**6. Gender identity and sexual orientation**

**Case example: RJ**

434 Recent Advances in Autism Spectrum Disorders - Volume I

RJ is a 28 year-old female with ASD who was attempting to negotiate an intimate relation‐ ship with another woman her age that did not have ASD. First of all, RJ explained that a homosexual relationship was better for her than a heterosexual relationship because her partner was more like her than another man would be, and it was already very difficult to consider an intimate relationship, let alone try to understand someone of a different gender. RJ was absorbed in her interest in drawing and hoped to get a job at some point in computer animation. She spent most of the hours in a day drawing when she was not at her part time job at the local animal shelter. When she was drawing, it was fine for her partner to sit next to her, but she didn't want to be disturbed or touched. She was unable to do something oth‐ er than drawing in the evening except on Saturdays, when she was able to include her part‐ ner in her schedule. Even on Saturday, she needed to find some time to herself because it took too much energy to be with her partner for a full day. When she attempted to do so, she would experience anxiety and frustration which would frequently culminate in an epi‐ sode of yelling, stamping her feet, and retreating to her room. On Saturdays, when she was attempting to spend time with her partner, RJ was only able to engage in certain activities. Her partner would frequently ask her to go to the movies, while RJ was unable to tolerate the feel of the seat cushions on her skin, the smell of the popcorn, and the loudness of the sound track. RJ could only eat at two restaurants in the neighboring area but preferred to eat at home. RJ could not understand her partner's frustration with her or her partner's need for physical affectionate contact. RJ was able to tolerate some sexual contact but avoided it whenever possible, as it was adverse to her but she understood from reading that it was an expected part of a relationship. After several months, RJ's partner terminated the relation‐ ship, much to RJ's relief. She was very happy to return home to her parents' house where she could have conversation with them at her initiative, and the expectations for social inter‐ action or disruption of her schedule were minimal. It was comforting to return to her fami‐ ly's schedule, which she knew well. She did have the insight to know that her parents wouldn't always be there and knew that she needed to work earnestly to maintain at least some relationship with friends. She understood that even though it may be difficult to do so, she would have to initiate contact and not rely on her friends solely to initiate such contact.

The only significant predictor of romantic functioning among those with ASD is level of social functioning [21]. When meeting someone with ASD, several irregularities are notice‐ able. Persons with ASD frequently will not look into the eyes of the person with whom they are interacting; instead they may look at their mouths or perhaps even another object in the room [20]. Some of those with ASD would state that looking directly at another's person's eyes is extremely anxiety provoking, whereas others with ASD may be disinter‐ ested. Personal physical spatial boundaries, which many people take as second nature, are not part of the social make-up in persons with ASD. They may stand too close to a per‐ son with whom they may be interacting, or they may seem distant and uninvolved. Those with ASD may not pay attention to socially acceptable standards of personal appearance and may appear unkempt or inappropriately dressed for an occasion, e.g. wearing a casu‐ al, comfortable outfit to a formal event. Persons with ASD have a very difficult time en‐ Gender identity usually develops in neurotypical children by the age of three [10] with rang‐ es of 3-5 years of age [32]. Gender identity may be more rigid in individuals with ASD [33]. For children with developmental disabilities, gender identity in general likely develops in synchrony with many other developmental delays, especially in language, communication and social relatedness, which in turn influences the child's ability to mentally represent their own gender either in images or language. There is no current established literature about gender identity development in children with ASD; however, a recent article on gender dys‐ phoria and identity difficulty found that clinics are reporting an overrepresentation of indi‐ viduals with ASD in their gender identity referrals [33].

Sexual orientation refers to a person's established patterns of overall attraction to another person, including emotional, romantic, sexual, and behavioral attractions [34] regardless of whether this pattern results in sexual behavior. Research in the last several decades estab‐ lished sexual orientation on a continuum from entirely heterosexual, bisexual, and homosex‐ ual to asexual [35-37]. The relatively novel term "sexual fluidity" refers to the situationdependent flexibility in someone's sexual responsiveness and may include both hetero- and same-sex experiences [37]. Same-sex behaviors among adolescents are reported between 5-10%, with similar percentages observed in adults [10].

Sexual identity develops normatively in adolescence related to puberty and overall body changes in the context of societal expectations about partner choices. For most adolescents with ASD, this development may occur later than that of their typically developing peers [38] and may include higher percentages of asexuality, but in most aspects of sexual devel‐ opment, the literature identifies similar desires and fantasies [21]. In fact, the literature on sexuality of children and adolescents with developmental disabilities cautions to not errone‐ ously regard people with disabilities as childlike, asexual or as inappropriately sexual [39].

vey the gender identity of ASD subjects did ask a question pertaining to marital status. Gilmour and colleagues found that the group, which was atypically more female, did not differ from the control group on the basis of marital status. This result was unexpected and may be specific to the group surveyed of 82 persons with ASD [42]. More research is clearly needed in this area, but attaining accurate statistical data will be difficult, as many high

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Patient, L is a 35-year-old male engineering student, who was accompanied by his wife for an initial assessment. L's wife believed that he had Asperger's disorder. He did not under‐ stand why this potential diagnosis would even matter to his wife. A major concern in their marriage was L's dislike for social situations. His wife worked at a bookstore and was fre‐ quently invited to her coworkers' houses to play games, watch movies, or perhaps have din‐ ner. L would begrudgingly attend but would then sit quietly and not interact with anyone. His wife's friends would attempt to include him in conversations, but L would frequently give one-word answers and not reciprocate or would engage in a long monologue about his most recent engineering project. He did not understand his wife's distress at these situa‐ tions. As a couple, it was their usual routine to have a date on Saturday night consisting of time spent together in an activity, followed by a sexual encounter. L did not understand why his wife would break this routine when she was upset by his lack of social interaction at her co-worker's home. He would become very angry and frustrated, slamming the door, and breaking small nearby items. His wife encouraged him to come to the appointment as a

way for her to begin to understand his behavior and to find ways to cope with him.

tective factors and could contribute to healthy sexual development.

For all individuals with disabilities, including ASD, there is an increased risk for physical and sexual abuse. In 2006, Murphy and Elias reported a sexual abuse rate that was 2.2 times higher than that of children without disabilities [39]. In a recent study, caregivers of individ‐ uals with autism reported that 16.6% had been sexually abused. Individuals with ASD can be subject to sexual victimization due to their trusting natures, desire to be socially accepted, lack of understanding of the meaning or possible consequences of their behavior, or expo‐ sure through internet contacts. Children who experienced sexual abuse were more likely to act out sexually or be sexually abusive toward others [43]. This mindset, although with seemingly honest intentions, places the ASD individual(s) at risk for sexual abuse, due to the lack of available sexual knowledge. Lack of knowledge can contribute to an individual not understanding appropriate boundaries and therefore they may not be able to distinguish when someone is touching them inappropriately. This, coupled with existing social deficits, has resulted in underreported sexual abuse in this population. Therefore, sexual education and public intervention strategies (which will be discussed later in this chapter) are key pro‐

functioning individuals with ASD are undiagnosed or misdiagnosed.

**Case example: L**

**8. Potential for abuse**

At the same time, several studies were identified by Healy and colleagues [19] that show that people with a disability may hold rather conservative views about their own sexuality related to negative caregiver attitudes toward certain sexual behaviors, including pre-mari‐ tal sex and homosexual activity. Still, in comparison to caregiving staff, family members may altogether be less inclined to openly discuss issues of sexuality. Family members seemed to prefer low levels of intimacy in the relationships of their child amidst a high ac‐ ceptance of platonic and non-intimate relationships [40].
