Autism, mental health and 'sexual and gender minority' status

The findings reported by Rita George & Mark Stokes [1] piqued my interest recently, and their conclusion that various mental health issues over-represented in autism (see here and see here for examples) might not be just solely connected to the presence of a diagnosis of autism.

Yes, I know this sounds like common sense (see here), but as I've come to realise in relation to lots of diagnostic labels, assumptions very often precede actual (peer-reviewed) evidence.

Based on responses on the DASS-21 (which is fast becoming the go-to measure for the self-report of things like stress, depression and anxiety-like behaviours with autism in mind [2]), researchers compared depression, anxiety and stress scores for over 300 people with autism compared with over 250 "typically-developing individuals." Alongside, membership of a minority grouping in terms of sex and gender, e.g. non-heterosexual, was also thrown into the statistical mix. Results suggested that along with differences in DASS scores being more generally observed between the groups: "As membership to a minority group became more restrictive, mental health symptoms worsened... suggesting stressors added."

Such an investigation follows a scheme of work by this authorship group who, quite recently, also reported that within the same participant group(?), some 70% of those with autism "reported being non-heterosexual" [3]. I was quite taken aback by the high rate of non-heterosexuality reported in this study, bearing in mind that this data was derived from an on-line sample and may not be entirely representative of the full autism spectrum as a function of the use of self-report for example (see here). I might also add that focusing just on autism to the exclusion of some other potentially important comorbid labels [4] could be something that needs to be looked at in future investigations in light of other results on gender variance for example [5].

Minus however, any 'I told you so' sentiments, I have previously mentioned about how gender and sexual identity in relation to autism is both a research-rising area and can often have some quite profound implications for the person concerned (see here). We can um-and-ah about whether there is a 'connection' between autistic traits and sexual orientation (see here) or whether something like gender dysphoria is more or less likely in the context of autism (see here), but there is no denying that gender and sexual identity are variables that can and do potentially impact on mental health. In support of the George/Stokes findings, one need only look to the non-autistic focused research literature to see how various aspects of health-related quality of life for example, are seemingly influenced by variables such as sexual orientation [6] and how this potentially plays out over both childhood and into adulthood [7].

So when George & Stokes talk about: "Specialized care is recommended for this vulnerable cohort" there could be some pretty profound implications associated with timely and appropriate education and support taking into account sexual and gender identity in the context of autism...

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[1] George R. & Stokes MA. A Quantitative Analysis of Mental Health Among Sexual and Gender Minority Groups in ASD. J Autism Dev Disord. 2018 Jan 23.

[2] Nah YH. et al. Brief Report: Screening Adults with Autism Spectrum Disorder for Anxiety and Depression. J Autism Dev Disord. 2017 Dec 2.

[3] George R. & Stokes MA. Sexual Orientation in Autism Spectrum Disorder. Autism Res. 2018 Jan;11(1):133-141.

[4] May T. et al. Trends in the Overlap of Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder: Prevalence, Clinical Management, Language and Genetics. Current Developmental Disorders Reports. 2018. Jan 17.

[5] 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.

[6] Marti-Pastor M. et al. Health-related quality of life inequalities by sexual orientation: Results from the Barcelona Health Interview Survey. PLoS One. 2018 Jan 24;13(1):e0191334.

[7] Petterson LJ. et al. Sex, Sexual Orientation, Gender Atypicality, and Indicators of Depression and Anxiety in Childhood and Adulthood. Arch Sex Behav. 2017 Jul;46(5):1383-1392.

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Sexual orientation as a function of autistic traits? Not so fast...

I was in two minds as to whether or not I should blog about the findings reported by Christiane Rudolph and colleagues [1] describing results observing that: "Autistic traits are associated with minority sexual orientation, and perhaps with uncertain self-identification and/or a defiance of traditional ways of categorizing sexual identity."

Two minds because (a) I'm not a great fan of sweeping generalisations in the context of autism or 'autistic traits' or anything related, and (b) although autism and sexual attraction preference(s) is a growing area of research interest (see here for example), I did wonder what the aim of the Rudolph study was, being as it was, based on 'autistic traits in the general population'. Was it trying to make a case for autistic traits as somehow being related to a person's sexual preference or just adding to the existing autism literature based on non-clinical population findings? As per this entry that you're reading, I did decide to take on the Rudolph findings because peer-reviewed science is peer-reviewed science. Also, how one has to exercise some degree of caution with the current results as they stand for various reasons...

So, the aim of the research game was to examine "autistic traits and sexual orientation" and whether one might be *associated* with the other. Over 47,000 adults were initially invited to participate; the cohort self-completed the Autism Spectrum Quotient (AQ) (the AQ-10) to measure 'autistic traits' and were also asked about their sexual orientation (hetero-, homo-, bisexual, none of the above). You'll immediately note that researchers were looking at two primary variables, albeit in quite a large sample group.

Results: "Participants with autistic traits were more likely to identify as bisexual (OR 1.73; 95% CI 1.01–2.9) and to feel that their sexual orientation could neither be described as hetero-, homo- nor bisexual (OR 3.05; 95% CI 2.56–3.63), compared to individuals without autistic traits." I say all that accepting that if one looks closely at the confidence intervals (CIs) particularly for the association with bisexuality - "95% CI 1.01–2.9" - you'll see that it comes ever so close to crossing 1 (1.01) which typically translates as no statistical difference between the groups.

The findings do kinda accord with what has been noted in other 'diagnosed autism' research literature. 'Uncertainty in attraction' and bisexuality, for examples, have been mentioned before (see here) as being potentially over-represented when examined in the context of the autism spectrum and continue to do so [2]. One might also opine that the presence of certain autistic traits (AQ measured of course) might also mean that 'honesty' in relation to some very personal questioning on sexual identity/preference(s) might be more likely among this group when extrapolating from other findings [3]. Indeed, greater honesty and also greater tolerance [4] it seems...

But... the AQ, the AQ... Regular readers of this blog probably already know what I think about the AQ as one of the premier 'are you autistic?' schedules (see here). It's most definitely measuring something, but I'm minded to suggest that that 'something' is not always exclusively autism or autism spectrum disorder (ASD) (see here and see here). In the context of using AQ with a supposed non-clinical population, I'll refer you to the findings reported by Phil Reed and colleagues [5] for example, who similarly noted that: "Higher AQ scores were associated with higher scores of loneliness, social anxiety, depression, and anxiety, as well as with lower scores of quality of life (QoL)." It's not outside the realms of possibility that the 'autistic traits' being measured by Rudolph et al may have also included facets of these states/conditions/labels, particularly if one assumes that issues like anxiety and depression are very much over-represented in the context of autism (see here) and given the large participant numbers included for study. At this point I'll also add in my view that when we talk about depression and anxiety as being 'comorbid' to autism, I don't think we're actually doing justice to how pervasive such issues can be for a person and whether they should instead be considered as something more than just comorbidity à la Mildred Creak and colleagues...

Insofar as other research *linking* elevated AQ scores in some 450,000 people to STEM (science, technology, engineering and mathematics) career choices (see here), or AQ scores being "significantly positively correlated with eating disorder psychopathology" [6] or even AQ scores potentially being associated with lower income [7] I'll leave you to debate/argue what the implications may or may not be in light of the Rudolph findings and why we should perhaps be rather cautious about any sweeping generalisations.

It's not that I don't 'accept' the Rudolph results for what they are, but I'm still however unsure about what the final aim of the study was...

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[1] Rudolph CES. et al. Brief Report: Sexual Orientation in Individuals with Autistic Traits: Population Based Study of 47,000 Adults in Stockholm County. Journal of Autism & Developmental Disorders. 2017. Oct 30.

[2] George R. & Stokes MA. Sexual Orientation in Autism Spectrum Disorder. Autism Res. 2017. Nov 21.

[3] de Schipper E. et al. Functioning and disability in autism spectrum disorder: A worldwide survey of experts. Autism Res. 2016 Sep;9(9):959-69.

[4] Dewinter J. et al. Sexuality in adolescent boys with autism spectrum disorder: self-reported behaviours and attitudes. J Autism Dev Disord. 2015 Mar;45(3):731-41.

[5] Reed P. et al. Loneliness and Social Anxiety Mediate the Relationship between Autism Quotient and Quality of Life in University Students. Journal of Developmental and Physical Disabilities. 2016; 28: 723-733.

[6] Tchanturia K. et al. Characteristics of autism spectrum disorder in anorexia nervosa: A naturalistic study in an inpatient treatment programme. Autism. 2017 Nov 1:1362361317722431.

[7] Skylark WJ. & Baron-Cohen S. Initial evidence that non-clinical autistic traits are associated with lower income. Molecular Autism. 2017; 8: 61.

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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