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Sexual Behavior in Male Adolescents and Young Adults with Autism Spectrum Disorder and Borderline/Mild Mental Retardation

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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. KeywordsAutism-Sexuality-Mild mental retardation-Borderline mental retardation-Belgium
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Abstract Group home caregivers of 24 institutional-
ized, male, high-functioning adolescents and young
adults with Autism Spectrum Disorder, were inter-
viewed with the Interview Sexuality Autism. Most
subjects were reported to express sexual interest and to
display some kind of sexual behavior. Knowledge of
socio-sexual skills existed, but practical use was mod-
erate. Masturbation was common. Many subjects were
seeking physical contact with others. Half of the sam-
ple had experienced a relationship, while three were
reported to have had sexual intercourse. The number
of bisexual orientations appeared high. Ritual-sexual
use of objects and sensory fascinations with a sexual
connotation were sometimes present. A paraphilia was
present in two subjects. About one third of the group
needed intervention regarding sexual development or
behavior.
Keywords Autism Æ Sexuality Æ Sexual behavior Æ
Sexual problems Æ Paraphilia
Introduction
The sexual development of children and adolescents
with autism spectrum disorders (ASD) and the sexual
behavior of persons with ASD remain a neglected
scientific and clinical issue. Nonetheless individuals
with ASD display sexual behavior and have sexual
feelings and needs (D. Haracopos & L. Pedersen,
unpublished; van Bourgondien, Reichle, & Palmer,
1997). As for typical persons sexuality can be a source
of intense pleasure or the cause of problems and frus-
tration. Clinicians with expertise in the field of ASD are
frequently asked by institutions and parents to give
advice on sexual behavior and sexual problems. Indi-
viduals with high-functioning autism (HFA) or Asper-
ger syndrome (AS) frequently express concerns and
frustrations in connection with sexuality and relations
with other persons. The surveys by Ruble and
Dalrymple (1993) and van Son-Schoones and van
Bilsen (1995) of parents of children with autism showed
that sexuality was high on the list of major concerns on
which parents of individuals with autism sought help.
The few studies on sexuality and ASD (D. Haracopos
& L. Pedersen, unpublished; Konstantareas & Lunsky,
1997; Ousley & Mesibov, 1991; Ruble & Dalrymple,
1993; van Bourgondien et al., 1997; van Son-Schoones &
van Bilsen, 1995) demonstrate that persons with ASD
display sexual interest and a wide range of sexual
behaviors. Sexual needs are usually expressed by mas-
turbation, which sometimes takes place in the presence
of other persons. Person-oriented sexual activity occurs,
but is usually limited to touching, holding hands and
kissing. Often the ‘‘partner’’ regards these activities as
undesired attentions. Intercourse is only rarely
reported. These studies suggest that sexuality can lead to
H. Hellemans (&) Æ D. Deboutte
University Center of Child and Adolescent Psychiatry
Antwerp, ZNA Middelheim, University of Antwerp,
Lindendreef 1, B-2020 Antwerp, Belgium
e-mail: Hans.Hellemans@telenet.be
K. Colson
CW Laken, Laken, Belgium
C. Verbraeken
CLB Lier, Lier, Belgium
R. Vermeiren
VU Medical Center, Amsterdam, The Netherlands
J Autism Dev Disord (2007) 37:260–269
DOI 10.1007/s10803-006-0159-1
123
ORIGINAL PAPER
Sexual Behavior in High-Functioning Male Adolescents
and Young Adults with Autism Spectrum Disorder
Hans Hellemans Æ Kathy Colson Æ
Christine Verbraeken Æ Robert Vermeiren Æ
Dirk Deboutte
Published online: 26 July 2006
Ó Springer Science+Business Media, Inc. 2006
problems for persons with ASD, including deviant forms
of masturbation that sometimes entail self-mutilation or
the use of unusual objects, hypermasturbation due to an
inability to reach orgasm, undressing or masturbation in
the presence of other people and the initiation of
unwanted physical contact. A common shortcoming of
these studies is that the samples were very diverse with
regard to cognitive abilities (D. Haracopos & L.
Pedersen, unpublished; Konstantareas & Lunsky, 1997;
Ruble & Dalrymple, 1993; van Bourgondien et al., 1997;
van Son-Schoones & van Bilsen, 1995). This makes it
difficult to conclude which behaviors are related to ASD
and which to mental retardation.
In the last 15 years, the care for persons with ASD
in Flanders (the Dutch-speaking part of Belgium) has
allowed to focus the attention on sexual matters.
Seminars on this topic have been organized for parents
and caregivers. Institutions and schools for children
and adolescents with ASD organize sex education
courses. Many institutions and schools have adopted
mentorship (individual counseling) for persons with
HFA and AS. Sexual topics are a regular feature of the
counseling provided by the mentor. Adults with HFA
and AS are enabled to seek help for their sexual and
relational problems, and partners of persons with AS
can meet to talk about these matters. The result is that
a corpus of experience and knowledge has been
established that has not yet been scientifically exam-
ined (Hellemans, 1989, 1996). Some clinical observa-
tions were done that need further investigation, such as
the occurrence of paraphilias in high-functioning per-
sons with ASD (fetishism, sexual orientation towards
children, cross-dressing). This observation has received
little attention in the literature (Kobayashi, 1996;
Lande
´
n & Rasmussen, 1997; Realmuto & Ruble, 1999;
Williams, Allard, & Sears, 1996).
The approach taken by this study is based on the
above considerations. An intellectually relatively
homogenous group of individuals with ASD was studied
by means of a semi-structured, investigator-based
interview. The purpose of this study was to make a
descriptive examination of the theoretical knowledge
and application of self-care and socio-sexual skills, the
sexual behavior and the sexual problems of a group of
high-functioning (Full Scale IQ above 70) male adoles-
cents and young adults with ASD living in an institution.
Method
Subjects
Subjects were recruited from all institutions in Flan-
ders offering residential care for high-functioning
persons with ASD. Five institutions were involved.
Adolescents with ASD in Flanders are sometimes
institutionalized because of the severity of the ASD or
because of behavior problems, but most often because
of the superior care institutions can provide compared
to schools. Schools tend to focus mainly on academic
skills, while institutions have more means to provide
training of daily living skills, leisure activities, social
and communicative skills. The group of 6–8 adoles-
cents (age 12–21 years) in which the individuals with
ASD live, is used as a therapeutic-training environ-
ment. The adolescents stay in the institution during the
week and spend the weekend at home. Sex education
was on the curriculum of all the institutions concerned.
Training in socio-sexual skills was given and individual
counseling (mentorship) was available. The level of
supervision in these groups is high. One to two care-
givers are present during daytime and one during the
night. A treatment schedule for each adolescent is
updated once or twice a year. This schedule includes an
evaluation of self-care and socio-sexual skills, and a
definition of individual treatment goals. Staff members
are informed about these goals. Each adolescent has a
supervising caregiver who is responsible for the
implementation of the rules. A psychologist is
responsible for the general supervision of the treat-
ment schedules. All the institutions provided many
opportunities for socialization, both inside and outside
the institution. Sexual policies of all the institutions
allowed heterosexual interaction (walking hand-in-
hand, kissing, caressing), with the exclusion of sexual
intercourse. One institution allowed homosexual
interaction with the exclusion of intercourse. No
institution allowed sexual interaction between subjects
and caregivers.
Exclusion criteria were a history of sexual abuse and
the existence of other handicaps (motor, sensory). This
yielded 37 potential subjects, of whom 12 were not
investigated because their parents did not give
permission. According to the caregivers of the institu-
tions not investigated candidates were not different in
sexual behavior or presence of sexual problems from
investigated candidates. One subject was subsequently
rejected because a prior history of sexual abuse came
to light during the study, resulting in a final study group
of 24 male adolescents. There were no other exclusions
based on a history of sexual abuse. The mean age was
17 years (range 15–21). The mean Full Scale IQ (prior
WISC-R results of all subjects were known) was 90
(ranging from 71 to 113). The mean Verbal IQ was
92 (64–116). The mean Performance IQ was 90
(61–122). All subjects had a pre-existing diagnosis
of autistic disorder (AD), Pervasive Developmental
J Autism Dev Disord (2007) 37:260–269 261
123
Disorder-Not Otherwise Specified (PDD-NOS) or AS
from a variety of specialized centers. The first author
(H.H.), a child psychiatrist who has extensive experi-
ence with diagnosing ASD made subtype diagnoses
using the DSM-IV criteria (American Psychiatric
Association, 1994) on the basis of an examination of
the individual medical records and information from
caregivers. Fourteen subjects got a diagnosis of AD, 6
of AS and 4 of PDD-NOS. Nine of the subjects (37%)
were on medication: 5 atypical neuroleptics (risperi-
done), 1 neuroleptic (benperidol), 1 psychostimulant
(methylphenidate) and 4 selective serotonin reuptake
inhibitors (SSRI). Two of the subjects were taking
medication because of their sexual problems: one was
receiving 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 an obsessive sexual interest in young
girls. In both cases the drugs were reported to have
little effect.
No comorbid diagnoses that could affect sexual
interest and behavior (e.g. temporal lobe seizures,
PTSD or depression) were reported in the medical files
of the subjects.
Information about the subjects was obtained from
the caregivers who supervised the subjects. For ethi-
cal and practical reasons, it was decided to interview
caregivers and not directly subjects. Because it was
the first study of this kind in Flanders, parents were
expected to be reluctant to approve to a direct
interview of their child. It was also easier to design an
interview of caregivers, than an interview of persons
with ASD, which would require specific interviewing
methods. Seventeen caregivers (5 female, 12 male;
mean age 36 years, range 23–51) were involved, with
a diversity of professional training, mainly educa-
tional staff but also occupational therapists. All were
being trained and monitored by the psychologist or
the remedial educationalist of the institution. The
caregivers knew the subjects for six months in two
cases and for at least one year in all other cases
(mean 3.8 years; range 0.5–11.00). Most of the care-
givers were involved in giving education on socio-
sexual skills. Some of the caregivers talked about
sexual matters with the subjects, while other
caregivers didn’t, which may explain some of the
inter-individual differences in knowledge about the
sexuality of the subjects. Some caregivers knew a lot
of details, while others had to give a lot of ‘‘un-
known’’ answers.
Parents and adult subjects signed an informed con-
sent 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 (ISA, H. Hellemans
& K. Colson, unpublished) was developed for this study.
The rst part of the ISA covers the theoretical knowl-
edge and 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). The second part of the ISA covers the ac-
tual sexual behavior. The third part asks about the
presence of specific autistic features in the sexual
behavior. The presence of sexual problems is determined
through open-ended questions throughout the interview.
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), and were recoded to a three-point
scale (1: poor, 2: moderate, 3: good). Items from the self-
care and socio-sexual skills scale were summed to yield
total scores. Cronbach’s a for the self-care skills scale
were 0.75 (theoretical knowledge) and 0.61 (application
in practice), and for the socio-sexual skills scale 0.82 and
0.83. Other questions (e.g. ‘‘Does N. masturbate?’’)
were dichotomized (behavior present/not present).
Because of the small sample size, an unequivocal
interpretation of more extensive categorical scales was
not possible. When necessary, the answers were also
qualitatively explored.
Results
Self-Care and Socio-Sexual Skills
The theoretical knowledge of self-care and socio-sexual
skills (Table 1) was rated adequate, while the actual
practice (Table 2) was inadequate for a number of
individuals. Most problems concerned a lack of inti-
mate hygiene, talking too frankly about sexuality,
touching the genitals in public and masturbation in the
presence of others.
Sexual Behavior (see Table 3)
Sexual Interest
As reported by the caregivers, all subjects but one
showed an interest in sexuality; 8 (33%) some and 15
262 J Autism Dev Disord (2007) 37:260–269
123
Table 1 Theoretical
knowledge of self-care and
socio-sexual skills
Poor Moderate Good Unknown
N % N % N % N %
Self-care skills
Washing the genitals 0 0 3 13 18 75 3 13
Changing underwear 0 0 1 4 23 96 0 0
Proper use of the toilet 0 0 1 4 23 96 0 0
Hygiene after using the toilet 0 0 0 0 22 92 2 8
Socio-sexual skills
Knowing whom it is allowed to
touch and kiss
00 28 2292 00
Suitable clothing 0 0 0 0 24 100 0 0
Talking about sex 1 4 6 25 16 67 1 4
Touching the genitals in public 1 4 5 21 16 67 2 8
Knowing where it’s allowed to
masturbate
00 3131875 313
Table 2 Application of self-
care and socio-sexual skills
Poor Moderate Good Unknown
N % N % N % N %
Self-care skills
Washing the genitals 2 8 5 21 10 42 7 29
Changing underwear 2 8 4 17 18 75 0 0
Proper use of the toilet 0 0 3 13 21 88 0 0
Hygiene after using the toilet 0 0 0 0 23 96 1 4
Socio-sexual skills
Knowing whom it is allowed to
touch and kiss
3 13 7 29 14 58 0 0
Suitable clothing 0 0 3 13 21 88 0 0
Talking about sex 3 13 5 21 15 62 1 4
Touching the genitals in public 7 29 4 17 13 54 0 0
Knowing where it’s allowed
to masturbate
3 13 3 13 15 62 3 13
Table 3 Sexual behavior
No Yes Unknown Not
applicable
N % N % N % N %
Shows interest in sexuality 1 4 23 96 0 0
Masturbates 1 4 10 42 13 54
Masturbation technique has been instructed 7 29 7 29 10 42
Has a peculiar masturbation technique 3 13 2 8 19 79
Masturbates in a compulsive way 4 17 4 17 16 67
Caresses other persons 11 46 11 46 2 8
Cares whether other person likes caressing 4 17 7 29 2 8 11 46
Kisses other persons 17 71 5 21 2 8
Cares whether other person likes kissing 2 8 3 13 2 8 17 71
Displays sexually intended touching 17 71 4 17 3 13
Cares whether other person likes sexually
intended touching
41700313 1771
Talks about need for relationship 14 58 10 42 0 0
Has had a close affective/physical relationship 8 33 13 54 3 13
Has attempted sexual intercourse 0 0 3 13 21 88
Has had sexual intercourse 16 67 3 13 5 21
Has expressed frustration about not being able
to establish or maintain a relationship
19 79 5 21 0 0
J Autism Dev Disord (2007) 37:260–269 263
123
(63%) a definite interest. One person was completely
lacking interest. He was described as mentally very
childish despite a normal physical and cognitive
development.
Masturbation
As reported by the caregivers, the number of subjects
about whom it was not known whether they mastur-
bated was high (13, 54%). About one person it was
definitely known that he did not masturbate, because
he was taught how to masturbate, but was not inter-
ested in doing so. Ten (42%) subjects were definitely
known to masturbate. Seven (29%) were taught a
masturbation technique. This took place during indi-
vidual counseling with the aid of verbal instruction,
photographs and/or videotapes. Two subjects were
instructed because they did not spontaneously discover
how to masturbate and because attempts to masturbate
were ineffective. This failure caused considerable
frustration and led to repeated, unsuccessful attempts
to masturbate (so-called ‘‘hypermasturbation’’,
D. Haracopos & L. Pedersen, unpublished). Peculiar
masturbation techniques and a repeated use of objects
were reported for both. The first one had an obsessive
interest in shoes and leather. Occasionally, he injured
himself during masturbation by strapping himself up
tightly with leather belts. The second one rubbed his
penis against some pillows that he kept for this pur-
pose. The other five subjects received instruction in
masturbation as part of the usual sex education course.
Masturbation usually took place in the bedroom (for
all 10 subjects known to masturbate) or in the bath-
room (2). Three adolescents occasionally masturbated
in the presence of others. For four subjects masturba-
tion had compulsive characteristics. One individual was
compelled to masturbate whenever he was naked,
leading to masturbation in the changing room of the
swimming pool in the presence of others. Another
subject was compelled to masturbate whenever he took
a shower, while another masturbated obsessively sev-
eral times a day. The last one had an obsessive interest
in sexuality in general, including masturbation.
Person-Oriented Behavior
As reported by the caregivers, 11 subjects (46%) car-
essed or cuddled other persons; four (17%) did not care
whether the other person enjoyed this or not. Five (21%)
subjects sometimes kissed other persons; two (8%) did
not care whether the ‘‘partner’’ liked the contact or not.
For one kissing was a repetitive behavior towards the
parents. For the other person, the kissing was sometimes
provoked by others and had to do with social naivety.
When his fellows in the group asked ‘‘Why don’t you
give that girl a kiss?,’’ he did so and got into trouble.
As reported by the caregivers, sexually intended
touching outside of a relationship occurred for four
subjects (17%). All of them were reported sometimes
to touch persons who did not like this.
Ten subjects (42%) talked with the caregivers about
the need for a close affective and/or sexual relationship.
Various reasons were given for this need: ‘‘to be like
normal young people’’ (60% of these ten subjects); the
sexual aspect of the relationship (60%); the affective
aspect of the relationship (60%); the desire ‘‘to do things
together’’ (30%), and ‘‘to have someone to look after
me’’ (20%). As reported by the caregivers, 13 subjects
(54%) had already had a close affective and/or physical
relationship at least once before, ranging from a brief
‘‘holiday romance’’ to a sexual relationship with inter-
course. According to caregiver reports the sexual devel-
opmental level of these relationships broke down as
follows: sexual level unknown (4% of the sample);
walking hand-in-hand (8%); kissing (13%); sitting on the
other’s lap (4%); mutual petting (8%). As reported by
caregivers three subjects (13%) had already made
attempts to have sexual intercourse, unknown to be
successful, while three (13%) had effectively had inter-
course (one heterosexual, two homosexual). Three of
these six subjects had a girlfriend outside the residential
group. The other three had had homosexual contacts
within their residential group. Two subjects currently had
a relationship with each other involving oral sex and
mutual masturbation. One of the two had already had two
other homosexual relationships with sexual intercourse.
Two attempts to have undesired homosexual relations
(once with attempted anal penetration) were reported.
Five subjects (21%) expressed their frustration
about not being able to establish a relationship.
Sexual Orientation
As reported by the caregivers, 18 subjects (75%) had a
pronounced hetero-, homo-, or bisexual orientation
(Table 4). The homosexually oriented subject was
Table 4 Sexual orientation
N %of
entire
group
% of group with
a clear sexual
preference
Unclear 6 25
Heterosexual (including
heterosexual pedophiliac)
14 58 78
Homosexual 1 4 6
Bisexual 3 13 17
264 J Autism Dev Disord (2007) 37:260–269
123
primarily interested in boys who were a few years
younger, but not prepubescent. A bisexual preference
was reported for three adolescents, in which the spe-
cific preference depended on the circumstances. They
displayed sexual behavior towards group members and
caregivers of both sexes.
Specific Autistic Features: Influence of Repetitive
Patterns and Sensory Fascinations on Sexual
Behavior
A specific interest in particular objects was noted for
six subjects. Two persons used these objects during
masturbation. For another person the nature of the
object (i.e. lingerie) had an obvious sexual connotation.
In the three other cases it was unknown whether the
object was used in a sexual way. Fascinations with a
potentially but unknown sexual connotation were
common. Five subjects were fascinated by hair (their
own and others), which was expressed by a frank
staring at hair. One individual had a tendency to stroke
the hair of others. Another person had a tendency to
look very closely at heads and faces. In all cases the
fascinations were not associated with obvious signs of
sexual excitement, but they certainly gave rise to
problems in social interaction. In two subjects sensory
fascinations were accompanied by obvious signs of
sexual excitement. One person sometimes became
sexually aroused by certain smells, while for another
subject ‘‘hardcore house’’ music evoked sexual arousal.
There were two reports of sexual preference based
on idiosyncratic characteristics. One individual was
attracted to persons with a tic in the eye or a
pronounced smell. The other appeared to be drawn to
strikingly unattractive women.
Ten subjects (42%) were interested in photographs
and videotapes featuring nude women. Two subjects
showed this interest with a striking lack of modesty: one
examined the pornographic magazines in the magazine
rack of a petrol station in the presence of his mother,
and another subject made no attempt to conceal his
collection of pornographic pictures.
Paraphilia
Two of the heterosexual subjects were primarily
attracted to young, prepubescent girls. One had a
platonic interest in young girls. The other one had an
intense sexual desire for young girls and met the criteria
for a DSM-IV-diagnosis of pedophilia. This subject
received specialized treatment in a center for sexual
perpetrators, and was legally prosecuted because of a
large number of child pornographic pictures that were
found on his computer.
One of the persons with a specific interest in par-
ticular objects met the DSM-IV-criteria for fetishism.
Sexual Problems
Sexual problems were described as severe for 7 subjects
(29%). These included masturbation in the presence of
others, deviant masturbation, unwanted sexual touch-
ing, unwanted attempts to intercourse, pedophilia,
fetishism, and anxiety states in connection with sexu-
ality. Two subjects displayed anxiety with regard to
ejaculation. One panicked during his first nocturnal
emission and developed an aversion to sperm. The
other evolved bizarre fantasies concerning the quantity
of fluid lost during ejaculation. One person, although
interested in sex, seemed to be repelled by sexuality. He
used to make denigrating remarks about other mem-
bers of the group who showed an interest in sex.
Most of these problems were dealt with within the
institution by means of individual counseling, sex
education courses, and training in socio-sexual skills.
As reported before, two of the subjects were taking
medication because of sexual problems.
Discussion
Earlier studies alike (D. Haracopos & L. Pedersen,
unpublished; Konstantareas & Lunsky, 1997; Ousley &
Mesibov, 1991; Ruble & Dalrymple, 1993; van
Bourgondien et al., 1997; van Son-Schoones & van
Bilsen, 1995) this study shows that the majority of high-
functioning adolescents and young adults with ASD
express sexual interest and display a variety of sexual
behaviors. Respondents reported a wider array of
sexual behavior than in earlier studies, mainly with
respect to the interest in relationships and the estab-
lishment of relationships.
Normal, age-appropriate sexual behavior was
reported to be present in many of the subjects.
Masturbation occurred frequently in the present sam-
ple, but the reported frequency was lower than in the
normal population. Masturbation occurs in 80% of male
adolescents in the age group of 14–15 years and 90% in
the age group of 16–19 years (Vogels & van der Vliet,
1990). The lower reported frequency is probably due to
the method being used. Frequency numbers in the
normal population typically are obtained through self-
report questionnaires. The number of persons about
whom it was not known whether they masturbated was
J Autism Dev Disord (2007) 37:260–269 265
123
higher than in other studies of persons with ASD
(D. Haracopos & L. Pedersen, unpublished; Ruble &
Dalrymple, 1993; Van Bourgondien et al., 1997). A
possible explanation may lie in the normal level of
intellectual development, which may have resulted in a
more concealed sexual expression. Also, the institutions
where these adolescents lived, offered respectful
privacy to the residents, e.g. the majority of the
individuals stayed in single bedrooms. The majority
masturbated in the privacy of bedroom and bathroom.
As reported by caregivers, many had also taken
some developmental steps towards the establishment
of an intimate, sexual relationship. Half of the group
expressed a wish for an intimate or sexual relationship
and endeavored to make this happen. Half ever had a
close affective and/or physical relationship, although
the sexual developmental level of these relationships
tended to be limited. The data on the developmental
steps towards a relationship in the present study are
not detailed enough to make comparison with normal
development possible. Also, the method being used
makes comparison difficult (interview of caregivers vs.
self-report questionnaires). Three subjects already had
(homo)sexual intercourse. The frequency of coital
experience is lower than in the normal population, but
higher than in other studies of people with ASD. The
three subjects with coital experience all were in the age
range 18–21 years. In the normal population 49% of
the 18-year olds (Brugman, Goedhart, Vogels, & Van
Zessen, 1995) to 73% of the 20-year olds have had
coital experience (Vanhove & Matthijs, 2003). In the
present sample none of the subjects in the age range
16–17 ever had coital experience. Frequencies in the
normal population are 35% at the age of 16 (Brugman
et al., 1995) and 45% (Brugman et al., 1995) to 47%
(Vanhove & Matthijs, 2003) for 17-year olds. In their
study group of persons with ASD, van Bourgondien
et al. (1997) reported only one person who had
successfully had sexual intercourse. Ruble and
Dalrymple (1993) made no mention of persons
with ASD who ever had sexual intercourse. In the
D. Haracopos and L. Pedersen study (1992, unpub-
lished), one woman had had intercourse with a normal
adolescent that clearly took advantage of her. Some
subjects of the Konstantareas and Lunsky study (1997)
reported experience with intercourse, but it is not
evident if the subjects fully understood what was meant
by the term intercourse. It appears that the need for a
sexual relationship and the ability to establish a
relationship is higher in a group of institutionalized
high-functioning persons with ASD than in the
populations described earlier in literature. The open-
minded climate in Flemish institutions, where it is
usually accepted that persons with autism have a right
to a sexual relationship, may play a role. It may also be
an increasing phenomenon in the western world to
allow more sexual freedom to adolescents overall and
to accept sexual needs of adolescents and adults with
developmental disorders. This last tendency may well
result in a more open reporting of such behavior.
Nevertheless, not all subjects could translate their need
into an actual relationship. Some of the interviewees
described the expression of frustration in the subjects
about the difficulties in establishing and maintaining
relationships.
Although age-appropriate sexual interests and
behaviors were reported, some inappropriate or devi-
ant, potentially harmful sexual behaviors cannot be
ignored in this study group. While socio-sexual skills
were reported to be fairly well known in theory, they
were often not used in practice. In some cases this was
reported to result in problematic behavior, such as
masturbation in the presence of others. Problems
relating to a lack of modesty were also reported, such as
touching the genitals in public and an excessively frank
discussion of sex. The relative frequency of masturba-
tion in public was lower than reported by D. Haracopos
and L. Pedersen (unpublished), who found a 53%
prevalence of masturbation in public. The large number
of mentally retarded individuals in their study group
may explain this higher percentage. The results of the
present study suggest that although the majority of the
subjects have learned to conceal their sexual behavior,
a substantial minority has not mastered this skill.
The results also demonstrate that persons with ASD,
even when normally intelligent, do not always discover
spontaneously how to masturbate. Difficulties in
achieving orgasm and/or incorrect masturbation tech-
niques occasionally provoked stress and hypermastur-
bation.
Many subjects were seeking physical contact,
sometimes in a frankly sexual way. They often failed to
make a satisfactory distinction between desired and
undesired contacts, which could be related to the lack
of social and emotional reciprocity.
The number of bisexual orientated persons appeared
rather high, compared to figures of bisexuality in
normal male adolescents and young adults (Vogels &
van der Vliet, 1990: 1.3%; Bagley & Tremblay, 1998:
7.7%). D. Haracopos and L. Pedersen (unpublished)
also found a high number (14%) of persons with autism
expressing interest in both sexes. It is not clear to what
extent living in a largely male community has affected
the development of a bisexual orientation. Further
longitudinal research should also investigate the sexual
orientation of the bisexual subjects when they have
266 J Autism Dev Disord (2007) 37:260–269
123
reached adulthood. Since many of the subjects were still
adolescent, it may be that their sexual orientation was
in an immature state.
As earlier studies have suggested, the results con-
firm that the presence in individuals with ASD of
repetitive behavior, stereotyped interests, and sensory
fascinations may influence the sexual development.
Specific features in our sample in line with this
suggestion were the presence of compulsive mastur-
bation, ‘‘autistic’’ fetishism with the ritual use of
objects, fascinations with a sexual connotation and
strange fears associated with sex. It should be noted
that the number of ‘‘unknown’’ answers in this section
of the study was high. It is therefore not possible to
make statements about the true prevalence of these
behaviors. A DSM-IV-diagnosis of paraphilia was
present in two subjects (one pedophilia, one fetishism)
and a tendency to pedophilia was present in one
subject. These numbers appear to be high, although the
prevalence of paraphilias in the normal population
of male adolescents and young adults is unknown
(Frenken, 2002; Maletzky, 1998).
In about one third of the study group, the sexual
development was considered problematical and inter-
vention seemed justified. Two subjects were receiving
medication for their sexual problems, and one person
was being treated in a specialized center. Overall the
results of the present study suggest that institutional-
ized, male, high-functioning adolescents with ASD are
at risk for inappropriate and even deviant sexual
behavior. The concept of counterfeit deviance
(Hingsburger, Griffiths, & Quinsey, 1991; Realmuto &
Ruble, 1999) has been proposed to explain deviant
sexual behavior in individuals with developmental
disorders. This concept means that deviant behavior
may arise from living in a system in which appropriate
sexual knowledge and relationships are not supported
(Hingsburger et al., 1991). Since the subjects of the
present sample were living in an environment where
sex education was on the curriculum, training in socio-
sexual skills was being given and individual counseling
(mentorship) on sexuality was available, counterfeit
deviance doesn’t seem to be the explanation for the
findings. The results should call for adequate diagnostic
attention being given to the presence of sexual prob-
lems in individuals with ASD.
The present study suggests some educational and
treatment implications. Since the majority of the sub-
jects are reported to have expressed sexual interest and
to have displayed sexual behavior, it may be concluded
that sex education is important in high-functioning
individuals with ASD. The finding that some subjects
are reported to have difficulties in achieving orgasm
and/or to be using incorrect masturbation techniques,
suggests that sexual education for individuals with ASD
must be practical and must include masturbation tech-
niques and socio-sexual skills concerning masturbation
practices. Because the interest and actual behavior in
about half of the sample includes intimate and sexual
relationships, sex education programs for high-func-
tioning adolescents with ASD should cover sexual
intercourse, contraception and sexually transmitted
diseases. The finding that the subjects often failed to
make a satisfactory distinction between desired and
undesired contacts, which could be related to the lack of
social and emotional reciprocity, suggests that, apart
from sexual education teaching knowledge and skills,
attention should be given to the education of empathic
and perspective-taking skills. Since in the present
sample socio-sexual skills were often not used in prac-
tice in spite of a lot of training and supervision, specific
sex education modules have to be developed. In this
regard it has to be mentioned that the literature on sex
education programs for people with ASD is very
limited (Ford, 1987; Gray, Ruble, & Dalrymple, 2000;
Koller, 2000; Meister, Norlock, Honeyman, & Pierce,
1994; Melone & Lettick, 1983). Sex education programs
for adolescents with mental retardation have been
developed (Craft, 1994; Kempton, 1999a, 1999b, 2003),
but they may not be applicable to the educational needs
of adolescents with ASD (Melone & Lettick, 1983). No
research has been done on the use of sex education
programs intended for normal adolescents (e.g. SIE-
CUS, 1996) in persons with ASD.
This study has a number of limitations. First, the
study focuses on a very small sample of institutionalized
individuals, which does not allow to draw conclusions
about the general group of high-functioning persons
with ASD. It is likely that persons with more severe
autistic symptoms and associated psychosocial prob-
lems tend to be institutionalized more frequently and at
an earlier age, which may interfere with the socio-sexual
development and behavior. Institutional life itself may
also affect sexual development and behavior, e.g.
because of peer influence. Second, due to the small
number of female residents in specialized institutions,
an exclusively male study group was investigated. A
third limitation lies in the study method. As van Bour-
gondien et al. (1997) indicated, it may be that the use of
questionnaires and interviews with caregivers results in
an underestimate of the frequency of sexual behavior.
The number of ‘‘unknown’’ replies in this study is
indeed rather high. A fourth limitation lies in the fact
that only residential caregivers and no parents were
interviewed. The study should therefore be supple-
mented with interviews with parents of adolescents with
J Autism Dev Disord (2007) 37:260–269 267
123
ASD living at home. Interviewing non-family caregivers
well acquainted with the individuals with autism may
also have advantages because sexual development is a
sensitive issue, especially when deviant behavior is
involved. Third party interviewees may well be more
willing to report such behavior than informants who
belong to the family. A fifth limitation relates to a
methodological problem in the theoretical knowledge
of socio-sexual skills section of the instrument being
used (ISA). The intensity of contact between caregivers
and subjects was different, and only the caregivers who
discussed these issues with the subjects could reliably
answer these questions. For some of the caregivers,
there could be a social desirability bias, since they were
also responsible for teaching socio-sexual skills. Future
research should address this issue by directly inter-
viewing individuals with ASD. Sixth, the subscale
application in practice of self-care skills had a low
Cronbach’s a. It may be that items of this scale have a
low internal consistency, although from a theoretical
point of view, we are apt to think that the items suit
together. A final limitation lies in the lack of a normal
control group and the lack of the possibility of com-
parison with normal population norms especially on the
presence of inappropriate and deviant behaviors in this
age group.
Much research still needs to be done: e.g. on the
sexuality of girls and women with ASD; on the sexual
behavior of persons with ASD and mental retardation;
on the sexual behavior of adults with ASD; on the
actual relationships of adults with HFA and AS and
their partners; on safety issues such as the vulnerability
to sexual abuse and the occurrence of sexually trans-
mitted diseases and unwanted pregnancy in individuals
with ASD.
The current study has shown that sexual issues are
important in persons with ASD, and that problematic
sexual behavior occurs frequently. Therefore, careful
diagnostic evaluation of the sexual development is an
important aspect of the assessment of individuals with
ASD. It is necessary to develop sex education courses
for persons with ASD and to investigate their effect on
the sexual development. Sexual education should be
given on a regular basis and be individualized, since
individuals with ASD may encounter diagnosis-specific
problems with respect to the sexual development.
Finally, further research should evaluate the necessity
of developing specific treatment interventions for those
persons with ASD who develop inappropriate or
deviant sexual behavior.
Acknowledgments We thank the subjects and their parents who
gave their consent to this study, and the caregivers who had to
stand the time-consuming ISA-interview. We also want to thank
Herbert Roeyers (University Ghent) and Peggy Cohen-Kettenis
(Free University Amsterdam) for their help in developing the
initial concept of this study. Preliminary results of this study were
presented as a poster at the 1st International Meeting for Autism
Research (IMFAR), San Diego, November 9th and 10th, 2001.
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Chapter
Several of Benhaven’s students entered adolescence in 1975–1976, and the staff felt a need for some action on sex education.* We were aware that a few of our students were almost the same age as our youngest teaching aides and showed signs of sexual interest in them. We needed to establish policies to guide our own behavior as well as theirs.
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Appropriate education in sexuality is critical to the development of a person's positive self-esteem. The development of a healthy self-image may overcome potential feelings of depression and loneliness for the person with autism. This paper addresses the need for and challenges to providing sexuality education to individuals with autism. It summarizes teaching methods and approaches which have proven to be successful with this population.
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Knowledge of sexual behavior in the United States is necessary for 1) directing risk-reduction interventions aimed at preventing transmission of human immunodeficiency virus (HIV) and other sexually transmitted pathogens and 2) appreciating the current normative patterns of sexual behavior. The authors reviewed American surveys that included measures of sexual behavior and analyzed the 1988-1990 General Social Surveys. Most American males have intercourse by 16-17 years of age, and females do so by 17-18 years of age. The majority of young adults aged 18-24 have multiple, serial sex partners. Among adults 25-59 years old, relative monogamy appears to be the norm: 80% of heterosexually active men and 90% of heterosexually active women in this age group report having had only one sex partner in the preceding year. The average frequency of intercourse among such monogamous individuals is one to three times per week. Approximately 25% of adults have had heterosexual anal intercourse. Up to 20% of adult men report that they have had a homosexual experience; 1%-6% report such an experience during the preceding year. Through accumulated studies, data are now available on normative sexual behavior across the life cycle. Such data should assist in psychiatric diagnosis and in the development of treatment goals that rely on assumptions regarding normative behavior. A large proportion of young heterosexual persons are at considerable risk for sexually transmitted disease. Sexual history taking and risk-reduction counseling should be integral components of psychiatric care.
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Four men with learning disabilities were considered to show transvestic fetishism, and a fifth to show transvestism. However, developmental retardation and personality problems may modify the concepts behind such categorisation.