**3. Normal sexual development**

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

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.,

difficult to redirect [2].

428 Recent Advances in Autism Spectrum Disorders - Volume I

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

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 adult is preparing to meet an intimate partner [10]. Gender identity, i.e. one's sense of male‐ ness or femaleness, also forms in the first three years of life. A clear, secure gender identity allows for satisfying, intimate adult relationships. Children may display masturbatory be‐ haviors and engage in a variety of sexual play activities that coincide with the development of socially expected norms in the context of natural curiosity about themselves and their en‐ vironment. Between the ages of 3 to 7, children explore their own body parts, recognize them as male or female, and become interested in the genitals of their peers, leading to sexu‐ al play [10]. During the latency years, overt sexual play becomes covert, with children begin‐ ning to have experience with masturbation, should libidinal urges occur. As latency-age children segregate along sexual lines, any sexual experiences are usually with those of the same gender [10]. More overt behaviors and interests emerge again in adolescence with the onset of puberty. Reports collected by the Centers for Disease Control and Prevention (CDC) in 2000 showed about 52% of males and 48% of females in grades 9 to 12 are engaging in sexual intercourse as reported by Delamater and Friedrich in 2002 [10]. Similar statistics were reported as recently as 2011 by the CDC, with 47.4% of 9-12th graders reporting that they had ever engaged in sexual intercourse [11]. Cultural differences are also apparent among groups regarding premarital intercourse [10].

For much of our history, the concept that individuals with any disability as sexual beings was unthinkable [15]. Those with developmental disabilities were frequently subjected to in‐ voluntary sterilization in the first half of the 20th century. The sexual nature of those with disabilities has been traditionally denied and/or ignored. It has also been viewed similarly with ASD individuals, whose sexuality is further complicated by social communication and language deficits [15]. Only recently has it been acknowledged that persons with ASD have the universal right to learn about relationships, marriage, parenthood, and appropriate sex‐ uality [8]. A major contribution to the field of autism and sexuality is the TEACCH Report published through the United Kingdom [16]. This article, based on the approach and con‐ cepts developed by Mesibov and Schopler [17] in the 1980's, put forth five basic assump‐

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**1.** People with autism of all levels of severity experience sexual drives, behaviors, or feel‐

**2.** Parent involvement and participation is a crucial ingredient in the area of sexual educa‐

**3.** Sexual education must be taught in a highly structured, individualized way using con‐

**4.** Sexual behaviors must be an important behavioral priority with less tolerance for devia‐

**5.** Sexual education must be taught in a specific individualized, developmental manner [16] This report was one of the first to acknowledge that individuals with autism have the same human sexual urges and behaviors as all humans and that those with ASD have the right to express their sexuality to the greatest level possible. These tenets therefore emphasize the need for sexual education for those with ASD, so they can be integrated into our society's rules concerning what sexual behaviors are considered either appropriate or inappropriate.

Keeping in mind that quite often individuals with ASD may also have an intellectual disa‐ bility [18], studies of individuals with a disability in general become important for the ASD population as well. The current literature already being conducted for those with disabilities is being applied to the expressed needs for education of those with ASD on how to develop sexual and intimate relationships. One study identified that those under the age of 18 had only limited knowledge about pregnancy and sexual anatomy while most individuals in‐ cluding adults were aspiring to form relationships and marriage [19]. In addition, general reluctance of family members and caregivers to acknowledge and respect the sexual rights of those with an intellectual disability was identified because these concepts created a cer‐

As with others individuals who have a disability, those with an Autism Spectrum Disorder di‐ agnosis possess the right to have a relationship, to marry, and/or to have children. Education about legal rights should be provided to those with ASD and extended especially to those whom they encounter, e.g. teachers, family, policemen, community members, etc. Education

tions concerning those with autism and are quoted below.

crete strategies with less of an emotional overtone

tain level of anxiety in those family members.

tions in this area due to the stringent expectations of society

tion

ings with which at some point in their lives they need assistance

Pubertal changes can begin as early as 9 years of age or as late as 14 years of age. With the onset of puberty, sexual development moves to the forefront. Puberty, governed by hormo‐ nal changes, is defined as the time when a male or female is capable of sexual reproduction. A growth spurt, skeletal changes, increases in muscle and fat tissue, development of breasts, pubic and axillary hair, and the growth of genitalia are all hallmarks of the pubertal process [12]. With the physical maturation of gonads, genitalia and secondary sex characteristics, one's sexual interest increases. Citing a study by Bancroft and colleagues (2003), Delamater and Friedrich noted that many males begin to masturbate between the ages of 13 and 15, whereas the onset for girls is more varied [10]. As older adolescents and young adults devel‐ op, more teens engage in sexual intercourse and develop a sexually active heterosexual life‐ style. Between 5 and 10% of adolescent males, and 6% of adolescent females, experiment with homosexual behavior. This exploration may be a transient experience, or it may devel‐ op into an adult homosexual identity [10]. One of the major psychological developmental tasks of later adolescence is to develop a firm sense of identity, of which one's gender identi‐ ty is an important aspect [13]. Achieving sexual maturity continues into adulthood with the ability to make informed decisions about one's partner choice, reproduction, and long-term intimate relationships.

### **4. Sexuality, disability, and ASD**

Sexual development is an intricate process that examines sexuality in regard to oneself and others. This process is often thought of in terms of normal development; however the devel‐ opmentally disabled also go through sexual stages as they physically mature. This concept can be difficult to accept for some providers and caretakers, due to their tendency to view the developmentally disabled as perennial children [14].

For much of our history, the concept that individuals with any disability as sexual beings was unthinkable [15]. Those with developmental disabilities were frequently subjected to in‐ voluntary sterilization in the first half of the 20th century. The sexual nature of those with disabilities has been traditionally denied and/or ignored. It has also been viewed similarly with ASD individuals, whose sexuality is further complicated by social communication and language deficits [15]. Only recently has it been acknowledged that persons with ASD have the universal right to learn about relationships, marriage, parenthood, and appropriate sex‐ uality [8]. A major contribution to the field of autism and sexuality is the TEACCH Report published through the United Kingdom [16]. This article, based on the approach and con‐ cepts developed by Mesibov and Schopler [17] in the 1980's, put forth five basic assump‐ tions concerning those with autism and are quoted below.

adult is preparing to meet an intimate partner [10]. Gender identity, i.e. one's sense of male‐ ness or femaleness, also forms in the first three years of life. A clear, secure gender identity allows for satisfying, intimate adult relationships. Children may display masturbatory be‐ haviors and engage in a variety of sexual play activities that coincide with the development of socially expected norms in the context of natural curiosity about themselves and their en‐ vironment. Between the ages of 3 to 7, children explore their own body parts, recognize them as male or female, and become interested in the genitals of their peers, leading to sexu‐ al play [10]. During the latency years, overt sexual play becomes covert, with children begin‐ ning to have experience with masturbation, should libidinal urges occur. As latency-age children segregate along sexual lines, any sexual experiences are usually with those of the same gender [10]. More overt behaviors and interests emerge again in adolescence with the onset of puberty. Reports collected by the Centers for Disease Control and Prevention (CDC) in 2000 showed about 52% of males and 48% of females in grades 9 to 12 are engaging in sexual intercourse as reported by Delamater and Friedrich in 2002 [10]. Similar statistics were reported as recently as 2011 by the CDC, with 47.4% of 9-12th graders reporting that they had ever engaged in sexual intercourse [11]. Cultural differences are also apparent

Pubertal changes can begin as early as 9 years of age or as late as 14 years of age. With the onset of puberty, sexual development moves to the forefront. Puberty, governed by hormo‐ nal changes, is defined as the time when a male or female is capable of sexual reproduction. A growth spurt, skeletal changes, increases in muscle and fat tissue, development of breasts, pubic and axillary hair, and the growth of genitalia are all hallmarks of the pubertal process [12]. With the physical maturation of gonads, genitalia and secondary sex characteristics, one's sexual interest increases. Citing a study by Bancroft and colleagues (2003), Delamater and Friedrich noted that many males begin to masturbate between the ages of 13 and 15, whereas the onset for girls is more varied [10]. As older adolescents and young adults devel‐ op, more teens engage in sexual intercourse and develop a sexually active heterosexual life‐ style. Between 5 and 10% of adolescent males, and 6% of adolescent females, experiment with homosexual behavior. This exploration may be a transient experience, or it may devel‐ op into an adult homosexual identity [10]. One of the major psychological developmental tasks of later adolescence is to develop a firm sense of identity, of which one's gender identi‐ ty is an important aspect [13]. Achieving sexual maturity continues into adulthood with the ability to make informed decisions about one's partner choice, reproduction, and long-term

Sexual development is an intricate process that examines sexuality in regard to oneself and others. This process is often thought of in terms of normal development; however the devel‐ opmentally disabled also go through sexual stages as they physically mature. This concept can be difficult to accept for some providers and caretakers, due to their tendency to view

among groups regarding premarital intercourse [10].

430 Recent Advances in Autism Spectrum Disorders - Volume I

intimate relationships.

**4. Sexuality, disability, and ASD**

the developmentally disabled as perennial children [14].


This report was one of the first to acknowledge that individuals with autism have the same human sexual urges and behaviors as all humans and that those with ASD have the right to express their sexuality to the greatest level possible. These tenets therefore emphasize the need for sexual education for those with ASD, so they can be integrated into our society's rules concerning what sexual behaviors are considered either appropriate or inappropriate.

Keeping in mind that quite often individuals with ASD may also have an intellectual disa‐ bility [18], studies of individuals with a disability in general become important for the ASD population as well. The current literature already being conducted for those with disabilities is being applied to the expressed needs for education of those with ASD on how to develop sexual and intimate relationships. One study identified that those under the age of 18 had only limited knowledge about pregnancy and sexual anatomy while most individuals in‐ cluding adults were aspiring to form relationships and marriage [19]. In addition, general reluctance of family members and caregivers to acknowledge and respect the sexual rights of those with an intellectual disability was identified because these concepts created a cer‐ tain level of anxiety in those family members.

As with others individuals who have a disability, those with an Autism Spectrum Disorder di‐ agnosis possess the right to have a relationship, to marry, and/or to have children. Education about legal rights should be provided to those with ASD and extended especially to those whom they encounter, e.g. teachers, family, policemen, community members, etc. Education and awareness are key factors in the ability to identify violations to individuals' basic human rights.

little knowledge about themselves. Part of what helps us create a sense of self is the ability to create an internal autobiography [25]. Persons with ASD have difficulty in this area, as they frequently cannot describe their own emotions or are unaware of what they are feeling (i.e. alexithymia) or have difficulty controlling their emotional responses (i.e. emotion dysre‐ gulation). As a result, many with ASD lack the ability to insightfully understand themselves or respond to the social climate in a meaningful way. Self-advocacy, a crucial skill for main‐ taining one's function in daily life, is something that can be very difficult for a person with ASD to learn. The ability to maintain personal safety without awareness of the environment

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Persons with ASD, either as a result of the above difficulties or due to a true lack of social interest, turn away from others into their own world. Self-absorption fosters another type of social disability. Persons with ASD frequently have restricted areas of interest (e.g. comput‐ er animation) and may have little to no desire in sharing this interest with others or attend‐ ing to the interests of others, since there can be a lack of ability to detach from the area of interest without anxiety or distress. The need for sameness and rigidity in daily routines may supersede one's ability to flexibly respond to another person, e.g. being unable to eat at another restaurant when only two specific restaurants are in that person's repertoire [26]. The need for aloneness or "down time" may be greater than the need to be with others, which may seriously jeopardize an attempt to relate to others in a more than superficial manner. Sensory sensitivities can create intolerance of what may be considered part of the human experience. For example, sensitivity to sound may prevent a person with ASD from engaging in activities where airplanes may be heard overhead or babies may be heard cry‐ ing. Also, sensitivity to touch can be especially difficult in relation to others, as those with ASD may not tolerate someone touching their skin or attempting to hug them. This particu‐ lar sensitivity may also affect the choice of clothes for someone with ASD, who may be un‐ able to wear clothes with sleeves or tags that they feel are restrictive and might lead one to

Executive function impairments, i.e. impairments in decision-making skills, cognitive flexi‐ bility, impulse control, organizational skills, and planning, create another layer of social dys‐ function [27]. Awareness of the passage of time may be compromised for someone with ASD, perhaps secondary to their self-absorption, and is an essential component of everyday function. Everyday memory problems or the ability to remember to plan and organize daily life activities can create social havoc. The ability to problem solve, make informed choices,

All of the above challenges are magnified when a person with ASD attempts to have an inti‐ mate emotional and perhaps sexual relationship. Intimacy is the sharing of emotional, cog‐ nitive, and physical aspects of oneself with those of another. A prerequisite for intimacy is the establishment of a firm sense of self-identity. Intimacy requires the flexibility to loosen one's identity in order to feel the pleasure of merging with one's partner in an emotional and physical connection. For all of the reasons above, a person with ASD may be unable to

or plan for the future becomes problematic in what is called "context blindness" [27].

share with another or may be limited in his or her ability to do so.

or the behaviors of others can pose a significant danger.

wear socially inappropriate apparel.

Although those with an ASD diagnosis have the right to date, marry and have children, there is a paucity of empirical research on family units and relationships for this particular group. Though some evidence does exist anecdotally, e.g. through blogs and books, this evi‐ dence is not scientifically sound. Therefore, future research should generate empirical stud‐ ies that focus on interpersonal relationships within the family unit and examine which factors or skills may contribute to their success.
