Evidence That Nine Autistic Women Out of Ten Have Been Victims of Sexual Violence

Abstract

Background:
Research indicates that sexual violence affects about 30% of women in the general population and between two to three times as much for autistic women.

Materials and methods:
We investigated prevalence of sexual abuse, autistic traits and a range of symptoms, using an online survey addressed to the women of the French autistic community (n = 225). We assessed victimization through an open question and through a specific questionnaire, derived from the Sexual Experiences Survey-Short Form Victimization.

Results:
Both case identification methods yielded high figures: 68.9% victimization (open question) compared to 88.4% (standardized questionnaire). Two thirds of the victims were very young when they were first assaulted: among 199 victims, 135 were aged 18 or below and 112 participants were aged 15 or below. 75% of participants included in our study reported several aggressions. Analyses indicate that primo-victimization was highly correlated to revictimization and that being young increased that risk. Young victims were also at higher risk of developing post-traumatic stress disorder. A third of the victims reported the assault. 25% of those were able to file a complaint (n = 12) and/or receive care (n = 13). For the remainder 75%, reporting did not lead to action.

Discussion:
Those findings indicate a very large proportion of victims of sexual assault among autistic women, consistently with previous research. The World Health Organization states unambiguously that sexual violence is systemic and that vulnerable individuals are preferably targeted by offenders. We therefore postulate that it would be erroneous to consider that victimization of autistic women is mainly due to autism. On the contrary, autism seems to be just a vulnerability factor. Some authors propose that educating potential victims to better protect themselves would help preventing abuse. We reviewed this proposition in the light of our results and found it to be impossible to apply since more than half of the victims were below or at the age of consent. Literature about sexual violence is discussed. Large-scale prevention programs proposed by World Health Organization and the Center for Disease Control aim at cultural changes in order to diminish gender inequality, that they identify as the very root of sexual violence.

Full text

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ORIGINAL RESEARCH
published: 26 April 2022
doi: 10.3389/fnbeh.2022.852203
Edited by:
Valentina Garibotto,
Geneva University Hospitals (HUG),
Switzerland
Reviewed by:
Maria Chiara Pino,
University of L’Aquila, Italy
Mark Relyea,
United States Department of Veterans
Affairs, United States
*Correspondence:
Fabienne Cazalis
fabienne.cazalis@ehess.fr
†These authors have contributed
equally to this work and share first
authorship
Specialty section:
This article was submitted to
Pathological Conditions,
a section of the journal
Frontiers in Behavioral Neuroscience
Received: 10 January 2022
Accepted: 23 March 2022
Published: 26 April 2022
Citation:
Cazalis F, Reyes E, Leduc S and
Gourion D (2022) Evidence That Nine
Autistic Women Out of Ten Have
Been Victims of Sexual Violence.
Front. Behav. Neurosci. 16:852203.
doi: 10.3389/fnbeh.2022.852203
Evidence That Nine Autistic Women
Out of Ten Have Been Victims of
Sexual Violence
Fabienne Cazalis1*†, Elisabeth Reyes2†, Séverine Leduc3and David Gourion4
1Centre d’Analyse et de Mathématique Sociales, CNRS-EHESS, Paris, France, 2Auticonsult, Paris, France, 3Independent
Practitioner, Paris, France, 4GHU Paris Psychiatrie & Neurosciences, Hôpital Sainte Anne, Paris, France
Background: Research indicates that sexual violence affects about 30% of women in
the general population and between two to three times as much for autistic women.
Materials and Methods: We investigated prevalence of sexual abuse, autistic traits
and a range of symptoms, using an online survey addressed to the women of the French
autistic community (n= 225). We assessed victimization through an open question and
through a specific questionnaire, derived from the Sexual Experiences Survey-Short
Form Victimization.
Results: Both case identification methods yielded high figures: 68.9% victimization
(open question) compared to 88.4% (standardized questionnaire). Two thirds of the
victims were very young when they were first assaulted: among 199 victims, 135 were
aged 18 or below and 112 participants were aged 15 or below. 75% of participants
included in our study reported several aggressions. Analyses indicate that primo-
victimization was highly correlated to revictimization and that being young increased that
risk. Young victims were also at higher risk of developing post-traumatic stress disorder.
A third of the victims reported the assault. 25% of those were able to file a complaint
(n= 12) and/or receive care (n= 13). For the remainder 75%, reporting did not lead to
action.
Discussion: Those findings indicate a very large proportion of victims of sexual
assault among autistic women, consistently with previous research. The World Health
Organization states unambiguously that sexual violence is systemic and that vulnerable
individuals are preferably targeted by offenders. We therefore postulate that it would be
erroneous to consider that victimization of autistic women is mainly due to autism. On
the contrary, autism seems to be just a vulnerability factor. Some authors propose that
educating potential victims to better protect themselves would help preventing abuse.
We reviewed this proposition in the light of our results and found it to be impossible to
apply since more than half of the victims were below or at the age of consent. Literature
about sexual violence is discussed. Large-scale prevention programs proposed by
World Health Organization and the Center for Disease Control aim at cultural changes in
order to diminish gender inequality, that they identify as the very root of sexual violence.
Keywords: autism, women, sexual violence, revictimization, post traumatic stress disorder, underage, abuse
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Cazalis et al. Sexual Violence Against Autistic Women
INTRODUCTION
Sexual violence is a major societal issue. World Health
Organization (WHO) states unambiguously that “Sexual violence
is a serious public health and human rights problem with
both short- and long-term consequences on women’s1physical,
mental, and sexual and reproductive health. Whether sexual
violence occurs in the context of an intimate partnership, within
the larger family or community structure, or during times of
conflict, it is a deeply violating and painful experience for the
survivor.”2Such wide-ranging consequences include long-term
depression, post-traumatic stress disorder (PTSD), substance
abuse and suicide (Devries et al., 2011;Hailes et al., 2019). It
is well demonstrated that women and vulnerable individuals
(children, disabled persons, elderly. . .) are at higher risk of
victimization (WHO, 2002;Machisa et al., 2017;Willott et al.,
2020). For example, prevalence of sexual abuse in adults with
intellectual disability reaches 32.9% (Tomsa et al., 2021). By an
intersecting effect, women with cognitive disabilities, such as
autism or attention deficit hyperactivity disorder, are therefore at
increased risk of being sexually assaulted. In this study, we have
investigated rates of sexual assault among a group of women on
the autistic spectrum, expecting elevated levels of victimization.
Proportion of Victims of Sexual Abuse in
the General Population
Sexual victimization is very common in the general population
(Sardinha et al., 2022). However, it has long been under-
recognized (Leight, 2022) because victims remain silent, due to
limitations in being able to report and reports often not being
believed. This is where sexual abuse differs from other forms of
violence: most victims who report it are met with suspicion and
denial and therefore are reluctant to talk about it (Ahrens, 2006;
Suarez and Gadalla, 2010;Kennedy and Prock, 2018). While the
underlying causes of such negative responses remain to be fully
elucidated, they can be explained by the strong persistence of
myths about sexual violence (e.g., “women provoke rape by the
way they dress,” “men have uncontrollable sexual urges,” “it is
not rape because she didn’t say no,” “she falsely accused him
of rape because she wants his money,” etc.) (Burt, 1980;Payne
et al., 1999;Flood and Pease, 2009). Such beliefs prevent victims
from reporting the assaults, and sometimes also prevent them
from identifying that the assault was an actual sexual aggression
(Weiss, 2009). Indeed, feelings of guilt, denial and shame, as well
as the legitimate fear of being blamed and stigmatized, are still
extremely prevalent among victims, who find it very challenging
to talk about the assault (Ahrens, 2006). Even professionals
such as clinicians or law officers are far from being immune
to such prejudices and do not offer the safe space that would
help victims recover thanks to adapted care and legal action
(Oram, 2019).
The last decade, however, has seen a steady change taking
place: there is a growing movement of victims who have found
1Unless otherwise specified, “woman” is equivalent to “assigned female at birth” in
this article.
2https://www.who.int/reproductivehealth/topics/violence/sexual_violence/en/
strength in numbers through social media. They have become
able to face social stigma in order to report what happened
to them (e.g., child abuse in church, abuse on women in
the entertainment industry, abuse on teenagers in competitive
sports, etc.). Such social movements might be beneficial for
victims in that they realize that they are not alone and
can find support. They might also be beneficial for society
in that they help acknowledging the extent of the problem,
since the massive amount of testimonies published everywhere
demonstrate that sexual abuse victims are much more numerous
than previously believed.
Statistics on prevalence in the general population indicate
elevated rates of victimization all over the world. The recent
WHO publication might be the most reliable reference on this
topic (WHO, 2021). It states that “30% of women aged 15 years
and older have been subjected to physical and/or sexual violence
from any current or former husband or male intimate partner, or
to sexual violence from someone who is not a current or former
husband or intimate partner, or to both these forms of violence
at least once” (p. XVI). In a recent study, Sardinha et al. (2022)
ran meta-analyses of 366 eligible studies, representing responses
of 2 million women aged 15 and older from 161 countries and
areas. They found that “27% (uncertainty interval [UI] 23–31%)
of ever-partnered women aged 15–49 years are estimated to
have experienced physical or sexual, or both, intimate partner
violence in their lifetime, with 13% (10–16%) experiencing it in
the past year before they were surveyed” (Sardinha et al., 2022).
In addition to instances of sexual assault during adulthood, one
must also consider victimization during childhood: rates of sexual
violence on children reach 12.7% (18% for girls and. 7.6% for
boys), according to a meta-analysis by Stoltenborgh et al. (2015).
Methodological Considerations
Regarding Assessment of Sexual
Victimization
Sexual victimization rates represent about one woman out of
three and one child out of ten. Readers may not have expected
such elevated figures, especially since many previous studies
have reported lower rates (although a few studies actually
reported higher numbers) (Dworkin et al., 2017). This is because
estimates of sexual violence depend on (i) the definition of sexual
violence; (ii) the choice of investigation methods (analysis of
formal complaints in police stations, clinical reports, telephone
interviews, internet surveys, open questions, etc.); and (iii)
the country where the investigation took place. Definitions of
sexual violence are obviously crucial when assessing levels of
victimization. For example, in their review of literature, Dworkin
et al. (2017) state that “17–25% of women and 1–3% of men will
be sexually assaulted in their lifetime.” In contrast, Cleere and
Lynn (2013) report much higher figures in their study of 302
college women, with 60.93% of their sample having experienced
some form of sexual aggression, including but not limited to
unwanted sexual contact. Regarding country-related variations,
rates may differ from one country to another. For example, in
France, rates of victimization were higher for men (3.9%) and
lower for women (14.5%) as compared to other countries. Such
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Cazalis et al. Sexual Violence Against Autistic Women
figures resulted from Hamel et al. (2016) the large-scale “Violence
and Gender Relations” (VIRAGE) survey that was conducted by
the French Institute for Demographic Studies (INED) in order to
assess lifetime levels of sexual aggression (rape, attempted rape,
unwanted sexual touching) in a sample of almost 16,000 women
and 12,000 men, aged 20–69 years old.
Despite this geographical and methodological variability, the
WHO (2021) study is actually very consistent with two other
large-scale studies that were conducted in the United States of
America. The National Crime Victimization Survey (NCVS) was
made using two methods of identification: self-report versus
interview, randomly assigned to a sample of 11,000 women aged
18–49, in order to assess rates of sexual aggression over the past
12 months. Their overall results show that 8.1% of participants
had suffered sexual violence over the past year. Their analyses
show that self-report led to slightly higher rates of reported
assaults than interviews (Cantor et al., 2021). The other large
United States-based study was titled “National Intimate Partner
and Sexual Violence Survey.” It was conducted on more than
12,000 persons by the National Center for Injury Prevention and
Control (CDC). Phone interviews regarding lifetime experience
indicate that rape affects 19.3% of women (and 1.7% of men),
other forms of sexual violence affect 43.9% of women (and 23.4%
of men) (Breiding et al., 2014).
Proportion of Victims of Sexual Abuse in
the Autistic Population
Several researchers have investigated whether autistic women
would exhibit higher levels of victimization than women
in the general population. Given that being on the autism
spectrum condition is characterized by experiencing difficulties
in social communication, such as decoding hidden intentions
and emotions of others, understanding implicit communication
and elements of context, it is expected that women on the
spectrum may be at considerable risk for sexual victimization, a
hypothesis confirmed by all published studies on this topic. To
this end, we have attempted here to conduct an exhaustive review
of such research.
Studies of Sexual Victimization in the Overall Autistic
Population
Brown-Lavoie et al. (2014) in a study using an online survey,
showed that 70% of autistic adults (n= 95) reported experiencing
some form of sexual victimization after age 14 and into
adulthood. In a study exploring self-reported experiences of
many forms of victimization and perpetration, researchers found
that adults on the autistic spectrum (n= 45) were more likely to
report several forms of victimization, including sexual violence,
than control participants (n= 42) (Weiss and Fardella, 2018).
In a Danish national survey on violence and discrimination
among people with different types of disabilities, 4 out of 23
autistic participants reported sexual victimization (Dammeyer
and Chapman, 2018). In a study investigating behavioral effects
of sexual molestation (as reported by caregivers) in n= 156
children on the autism spectrum, the authors found that 16.6%
of their sample had been sexually molested and that those
children were ten times more likely than the others to act out
in a sexual way, a well-known behavioral consequence of such
abuse (Mandell et al., 2005). In another study examining reports
provided by caregivers about autistic children and teenagers
(n= 350), it was found that 10% of the sample had been sexually
molested (Brenner et al., 2018). Interestingly, the Brenner et al.
(2018) study stands out in that it is the only one that represents
the full autistic spectrum, with 42% of their sample falling below
the IQ cutoff (70) for Intellectual Disability and 36% of the
sample presenting with very low verbal ability. It must be noted,
though, that reports by caregivers are not as reliable as personal
reports. This is illustrated in a study of 100 dyads of young
autistic adults and their parents: 62% of the young adults reported
some level of victimization as compared to 54% of their parents
(Hartmann et al., 2019).
Studies of Sexual Victimization in Female and Queer
Autistic Population
However, those six studies cited above did not report whether
there were differences between male and female participants.
Yet, since women are disproportionately more at risk of sexual
victimization than men in the general population, it seems very
likely that a similar difference would be observed within the
autism spectrum. Indeed, in a large scale Swedish longitudinal
twins’ study, 18 years old autistic female participants presented
an “almost three times increased risk of self-reported coercive
sexual victimization.” Female participants with ADHD were
also more victimized than controls, with a two times increased
risk (Gotby et al., 2018). In research combining psychometrics
and in-depth interviews about the inner experience of being
an autistic adult woman, 9 out of 14 participants reported
rape by their romantic partner (n= 7) and/or by strangers
(n= 3) (Bargiela et al., 2016). In a study of college students
involving nine campuses, participants on the autistic spectrum
(n= 158) were twice as likely to report unwanted sexual contact
as compared to students without ASC, but the analysis was
limited by the small size of the group of victimized autistic
participants (n= 13). Interestingly though, out of those 13
victims, 8 were female and 3 were non-binary, despite the autistic
sample including more males (n= 93) than female (n= 44)
and non-binary (n= 21) participants (Weiss, 2009). Of note,
participants with ADHD were also very much victimized, as
in the previously mentioned study by Gotby et al. (2018). In
a large-scale study, autistic traits and PTSD symptoms were
measured in 1247 adult women, who also reported whether
they had been abused during childhood. The authors found that
participants “in the highest versus lowest quintile of autistic traits
were more likely to have been sexually abused in childhood
(40.1% versus 26.7%) [. . .] and to have been pressured into
sexual contact (25.4% versus 15.6%) [. . .]. High levels of PTSD
symptoms were more prevalent in the highest versus lowest
quintile of autistic traits (6–7 PTSD symptoms, 10.7% versus
4.5%)” (Roberts et al., 2015). In a large-scale study investigating
how childhood trauma is related to self-harm in adulthood,
there was a subgroup of n= 150 individuals on the autism
spectrum. Analyzing that data, Warrier and Baron-Cohen (2021)
found that autism is strongly correlated with sexual molestation
during childhood, and that this effect was even much stronger
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Cazalis et al. Sexual Violence Against Autistic Women
in women. Recent research by Pecora et al. (2019, 2020) focused
on two major intersecting risk factors for sexual victimization:
sexual orientation and gender identity. It is well established that
members of the LGBTQIA++3community are still very much
persecuted and attacked in most countries. Autistic individuals
assigned female at birth are overwhelmingly part of the queer
community, to the point that women who are cis-gender and
strictly heterosexual actually constitute a minority on the autism
spectrum (Greenberg et al., 2018;Pecora et al., 2019, 2020).
Therefore, exploring “the nature of negative experiences in
autistic and non-autistic females across gender identity and
sexual orientation” was a much-needed investigation in order
to understand the complexity of sexual and sentimental life of
these persons. In their 2019 study (135 autistic females, 96 autistic
males, 161 non-autistic females), they found that autistic females
expressed less sexual interest than autistic males but not less than
non-autistic females. The authors categorized negative sexual
experience as (1) sexual experiences that were later regretted;
(2) unwanted sexual experiences; and (3) being the victim
of an unwanted sexual advances. While the methodological
pertinence of such categorization is questionable, results are
highly significant: autistic females were 7.15 and 2.52 times more
likely to undergo negative sexual experience than autistic males
and non-autistic females, respectively (Pecora et al., 2019). In
their 2020 study, they included n= 134 autistic persons assigned
female at birth and brought up even more important findings:
their autistic sample was 70% queer; being autistic represented
a 2.38 fold increased risk of negative sexual experience as
compared to controls; within the spectrum, homosexual persons
had a 3.29 fold increased risk as compared to heterosexual
ones (Pecora et al., 2020). The last study that we reviewed
was recently published by Joyal et al. (2021). They included
68 (27 females) young adults on the autism spectrum. Their
research show that, regarding negative sexual events, young
autistic women are four times more likely than young autistic
men and twice as likely than non-autistic women to undergo
such experience. Very interestingly, the researchers found out
that, within the autistic spectrum, being a (a) late diagnosed
(b) female with (c) sufficient education about sexuality and
(d) desire for sex were at the same time strong predictors of
positive sexual experience and strong predictors of negative
sexual experience.
Elevated Risks of Sexual Victimization in Autistic
Individuals Identified as Female
We tentatively conclude from this short review that being autistic
means undergoing a 10–16% risk of enduring sexual molestation
as a child and a 62–70% risk of being sexually victimized in
adulthood. Most victims are girls and women: autistic female risk
of being sexually assaulted is between two and three times as
much than non-autistic females and about four times as much
than autistic males. Those figures are consistent with the general
population rates: around 30% of women and 12% of children are
sexually victimized in their lifetime.
3LGBTQIA++: lesbian, gay, bisexual, transgender, questioning, queer, intersex,
asexual, pansexual, and allies. In this text, we chose to use the umbrella term
“queer.”
In the line of this research, we have conducted an internet-
based survey in order to measure the prevalence of sexual
victimization in women on the autism spectrum (n= 225)
by using standardized assessment. Thereby, we have recruited
participants to our survey through the websites of non-profit
organizations in order to investigate their lifetime prevalence
exposure to sexual aggression and abuse, their autistic traits,
as well as comorbid psychiatric disorders for which they were
treated (depression, anxiety disorders) and behaviors that can
be connected with childhood or adult sexual abuse (i.e., suicide
attempts, self-mutilations, substance abuse...) insofar as these
behaviors may represent “red flags” that can alert relatives and
clinicians. Our study first aim was to confirm previous results
using a larger sample. More importantly, our goals were to
expand such results by investigating several dimensions of sexual
victimization that bear clinical and social significance, such as
age at first assault, that we hypothesized to be correlated to
levels of revictimization. We also used two modes of inquiry
(directed versus open question) because we expected that they
would yield different results. Last, we explored other dimensions
such as health consequences of aggression, with a focus on
post-traumatic stress-disorder, and follow-ups of the aggression
such as reports and opinions of victims regarding prevention
methods. Importantly, in our study, sexual victimization was
defined as one or several of the three following situations:
unwanted sexual contact; rape; attempted rape. Our definition
was therefore limited and did not include other forms of sexual
violence such as sexual harassment, stalking, indecent exposure,
revenge porn, etc.
MATERIALS AND METHODS
This internet-based study was conducted in France in April
and May 2018. A total of 234 participants completed the
questionnaire. Our final sample was n= 225, since 9 participants
did not meet inclusion criteria (3 did not provide consent
for their data to be used; 2 obtained a Ritvo Autism and
Asperger Diagnostic Scale (RAADS) score less than 14; 4 were
aged less than 18).
In order to facilitate results replication and refutation, an
extended and detailed version of the statistics section is provided
as Supplementary Material, as well as an English translation of
the questionnaire.
Repository URL for R code is: https://nakala.fr/10.34847/nkl.
4021h29a.
Repository URL for dataset is: https://nakala.fr/10.34847/nkl.
d3d35i2o.
Recruitment of Participants
Due to social and communication difficulties, many women on
the autism spectrum join online autism communities where
they can find help and support from peers and where they
may feel more comfortable discussing issues of sexual violence
that they have experienced. We have contacted several local
organizations dedicated to autism (Association Francophone
des Femmes Autistes, Asperger Amitié, Asperger Aide, France
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Cazalis et al. Sexual Violence Against Autistic Women
Asperger. . .) and asked them for their support by sharing to their
community an internet link to a data collection site.
Procedure
After a short description of the study, women were asked to
participate in this survey if they were identifying as autistic
women. Participants provided consent for their data to be
used in the study after completing anonymously the online
questionnaire. A trigger warning was included before questions
regarding victimization, as well as an invitation for victims to
contact a health practitioner. After pre-submission, the president
of the ethics committee of Paris V decided that it was not
necessary to review the study insofar as the participants were
strictly anonymous (no identifying data were collected, nor IP
addresses of respondents). As per French laws regarding data
privacy, the questionnaire was declared to CNIL authorities
(National Commission on Informatics and Liberty) under
identifier # 2172655.
Measures
All participants answered to three questionnaires, for a total of
38 questions, using an online survey system4. All questions were
multiple choice questions with the exception of questions #8, #13,
#33, #36, #37 which were multiple response questions (i.e., “check
all that apply”). In addition, questions #8, #9, #13, #33, #34, #36,
#37 included an open field question: “Other (please specify).”
Scope of Questions
◦Questions #1–6: socio-demographic information.
◦Questions #7–9: health level and A.S.D diagnosis.
◦Questions #10–12: sexual activity and sexual orientation.
◦Question #13: victimization status in an open question
form allowing multiple responses. Choices were as follows:
(1) I haven’t been sexually assaulted; (2) I have been
sexually assaulted; (3) I have been raped; (4) I underwent
an attempted rape; (5) I do not know; (6) Other
(with open field).
◦Questions #14–27: autistic traits (RAADS-14 scale)
(Ritvo et al., 2011).
◦Questions #28–31: victimization level (items 1, 2, 3, and 5
of the Sexual Experiences Survey (SES) scale – Short Form
Victimization) (Johnson et al., 2017).
◦Questions #32–33: age at first assault and
revictimization status.
◦Question #34: for victims, did they report the assault
(with no specification to whom)? And what were the
consequences of reporting (being believed or not; receiving
psychological care or not; filing a complaint or not)?
◦Question #35: for victims, what could have prevented the
assault? (listed options were chosen by the authors based
on clinical interviews).
◦Question #36–37: presence of psychiatric disorders and
assessment of consequences following the assault.
◦Question #38: participants’ consent to have their responses
used in this study.
4www.surveymonkey.com
Measure of Autistic Traits With RAADS-14 Scale
The RAADS scale is considered to be one of the most reliable
self-report screening tools for ASD. In the validation study of
the RAADS-14 based on the 80 item Ritvo Autism and Asperger
Diagnostic Scale-Revised [RAADS-R (Ritvo et al., 2011)], the
median score for ASD was 32, and 11 for other psychiatric
disorders, whereas a cut-off score of 14 or above reached a
sensitivity of 97% and a specificity of 46–64%.
We calculated the mean, median and standard deviation
of the RAADS scores across our sample of participants.
We also calculated scores for the three sub-components of
RAADS: “social communication” (columns 1, 4–6, 8, 9, and 11);
“hyper-focalization” (columns 12–14) and “sensory reactivity”
(columns 7 and 10).
Measure of Sexual Victimization With Sexual
Experiences Survey Questionnaire
In order to assess victimization status of participants, we used
a French translation of items 1, 2, 3, and 5 of the Sexual
Experiences Survey Short Form Victimization questionnaire
(SES-SFV). The Sexual Experiences Survey (SES) and its recent
10-items update (SES-SFV) are the most widely used measures
of unwanted sexual experience (Johnson et al., 2017). The fact
that it consists of questions about specific situations is important,
since responders may not realize that their experiences could be
classified as victimization.
Of important note, we did not apply the recommended
analysis method for answers to SES-SFV, which distributes
them into six situations: non-victim, sexual contact, attempted
coercion, coercion, attempted rape and rape. This is due to the
fact that the distinction between coercion and assault does not
exist in France, where sexual relationships obtained through
coercion are legally categorized as rape in France. Therefore, we
have used the following categories instead: sexual touching (s1),
oral rape (s2), vaginal/anal rape (s3) and attempted rape (s4).
In our analyses, (s2) and (s3) were pooled together in a single
category titled “rape.”
Statistics
Statistical analyses were realized with R (R 4.1.1 2021.08.10). We
used the following methods5: descriptive statistics (percentages,
means, medians and standard deviations). We used non-
parametric statistical analyses because data was mostly non-
continuous. We used Chi square test to assess for significant
differences between subgroups. When applicable, we also used
McNemar test and conditional probabilities in order to confirm
Chi square tests’ results, because differences in sample sizes
of our subgroups could increase type 1 and type 2 errors.
In order to assess whether some characteristics of our sample
increased measured risks (e.g., developing Post Traumatic Stress
Disorder), we used three methods: two-sample test for equality
of proportions, Wilcoxon test and univariate logistic regression
with odds ratio and confidence intervals. Unless otherwise
specified, we used Yates continuity correction as post hoc
5As mentioned above, the details can be found in the commented version of our R
code (Repository URL for R code is: https://nakala.fr/10.34847/nkl.4021h29a).
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Cazalis et al. Sexual Violence Against Autistic Women
correction in all cases. Bonferroni correction was additionally
used when applicable.
RESULTS
Population Description
Socio-Demographics
All participants declared themselves female except one.
Participants’ characteristics are reported in Table 1.
Diagnosis and Comorbidities
In our sample, 60 (26.7%) participants were self-diagnosed,
143 participants (63.6%) declared having received professional
diagnosis, and the remainder 22 (9.8%) participants declared
situations ranging from early questioning to being currently
in the diagnosis process. Hundred and forty-nine participants
(66.2%) received IQ testing: 25 (16.7% of those whose IQ
was assessed) reported average IQ scores [90–119], 45 (30.2%)
reported above average scores [120–129] and 78 (52.3%) reported
IQ >130.
Participants reported their state of health as good to excellent
for 119 (52.9%) of them, while 67 (29.8%) rated their health as
average and 39 (17.3) reported bad health state. Participants also
reported existing comorbidities as follows:
TABLE 1 | Socio-demographic characteristics of participants.
Socio-demographic characteristics N(%)
Age range
18–20 4 (1.8%)
21–29 47 (20.9%)
30–39 91 (40.4%)
40–49 62 (27.6%)
50–59 17 (7.6%)
60 and more 4 (1.8%)
Education levels
No diploma 5 (2.2%)
Grade school 1 (0.4%)
Junior high school 7 (3.1%)
High school (no diploma) 22 (9.8%)
High school diploma 43 (19.1%)
University – License degree (3 years) 67 (29.7%)
University – Master’s degree (5 years) 67 (29.7%)
University – Doctoral degree (8 years) 13 (5.7%)
Occupation
Student 23 (10.2%)
Employee 41 (18.2)
Executive 25 (11.1%)
Independent worker 25 (11.1%)
Unemployed – looking for a job 23 (10.2%)
Unemployed – not looking for a job 17 (7.6%)
Disability payments 23 (10.2%)
Sick leave or inability to work 31 (13.7%)
Other (please specify) 17 (7.6%)
•Depression: 140 (62.2%)
•Anxiety: 127 (56.4%)
•Post-traumatic Stress Disorder (PTSD): 60 (26.7%)
•ADHD: 25 (11.1%)
•Bipolar disorder: 15 (6.7%)
•Borderline personality disorder: 12 (5.3%)
•Substance abuse: 9 (4.0%)
•Alcohol abuse: 8 (3.6%)
•Schizophrenia: 2 (<1%)
Regarding comorbidities, participants could declare more
than one existing comorbidity as shown in Table 2.
Sex Life
Table 3 provides description of participants’ sex lives. Out of 125
individuals who declared having been sexually active over the last
six months, 96 (77%) were in a relationship/married, while 29
(23%) were not in a relationship/married.
Measure of Autistic Traits (Ritvo Autism
and Asperger Diagnostic Scale)
Description of Ritvo Autism and Asperger Diagnostic
Scale Results
RAADS total scores: mean = 34.88; median = 36.00; SD: 5.24.
TABLE 2 | Number of comorbidities.
Number of
comorbidities
012345
Number of
participants
56
(24.9%)
35
(15.6%)
59
(26.2%)
59
(26.2%)
12
(5.33%)
4
(1.8%)
TABLE 3 | Sex life characteristics of participants.
Sex life characteristics N(%)
Relationship status
Single 68 (30.2%)
In a relationship 80 (35.6%)
Married 50 (22.2%)
Divorced/separated 26 (11.6%)
Widow 1 (0.4%)
Sexual orientation (sexually attracted by)
Opposite sex only 64 (28.4%)
Bisexual 135 (60.1%)
Same sex only 3 (1.3%)
Asexual 23 (10.2%)
Sexual experience with (over lifetime)
Opposite sex only 122 (54.2%)
Bisexual 86 (37,5%)
Same sex only 5 (2.2%)
Asexual 12 (5.3%)
Frequency of sexual relationships over the last six months
I have not had any sex 100 (44.4%)
I have sex less than once a month on average 33 (14.7%)
I have sex between once and three times a month on average 41 (18.2%)
I have sex between four and ten times a month on average 36 (16.0%)
I have sex more than ten times a month on average 15 (6.7%)
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FIGURE 1 | Distribution of RAADS scores of self-diagnosed participants
compared to the distribution of all participants.
RAADS sub scores social communication: mean = 16.06;
median = 17.00; SD = 3.61.
RAADS sub scores hyper focalization: mean = 8.05, 9, 1.64;
median = 9.00; SD = 1.64.
RAADS sub scores sensory reactivity: mean = 5.30;
median = 6.00; SD = 1.30.
Figure 1 illustrates the comparison of self-diagnosed
participants to the whole sample in terms of RAADS scores
distribution.
Sexual Victimization
Description of Q13 Results: Open Question About
Victimization Status
Hundred and fifty-five (68.9%) participants declared being victim
of one or another form of sexual violence. 22 (9.8%) participants
declared not having been victimized while 39 (17.3%) declared
that they did not know. Declared victims were distributed
as follows: assault: 117 (52.0%); rape: 69 (30.7%); attempted
rape: 23 (10.2%).
Description of Sexual Experiences Survey Results:
Guided Questions About Victimization Status
Hundred and ninety-nine (88.4%) participants reported being
victim of one or another form of sexual violence. Twenty-
six (11.6%) participants declared not having been victimized.
Reported victims were distributed as follows: sexual touching
and/or rape attempt: 196 (87.1%); rape: 155 (68.9%).
While some participants reported only one type of aggression,
others reported being victims of several types of aggressions, as
illustrated in Figure 2:
Victims of sexual touching only: n= 22 (9.8%).
Victims of attempted rape only: n= 5 (2.2%).
Victims of rape only: n= 3 (1.3%).
Victims of several categories of assaults: n= 169 (75.1%).
Non-victims: n= 26 (11.6%).
Description of Q32–33: Age at First Aggression,
Frequency of Abuses and Cases of Multiple
Offenders
Age at first aggression was distributed as follows:
•Less than 9 years old: 43 (19.1%)
•Between age of 10 and 12: 36 (16.0%)
•Between age of 13 and 15: 33 (14.7%)
•Between age of 16 and 18: 23 (10.2%)
•Between age of 19 and 30: 59 (26.2%)
•More than 30 years old: 5 (2.2%)
•Non-victims: 26 (11.6%)
Cases of multiple aggressions were distributed as follows
(choices could be cumulative):
•There was only one case of aggression: 30 (13.3%)
•It happened several times with the same offender: 91
(40.4%)
•It happened several times with several offenders: 126
(56.0%)
•Non-victims: 26 (11.6%)
Description of Strategies Used by Perpetrators, With
Detailed Description Depending on the Type of
Aggression
Participants reported that offenders used different strategies
depending on the type of aggression, as illustrated in
Figure 3. The Cronbach’s alpha was 0.7 and the McDonald’s
omega total was 0.74.
Description of Q37: Consequence of Aggression at
6 Months
Participants reported consequences of the aggression during the
6-month period following the assault. As illustrated in Figure 4,
distribution of such consequences among victims (according to
SES questionnaire) is as follows:
•Sleep disorder: 96 (48.2%)
•Disgust for sex: 93 (46.7%)
•Self-harm: 63 (31.7%)
•Weight gain: 45 (22.6%)
•Drugs and/or alcohol abuse: 39 (19.6%)
•Suicide attempt: 30 (15.1%)
•Tattoo/piercing: 19 (9.5%)
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FIGURE 2 | Percentage of participants in combinations of types of assaults.
Description of Q34–35: Help Requests and
Prevention Opinions
Among the 199 victims, 111 (55.8%) did not report the assault.
Among the 69 who told others about the assault, 18 (26.1%) were
not believed. Among the 51 who reported the assault and who
were believed (25.6% of the victim total), 34 (66.7%) received no
care and no complaint was filed, 8 (15.7%) received care and a
complaint was filed, 4 (7.8%) did not receive care but a complaint
was filed, 5 (9.8%) received care but no complaint was filed.
The remainder of victims either answered “other” (16, 8%) or
were among the 29 participants (12.9% of the full sample) who
answered “not applicable” alongside the non-victims.
Participants also chose which of the following sentences best
reflected their own opinions regarding prevention methods:
•Sexual manipulators or predators seem to spot you more
easily because of your difficulties in sexual interactions:
n= 50 (22.2%).
•Knowledge of self-affirmation strategies learned in therapy
(or social skills groups) could have helped you stay safe
better: n= 39 (17.3%).
•Your family members should have been more attentive:
n= 37 (16.4%).
•Female teenagers with Asperger syndrome and their
parents should be better informed about the risk of sexual
abuse: n= 23 (10.2%).
•Nothing could have protected you from this or these
assault(s): n= 24 (10.7%).
•Health professionals should have given you adapted
prevention advice such as better identifying sexually
ambiguous situations with men: n= 18 (8.0%).
•The officials of the institution (high school, university,
company) in which you were should have been more
watchful: n= 8 (3.6%).
•Not applicable (this is not relevant to me): n= 26 (11.6%).
Hypothesis #1: Open vs. Guided Questions
(Question#13 vs. Sexual Experiences Survey
Questionnaire) Yield Different Results
In order to compare answers from the two sexual assault
questionnaires, we checked overlaps and incongruencies between
Question#13 and SES questionnaire. We looked at how many
participants who had chosen at least one of the positive answer
columns (the assault, rape and attempted rape options) in the
open question were also victims according to SES, checking the
same for participants who hadn’t. We also looked at how many
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FIGURE 3 | Strategies used depending on the type of assault.
participants who didn’t know or declared being non-victims in
the open question were nevertheless victims according to SES,
and how many weren’t.
While 153 (68%) participants reported victimization in both
SES and question#13, there were 46 (20.4%) participants who
did not identify as victims in question#13 but nevertheless were
classified as victims according to the SES questionnaire. On the
other hand, only 2 (<1%) participants reported being victims
when answering to question#13 but were not categorized as
victims according to SES questionnaire.
Also, among the 39 participants who answered “I don’t know”
to question#13, 34 of them were actually categorized as victims
according to SES questionnaire. More precisely, those 34 victims
reported one or more of the following assaults: Sexual touching:
31 (91.2%); rape: 22 (64.7%); rape attempt: 16 (47.1%).
Moreover, among the 22 participants who answered being
non-victims to question#13, 5 were recategorized as victims
according to SES questionnaire, distributed as follows: Sexual
touching: 3 (60%); rape 1 (10%); rape attempt: 4 (80%). Those
results are illustrated in Figure 5.
In order to check consistencies between the two modes of
investigation (question#13 and SES), we used two methods:
Chi-square tests and Mc Nemar tests were run on the
contingency tables.
Chi squared tests results were as follows and remain significant
after a Bonferroni correction:
- Sexual touching (SES) or assault (open question): p= 2.27e-
07∗
- Rape: p= 2.01e-08∗
- Rape attempt: p= 4.61e-05∗
McNemar tests results were as follows:
- Sexual touching (SES) or assault (open question): p= 2.05e-
15
- Rape: p<2.2e-16
- Rape attempt: p<2.2e-16
Hypothesis #2: Being Victim of One Aggression
Increases the Risk of Further Aggressions
In order to investigate whether being victim of one assault
increases the risk of revictimization, we used conditional
probabilities within SES questionnaire, with the following results:
-P(sexual touching | rape) = 96.8%
-P(sexual touching | attempted rape) = 93.6%
-P(rape| sexual touching) = 79.4%
-P(rape| attempted rape) = 80.0%
-P(attempted rape| sexual touching) = 54.5%
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FIGURE 4 | Consequences of assault within 6 months of happening.
-P(attempted rape| rape) = 56.8%
We ran Chi-square tests on the contingency tables within SES
questionnaire (see Table 4), with the following results, which
remain significant after a Bonferroni correction:
- Sexual touching and rape: p= 2.27e-07∗
- Sexual touching and rape attempt: p= 0.0002∗
- Rape and rape attempt: p= 0.0007∗
- Sexual touching and rape and rape attempt: p= 1.72e-14∗
We also ran McNemar tests on the contingency tables within
SES questionnaire, with the following results:
- Sexual touching and rape: p= 6.53e-07∗
- Sexual touching and rape attempt: p= 6.05e-16∗
- Rape and rape attempt: p= 3.10e-06∗
Hypothesis #3: Being Young at First Aggression
Increases the Risk of Further Aggressions
We investigated whether the age at first assault is related to the
risk of revictimization by another offender, as shown in Figure 6.
We did a logistic regression in which having had several
abusers was the dependent variable and the age of first
assault the independent variable, with the following results:
P-value = 0.0027∗; Odds-ratio = 0.75; confidence interval = (0.62–
0.90). The influence of age of first assault remained when
controlling for PTSD and presence of several assaults by the same
offender, with the latter also showing significant correlation with
the dependent variable.
We ran another logistic regression in which being victim
of several assaults by the same offender was the dependent
variable and the age of first assault the independent variable,
with the following results: P-value = 0.0513; Odds-ratio = 0.84;
confidence interval = (0.70-1.00). The influence of age of
first assault increased to the point of becoming significant
when controlling for PTSD and presence of several offenders,
with the latter also showing significant correlation with the
dependent variable.
Hypothesis #4: Perpetrators Use Different Aggression
Strategies Depending on Aggression Types
We investigated whether offenders used different aggression
strategies depending on the type of assault. Chi-square tests were
done on a contingency table within SES of all five strategies and all
types of assault (see Tables 5,6) to see if there were any differences
in the distribution of strategies between the three types of assault.
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FIGURE 5 | Comparison of assaults reported by participants through the two
questionnaires.
TABLE 4 | Contingency tables for types of assault two by two.
Rape Attempted rape
Non-victim Victim Non-victim Victim
Sexual
touching
Non-victim 31 (13.8%) 5 (2.2%) 29 (12.9%) 7 (3.1%)
Victim 39 (17.3%) 150 (66.7%) 86 (38.2%) 103 (45.8%)
Attempted
rape
Non-victim 48 (21.3%) 67 (29.8%)
Victim 22 (9.8%) 88 (39.1%)
Importantly, since strategy “d= threatening physical harm” was
so rare, we had to exclude it from the contingency tables in
which it would have been its own category, but kept it when
it was a component of a larger category. Of note, we also ran
those tests without Yates correction, with comparable results. As
a reminder, the remaining strategies are: manipulation/mental
ascendency/harassment (“a”), anger/disgust/malicious criticism
(“b”), using surprise to take advantage (“c”) and use of force
(“e”). The p-values that are significant remain so after a
Bonferroni correction.
Hypothesis #5: History of Sexual Aggression and the
Risk of Post-traumatic Stress Disorder Are Correlated
Participants could declare one or more existing comorbidities.
The mean number of declared comorbidities was different
depending on victimization. We also report here the details of
comorbidities declared by each group (see Table 7). In order to
test if victimization increased the number of comorbidities, we
used Wilcoxon test to compare mean number of comorbidities in
victims versus non-victims, resulting in p= 0.016∗.
In order to test if victimization increased the risk of a specific
type of comorbidity, we ran two-sample tests of equal proportions
within SES, leading to the following p-values: p= 0.7707 for
depression, p= 0.1817 for anxiety and p= 0.1054 for PTSD.
Of note, the same analysis ran without Yates correction led to
significant p-value for PTSD only: p= 0.0467∗.Figure 7 illustrates
the percentage of PTSD in victims depending on age at first
assault.
In order to test whether SES victimization increased the
risk of PTSD, we ran logistic regressions with the following
results: p-value = 0.0760, odds-ratio = 3.08, confidence
interval [1.02–13.33]. Using RAADS score, current age
and education level as control variables revealed RAADS
score to have the strongest correlation. Using the RAADS
score as the sole predictor yielded the following results:
p-value = 0.0125∗, odds-ratio = 1.09, confidence interval [1.02–
1.16]. Last, among SES victims, we explored whether age at
first aggression was a predictor of PTSD, with the following
results: p-value = 0.0162∗, odds-ratio = 0.78, confidence interval
[0.64–0.95]. Controlling for presence of several assaults from
the same assaulter and presence of several assaulters, two other
variables correlated with age at first assault, did not significantly
change this result.
In order to investigate whether multiple assaults perpetrated
by one or several offenders made a difference regarding the risk of
developing a PTSD, we ran two-sample tests of equal proportions
within SES, with the following results:
- Victims of several assaults from several offenders and
victims of only one offender (be it one or several assaults):
p= 0.6465.
- Victims of several assaults from same offender and other
victims (several offenders +only one assault): p= 1.
We also ran logistic regressions among victims in order to
test if the risk of developing PTSD was increased by multiple
victimization by
- the same offender: p-value = 0.948; odds-ratio = 0.98;
confidence interval [0.52–1.82]
- several offenders: p-value = 0.535; odds-ratio = 1.23;
confidence interval [0.65–2.38]
Hypothesis #6: Presence of Autistic Traits Increases
the Risk of Sexual Aggression
We investigated whether presentation of autistic traits
constituted a risk factor for sexual victimization. In order
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FIGURE 6 | Percentages of participants with several abusers depending on age at first assault.
TABLE 5 | Numbers used in the single strategy centered contingency tables.
Sexual touching
victim answers
Attempted rape
victim answers
Rape victim
answers
Used Not used Used Not used Used Not used
Strategy a 67 122 60 50 112 140
Strategy b 21 168 7 103 25 227
Strategy c 70 119 18 92 62 190
Strategy e 31 158 22 88 47 205
to compare RAADS scores of victims and non-victims according
to SES, we used Wilcoxon tests and logistic regressions. Adding
current age and education level as independent variables to
the logistic regressions did not significantly change the results.
Results are illustrated in Figure 8 and reported in Table 8.
DISCUSSION
Sample Description Is Consistent With
Literature and Clinical Observations
The description of our population sample is revealing of what
autism in women looks like and is in line with previous studies
(Lai et al., 2017;Ormond et al., 2018). Participants included in
TABLE 6 | p-Values of difference in presence of strategies depending on
aggression type.
All three
types of
aggressions
Sexual
touching and
rape attempt
Rape and
rape
attempt
Sexual
touching and
rape
Strategy a 0.0051* 0.0019* 0.0978 0.0710
Strategy b 0.3963 0.2489 0.3707 0.8046
Strategy c 0.0002* 0.0003* 0.1096 0.0066*
Strategy e 0.7101 0.5296 0.8767 0.6267
*p < 0.05.
our study (n= 225) were of all ages but predominantly in their
thirties. A quarter of participants were self-diagnosed.
We asked participants if they had received IQ testing. Among
the 66.2% who answered yes, 82.5%, (n= 123, i.e., more
than half of our total sample) obtained a score >120 and
52.3% (n= 78, i.e., more than a third of our total sample)
reported IQ >130. Of course, we can’t extrapolate such numbers
to the whole sample, because of a potential clinical bias: it
cannot be excluded that IQ testing was more often realized in
individuals displaying signs of high IQ, since clinicians may
have found that such measures would prove helpful to this
subpopulation. Nevertheless, 34.6% of our total sample scored
over 130. If true (we had no direct access to the IQ tests; recall
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TABLE 7 | Consequences within 6 months of assault.
Victims (n= 199,
according to SES)
Non-victims (n= 26,
according to SES)
Number of comorbidities
Mean (±SD) 1.84 (±1.34)* 1.19 (±1.02)*
Median 2 1
Types of comorbidities
Depression 125 (62.8%) 15 (57.7%)
Anxiety 116 (58.3%) 11 (42.3%)
Post-traumatic stress disorder (PTSD) 57 (28.6%)*93 (11.5%)*
ADHD 23 (11.6%) 2 (7.7%)
Bipolar disorder 15 (7.5%) 0 (0.0%)
Borderline personality disorder 12 (6.0%) 0 (0.0%)
Substance abuse 9 (4.5%) 0 (0.0%)
Alcohol abuse 8 (4.0%) 0 (0.0%)
Schizophrenia 2 (1%) 0 (0.0%)
9Of note, the difference appears to be significant only when Yates correction is not
applied.
*p < 0.05.
memory bias and social desirability bias cannot be excluded),
these results seem to be a rather exceptional situation, and it
confirms field observations that report sharp mindedness in the
population of “high-functioning”6autistic women. Two thirds of
these women graduated university, but only half of them were
professionally active (work or studies). Despite demonstrably
high cognitive abilities and education levels, participants in
our study experienced employment difficulties. This discrepancy
illustrates the well-documented employment issues endured by
autistic persons.
More than half of the participants (57.8%) were involved in
a relationship and more than half (55.6%) had been sexually
active over the last six months (mostly the same individuals,
77% of them being in a relationship while the remainder was
not). Of important note, more than half of our sample had
only experienced heterosexual sex over their lifetime, despite
the extremely high percentage of declared queer orientations
(71.6%). This gap between aspiration and experience might be
partly explained by social factors that are non-specific to autistic
women (i.e., cultural stereotypes, lower proportion of potential
partners...), but could also be linked to autistic characteristics,
such as camouflaging and social imitation strategies that have
been previously described in autistic women (Lai et al., 2017).
Another partial and cumulative explanation could be that since a
large majority (60.1%) of our participants were actually bisexual,
we may postulate that they simply settled with the most available
type of romantic relationship. Of note, our results are very
consistent with literature describing that sexual orientation in
autistic women is very diverse (Greenberg et al., 2018;Pecora
et al., 2019, 2020).
Interrogated about their health, while only 17% of participants
reported poor health status, more than 75% reported at least
one psychiatric comorbidity, as if mental health disorders
6“High functioning” here means that our participants had to be able to fill a
questionnaire in order to be included.
comorbidities were not health issues. Depression and anxiety
were by far the most prevalent comorbidities (62.2 and 56.4%
respectively). PTSD came in third place (26.7%). These results
should however be interpreted cautiously because of the absence
of structured clinical interviews for psychiatric diagnosis in this
study. Considering that all these findings are in agreement with
reports and studies on the topic of autism in adult women,
it is reasonable to see our sample as reliably representative
(Lai and Baron-Cohen, 2015).
In order to confirm autism diagnosis reported by participants,
we collected their RAADS scores. We only included in the
analyses participants who obtained RAADS score >14 (merely
two participants were excluded solely on that criterion).
Mean RAADS in our sample was equal to 34.9 ±5.2
and median was equal to 36, well above the median = 32
reported in the validation study of that scale (Ritvo et al.,
2011). Moreover, the distribution of RAADS scores of self-
diagnosed participants reflected that of the clinically diagnosed,
confirming that including this sub-group in the analyses was
methodologically acceptable.
Sexual Victimization Is Very High, and
Victims Are Young
We assessed victimization status twice: through an open question
(Question#13) and through a specific questionnaire (SES-SVF).
Both methods yielded extremely high figures: open question
resulted in 68.9% victimization, compared to 88.4% with SES-
SFV questions. Those results are very high but nonetheless
extremely consistent with the findings that we have reviewed
earlier: a rate of almost 30% victimization in non-autistic women
and a 2 to 3-fold increased victimization of autistic women
(Roberts et al., 2015;Bargiela et al., 2016;Weiss and Fardella,
2018;Pecora et al., 2019, 2020;Joyal et al., 2021;Warrier
and Baron-Cohen, 2021). Moreover, results indicate that sexual
aggressions started while most of the victims were underage or
barely able to legally consent: out of 199 victims, more than two
thirds (68%, n= 135 victims) where aged 18 or below when the
first aggression took place; more than half (56%, n= 112) being at
or below age of consent (15 in France).
Regarding ascertainment procedure, we used two methods of
case identification. As expected, the SES-SVF questions revealed
a significantly higher level of victimization than the open
question. This confirms that it is necessary to ask questions
about specific situations, rather than using open questions, in
order to identify all victims, since some victims may need many
years of processing memories about the assault before realizing
that the non-consensual sex that happened to them qualifies as
a legal offense/crime. One participant wrote this “It happened
many times over my lifetime (as child, as a teen, as an adult).
It is only 5 years ago, at the age of 50, that I understood
that I had been victim of sexual violence.” Another participant
wrote “This event remained out of my consciousness’ access
for many years.” We indeed found several instances of such
confusion in our sample: 34 out of 39 participants who answered
“I don’t know” to the open question were nevertheless identified
as victims through SES. Furthermore, 5 out 22 participants
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FIGURE 7 | Post-traumatic stress disorder rates depending on age at first assault.
who responded “non-victim” to the open question were actually
victims according to SES. Last, Chi-squared test results indicated
that participants were consistent: all but two of those who
declared being victim in the open question declared the same
thing in SES-SFV questions.
Sexual Revictimization Is Also Very High
Sexual revictimization among our participants was very
important: 84.9% of victims were revictimized (n= 169 out
of 199). In other words, 75.1% of all participants reported
several aggressions. By contrast, only 13.3% (n= 30) were
assaulted just once over their lifetime – with the assault
consisting of unwanted sexual touching for most of them
(n= 22).
We used four different statistical methods to assess whether
being victim of one assault increased the risk of being victim of
another one, and all yielded significant results, reaching a clear-
cut conclusion that, yes, primo-victimization is a major gateway
to further victimization. This is actually also the case for non-
autistic women: half of those who were molested as children
will suffer from new occurrences of sexual violence later in life
(Walker et al., 2019).
Being young made things worse in our sample: young age
was a significant factor of revictimization later in life. One
possible contributor to this mechanism is that children who are
molested often exhibit disturbed behaviors. As Mandell et al.
(2005) found out, molested autistic children were ten times more
likely than the others to act out in a sexual way. Such reaction
is particularly maladaptive, since hyper-sexualized behavior by
children facilitates exploitation and abuse by offenders. To make
things worse, it happens that autistic girls are entering puberty
significantly earlier than non-autistic girls, and earlier than
autistic boys as well (Corbett et al., 2020). This precocious
puberty is in itself enough to put those girls even more at risk
as it was demonstrated in a study by Skoog and Özdemir (2016):
“early maturing girls are sexually harassed as a result of natural
and normative sexual development, which happens earlier than
for most of their peers.” In any case, natural early maturing
and maladaptive oversexualization are extremely easy to spot,
therefore attracting predators.
Rape Severely Impacts Health of Victims
As mentioned in the introduction to this text, sexual violence
has a very negative impact on health. In our sample, participants
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FIGURE 8 | Distribution of RAADS scores of non-victims (per SES) compared
to distribution of RAADS scores of all participants.
who had endured sexual violence exhibited significantly more
comorbidities than participants who hadn’t. Further testing
suggested that, among all comorbidities, it is specifically PTSD
that is increased after the aggression, in accordance with a
recent meta-analysis (Hailes et al., 2019). Given the small
number of non-victims in our sample, results were not clear
cut: test of equal proportions was only significant without
post hoc correction and the p-value of logistic regression did
not reach significance despite high odds-ratio (3.08) and a
confidence interval starting above 1. This is obviously a strong
limitation for between-groups comparison. Notwithstanding,
in accordance with Roberts et al. (2015) and Kildahl et al.
(2019), we postulate that sexual assault actually increases the
risk of PTSD in autistic women, as it does in the general
population. Within the victim group, however, statistics results
are unambiguous. PTSD rates and RAADS scores correlate
strongly, as it was described by Roberts et al. (2015), though
it is not possible to determine causality. Actually, if there is
no doubt that mental health in general and sexual violence
victimization are strongly correlated, causality seems to be bi-
directional (Machisa et al., 2017;Oram, 2019): victimization
affects mental health very negatively on the one hand, and
suffering from mental health problems dramatically increases
the risk of victimization on the other hand. Such vicious
cycle explains well the mechanism of revictimization. In our
study though, being young at first aggression was a significant
predictor of developing PTSD. In contrast, being victim of several
aggressions doesn’t seem to increase the risk of PTSD. Therefore,
it seems that for the specific case of autism and PTSD, it is really
sexual aggression that induces PTSD in autistic women and not
the other way around.
Besides PTSD, victims also reported consequences that
occurred within the 6 months following the assault. Half of
them suffered from sleep disorder (48.2%) and disgust for sex
(46.7%) and third of them attempted self-harm (31.7%). It is
specifically rape that induces such deleterious effects, as opposed
to victims of attempted rape only or unwanted sexual touching
only. Of course, this is to be interpreted with caution because
there is a discrepancy in sample sizes: 44 victims did not endure
rape while 155 did.
Other major vulnerability factors associated with autism and
with mental health issues such as social isolation, social stigma
and social rejection should be further studied in order to better
describe the mechanisms of abuse (Little, 2009;Edelson, 2010).
Few Victims Report Sexual Violence
In our study, only a third of the victims reported the assault
(34.6%, n= 69). For the vast majority of those victims (n= 52,
i.e., 75.4% of those who reported), such accusation had strictly
no effect (no medico-legal action was taken). Even worse, 18
out of 52 were not even believed. A lot has been written about
the devastating effects of denunciating sexual violence only to
be ignored or even be considered a liar, adding insult to the
injury. This is not at all specific to autism: an abundant literature
indicates that victims of sexual violence, whatever their gender,
TABLE 8 | Ritvo Autism and Asperger Diagnostic Scale score as a risk for victimization.
Victims (n= 199,
according to SES)
Non-victims (n= 26,
according to SES)
Wilxocon tests Logistic regression
RAADS total Mean: 34.94 (±5.27) Mean: 34.38 (±5.05) p= 0.5707 p= 0.6080,odds-ratio = 1.02, confidence interval [0.94–1.10]
RAADS “social communication”
sub-scores
Mean: 15.98 (±3.67) Mean: 16.65 (±3.14) p= 0.4755 p= 0.3750,odds-ratio = 0.95, confidence interval [0.83–1.06]
RAADS “hyper focalization”
sub-scores
Mean: 8.12 (±1.60) Mean: 7.54 (±1.92) p= 0.1272 p= 0.0986,odds-ratio = 1.19, confidence interval [0.95–1.47]
RAADS “sensory reactivity”
sub-scores
Mean: 5.37 (±1.19) Mean: 4.77 (±1.90) p= 0.1354 p= 0.0327*, odds-ratio = 1.31, confidence interval [1.01–1.68]
*p < 0.05.
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age and social status, often experience similar skepticism and
indifference to their suffering (Burt, 1980;Ahrens, 2006;Suarez
and Gadalla, 2010;Kennedy and Prock, 2018;Bhuptani and
Messman, 2021). Ahrens writes that “Speaking out about the
assault may therefore have detrimental consequences for rape
survivors as they are subjected to further trauma at the hands
of the very people they turn to for help” (Ahrens, 2006). This
overpowering phenomenon of disbelief has been shown to be
the main reason why most victims do not talk at all about it,
internalizing pain and shame instead (Kennedy and Prock, 2018).
It also explains why major and coordinated social movements
such as #Metoo appear to many victims as the only way toward
regaining agency and dignity. Furthermore, in our study, among
the very few participants (n= 17) whose testimony was acted
upon, only 13 received care and only 12 filed a complaint. How
many of those 12 complaints resulted in the perpetrators being
actually condemned is here a matter of imagination as such a
question was not part of the questionnaire.
Autism Is a Risk Factor, but in What
Way?
We have explored whether autistics traits, translated into metrics
thanks to the RAADS scale, could be related to victimization.
Results do not indicate clearly that autism is in itself a factor.
Indeed, we found only one significant result: logistic regression
indicated that the higher someone scores on the “sensory
reactivity” sub-scores of the RAADS scale, the more elevated
the risk of sexual victimization is. It is impossible to infer
the direction of a putative causal effect, or even if it is just
a correlation due to a confound yet to be determined. Very
reactive individuals are indeed easily identified (they may wear
sunglasses or noise canceling headphones) and that may help
sexual predators to spot them. However, it could be the opposite:
victims could display heightened reactivity due to trauma (a
PTSD symptom). And last, it could be two effects of a common
cause: for example, the trauma of being severely bullied at school
could increase such sensitivity while at the same time making the
victims more vulnerable to sexual violence.
However, a true effect of autism cannot be excluded of course.
We did find a significant correlation between PTSD and total
RAADS score after all, and PTSD was significantly correlated
with victimization. But that could be interpreted both ways: (i)
high autism traits lead to more victimization, leading to more
PTSD, or (ii) PTSD might be the confound mentioned above,
with PTSD being at the same time a consequence of sexual
violence and the cause of heightened sensitivity in adulthood. In
any case, it must be reminded here that the very small number of
non-victims, the statistical negative results of our between group
comparison are not very reliable. The absence of proof is not
proof of absence and further research is needed here.
What Could Prevent Sexual Victimization
of Autistic Women?
At that point, it seems important to ponder about the fact that
several of the publications that we have cited above mention
sexual education as the primary prevention method against
sexual violence. Brown-Lavoie et al. (2014) for example, assert
that sex education mediates the rates of abuse7. However, in the
case our sample, such a solution would not be deontologically
applicable since half of the victims were below the age of
consent, and therefore out of the scope of applied sex education.
Even for victims who were aged between 15 and 18, this is
not applicable: expecting minors with a disability to protect
themselves thanks to education can be equated to another
form of victim-blaming. Suggesting to a victim that she should
have learned how to better state her personal limits is not
fundamentally different than telling her that her skirt was too
short. Be it in a more benevolent and well-intended way, it is as
hurtful and unfair.
This is not to say that there is no need to be informed.
Quite the opposite, sex education is very important for
everyone in order to foster safe relationships. But, according
to Sala et al. (2019) sex education programs teaching how to
stay safe from abuse are poorly validated. More importantly,
considering that it is the victim’s duty to prevent the sex
crime is without doubt a remnant of rape culture8. Regrettably,
the opposite proposition is not as often suggested. Educating
potential offenders instead of educating potential victims would
be more ethical and might prove a more efficient method,
although it would be of limited efficiency since offenders are
usually not enamored youngsters unable to control their sexual
urges, thereby becoming unintentional sex offenders. That is
simply another rape myth (Payne et al., 1999). On the contrary,
most offenders are smart predators, who are very aware of what
they are doing (Burt, 1980;Hanson and Morton-Bourgon, 2005;
Methot-Jones et al., 2019;Cardona et al., 2020;Russell and King,
2020). As Russell and King (2020) describe it: “Psychopathy and
narcissism are known predictors of sexual violence.” Moreover,
the callousness and cynicism of perpetrators is actively supported
by a systemic rape culture, that is a “sociocultural context that
sexually objectifies the female body and equates a woman’s worth
with her body’s appearance and sexual function,” an internalized
mechanic called objectification theory (Szymanski et al., 2011).
As Methot-Jones et al. (2019) write, “individuals high in
psychopathic traits see women as sub-human, this dehumanizing
appraisal may be facilitating attitudes and behaviors that are
consistent with the idea that women are less than human
and deserve to be treated as such.” Objectification theory is
particularly well illustrated by the systematic use of rape as a
weapon of war in all ages and cultures (Bourke, 2014).
It seems intuitively right that, since autistic girls may
misunderstand the complex games of flirting and dating, teaching
them on how to behave in romantic relationships would help
them achieve a satisfying love life (McMahon et al., 2021).
However, this can only be successful in equal, fair and respectful
relationships, not in situations where they are preyed upon.
As Gotby et al. (2018) wrote in their study: “our findings that
there were no specific effect of ASD or ADHD symptoms when
7We are doubtful of Brown-Lavoie conclusion because the sex education they
assessed was about STD and birth control, not about being safe from abuse. It is
very possible, however, that sex education as they defined it was a confound.
8Cf. the Gatekeeper model.
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Cazalis et al. Sexual Violence Against Autistic Women
controlling for general symptom load, fail to lend support to
the hypotheses that social deficits, communication difficulties or
impulsivity [. . .] mediates the association between ASD/ADHD
and coercive sexual victimization. This suggests that rather than
focusing on a specific symptom-cluster or diagnosis, it is the
general [neurodevelopmental disorder] phenotype that predicts
increased risk of victimization” (Gotby et al., 2018). This is in
agreement with research showing that women with ADHD are
also at very high risk of being victimized (Snyder, 2015). It means
that it is not autism in itself, nor the social communication
difficulties associated with autism, that increase vulnerability to
sexual violence but the fact of being perceptibly different. Or,
alternatively, being different increases the risk of bullying and
rejection, and in that case, it would be ostracization and stigma
that would be the actual factors increasing victimization. Of
course, as stated by Hartmann et al. (2019) sex education may still
prove to be marginally protective: “While individuals with ASD
are certainly not at fault or responsible for experiences of sexual
abuse or victimization, misinformation about healthy sexuality
(e.g., personal space, communication of consent, appropriate and
inappropriate sexual behaviors) may in some cases contribute to
adverse sexual encounters” (Hartmann et al., 2019).
Beside those considerations, another major criticism against
the “preventing through sex educating” method is that victims are
very often in a state of stupor and dissociation during the assault.
They are therefore unable to react, sometimes even unable to
comprehend, and no education can prevent that. Let’s remember
here that the overwhelming majority of sex crimes are committed
by persons who are closely related to the victims, a parent, a
teacher, a boyfriend (WHO, 2021;Sardinha et al., 2022). In some
cases, the state of psychological shock that accompanies such
assault by a loved one can be so massively devastating that the
victim is stunned into derealization and cannot understand, or
even remember, what is happening. As one of our participants
wrote: “There was no use of force, no threats, nothing. It was in
the waiting line to the cafeteria. I was frozen.”
The SES-SFV responses provided yet another
counterargument to the model of sex education as a prevention
tool in that it collects information about the strategies used by
offenders. Perpetrators primarily used two strategies to violate
and abuse: manipulation/mental ascendency/harassment (“a”)
and using surprise to take advantage (“c”). Strategy “c” was the
first choice for imposing unwanted sexual contact, while strategy
“a” was preferably used for rape attempt and rape. This might
prove crucial for understanding why and how sexual violence
happens so often in this population. As we have seen, one out
of three non-autistic women is a victim of sexual violence. How
could autistic women who, by very definition, are ingenuous
and cannot guess hidden motives, defend themselves better
than non-autistic persons against deviousness, treachery and
deception? As Roberts et al. (2015) accurately write: “Deficits in
emotional and social cognition, specifically, inability to identify
sexually inappropriate behavior [. . .] and inability to identify
one’s own discomfort at inappropriate behavior [. . .] increase
risk of victimization and characterize persons with autistic
traits.”. One participant wrote “It was because I believed that he
would love me. I was raped and I never had any other experience
since then. I was 19, I am now 36.” Another participant stated
that she had “sexual relationships before the age of 15 with an
adult over 30 who clearly took advantage of the situation.”
Interrogated about prevention methods, one victim out of ten
answered that nothing could have protected them. One out of
four considered that their autistic traits made them easy to spot
by sexual predators. Four out of ten thought that knowledge
about risk and self-affirmation strategies could have prevented
the assault. However, as we asserted, the high proportion of
underage victims renders such a method irrelevant since it would
mean putting the responsibility of avoiding victimization on the
shoulders of the minor victims.
In addition, it is very important to remember that, contrary
to widespread myths regarding rape, offense is almost always
perpetrated by a close person, exploiting ascendancy or
hierarchical power over the victim. What could education do
against situations such as the ones reported by our participants: “I
was repeatedly raped by a relative during infancy and childhood”;
“the first time, I was 6 years old”; “someone who had authority
over me (father)”? On the contrary, as mentioned by one out
of five participants, the most efficient protection, especially in
the case of vulnerable individuals, is the presence of a vigilant
caregiver. Educating families and professional about the risk
of sexual victimization of girls on the autism spectrum should
therefore be a priority.
Our research indicates that almost 9 autistic women out of 10
are sexually victimized, at huge costs for their mental and physical
health. Of course, one major limitation of our study is that it
is based on voluntary participation and that represents a bias
since concerned individuals, i.e., victims, may be more willing
to contribute to such research than non-victims. However, this
bias might not impact results a lot, since our findings are very
consistent with literature about sexual violence against autistic
women and against women in general. So, what could be done
to prevent such generalized issue? The WHO study (WHO,
2021) shows unambiguously that sexual violence is systemic and
that vulnerable individuals are preferably targeted by offenders.
Therefore, we state that it would be a methodological and
deontological mistake to consider that victimization in autistic
women is mainly due to autism. On the contrary, we postulate
that the main cause of sexual violence against autistic women
is their womanhood, since perpetrators preferably target women
and girls. Therefore, it is reasonable to consider that autism is
not the cause of sexual victimization in autistic women but just a
factor increasing their vulnerability.
Prevention is absolutely necessary, certainly not in the sole
form of sex education but rather by promoting profound
cultural changes such as recommended by the Center for Disease
Control (CDC) and World Health Organization (WHO): both
organizations indeed strongly affirm that the very root of sexual
violence is gender inequality. As Jessica Leight formulates it
(Leight, 2022), “the literature analyzing the effectiveness of
strategies to prevent and reduce intimate partner violence
[. . .] is now encapsulated in the RESPECT framework and its
implementation plan.” As a tentative conclusion, we report here
the most recent recommendations for preventing sexual violence
as published by the CDC and the WHO. From the CDC, the
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Cazalis et al. Sexual Violence Against Autistic Women
Division of Violence Prevention of the National Center for Injury
Prevention and Control has published a technical package to
prevent sexual violence, titled the STOP-SV (Basile et al., 2016),
that advocates sexual violence prevention along five dimensions:
•S: Promote Social Norms that Protect Against Violence
•T: Teach Skills to Prevent Sexual Violence
•O: Provide Opportunities to Empower and Support Girls
and Women
•P: Create Protective Environments
•SV: Support Victims/Survivors to Lessen Harms
The WHO has published a framework, very consistent with
the above model, titled the RESPECT framework (World Health
Organization, 2019).
•R – Relationship skills strengthened. This refers
to strategies to improve skills in interpersonal
communication, conflict management and shared decision-
making.
•E – Empowerment of women. This refers to economic
and social empowerment strategies including those that
build skills in self-efficacy, assertiveness, negotiation, and
self-confidence.
•S – Services ensured. This refers to a range of services
including health, police, legal, and social services for
survivors of violence.
•P – Poverty reduced. This refers to strategies targeted
to women or the household, whose primary aim is to
alleviate poverty.
•E – Environments made safe. This refers to efforts
to create safe schools, public spaces and work
environments, among others.
•C – Child and adolescent abuse prevented. This includes
strategies that establish nurturing family relationships.
•T – Transformed attitudes, beliefs and norms. This refers
to strategies that challenge harmful gender attitudes, beliefs,
norms and stereotypes.
In her seminal article, “Cultural myths and supports for
rape,” Martha R. Burt wrote that “the task of preventing rape
is tantamount to revamping a significant proportion of our
societal values” (Burt, 1980). The CDC and WHO sexual violence
prevention programs, designed four decades after Burt wrote
those words, indicate that such profound change is taking place.
Vulnerable populations, such as autistic women, shall benefit
from this evolution.
DATA AVAILABILITY STATEMENT
The datasets presented in this study can be found in
online repositories. The names of the repository/repositories
and accession number(s) can be found below: Repository
URL for dataset is: https://nakala.fr/10.34847/nkl.d3d35i2o;
Repository URL for R code is: https://nakala.fr/10.34847/nkl.
4021h29a.
ETHICS STATEMENT
Ethical review and approval was not required for the
study on human participants in accordance with the
local legislation and institutional requirements. The
patients/participants provided their written informed consent
to participate in this study.
AUTHOR CONTRIBUTIONS
FC: writing and supervising statistical analyses. ER: statistical
analyses and proofreading. SL: co-initiator of the study and
experimental design. DG: initiator of the study, experimental
design, data collection, and preliminary analyses. All authors
contributed to the article and approved the submitted version.
ACKNOWLEDGMENTS
Quality research on autism cannot be conducted without the
input of concerned individuals. We are deeply grateful to Marie
Rabatel who drew our attention to the importance of Post-
Traumatic Stress Disorder consecutive to sexual violence in
autistic women. She was also of invaluable help for broadcasting
this study toward potential participants. We extend our thanks to
French non-profit organizations such as Association Francophone
des Femmes Autistes, Asperger Amitié, Asperger Aide, France
Asperger. . .
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fnbeh.
2022.852203/full#supplementary-material
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Conflict of Interest: ER was employed by Auticonsult.
The remaining authors declare that the research was conducted in the absence of
any commercial or financial relationships that could be construed as a potential
conflict of interest.
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