Self-reported sexual attraction and autism continued

"Attention to gender identity and sexual diversity in education and clinical work with people with ASD [autism spectrum disorder] is advised."

So said the findings reported by Jeroen Dewinter and colleagues [1] (open-access) adding to something of an important theme in autism research circles in recent times (see here). Drawing on self-reported responses for some 675 people diagnosed (self-reported diagnosis) with an autism spectrum disorder (ASD) compared with over 8000 not-autism (self-reported?) controls on 9 questions, some interesting trends were observed. Those questions asked about information in relation to "assigned gender at birth, gender identity, sexual orientation (sexual attraction and sex of the partner), relationship status and evaluation of relationship status, duration of the relationship, living situation, and whether the partner has (or is suspected of having) ASD."

I mentioned that participants "self-reported a diagnosis on the autism spectrum" but to be fair, authors did also employ the Autism Spectrum Quotient—Short Version (AQ) "to assess autistic traits" of their ASD group. I've been a little critical of the AQ on other occasions on this blog (see here) but am willing to concede that as a rough-and-ready measure, it's about as good as we have at the moment.

Results: "Most men and women in the ASD group identified conforming their assigned gender at birth." Bearing in mind data on gender identity were not actually available for the control group, authors did note that about a quarter of women with ASD in their cohort and just short of 10% of men "reported some gender non-conforming feelings."

In terms of sexual orientation, researchers noted that: "Sexual orientation was more varied in ASD compared to controls in both men... and women." So: "Compared to general population peers, more people with ASD, especially women, reported sexual attraction to both same- and opposite-sex partners."

Relationship status was also something asked about during the study. Fewer participants with ASD reported being in a relationship at the time of inquiry compared with controls (50% vs. 70%) but for those in a relationship, most were living with their partner and most were pretty satisfied with their relationship. Yet also: "Of the singles, 29% regretted their relationship status" so one has to careful about sweeping generalisations.

There is quite a bit of important information included in this article but there are also caveats. Aside from the self-report angle to autism diagnoses, the question in my mind is: how representative is this sample in terms of the very heterogeneous autism spectrum? Y'know, self-report typically implies insight from the more 'able' end of the autism spectrum, or at least those able to self-report, and onward whether sweeping generalisations are necessarily warranted to covering the entire autism spectrum (see here). Bearing in mind also the gaps in some of the responses for the control group, I also wonder whether honesty could be a key variable when it comes to comparisons with the ASD group. I say this on the basis that very personal information about sexual identity and/or thoughts and feelings might be more honestly described by those with autism than those without autism. As the authors put it: "autistic participants being less influenced by societal views or stereotypes on attraction and gender." Such a suggestion could accord with other work looking at context effects in relation to autism [2].

The specific point about more women with ASD in the Dewinter study reporting greater levels of "sexual attraction to both same- and opposite-sex partners" and more "gender non-conforming feelings" adds to other independent findings in the peer-reviewed domain (see here). Again, such observations highlight how sex education in the context of autism (as indeed, in the context of the general population) needs to be inclusive of the spectrum of sexuality.

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[1] Dewinter J. et al. Sexual Orientation, Gender Identity, and Romantic Relationships in Adolescents and Adults with Autism Spectrum Disorder. J Autism Dev Disord. 2017. June 9.

[2] Farmer GD. et al. People With Autism Spectrum Conditions Make More Consistent Decisions. Psychol Sci. 2017 Jun 1:956797617694867.

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Self-reported sexual attraction and autism

The findings reported by Tamara May and colleagues [1] are discussed today, looking at self-reported sexual attraction and past sexual relationships among adolescents diagnosed with an autism spectrum disorder (ASD) compared with not-autism controls.

Asking 14-15 year olds who took part in The Longitudinal Study of Australian Children (94 diagnosed with autism and some 3400 controls) some rather personal questions, researchers reported that: "ASD males reported fewer prior boyfriends/girlfriends" and "female adolescents with ASD have differences in sexual attraction compared with non-ASD females." Those female 'differences' included things like greater "uncertainty in attraction" and "lower rates of heterosexual preference."

Minus sweeping generalisations, the use of self-report in this study is a bit of a bonus in this context. Quite a few times on this blog I've been a little critical when self-report is used in the context of autism research (i.e. not necessarily as objective as some of the schedules out there administered by trained professionals) but when it comes to aspects of sexuality and relationships, it is the person who most definitely knows best [2]. If I did have one slight issue with this work it would be to ask the question: how representative of the autism spectrum were the participant group included for study? Y'know, self-report implies language use and all that...

This work does continue a theme in autism research. Although perhaps seemingly obvious, it confirms a few important things; primarily that young adults on the autism spectrum are in the most part, interested in sex and relationships [3] (accepting that 'sex' and 'relationships' are not necessarily one and the same). I know for some this is not new news (see here) but such a finding can sometimes get lost in all the chatter about presenting symptoms, challenges and the like when it comes to the autism spectrum.

Insofar as the finding that females with ASD included in the May cohort were more likely to report lower rates of heterosexual preference and higher rates of bisexuality, this is not a new finding. Bejerot & Eriksson [4] previously reported that "tomboyism and bisexuality were overrepresented amongst women with autism spectrum disorder" (not that tomboyism is necessarily a measure of bisexuality). Other groups have also mentioned this finding too [6]. This could have implications for things like sex education and ensuring that sex education covers 'all the bases' in terms of the spectrum of sexuality. I also draw back from making too many links with the literature for example, on gender dysphoria and autism / autistic traits (see here) but I daresay this might also show also some importance, at least for some.

Sex and relationships are an integral part of growing up. Children on the autism spectrum [typically] grow up to be adults on the autism spectrum, and sex - thoughts, feelings, actions - will figure as part of that maturation process, the same as it does for everyone else. Providing comprehensive and tailored sex education [5] should be an important part of discussions; parents as well as educators, need to be in on those important discussions...

Noting the date today (May the 4th), a customary link is required.

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[1] May T. et al. Brief Report: Sexual Attraction and Relationships in Adolescents with Autism. J Autism Dev Disord. 2017 Mar 24.

[2] Dewinter J. et al. Parental Awareness of Sexual Experience in Adolescent Boys With Autism Spectrum Disorder. J Autism Dev Disord. 2016 Feb;46(2):713-9.

[3] Fernandes LC. et al. Aspects of Sexuality in Adolescents and Adults Diagnosed with Autism Spectrum Disorders in Childhood. J Autism Dev Disord. 2016 Sep;46(9):3155-65.

[4] Bejerot S. & Eriksson JM. Sexuality and gender role in autism spectrum disorder: a case control study. PLoS One. 2014 Jan 31;9(1):e87961.

[5] Ingudomnukul E. et al. Elevated rates of testosterone-related disorders in women with autism spectrum conditions. Horm Behav. 2007 May;51(5):597-604.

[6] Hannah LA. & Stagg SD. Experiences of Sex Education and Sexual Awareness in Young Adults with Autism Spectrum Disorder. J Autism Dev Disord. 2016 Dec;46(12):3678-3687.

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May T, Pang KC, & Williams K (2017). Brief Report: Sexual Attraction and Relationships in Adolescents with Autism. Journal of autism and developmental disorders PMID: 28342163

Interest in romantic relationships is high in autism

It's official: "the vast majority of high-functioning adults with ASD [autism spectrum disorder] are interested in romantic relationships." Yes, the scientific findings reported by Sandra Strunz and colleagues [1] have said as much.

Sorry to be so sarcastic about them but coming from a place where the words 'the bleedin' obvious' are commonly used, I couldn't believe that in 2016 anyone would genuinely believe otherwise. Yes, I know the autism awareness et al message still has some distance to go, but underneath every diagnostic label including autism there are people: people with hopes, dreams, wants, needs and yes, even desires...

With all due respect to the authors and the work they put into doing this study - "total sample comprised 229 high-functioning adults with ASD (40% males, average age: 35 years)" - there is an interesting detail included in their paper such that: "7% had no desire to be in a romantic relationship." What this perhaps tells us is that when it comes to reporting on issues like quality of life and long-term outcome (see here) with autism in mind, people should be wary of making sweeping generalisations. But 7% means that 93% did have a desire for romance in their lives...

Insofar as where next with this area of research, well, there are a few avenues to suggest. Intimacy as one part of a 'romantic relationship' is something still in need of a lot more discussion as and when autism is included in the mix, in terms of education and aspects like safety and sexual health for example (see here). As difficult as it might be for some to acknowledge, people are generally 'designed' for relationships with others, and even those who might present with sometimes extreme disability as a result of their autism or related issues should not necessarily be seen as asexual in terms of their wants and needs. I know this issue has crossed into the legal domain in past times and intersects with other important areas such as competence and vulnerability. There are no easy answers.

Perhaps another important area for further research concerns how romantic relationships might affect the presentation of autism or other important (over-represented) comorbidities. Y'know, in the context of how relationships might be protective against certain things and how these manifest when it comes to the autism spectrum particularly where issues like depression and anxiety are over-represented (see here). That also the 'products' of some romantic relationships (yes, the brood) can also impact on health and wellbeing is another important area requiring quite a bit more investigation with autism in mind particularly in the context of parenting experiences.

But let's not complicate matters too much and turn the wants and desires of people into something that needs to be continually scrutinised and experimentally analysed. People generally want to be close to other people and autism should not necessarily be seen as a barrier to this...

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[1] Strunz S. et al. Romantic Relationships and Relationship Satisfaction Among Adults With Asperger Syndrome and High-Functioning Autism. J Clin Psychol. 2016 May 16.

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Strunz S, Schermuck C, Ballerstein S, Ahlers CJ, Dziobek I, & Roepke S (2016). Romantic Relationships and Relationship Satisfaction Among Adults With Asperger Syndrome and High-Functioning Autism. Journal of clinical psychology PMID: 27196958

Gender dysphoria and autistic traits?

"Gender dysphoria is a condition where a person experiences discomfort or distress because there is a mismatch between their biological sex and gender identity."

That's how NHS Choices describe gender dysphoria illustrating how biological sex and gender identity are not always one and the same for everyone. I might add that science is also coming around to the idea that the dichotomy of two biological sexes (male and female) might also not be as accurate as we've all been led to believe.

With that short introduction in mind, I'm turning to the paper by Daniel Shumer and colleagues [1] today and their findings "consistent with growing evidence supporting increased prevalence of ASD [autism spectrum disorder] in gender dysphoric children." Based on the retrospective analysis of a small group of children and young adults presenting at a gender clinic, results using the "Asperger Syndrome Diagnostic Scale (ASDS)" suggested that "possible, likely, or very likely Asperger syndrome" might be a feature of almost a quarter of those presenting with gender dysphoria (9/39). Further: "routine assessment of ASD is recommended in youth presenting for gender dysphoria."

The issue of gender dysphoria and/or gender identity issues and autism has been popping up now and again in the peer-reviewed autism research literature for some years. The case report by Landén & Rasmussen [2] represents one of the earliest documentations of gender dysphoria alongside a diagnosis of autism and included the idea that there may be a "predisposition to gender dysphoria in autism." Whilst the small participant number included in the Shumer study and the introduction of 'possible' or 'likely' to a diagnosis of Asperger syndrome were perhaps contributory to the impressive 'correlation' posed between the label and gender dysphoria, other more controlled study has also hinted that autism or autistic traits may be over-represented among this group. de Vries and colleagues [3] for example, utilised the DISCO (Diagnostic Interview for Social and Communication Disorders) among children and adults attending a gender identity clinic and reported that ~8% of their total sample group (N=208) reached ASD thresholds. As they pointed out in their paper, the rate of ASD found in their sample: "confirms the clinical impression that ASD occurs more frequently in gender dysphoric individuals than expected by chance."

The idea that autism or autistic traits might show some link to gender dysphoria also taps into an interesting area of autism research based on the suggestion of sex hormones and cognitive styles exemplified in discussions about the 'extreme male brain theory' for example (see here for further discussions). Jones and colleagues [4] reported that Autism Spectrum Quotient (AQ) scores showed some interesting patterns particularly among transmen "(female-to-male transsexual people)" when compared to other groupings (transwomen, typical males, typical females and those with Asperger syndrome). They concluded that: "Transmen have more autistic traits and may have had difficulty socializing with female peers and thus found it easier to identify with male peer groups." Bearing in mind some words of caution about what the AQ is actually measuring (see here) and how we [structurally] define 'male' and 'female brains (see here) the results are perhaps consistent with some of the notions detailed in the extreme male brain theory.

There remains however, quite a bit more research to do looking at gender dysphoria and autism or autistic traits. That developmental processes may be part and parcel of any association has been suggested [5] and as always, I remind you that autism does not generally exist in a diagnostic vacuum (see here). Indeed, one might see some intriguing links taking into account suggestions about gender dysphoria and schizophrenia for example [6] in light of the bridges built (and destroyed) down the years potentially linking cases of autism and cases of schizophrenia (see here). That also the presence of another quite common comorbidity appearing alongside autism - ADHD (attention-deficit hyperactivity disorder) - might also play a role [7] further exemplifies just how complicated the relationships / connections might actually be.

Perhaps also we need to talk about sex and gender quite a bit more when it comes to autism...

A video and some music to close, and because its that time of year when resolutions are made to 'get fit'...

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[1] Shumer DE. et al. Evaluation of Asperger Syndrome in Youth Presenting to a Gender Dysphoria Clinic. LGBT Health. 2015 Dec 1.

[2] Landén M. & Rasmussen P. Gender identity disorder in a girl with autism--a case report. Eur Child Adolesc Psychiatry. 1997 Sep;6(3):170-3.

[3] de Vries AL. et al. Autism spectrum disorders in gender dysphoric children and adolescents. J Autism Dev Disord. 2010 Aug;40(8):930-6.

[4] Jones RM. et al. Brief report: female-to-male transsexual people and autistic traits. J Autism Dev Disord. 2012 Feb;42(2):301-6.

[5] VanderLaan DP. et al. Autism spectrum disorder risk factors and autistic traits in gender dysphoric children. J Autism Dev Disord. 2015 Jun;45(6):1742-50.

[6] Rajkumar RP. Gender identity disorder and schizophrenia: neurodevelopmental disorders with common causal mechanisms? Schizophr Res Treatment. 2014;2014:463757.

[7] Strang JF. et al. Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Arch Sex Behav. 2014 Nov;43(8):1525-33.

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Shumer DE, Reisner SL, Edwards-Leeper L, & Tishelman A (2015). Evaluation of Asperger Syndrome in Youth Presenting to a Gender Dysphoria Clinic. LGBT health PMID: 26651183

Mental illness and blood-borne viral infections

"People with serious mental illness are at risk of blood-borne viral infections." But: "Serious mental illness is unlikely to be a sole risk factor and risk of blood-borne viral infection is probably multifactorial."

Those were the primary conclusions reached in the paper by Elizabeth Hughes and colleagues [1] (open-access) who conducted a systematic review and meta-analysis of the available peer-reviewed literature looking at the prevalence of various blood-borne viral infections in people diagnosed with a serious mental illness. The infections included in their analysis were: “hepatitis C”, ‘HCV’, “hepatitis B”, ‘HBV’, “HIV”, “human immunodeficiency virus” alongside the more generic term“blood borne virus”. These terms were cross-referenced with various search criteria covering that 'serious mental illness' term including schizophrenia, bipolar disorder and more generic descriptions such as mental disorder/illness.

From nearly 400 research abstracts, 91 studies were analysed. Forty-four studies including over 21,000 research participants assessed HIV infection. Nineteen studies with over 8000 participants looked at the prevalence of HBV. Twenty-eight studies (n=14,888) looked at HCV.

The results: "The prevalences of blood-borne viral infections in people with serious mental illness were higher than in the general population in places with low prevalence of blood-borne viruses, such as the USA and Europe, and on par with the general population in regions with high prevalence of blood-borne viruses (Africa for HIV and southeast Asia for hepatitis B virus and hepatitis C virus)." The actual estimates came in at 6% of those with a serious mental illness in the USA with HIV (compared with ~2% in Europe) and and an estimated 17% with HCV in the USA (compared with ~5% in Europe). Data for other continents of the world were a little more hit-and-miss according to the available studies for analyses.

Whilst important data, such findings need to be treated carefully save any sweeping generalisations made about such associations. If there are lessons that need to be learned when it comes to the concept of mental ill-health, it is that (a) stigma and 'generalisation' can cause infinite problems to this community (and indeed, influence their seeking help in the first place) and (b) health inequalities are already rife when it comes to the application of psychiatric labels (see here for example). Society is getting better at talking about blood-borne viral infections such as HIV these days (made easier by certain high-profile people talking about their own experiences) and in that context, the data from Hughes et al appears in more enlightened times.

As to the implications from this data, the authors make a number of important points outside the need for further "robust epidemiological research" in this area. Discussions about sexual health should be more widely encouraged with people with a serious mental illness is one aspect (yes, people with schizophrenia and/or bipolar disorder still can and do have sex) as is the need to focus on other possible routes of infection such as intravenous drug use. Again, avoiding any sweeping generalisations, Hughes and colleagues also talk about how "patients might have sexual partners who inject drugs, facilitating viral transmission" and the need to cover this topic during consultations particularly if relationships include "sexual exploitation and violence." Allied to the topic of appropriate management as and when blood-borne viral infections are detected [2], and one can perhaps see some wide-ranging conversations needed to be had in this important area.

I might also suggest that a heightened risk of other blood-borne infections potentially associated with certain psychiatric labels might also be included in those conversations and the possibility of where that could lead [3]...

Music: Izzy Bizu - White Tiger.

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[1] Hughes E. et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis. Lancet Psychiatry. 2015. Nov 24.

[2] Helleberg M. et al. Associations between HIV and schizophrenia and their effect on HIV treatment outcomes: a nationwide population-based cohort study in Denmark. Lancet HIV. 2015 Aug;2(8):e344-50.

[3] Okusaga O. et al. Combined Toxoplasma gondii seropositivity and high blood kynurenine - Linked with nonfatal suicidal self-directed violence in patients with schizophrenia. J Psychiatr Res. 2015 Oct 9;72:74-81.

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Hughes, E., Bassi, S., Gilbody, S., Bland, M., & Martin, F. (2015). Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis The Lancet Psychiatry DOI: 10.1016/S2215-0366(15)00357-0

Let's talk about sex and autism (reviewed)

The review from Nicola Beddows and Rachel Brooks [1] highlighting the important issue of sexual behaviour with autism in mind is brought to your attention today.

Trawling through the peer-reviewed literature looking at reports of inappropriate sexual behaviour present in adolescents diagnosed with an autism spectrum disorder (ASD), the authors concluded that various behaviours were included and that there were a variety of possible reasons for said behaviours. Indeed they report that: "Despite being such a common problem for schools, institutions and families to manage, it is surprising how sparse literature is particularly regarding why inappropriate behaviour occurs and what education is effective."

Sex education is a topic that has cropped up quite early on in the life of this blog (see here). Although jesting with the inclusion of an excerpt from a Seinfeld episode in that particular entry, the important message was that more efforts need to be made to talk about sex and the various details around the topic with young people on the autism spectrum. And when I say 'young people' I mean young people (not just as and when hair starts sprouting and other bodily changes start happening to accompany that golden time called PUBERTY).

Beddows & Brooks make some important points about how to approach the topic of sex education with autism in mind: "It is suggested that individualized, repetitive education should be started from an early age in an accessible form. Social skills development is also important before more technical aspects of sex education are taught." I can't disagree with such sentiments, although would also link you to some writings from an expert in this area (Dr Lynne Moxon) about sex education and the 'special' child and a document from NHS Choices covering an equally important area: sexual health. I might also add that some research groups seem to be listening to the idea that sex education training could be a useful add-on for some people on the autism spectrum [2]...

'Don't be afraid to talk about sex' is the message. So also said Salt-N-Peppa...

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[1] Beddows N. & Brooks R. Inappropriate sexual behaviour in adolescents with autism spectrum disorder: what education is recommended and why. Early Interv Psychiatry. 2015 Aug 12.

[2] Visser K. et al. Study protocol: a randomized controlled trial investigating the effects of a psychosexual training program for adolescents with autism spectrum disorder. BMC Psychiatry. 2015 Aug 28;15(1):207.

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Beddows N, & Brooks R (2015). Inappropriate sexual behaviour in adolescents with autism spectrum disorder: what education is recommended and why. Early intervention in psychiatry PMID: 26265030

Coffee does not always mean coffee

The title of this post is based on an episode of Seinfeld. I wasn't a huge Seinfeld fan but happily bumped into the odd episode late night on BBC2 now and again. To quote:

Donna: Would you like to come upstairs for some coffee?
George: Oh, no, thanks. I can't drink coffee late at night, it keeps me up.

And with that comes George's realisation that 'coffee doesn't mean coffee, coffee means sex!'

I am hoping that this post manages to get through the many Internet filters and does not single this blog out as being one of 'those' kinds of blogs (which, in my best British prudish voice, 'it most certainly is not'). I want to talk about sex (education) in this post and how information about sex, sexuality and relationships are being transmitted to people with autism spectrum and related conditions. This is going to be quite a candid post, so please do not get too offended. It is quite a long post also.

I will readily admit that I am not an expert on this (or any) area of autism, merely an interested follower of the various discussions and research being carried out. I do know a few people in the psychology and autism research world who specialise in this topic in terms of either being research active or being at the coalface when it comes to teaching sex education to children and young adults with autism. Having seen one or two of them talk about this issue and present some data, I have to say it made for some interesting listening.

Parents the world over, whether with children with autism or not, will eventually be faced with the issue of 'the birds and the bees' and how to communicate an effective message about sex and relationships. Even where older children and adults present with profound difficulties in areas like cognitive skills or language, the chances are that sex or sexual behaviour will at some point emerge and need to be discussed. Of course such issues might be barriers to communicating about sex, but experience would tend to suggest not to under-estimate a person's capacity to receive such information.

In the more general world of sex education research, there is still quite a bit of discussion about how and when parents should communicate information about sex. I heard one speaker talk about this at a conference last year; some of her findings can be seen here. There are perhaps a few lessons from this research which are just as applicable to boys and girls with autism, as they are to everyone else. Things like:

• Children and adolescents generally want information about sex and relationships from their parents. Gone are the days (like mine) where boys and girls were separated off at school and taught about each others 'bits' by nervous biology teachers alone and without the aid of parental support. Children want parents to get involved.
• Mums in particular are seen to have an integral role in disclosing information and advice about sex to their children. Dads play a role but I assume that girls especially might perhaps feel a little more comfortable with a 'female' perspective. Whether this is due to societal conditioning (Dad's can't talk about menstruation apparently) or merely the fact that mums have been there and done that, I don't know. Both parents can contribute.
• Boys are perhaps more likely to use other 'sources' of information for their sex education particularly in the age of the Internet. This may or may not give a 'distorted' idea about certain 'normalities' (if there is such a concept) in sex and relationships depending on which sources are used. Not every plumber or gas engineer for example provides 'that kind of service' to lonely housewives.
• Parents generally want to be able to talk to their children about sex, but perhaps feel uncomfortable or lacking in the necessary schemes and plans to communicate such issues in an effective way. Starting the evening meal with the words 'let's talk about sex' is probably going to make for an interesting evening and some subsequent interesting playground conversations among young offspring.

I'd like to think that these same issues are pertinent the world over, and across things like autism and other developmental conditions. When specifically applied in the context of autism, there is perhaps an even greater requirement to ensure that sex education is imparted timely and properly given issues like the increased 'vulnerability' of some people on the spectrum when it comes to sex and the perhaps greater potential for abuse or being manipulated. Unfortunately this scenario does happen.

One of the best people I have heard talk about sex and autism is Lynne Moxon. Lynne is a bit of an expert in this area as well as being a resident here in the bracing North-East of England. You can download one of her (fairly) recent Powerpoint presentations here from a conference back in 2008 (scroll down the speaker list to download her talk titled: Issues within puberty and sexuality in people with autism spectrum disorders). I won't go through her presentation in rote fashion but would like to draw out a few important points that she raises.

Puberty (or should that be PUBERTY!). A previous post on this blog has discussed that most taxing of times for children and parents, puberty, in relation to autism. Bearing in mind the more generalised 'guidance' being suggested about the timing of sex education (earlier rather than later), I think most parents would have been confronted with sex education issues with their children before the start of puberty. I don't say this in such a way as to say 'it must have been discussed' because the situation is likely to be different between different children and different families. Given the physical changes associated with puberty, one could perhaps expect that this might be a good time to 'top-up' the knowledge about sex and relationships.

Communicating the message. There are a variety of ways of talking about sex and relationships. I know some parents have talked about how their child with autism liked to hear about it 'textbook' fashion - so getting out the pictures and going through the biological details one by one, using the proper names (not our social inventions) for the various bits and pieces, and importantly explaining that the pictures are representations, and different people come in different shapes and sizes. Techniques such as social stories might also come in handy in these descriptions to discuss tricky things like masturbation and the 'right' and 'wrong' times to do it. I would also draw attention to the fact that Lynne does also talk about other important issues: personal hygiene (making sure that everything is kept clean), how sex is portrayed in the media (and often does not reflect 'real life'), sexual diseases and the various types of contraception available.

Outside of Lynne's work, there are a few other valuable sources of information. The writings of Marc Segar have been linked to in a previous post. For those who don't know, Marc was a young man with Asperger syndrome who wrote a very useful 'survival guide' based on his life and experiences nearly 15 years ago now (it can be download for free here). Marc talks quite a bit about the various social nuances related to sex and relationships; more to do with the social situations where sex and relationships might crop up. So things like the use of chat-up lines (p.16), what to do when you like someone (pp.14-15) and even little details, such as when someone is a virgin, the various intricacies about not communicating this fact when in a social group of men in particular. I found Marc's writings to be insightful and worth a read.

I do hope that I have not offended anyone with some of the content used in this post, given that most [all] parents will have to discuss such issues at one time or another. I will restate my non-expertise in this area of autism; please do not take this as anything but a post on how people have talked about sex education and autism and the various issues involved. People with autism are as different, complicated and individual as anyone else, so it is unlikely that there is a 'one-size-fits-all' method for imparting advice on sex and relationships. Parents however know their children best and therefore should be in the driving seat as to when and how the message about sex is communicated.