**5. Characteristics common to ASD persons**

The overarching confounding factor for individuals with ASD to develop normative sexual identity, sexual orientation, and sexual behaviors is their core social disability [20] that in turn influences the person's opportunity and availability for romantic and intimate relation‐ ships. While levels of romantic and sexual functioning typically increase with age, a devel‐ opmental lag was reported for individuals with ASD [21]. In a survey of parents of 38 neurotypically developing adolescents and young adults and 25 adolescents and young adults with ASD, Stokes and colleagues found support for their research hypotheses that in‐ dividuals with ASD had less access to peers and friends, engaged in more unacceptable be‐ haviors in attempting to initiate romantic relationships, and persisted in their pursuit of the relationship even when non-mutual interests were evident [21]. In 2012, Shandra and Chowdhury conducted a study on the first sexual experiences of adolescent girls with and without disabilities and reported that social isolation (not the adolescents' impairment) was the primary contributor to difficulties, based on their review of the literature and analyses of a national longitudinal data bank. Results also suggested that having a mild disability in‐ creased the likelihood of having sexual intercourse with a stranger for the first time, rather than with a steady dating partner [22].

Several characteristics of those with ASD interfere with the capacity to develop meaningful adult social relationships, which are necessary for developing sexual, intimate relationships. Foremost is the difficulty with social judgment [8], i.e. missing nonverbal communication, poor eye contact, theory of mind problems, and flexibility in response. Lack of experience in peer re‐ lationships prevents the development of the common pathway through which adolescents learn about sexuality [23]. Problematic decision-making skills complicate the capacity to main‐ tain the everyday details of a relationship, such as initiating dates, or remembering plans. Lack of flexibility, along with self-absorption, creates significant areas of conflict in a potential rela‐ tionship. Emotional dysregulation resulting in feelings that are too intense, or perhaps mis‐ placed, together with a lack of awareness of the other's response can quickly end a relationship. Sensory sensitivities, such as inability to tolerate touch or other physical sensations, sound sen‐ sitivities, or food texture issues can cause dating to be fraught with problems [24].

Many persons with ASD have little self-awareness and as noted above, do not understand their impact on others. Another dimension of this issue is that persons with ASD may have 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 or the behaviors of others can pose a significant danger.

and awareness are key factors in the ability to identify violations to individuals' basic human

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

The overarching confounding factor for individuals with ASD to develop normative sexual identity, sexual orientation, and sexual behaviors is their core social disability [20] that in turn influences the person's opportunity and availability for romantic and intimate relation‐ ships. While levels of romantic and sexual functioning typically increase with age, a devel‐ opmental lag was reported for individuals with ASD [21]. In a survey of parents of 38 neurotypically developing adolescents and young adults and 25 adolescents and young adults with ASD, Stokes and colleagues found support for their research hypotheses that in‐ dividuals with ASD had less access to peers and friends, engaged in more unacceptable be‐ haviors in attempting to initiate romantic relationships, and persisted in their pursuit of the relationship even when non-mutual interests were evident [21]. In 2012, Shandra and Chowdhury conducted a study on the first sexual experiences of adolescent girls with and without disabilities and reported that social isolation (not the adolescents' impairment) was the primary contributor to difficulties, based on their review of the literature and analyses of a national longitudinal data bank. Results also suggested that having a mild disability in‐ creased the likelihood of having sexual intercourse with a stranger for the first time, rather

Several characteristics of those with ASD interfere with the capacity to develop meaningful adult social relationships, which are necessary for developing sexual, intimate relationships. Foremost is the difficulty with social judgment [8], i.e. missing nonverbal communication, poor eye contact, theory of mind problems, and flexibility in response. Lack of experience in peer re‐ lationships prevents the development of the common pathway through which adolescents learn about sexuality [23]. Problematic decision-making skills complicate the capacity to main‐ tain the everyday details of a relationship, such as initiating dates, or remembering plans. Lack of flexibility, along with self-absorption, creates significant areas of conflict in a potential rela‐ tionship. Emotional dysregulation resulting in feelings that are too intense, or perhaps mis‐ placed, together with a lack of awareness of the other's response can quickly end a relationship. Sensory sensitivities, such as inability to tolerate touch or other physical sensations, sound sen‐

sitivities, or food texture issues can cause dating to be fraught with problems [24].

Many persons with ASD have little self-awareness and as noted above, do not understand their impact on others. Another dimension of this issue is that persons with ASD may have

rights.

factors or skills may contribute to their success.

432 Recent Advances in Autism Spectrum Disorders - Volume I

than with a steady dating partner [22].

**5. Characteristics common to ASD persons**

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 wear socially inappropriate apparel.

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

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

#### **Case example: RJ**

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.

gaging another person in conversation, i.e. they have difficulty initiating conversation or maintaining conversation through reciprocal social interaction [26]. A person with ASD may answer questions when asked or begin a scripted monologue that is repetitive in na‐ ture about an area of interest, with little to no awareness of the reaction of the person with whom they are interacting. Part of the reason for this lack of awareness is that a per‐ son with ASD is frequently unaware of the meaning of nonverbal behavior as a means of communication. The concept of theory of mind states that a person cannot understand the thoughts, intentions, and feelings of others or what another person means during an inter‐ action, other than the concrete nature of the words stated [28]. For example, when a moth‐ er asked her child to "go sit in the tub", the child sat in the tub with all of her clothes on, when the mother of course meant to prepare for a bath. This may seem obvious to most people but might not be so obvious to a person with ASD. As a corollary, a person with ASD frequently cannot read the emotional meaning behind a verbal or nonverbal commu‐ nication, i.e. interpret social cues [29]. A study by Izuma supports that people with autism lack the ability to take into consideration what others think of them [30]. Partially due to this lack of awareness, someone with ASD may respond in a very blunt or honest way to a statement of another person with whom they are interacting. For example, when asked a question such as "Do you like my new dress?", the person with ASD might say all the reasons they feel the dress is unattractive, being unaware of the emotional impact such statements might have on the person to whom they are making such comments [31].

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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‐

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

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

**6. Gender identity and sexual orientation**

viduals with ASD in their gender identity referrals [33].

5-10%, with similar percentages observed in adults [10].

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‐ gaging another person in conversation, i.e. they have difficulty initiating conversation or maintaining conversation through reciprocal social interaction [26]. A person with ASD may answer questions when asked or begin a scripted monologue that is repetitive in na‐ ture about an area of interest, with little to no awareness of the reaction of the person with whom they are interacting. Part of the reason for this lack of awareness is that a per‐ son with ASD is frequently unaware of the meaning of nonverbal behavior as a means of communication. The concept of theory of mind states that a person cannot understand the thoughts, intentions, and feelings of others or what another person means during an inter‐ action, other than the concrete nature of the words stated [28]. For example, when a moth‐ er asked her child to "go sit in the tub", the child sat in the tub with all of her clothes on, when the mother of course meant to prepare for a bath. This may seem obvious to most people but might not be so obvious to a person with ASD. As a corollary, a person with ASD frequently cannot read the emotional meaning behind a verbal or nonverbal commu‐ nication, i.e. interpret social cues [29]. A study by Izuma supports that people with autism lack the ability to take into consideration what others think of them [30]. Partially due to this lack of awareness, someone with ASD may respond in a very blunt or honest way to a statement of another person with whom they are interacting. For example, when asked a question such as "Do you like my new dress?", the person with ASD might say all the reasons they feel the dress is unattractive, being unaware of the emotional impact such statements might have on the person to whom they are making such comments [31].
