continued use of self-report from autistic adolescents
and adults in sexuality research will help build more accurate
data about autistic people’s genuine, rather than assumed, sex-
ual experiences. For example, in a recent survey including
autistic adolescents and their parents, adolescents reported in-
creased privacy behaviour and experiences of victimisation
compared with that reported by their parents [47•]. The au-
thors hypothesised that this may be due to different ap-
proaches in answering (e.g. parents reporting on their child’s
behaviour across the lifespan rather than current conduct; par-
ents being unaware of the full extent of their child’s sexual
experiences). This illustrates the need for multiple informants
when gathering data, identifying needs and planning for sup-
ports and interventions related to sexuality with autistic
individuals.
Gender Diversity and Dysphoria
Gender dysphoria (GD) is a clinical condition characterised by
psychological distress concerning an incongruence between
an individual’s gender identity and the social perception of
their gender identity and birth-assigned biological sex.
Individuals experiencing GD often have a wish to change their
body and presentation in congruence with their gender iden-
tity and may engage in the necessary processes to do so [1].
Most individuals are cisgender, meaning that they experience
a sense of congruence between their assigned sex at birth, their
social role, physical and aesthetic presentations, as well as

attributes and expectations associated with their birth-assigned
sex. As noted, there appears to be an association between
autistic traits and clinically indicated GD; many autistic peo-
ple within qualitative studies also describe subthreshold gen-
der dysphoria experiences, such as discomfort or scepticism
towards traditional societal gender role expectations [48, 49].
From a biological perspective, greater prenatal testosterone
levels are linked with autistic traits [50] as well as with same-
sex attraction in women [51]; however, this theory does not
contribute to explaining the link between GD and autistic
traits also present in males. Psychosocial theories speculate
about reduced implicit learning of gendered roles in childhood
for autistic children. They suggest that autistic children may
take longer than neurotypical children to develop a sense of
stable gender identity due to difficulties with implicit social
learning and possible rejection and sense of difference to their
gendered group [52–54]. Authors have also raised the possi-
bility of cross-gendered roles and behaviours being related to
rigidity and obsessive-compulsive symptoms and/or special
interests [55–57]. From a psychological perspective, some
have suggested that the rigid thinking style typical within au-
tism could contribute to more inflexible interpretations of gen-
der roles, wherein autistic individuals may develop a gender
identity incongruent with birth sex if their characteristics do
not fit the stereotype [58, 59].
Interest in atypical expressions of gender in autism
emerged gradually in various case studies describing autistic
children, adolescents and adults who demonstrated cross-
dressing and preoccupation with opposite-gendered behav-
iours [52, 55–57, 60, 61]. Increased attention to a potential
association emerged when higher-than-usual prevalence of
autistic traits were identified in individuals presenting at
clinics for treatment associated with GD. This observation
was made in a number of studies including children, adoles-
cents and adults [37–39]. In a recent narrative review of GD
and autism by Van Der Miesen et al. [62], up to 20% of
individuals presenting at gender clinics endorsed ASD traits
within the clinical range. Within a recent Australian chart re-
view study of young people (n = 104) [63••] presenting at a
gender specialist clinic, the Social Responsiveness Scale,
Second Edition (SRS-2) was used to screen for autistic traits.
Within the sample, 49% scored in the clinical range on the
SRS-2, with 22.1% being in the severe range of the DSM-5
subscale, indicating likely ASD diagnosis. Overall, propor-
tions of high autistic traits amongst those presenting at gender
specialist clinics appear much higher than estimates of the
prevalence of ASD (e.g. 1 in 59 in the USA [2] and approx-
imately 1 in 132 globally [64]).
Studies focusing on autistic samples also suggest higher
than expected prevalence of GD characteristics. Van Der
Miesen et al. [59] found that significantly more autistic ado-
lescents (6.5%) and adults (11.4%) endorsed a desire to be the
opposite sex compared with 3–5% in normative population
Curr Dev Disord Rep
data from the Netherlands, and various studies demonstrate
an increased rate of parents of autistic children and adoles-
cents endorsing that their child ‘wishes to be the opposite
sex’ (e.g. approximately 7:1 compared with normative data
in two studies [54, 65] and approximately 2:1 times more
likely in adolescents and adults in another [59]). George and
Stokes’ [66] autistic sample (n = 309) also showed significant-
ly higher levels of GD traits than their control group (n = 261),
with a positive correlation (r = 0.37) found between autistic
traits and GD traits.
Similar to increased diversity with sexual orientation, GD
and gender non-conformity may be more commonly experi-
enced amongst autistic women than autistic men. Compared
with autistic males, autistic females reported higher rates of
subjective gender dysphoria [66], and adolescent autistic fe-
males endorse stronger wishes to be the opposite sex [59] and
report lower group identification and more negative feelings
associated with female gender than autistic men [67].
Interviews with adolescent and adult autistic females reveal
some common experiences with gender, such as challenges
identifying common interests with and navigating female
friendship groups. For example, autistic females show less
interest in talking about ‘boys’ and ‘gossiping’ than their typ-
ically developing peers and often prefer the company of male
peers because they are more ‘blunt’ and ‘relaxed’. This social
preference may influence the gender that autistic girls most
closely identify with. Many autistic girls experience being
bullied by both girls and boys at school [29, 42, 68].
However, many of these women also reported pretending to
be ‘normal’ around female peers, revealing the complex strain
of maintaining a gender-appropriate façade for the sake of
fitting in [26, 29] while rejecting the gender stereotypes.
Some adult women also reported less interest in motherhood
and discomfort with aspects of female physicality such as
breasts and menstruation [44].
However, this is not to suggest that autistic boys and men
do not deviate from typically masculine norms or experience
gender dysphoric symptoms. Studies have demonstrated less
typically masculine traits amongst autistic men compared with
neurotypical men [69], and interestingly, more autistic men
than women in George and Stokes’ [66] study demonstrated
transgenderism and engaged in hormone replacement treat-
ment and cross-dressing, despite higher levels of subjective
gender dysphoric traits amongst autistic women. The authors
hypothesised that this may be due to the greater level of flex-
ibility in gender presentation afforded to females in the current
cultural climate, such that it may be more accessible to present
in masculine clothing and present as male than vice versa.
Strang et al. [70••] recently published a qualitative exami-
nation of transgendered and gender-diverse autistic youth’s
experiences. The study has several strengths in that it follows
22 young people over approximately 2 years, describing both
stability and some shifts in participants’ experiences and
Curr Dev Disord Rep
gender identities in that time. The study also included autistic
advocates to assist with analyses and interpretation of emer-
gent themes. Two participants de-transitioned to cisgender by
the end of the study, but the majority remained relatively sta-
ble in their trans identity. Themes included the following:
having memories of feeling different since childhood, feeling
an urgent desire to transition and be affirmed within their
identity and difficulties posed by both neurodiversity,
gender-diversity and harassment from others—yet many
expressed hope for the future. The authors acknowledged that
it was sometimes difficult to understand the subjective de-
scriptions of participants. They recommended facilitation of
gender exploration over time and longitudinal mapping of
gender identity in this population by parents and supports in
order to inform treatment options.
Taken together, evidence of a link between these two con-
ditions (ASD and GD) remains an important empirical ques-
tion; the importance of avoiding mere speculation has been
emphasised as current theories lack strong evidence [30].
Some authors have suggested a complex interplay between
neurodiversity and gender diversity, more so than comorbidi-
ty, i.e. that two disorders are extant in one individual, with
separate aetiological pathways. Van Schalkwyk [71] posits
that gender diversity may be an expected outcome amongst
individuals whose identity formation is less contingent on
social information, as may be the case for autistic individuals.
Further, those who experience nonnormative gender identities
may have acquired social difficulties related to minority stress
(i.e. the notion that stigma, prejudice and discrimination create
a stressful social environment that contributes to mental health
problems amongst those with minority sexual orientation and
gender identities [72]). Ongoing research focused on the sub-
jective experience of autistic individuals will be important to
establish trends and continue to build guidelines for support
and clinical management.
Vulnerabilities in the Sexual and Romantic Sphere
There is evidence suggesting that autistic people may be vul-
nerable to developing inappropriate sexual behaviour, as well
an increased risk of experiencing sexual coercion and
victimisation by others [24, 29, 73, 74]. Earlier literature on
sexuality and autism noted inappropriate behaviours [11,
75–77]. These observations likely underlay discourses of sex-
ual deviance, deficits and the need for sexual education [78].
Paradoxically, the outcome of this body of work appears to
have been to encourage the creation of environments to sup-
port autistic person’s assumed asexuality and/or sexual devi-
ance, by unnaturally constraining the autistic person’s oppor-
tunity for healthy sexual expression [79]. A cycle may have
been created whereby subverted sexual interests, combined
with impaired social and communication skills and reduced
social opportunities, likely produced the inappropriate and
risky sexual behaviours thought characteristic of those with
autism. In addition, parents and teachers frequently report
concerns about abuse, coercion and harm towards autistic
people, as well as concerns that their behaviour may be
misinterpreted as sexual [77, 80]. Thus, the sexuality of autis-
tic people, within segments of the literature, has been de-
scribed as a phenomenon needing appropriate management.
Inappropriate Behaviour Recent studies also demonstrate the
occurrence of inappropriate sexual behaviours. Fernandes
et al. [73] examined inappropriate sexual behaviour in two
groups, one consisting of 108 autistic people diagnosed with
autistic disorder or PDD-NOS per DSM-IV (78% male), 94%
of whom had IQs at 70 or below at the time of diagnosis.
Within this group, almost a third demonstrated a lifetime oc-
currence of inappropriate sexual behaviour according to par-
ent report, such as public masturbation, indecent exposure and
inappropriate heterosexual behaviour; most only demonstrat-
ed one of these behaviours. Their other sample consisted of 76
males with Asperger syndrome, IQ ranging from 66 to 143,
but considered a ‘higher functioning’ sample according to
global assessments. Within this sample, 39 responded to ques-
tions about inappropriate sexual behaviours, with 10% of
those endorsing inappropriate behaviours including sexual in-
terest towards younger children, indecent exposure and inap-
propriate heterosexual behaviour. Approximately a quarter of
this sample endorsed paraphilias such as fetishism or voyeur-
ism; those without paraphilias in this sample had higher IQ
scores, lower scores on a measure of autistic traits and higher
measures of global functioning. It is unclear if social desirabil-
ity biases may have influenced these results.
Within Schottle et al.’s [32] sample, significantly more au-
tistic men scored above the cut-off on measures of hypersex-
ual behaviour, frequency of masturbation, paraphilic fantasies
and behaviours (such as paedophilic sexual fantasies, masoch-
ism, voyeurism, sadism, etc.) compared with control group
men, while no such difference was found between autistic
and control group women. While these fantasies and behav-
iours are not pathological when performed safely and consen-
sually (e.g. sado-masochistic sexual practices between
consenting adults), they may pose a vulnerability to engaging
in inappropriate behaviours if left unchecked or exercised
without full awareness of the rights of those involved. It is
foreseeable that given social difficulties described by autistic
people in understanding courtship and subtle sexual/romantic
behaviour, they may be more vulnerable to engaging in inap-
propriate or later-regretted paraphilic behaviours. Control
group women showed a greater frequency of engaging in sex-
ual intercourse, as well as desire for sexual intercourse, com-
pared with autistic women. Control group women also report-
ed more masochistic sexual behaviours than autistic women,
while no other differences were found in terms of other para-
philic fantasies or behaviours.

Victimisation Regarding risk of sexual victimisation, a recent
prospective, longitudinal, twin study in Sweden (N = 4500)
demonstrated that the ‘general factor’ of neurodevelopmental
disorder symptom load (e.g. ASD, ADHD) represents a mod-
erate risk factor for sexual coercion, with the authors
hypothesising a gene-environment interaction wherein sexual
predators may target individuals with neurodevelopmental
disorders [81••]. Although one study demonstrated no differ-
ence in risk of sexual victimisation between autistic males and
females [24], the evidence suggests that autistic women may
be more vulnerable to exploitation than autistic men; for ex-
ample, ASD in females was associated with a threefold risk of
sexual coercion [81••].
A recent study by Pecora et al. [21] demonstrated that au-
tistic women were less interested in sex compared with autistic
males but had equivalent levels of interest to control group
females. Additionally, autistic women were more likely to
report unwanted sexual experiences compared with TD wom-
en and autistic men, report more unwanted sexual advances
compared with typically-developing women and report en-
gaging in more sexual experiences that they later regretted
compared with autistic men. Evidence from Pecora et al.
[31] suggested that homosexually oriented autistic women
may be even more vulnerable to having experienced an un-
wanted sexual behaviour and engaging in a later-regretted
sexual behaviour compared with their heterosexual autistic
counterparts. Compared with heterosexual TD women, homo-
sexual TD women were more likely to have experienced un-
wanted sexual advances, but no differences were found in
terms of engaging in unwanted/regretted sexual behaviour.
Clinical Implications
When considering issues of sexuality, gender and autism, cli-
nicians may note that trends and self-reported difficulties cen-
tre around common themes. These often include difficulty
deciphering and responding to communicative signals and
navigating courtship processes such as flirting, discerning
the intimacy within different relationship structures, uncer-
tainty or exploration in sexual orientation and difficulty iden-
tifying and expressing their own emotions. There may be a
sense of alienation, frustration or pessimism resulting from
previous negative experiences and poorer mental health symp-
toms and personal wellbeing related to minority stress. Given
the vulnerability to coercion identified amongst those with
neurodevelopmental disorders, particularly autistic women
[81••], it is pertinent to screen for sexually coercive experi-
ences, currently or in the past, and provide linkages with ap-
propriate information, services and psychoeducation on
healthy relationship functioning and consent.
Regarding gender, themes related to uncertainty over gen-
der identity, peer rejection, feeling different and/or feeling
unhappy with traditional gender roles and expectations, as
Curr Dev Disord Rep
well as less motivation to comply with these, may be expected
in clinical settings. Amongst some autistic individuals, there
may be a key sense of gender dysphoria. With these individ-
uals, it may be helpful to facilitate exploration of gender and
utilise Strang et al.’s [82] recommendations outlined for co-
occurring ASD and GD. These guidelines emphasise the over-
laps in phenomenology between those with possible ASD and
GD diagnoses. Thus, it appears important to screen for
gender-related issues in ASD populations and, where there
may be significant gender dysphoric symptoms, an extended
diagnostic process requiring suitably skilled clinicians. Initial
guidelines on managing co-occurring ASD and possible GD
recommend diagnostic approaches using longitudinal data,
multiple informants and robust developmental assessment, to
distinguish between developmentally manifest, brain-based
phenomenology pertinent to ASD and acquired social diffi-
culties, not indicative of ASD, that may be reversible in those
with GD [23].
In clinical settings, it may be helpful to formulate issues of
sexuality, gender and relationships amongst autistic people
using both a biopsychosocial and developmental framework.
A biopsychosocial lens may help to understand the individ-
ual’s specific characteristics, as well as how any issues are
developed and maintained, while highlighting the individual’s
strengths and resilience factors. The developmental frame-
work could be used to locate the individual’s understanding,
experiences, identity and desires regarding sexuality, gender
and relationships, comparing this with typical development to
highlight key areas of convergence or divergence, and focus
on what they may specifically need help with. Assessing in-
dividuals’ sexual knowledge and channels of information may
also be helpful, as different individuals may have been ex-
posed to varying degrees of sexual education.
Using a formulation drawn from these two frameworks
may help clinicians work holistically with the individual,
along with the family where desirable, to identify key areas
for intervention. Additionally, given the purported increase in
sexual and gender variation in autistic populations, those with
autism are likely to also experience poorer mental health and
lower wellbeing outcomes as a result of minority stress,
wherein belonging to multiple minority groups appears to in-
crease distress [63••, 83••]. This may in turn increase an indi-
vidual’s sense of isolation and difficulty navigating early sex-
ual and romantic experiences. Social connection and intimate
relationships are associated with good health, good psycho-
logical wellbeing and increased stress resilience [84, 85].
Unsurprisingly, lower social connection is correlated with a
host of negative affective states and poorer health outcomes
[86]; e.g. loneliness is associated with psychological distress,
social anxiety, avoidance of social situations and depression
[87].
It is therefore important to consider how autistic individ-
uals can be supported in navigating issues of sexuality, gender
Curr Dev Disord Rep
and intimacy through adolescence and emerging adulthood,
especially when sexual and gender minority identity is
present. Linkages with appropriate support groups in
local areas may be particularly important where possi-
ble, and when these are not available, directing individ-
uals and families to resources on these topics, such as
books, documentaries, films, online support groups and
blogs written by autistic people. This may help to pro-
mote a sense of belonging and to normalise experiences by
finding similarity with others.
Conclusions
While historically autistic people may have been characterised
as asexual or unlikely to be in romantic and sexual relation-
ships, there has been a shift over time to acknowledging that
most autistic individuals are interested in sexual and romantic
relationships and much recent research utilises self-report
methods and multiple informants to understand sexuality
and gender within autism. There appears to be a link between
autistic traits and increased rates of non-heterosexuality, both
within the general population and within autistic samples, per-
haps especially amongst autistic women. Likewise, a possible
link between GD and ASD is suggested, and ongoing research
may help to understand and clarify this link. Risk of sexual
victimisation appears higher amongst those with
neurodevelopmental disorders including autism, and especial-
ly amongst autistic females, and there remains evidence of
higher rates of inappropriate sexual behaviours amongst au-
tistic populations. The authors of this paper have highlighted
issues for clinical consideration and suggest a holistic,
biopsychosocial and developmental framework in supporting
autistic individuals in matters of sexuality and gender identity.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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