**2. Autism overview**

Autism Spectrum Disorders, as currently defined by the Diagnostic and Statistical Manual (DSM-IV-TR) criteria, include the diagnoses of Autistic Disorder, Asperger's Disorder and Per‐ vasive Developmental Disorder NOS. The three major diagnostic categories include the fol‐ lowing: 1) language impairment, 2) social impairment, and 3) repetitive behaviors/restricted interests, with the impairments present prior to the age of three. Autism has been conceptual‐ ized under this diagnostic rubric as a spectrum of disorders with symptoms ranging from se‐ vere to minimally impaired [1]. With the advent of the DSM-5, only two major criteria will be included: 1) social communication impairment, and 2) repetitive behaviors/restricted interests.

© 2013 Urbano et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The DSM-5 envisions autism as a unitary diagnosis with multiple levels of symptom severity impairing the ability to function [2]. The DSM-5 will use a system of three modifiers to signify level of severity: Level 1 is characterized for patients requiring support as they display difficul‐ ty initiating social situations and demonstrate atypical social responses. Rituals and repetitive behaviors cause significant interference for these individuals. They also resist redirection and attempts to be interrupted when involved in restricted interests or repetitive behaviors. Level 2 is characterized for patients "requiring substantial support," as they have marked deficits in verbal and nonverbal social communication skills, which are apparent even with supports in place. They demonstrate limited ability to initiate social interaction and have a reduced or ab‐ normal response to social overtures from others. Repetitive behaviors and restricted interests are obvious enough to be noticed by a casual observer. These patients become distressed or frustrated when they are interrupted or redirected. Level 3 is characterized for patients requir‐ ing very substantial support, as they have severe deficits in verbal and nonverbal social com‐ munication skills. Repetitive behaviors or rituals markedly interfere with functioning in all spheres. They demonstrate marked distress when routines are interrupted, and they are very difficult to redirect [2].

children and youth in foster and juvenile justice settings). Inclusion of "subtler" symptoms, such as those reflected in the following items from the Social Responsiveness Scale (© West‐ ern Psychological Services), improved the sensitivity of identifying persons with high-func‐ tioning ASD (such as persons diagnosed with Asperger's disorder): impaired social understanding or awareness, literal or pedantic use of language, difficulties in adjusting be‐ havior to various contexts, unusual prosody, and problems with body orientation or social distance [3]. Additional research must be conducted to determine the discriminative diag‐

Relationships, Sexuality, and Intimacy in Autism Spectrum Disorders

http://dx.doi.org/10.5772/53954

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Along with the proposed diagnostic criteria, estimates of the prevalence of autism have also changed. Recently, the prevalence estimates of the Autism and Developmental Disabilities Monitoring (ADDM) Network for children aged 8 years utilized a consistent "recordsbased" surveillance methodology in 14 sites across the United States, examining both health and education records [5]. The overall estimated 2008 prevalence of autism spectrum disor‐ ders was 1 in 88 children, demonstrating a steady increase in prevalence since 2002 [6]. Al‐ though the ADDM Network sites are not a nationally representative sample, the methodology used in obtaining prevalence estimates of children aged 8 years has been con‐ sistent since the monitoring began, so valid comparisons can be made with earlier years. These comparisons show that the estimated prevalence in 2008 increased by 23% in compar‐ ison to 2006, and by 78% when compared to 2002. The increase in prevalence may simply reflect greater awareness and better ascertainment of autism spectrum disorders by health agencies and schools, as suggested in a community mental health surveillance study in Eng‐ land [7]. The England study showed that the prevalence of autism in adults, when properly

Sexual development is a complex process that includes sexuality in relation to oneself and others. Sexuality encompasses a broad variety of physical, emotional, and social interac‐ tions. It includes sexual beliefs, attitudes, knowledge, values, and behavior and concerns the anatomy, physiology, and biochemistry of the sexual response system. Sexuality involves

As with other individuals, those with ASD grow and mature along many developmental lines [9]. The social developmental line includes the development of sexuality, while the physical line includes that of puberty. Sexuality begins in infancy and progresses through adulthood until death. Each life stage brings about physical changes and psychosocial de‐ mands that need to be achieved for sexual health to be attained. The capacity for a sexual response, both male and female, has been found as early as in the 24-hour period after birth. The rhythmic manipulation of genitals similar to adult masturbation begins at 2.5 to 3 years of age are a natural form of sexual expression [10]. Also during the first three years of life, a child forms an attachment to his or her parents that is facilitated by physical contact. A sta‐ ble, secure attachment with parents enhances the possibility of such an attachment when an

one's thoughts, feelings, behaviors, relationships, roles, identity, and personality [8].

nostic value should be placed [4].

diagnosed, was approximately the same as in children.

**3. Normal sexual development**

Proposed changes to the DSM-5 diagnostic criteria include the creation of a single broad au‐ tism spectrum disorder (ASD) diagnosis that encompasses current specific DSM-IV-TR diag‐ noses. Further, the proposed DSM-5 criteria reflect the tension between considering core symptoms from a dimensional perspective (i.e., symptoms are distributed in the population and patients are distinguished from unaffected persons by the severity of their symptoms), as opposed to the presence of discrete symptoms reflecting categorical distinctions between affected and unaffected persons [3]. A dimensional approach suggests that the core symp‐ toms are quantitative traits which vary along a continuum and reflect the expression of, and interactions between, commonly occurring genetic variations and effects of environmental factors, whereas categorical approaches favor models attributing risk of illness to large ef‐ fects of single genes, especially genes involved in brain development or maintenance of syn‐ aptic architecture [3]. In fact, the DSM-5 diagnostic criteria may be best represented by an empirically-derived hybrid model that merges the dimensional and categorical aspects of symptoms of autism (i.e., there are threshold values for numbers and severity of symptoms that define a categorical diagnosis of an ASD). From a biological perspective, although symptoms may be viewed along a continuum, the diagnosis of autism implies the altered, albeit subtle, architecture of the brain. The two core symptom domains of DSM-5, whose se‐ verity can vary along a continuum, were validated independently and include 1) impaired social communication and interaction (SCI), and 2) restricted, repetitive behavior (RRB) [3,4]. There is still work left to be done with respect to determining the number of criteria that must be satisfied in order to assign an ASD diagnosis. The DSM-5 criteria are clearly being shown as superior to the DSM-IV-TR criteria in terms of specificity. However, a bal‐ ance must be struck between reducing "false positives," which maximizes specificity, and assuring that criteria are sufficiently sensitive to capture ASD-affected persons that would benefit from intervention and services. This is an especially big concern among caregivers of persons that would have previously received a diagnosis of Asperger's disorder and for children and adolescents with poor historical information about early-life symptoms (e.g., children and youth in foster and juvenile justice settings). Inclusion of "subtler" symptoms, such as those reflected in the following items from the Social Responsiveness Scale (© West‐ ern Psychological Services), improved the sensitivity of identifying persons with high-func‐ tioning ASD (such as persons diagnosed with Asperger's disorder): impaired social understanding or awareness, literal or pedantic use of language, difficulties in adjusting be‐ havior to various contexts, unusual prosody, and problems with body orientation or social distance [3]. Additional research must be conducted to determine the discriminative diag‐ nostic value should be placed [4].

Along with the proposed diagnostic criteria, estimates of the prevalence of autism have also changed. Recently, the prevalence estimates of the Autism and Developmental Disabilities Monitoring (ADDM) Network for children aged 8 years utilized a consistent "recordsbased" surveillance methodology in 14 sites across the United States, examining both health and education records [5]. The overall estimated 2008 prevalence of autism spectrum disor‐ ders was 1 in 88 children, demonstrating a steady increase in prevalence since 2002 [6]. Al‐ though the ADDM Network sites are not a nationally representative sample, the methodology used in obtaining prevalence estimates of children aged 8 years has been con‐ sistent since the monitoring began, so valid comparisons can be made with earlier years. These comparisons show that the estimated prevalence in 2008 increased by 23% in compar‐ ison to 2006, and by 78% when compared to 2002. The increase in prevalence may simply reflect greater awareness and better ascertainment of autism spectrum disorders by health agencies and schools, as suggested in a community mental health surveillance study in Eng‐ land [7]. The England study showed that the prevalence of autism in adults, when properly diagnosed, was approximately the same as in children.
