Sexuality, Gender Identity, Romantic Relations, and Intimacy Among Individuals with Autism Spectrum Disorder: A Narrative Review of the Literature

Abstract

Sexual health is a vital aspect of overall well-being, yet individuals with autism spectrum disorder (ASD) face significant stigma and discrimination, affecting self-esteem, relationships, and sexual expression. This review examined the recent literature (2020–January 2024) on intimacy and sexuality among adolescents and young adults with ASD, incorporating 32 studies. Findings highlight poorer sexual health among autistic individuals compared to the general population, with difficulties in forming romantic relationships and navigating sexual interactions due to hypersensitivity. Autism is also linked to non-conforming gender identities and asexuality, exposing individuals to dual stigma within the LGBTQ+ community. Autism-related traits hinder sexual health knowledge, increasing risks of victimisation, abuse, and sexually transmitted infections. Comprehensive sexual education and inclusive support are crucial to address these challenges and promote sexual well-being for autistic individuals.

1. Introduction

Sexuality encompasses a broad spectrum of human experiences, including aspects such as sexual orientation, gender identities, and eroticism, as well as reproduction, as outlined by the World Health Organization (WHO) in 2006 [1]. Gender, on the other hand, encompasses a variety of identities, expressions, and societal roles. The WHO emphasises the importance of sexual health, noting its close connection to overall well-being and its significance for individuals, families, and communities in terms of social and economic development.

Recognizing the importance of accurate information and supportive healthcare environments, people must have access to resources concerning gender and sexuality. These rights, including freedom of expression, equality, and privacy, are integral to ensuring the well-being of individuals across diverse sexual and gender identities [1].

Attitudes toward autism, sexuality, and gender have undergone a transformative process over time, evolving from a disregard for the sexual experiences of autistic individuals to a recognition of the diverse spectrum of sexual and gender identities. Despite progress, many rights pertaining to sexual and gender diversity remain unfulfilled for autistic individuals [2,3,4].

Autism is characterised by challenges in social communication and repetitive behaviours [5]. Language preferences within the autistic community vary, with a preference for the term “autistic” commonly observed [6,7]. Research on sexuality and gender in autistic individuals has expanded significantly over the past decades, emphasising the importance of supporting healthy sexual development [8].

Romantic relationships play a vital role in providing social support and resources, which are linked to better mental and physical health outcomes [9,10,11]. Despite having similar levels of interest, autistic individuals are less likely to engage in romantic relationships [12,13,14,15]. Research indicates higher levels of non-heterosexual attraction among autistic individuals and their vulnerability to sexual coercion [8,16]. Moreover, there is greater diversity in gender identity within the autistic population, with a suggested link between autism and gender dysphoria [17,18]. Sex differences have also been observed, with higher rates of gender variance reported in individuals assigned female at birth [18,19,20]. However, studies examining children with gender dysphoria have shown comparable levels of autism symptoms between genders [21].

A frequent finding in studies of sexuality indicates a greater incidence of non-heterosexual orientations among individuals on the autism spectrum. Sexual orientation encompasses a multifaceted construct, primarily involving sexual identity, sexual attraction, and sexual behaviour [16]. These aspects span a spectrum and signify a person’s inherent sexual preferences [22]. Commonly, sexual orientation is categorised under labels such as “heterosexual” and “homosexual” [23,24], but individuals may also adopt other identifiers, such as “lesbian”, “gay”, and “bisexual” [24]. Research comparing autistic individuals to their non-autistic peers has shown a greater alignment with non-heterosexual orientations [16,25] and increased non-heterosexual interests in autistic individuals [13]. Another critical aspect influencing autistic individuals’ sexuality includes their sexual experiences, particularly the heightened sexual risks and vulnerabilities noted among autistic females. These risks are often compounded by inadequate sexual knowledge and challenges in social interactions, leading to a spectrum of negative sexual experiences, including victimisation and abuse [26,27,28]. Despite these unique challenges, autistic individuals frequently receive less comprehensive sex education than their neurotypical counterparts. According to the UN Convention on the Rights of Persons with Disabilities (2006) [29], everyone, including those with disabilities, deserves the opportunity to explore and express their sexuality to lead a fulfilling life. The convention and the subsequent literature emphasise the importance of providing individuals with disabilities access to accurate sexual information [30]. Adequate sex education can enhance the quality of life for people with disabilities and reduce their risk of negative sexual experiences, such as exploitation and abuse [31,32]. For autistic students, a sex education program covering appropriate sexual behaviour and socialisation is beneficial, as these students often struggle with sexual behaviour, knowledge, and self-esteem, and recognizing the nuances of privacy, personal boundaries, and safety [32]. The absence of proper sex education and knowledge can also heighten the risk of sexually transmitted infections (STIs), which remain a significant public health concern due to their potential for long-term physical health issues. However, some studies have suggested a lower risk of STIs among autistic people and those with intellectual disabilities and other developmental disorders [33].

Our study aims to provide a comprehensive review of the latest research, from 2020 to 2024, on sexuality and affectivity in autistic individuals. In this direction, we chose to focus on the post-COVID period specifically to additionally investigate whether the pandemic has affected the psychosexual well-being of individuals with autism spectrum disorder (ASD). Given the unique challenges posed by the pandemic, such as increased isolation and changes in social interactions, we believed it essential to explore whether these disruptions have had a lasting impact.

In particular, this review focuses on the specific challenges faced by autistic individuals in developing and maintaining romantic relationships, as well as in experiencing intimacy and sexuality. Identifying the elements that both aid and hinder successful romantic and sexually fulfilling relationships for autistic individuals is crucial. Investigating these challenges is essential for devising specific psychosocial interventions to improve the well-being and social integration of this group. Recognizing the significance of sexuality and romantic relationships as essential components of human existence emphasises the need to approach these issues with compassion, knowledge, and inclusiveness.

2. Materials and Methods

2.1. Study Selection and Exclusion Criteria

The selection process involved MB, CE, EDA, and VG, who independently screened the titles and abstracts of the identified studies. In cases of disagreement, an ALA author was consulted to resolve any discrepancies. All authors then reached a consensus on the inclusion of the final studies by discussing the relevance and quality of each article. This collaborative process ensured consistency in the selection criteria and helped minimise bias in study selection.

Criteria for inclusion were the following:

• Original studies, reviews, empirical studies;
• Articles published in English;
• Focus on intimacy and sexuality among individuals with autism spectrum disorder;
• Focus on the perspective of the autistic individuals themselves.

Criteria for exclusion were the following:

• Case studies, books, letters, opinion papers, commentaries, and articles with no focus on the target perspective;
• Articles with a medical or juridical focus;
• Studies not published in English;
• Studies with a population that did not explicitly include autism spectrum disorder;
• Studies with a population of children;
• Focus on others’ perspectives (i.e., perspectives of families, teachers, clinicians… on the subject).

2.2. Search Strategy and Databases Used

We chose only articles published in English between 2020 and January 2024 to capture the most current information. This specific time frame was selected to account for the potential disruptions caused by the pandemic to the social and sexual experiences of autistic individuals. However, a few studies from 2019 were included after reviewing the records’ abstracts, given their particular relevance to the review’s aims and contributions to the understanding of our topic of interest.

This review follows a narrative methodological framework, which allows for the synthesis of diverse studies exploring various aspects of sexuality, intimacy, and romantic relationships in autistic individuals. The narrative approach was chosen to provide a comprehensive overview of the existing literature, drawing connections across studies that utilise different methodologies and research designs.

The electronic databases used were Web of Science, Scopus, PubMed and PsycInfo. Searches were performed using the Boolean operators AND/OR with the following search string on titles, abstracts, and keywords: (autism OR asd OR “Autism Spectrum disorder” OR neurodiverse) AND (adolescence OR “young adult” OR “teenager”) AND (sexuality OR intimacy OR love OR romance OR romantic).

We selected these databases for their comprehensive coverage of multidisciplinary studies, including psychology, social sciences, and health sciences, which were key areas for our review. These databases provided access to a wide range of peer-reviewed articles relevant to the intersection of autism, sexuality, and intimacy. The reference sections of the included articles were reviewed for additional relevant publications that may have been missed. After an initial search of each database, a total of 130 potential records were identified and exported to Zotero, and 22 sources were eliminated as duplicates. The titles and abstracts of the remaining 108 articles were screened. The search results are presented in a flow chart (see Figure 1). See File S1 for the Search Strategy.

2.3. Relevance Assessment, Qualitative Analysis, and Review Type

The relevance of the studies was determined by their examination of intimacy, sexuality, and romantic relationships among autistic individuals. Priority was given to research that provided an in-depth exploration of these themes, particularly from the perspectives of adolescents and young adults with autism. A qualitative analysis was conducted to synthesise the key themes and insights across the selected studies, offering a nuanced understanding of the challenges faced by autistic individuals in the realms of sexuality and relationships. This qualitative approach was essential for identifying patterns and differences among the studies, enabling a comprehensive narrative synthesis. This review employs a narrative methodological framework, which facilitates the integration of diverse studies investigating various dimensions of sexuality, intimacy, and romantic relationships in autistic individuals. It synthesises and interprets findings from a wide range of qualitative and quantitative research without adhering to a systematic methodology. No formal protocol was registered for this review, as the narrative approach did not necessitate compliance with a predefined protocol, allowing for a more exploratory examination of the literature.

Moreover, to provide a comprehensive synthesis of the findings,

Table 1. Summary table.

Authors	Year	Population	Demographics	Methods	Key Findings
Allely [34]	2020	Individuals with autism spectrum disorder (ASD)	No specific age or gender data provided	Systematic PRISMA review	Limited research on zoophilia and bestiality in individuals with ASD. ASD may be associated with deviant sexual behaviour due to restricted interests or impaired social skills. Importance of sex education for individuals with ASD.
Ronis et al. [35]	2021	561 individuals with High-Functioning ASD	21–72 years old, majority Caucasian	Online survey assessing sexual and gender identity	5.1% self-identified as asexual. Variability in sexual attraction. Asexual identity is linked to social difficulties rather than purely lack of sexual attraction. Researchers should use multidimensional approaches to assess sexual identity.
Płatos et al. [36]	2023	15 young adults with ASD	18–32 years old	Randomised controlled trial of PEERS for Young Adults curriculum	Significant improvement in social cognition and social skills through the PEERS program. Limited improvement in social engagement and dating skills, suggesting a need for continued post-treatment support.
Rothman et al. [37]	2022	55 autistic individuals	18–44 years old	Feasibility test of online HEARTS program	Improvement in coping, motivation for socialising, and positive thinking. Interpersonal competence and loneliness did not significantly improve. Participants appreciated having an autistic co-teacher.
Sala et al. [38]	2020	Autistic individuals	No specific demographics provided	Review of literature	Autistic individuals show higher rates of non-heterosexual attraction, more inappropriate sexual behaviours, and greater gender dysphoria. Issues like courtship and flirting are major challenges.
Sala et al. [39]	2020	31 autistic and 26 non-autistic individuals	No specific demographics provided	Online survey with thematic analysis	Both groups desire intimate relationships. Autistic individuals face specific communication difficulties and stigma. Adaptations like clear communication can help overcome barriers.
Yew et al. [40]	2023	95 autistic and 65 non-autistic individuals in long-term relationships	No specific demographics provided	Online survey assessing relationship satisfaction factors	Autistic participants reported higher satisfaction in relationships than non-autistic participants. Social loneliness and partner responsiveness were important factors influencing relationship satisfaction.
Yew et al. [41]	2021	Autistic individuals	No specific demographics provided	Systematic review of romantic relationship initiation and maintenance	Social and communication challenges are the main barriers to relationship satisfaction. Partner support plays a critical role in relationship success.
Smith et al. [42]	2021	13 neurodiverse couples	One partner diagnosed with autism	Phenomenological interviews	ND couples experience similar relationship phases to those of non-ND couples but face unique communication challenges. Support from neurotypical partners is critical. Lack of adequate resources for ND couples was highlighted.
Pecora et al. [43]	2020	Individuals with autism spectrum disorder (ASD)	Primarily Western, without intellectual disability	Literature review	Individuals with ASD face difficulties in forming relationships, with increased risks of victimisation and inappropriate sexual behaviours. There is a high prevalence of non-heterosexuality and gender variance among individuals with ASD.
Bush et al. [44]	2020	Young women with ASD, 18–30 years	No specific demographics provided	Comparative study on asexual spectrum vs. other orientations	Women with ASD on the asexual spectrum report lower generalised anxiety. Sexual satisfaction varies, with asexual individuals finding satisfaction outside of partnered sex. Highlights asexuality as a non-pathological identity.
Strnadová et al. [45]	2021	High school students with intellectual disability and/or ASD	No specific demographics provided	Scoping review	Limited access to comprehensive sex education for students with ASD. Barriers include a lack of tailored curricula and societal stigma. Recommendations include early and explicit communication, parent involvement, and practical workshops.
Dewinter et al. [46]	2023	Autistic youth and adults	No specific demographics provided	Literature review and community-driven recommendations	Emphasis on education, healthcare access, and research for individuals with ASD to promote healthy sexual and gender identities. Recommendations to prevent victimisation and increase healthcare professional awareness.
Gray et al. [47]	2021	120 autistic individuals	Various sensory profiles	Qualitative analysis	Sensory processing differences affect sexual and relationship experiences for individuals with ASD. Sensory sensitivities lead to adaptations in intimacy. Recommendations for targeted support and education on managing sensory aspects in relationships.
Weir et al. [33]	2021	2386 adults, including 1183 autistic individuals	Age range 16–90	Anonymized online survey	Autistic individuals display a wider range of sexual orientations and experience similar STI risks. Higher likelihood of non-heteronormative orientation. Need for inclusive sexual health education and healthcare accessibility.
Pecora et al. [48]	2020	295 female participants (134 autistic, 161 non-autistic)	Mean age: 26.2 (autistic), 22.0 (non-autistic)	Online survey with Sexual Behaviour Scale-III	Autistic females, especially non-heterosexual, face higher rates of unwanted sexual experiences. Highlights vulnerabilities and the need for tailored interventions for gender-diverse and sexual minority groups with ASD.
Clarke & Lord [49]	2020	253 individuals with ASD	Age 2–26	Longitudinal cohort study	Social competence in adolescence predicts adult outcomes (employment, independence, friendships). Adults with ASD face significant barriers in employment and relationships. Suggests the need for personalised success measures for individuals with ASD.
Hillier et al. [50]	2020	4 autistic individuals (male, transgender; agender/nonbinary; agender; queer)	Age 20–38	Qualitative analysis	Main themes are experiencing dual identities, autism spectrum and LGBTQ+ statuses; multiple challenges experienced by those with minority status; isolation caused by lack of understanding; lack of service provision.
Picard-Pageau & Morales [51]	2022	Individuals with an ASD diagnosis or in regular contact with them (family, therapist, teacher)	Age < 23 years old	Systematic review	Interventions focusing solely on knowledge transfer may not be sufficient to improve behavioural outcomes in youth with ASD. Combining direct intervention with homework or targeting parents may yield better results. School-based interventions show mixed results, while health professional interventions lack conclusive evidence.
Dekker et al. [52]	2023	38 male adolescents divided into neurotypical or autistic groups	Age 14–19	Comparative study	There are no significant differences between groups concerning to what extent partners’ characteristics were desired. Autistic adolescents desire similar characteristics as TD adolescents in their romantic partners and friends.
García-Barba et al. [53]	2024	332 participants (57.5% women; 42.5% men)	Age 21–73	Online survey and data analysis	In autistic individuals, sexual cognitions are less diverse and occur more slightly and less frequently than in their neurotypical peers; nonetheless, their positive content may be indicative of sexual well-being.
Hancock et al. [54]	2019	459 individuals (232 diagnosed with ASD)	Age 5–17	Online survey and data analysis	Individuals with ASD experience similar levels of interest in relationships compared to their neurotypical peers, but face more challenges in initiating and maintaining them. This is due to difficulties in social interaction and anxiety in social situations.
Genovese [55]	2021	No participants	Age 10–21	Narrative review	Autistic adolescents face unique challenges during a developmental period marked by increased social and emotional demands. Their difficulties in social interaction and emotional regulation can hinder their ability to navigate these challenges, potentially leading to emotional distress and behavioural problems.
Joyal et al. [56]	2021	194 participants	Age 16–22	Exploratory study	Individuals with ASD share similar romantic desires and expectations to those of their neurotypical peers, but they often have fewer opportunities for sexual experiences. They may also experience difficulties in understanding and navigating sexuality due to limited knowledge and social skills. Early diagnosis and comprehensive sex education can positively impact their sexual experiences.
Lewis et al. [57]	2020	67 individuals who identified as autistic sexual minorities	Age > 18	Theme analysis of online interviews	Main themes: self-acceptance as a journey; autistic traits complicate identification of sexual orientation; social and sensory stressors affect sexuality; feeling isolated; challenges in establishing satisfying relationships; difficulty recognizing and communicating sexual needs; a “double minority” status that increases vulnerability in sexual relationships.
Maggio et al. [58]	2022	11 articles	Not applicable	Scoping review	Individuals with ASD may experience atypical sexual development, including higher rates of gender dysphoria and inappropriate sexual behaviours. They often have reduced sexual awareness and a higher prevalence of diverse sexual orientations. Comprehensive sexual health education and support are crucial for improving their quality of life and reducing risky behaviours.
Mogavero & Hsu [59]	2019	134 participants, 46 with ASD and 88 without ASD	Age 18–57	Qualitative study	Autistic individuals can form successful romantic relationships, but struggle with initiating and maintaining them due to challenges in social skills and communication. Many lack adequate knowledge about romantic relationships. The prevalence of minority sexual orientations and gender identities is higher among autistic individuals, highlighting the importance of inclusive sex education.
Noble et al. [60]	2023	124 participants	Age 18–25	Data analysis	Autistic students experience both positive and negative aspects of romantic relationships. While they share similar desires for relationships to those of their neurotypical peers, they face challenges due to social communication difficulties and rigid thinking patterns that can lead to increased anxiety, fear of rejection, and difficulties in maintaining relationships.
Pedgrift & Sparapani [61]	2022	46 participants	Age 18–29	Testing of a sexual education program	This sexual education tool is a promising program for professionals to use with their adult clients with neurodevelopmental disabilities.
Picard-Pageau et al. [62]	2023	Not specified	Age > 18	Toolkit design	The tool developed in this study seems to be more relevant for providing support to school-based workers than to specialised clinicians.
Strang et al. [63]	2023	93 participants, evenly divided between autistic transgender, autistic cisgender, and allistic transgender groups	Age 13–21	Data analysis	Autistic transgender adolescents experience higher levels of internalising symptoms compared to their allistic transgender and autistic cisgender peers. Social difficulties, executive function deficits, and female gender identity contribute to these increased mental health challenges.
Torralbas-Ortega et al. [64]	2023	8 participants	Age 14–27	Qualitative analysis	Communication and social interaction problems are barriers for young adults in developing affective/sexual relationships, leading to negative feelings and experiences that reinforce avoidance behaviours. Families have poor perceptions of their ability to provide guidance on the matter. There are reports of poor sex education and lack of support.
Rocha et al. [65]	2023	108 participants	Age 18–58	Online survey, psychometric assessment	Identified three dimensions of psychosexual well-being: sexual knowledge, sexual feelings and attitudes, and sexual self-concept. Found significant differences between autistic and neurotypical groups in sexual self-concept, with autistic individuals reporting lower scores due to difficulties in social communication, reduced exposure to sex education, and increased anxiety in social interactions. Emphasised the need for tailored educational interventions.
Kohn et al. [66]	2023	27 autistic individuals and 122 non-autistic individuals	Autistic individuals: age 19–26; non-autistic individuals: age 18–25	Cross-sectional study	Autistic adults had comparable factual sexual knowledge to non-autistic adults but faced greater difficulties in pragmatic communication. Pragmatic language abilities were significantly associated with accuracy in defining anatomical terms. Autistic adults had significantly fewer partnered experiences and impaired pragmatic language. Within both groups, pragmatic skill predicted accurate sexual knowledge above and beyond general communication abilities.

systematically presents essential details from the included studies, such as authorship, publication year, participant demographics, methodologies, and key outcomes. The inclusion of this table aims to facilitate cross-study comparisons and underscore significant patterns and divergences within the literature. This structured overview supports the thematic analysis and deepens the contextual understanding of the review’s findings.

2.4. Synthesis Process and Themes

The synthesis of the selected studies followed a thematic analysis approach. Key findings from each study were extracted, and common themes were identified through repeated readings. This process enabled the organisation of results into core themes that underscore the unique challenges faced by autistic individuals in their intimate and romantic relationships. The qualitative approach provided a comprehensive narrative synthesis, drawing patterns from the diverse methodologies employed across the studies. The main themes identified include the following: (1) intimacy, sexuality, and relationships among autistic people, (2) gender identity and sexual orientation, and (3) challenges.

Table 2. Themes and sub-themes for thematic analysis.

Themes	Sub-Themes
Intimacy, sexuality, and relationships among autistic people	1.1. Experiences of intimacy: similarities and differences between autistic and non-autistic participants. 1.2. Sensory processing and sexuality. 1.3. Insights from long-term relationships involving autistic individuals.
Gender identity and sexual orientation	2.1. Gender identity. 2.2. Sexual orientation. 2.3. Asexuality.
Challenges	3.1. Hypothetical explanations. 3.2. Heightened risk and harsh realities: addressing sexual abuse and victimisation in autistic individuals. 3.3. Rethinking sexual health risks in the autistic population. 3.4. Sexual health and autism: navigating challenges and promoting inclusive education and support. 3.5. Barriers to effective sex education. 3.6. Facilitators for improved sex education. 3.7. Innovative strategies for sexual education and relationship skills in autistic individuals.

shows the themes and sub-themes identified at the end of the process.

The following table (

Table 3. Qualitative assessment.

Authors	Year	Published in	Quartile	H Index
Allely [34]	2020	Journal of Intellectual Disabilities and Offending Behaviour	Q3	14
Ronis et al. [35]	2021	Archives of Sexual Behavior	Q1	133
Płatos et al. [36]	2023	Journal of Autism and Developmental Disorders	Q1	208
Rothman et al. [37]	2022	Autism	Q1	123
Sala et al. [38]	2020	Journal of autism and developmental disorders	Q1	208
Sala et al. [39]	2020	Current Developmental Disorders Reports	Q3	33
Yew et al. [40]	2023	Autism	Q1	123
Yew et al. [41]	2021	Personal Relationships	Q1	97
Smith et al. [42]	2021	Journal of Autism and Developmental Disorders	Q1	208
Pecora et al. [43]	2020	Child and Adolescent Psychiatric Clinics of North America	Q1	88
Bush et al. [44]	2020	Journal of Autism and Developmental Disorders	Q1	208
Strnadová et al. [45]	2021	Sex Education	Q1	45
Dewinter et al. [46]	2023	Autism	Q1	123
Gray et al. [47]	2021	Autism in Adulthood	Q1	16
Weir et al. [33]	2021	Autism Research	Q1	93
Pecora et al. [48]	2020	Molecural Autism	Q1	79
Clarke & Lord [49]	2020	Development and Psychopathology	Q1	192
Hillier et al. [50]	2020	International Journal of Transgender Health	Q1	54
Picard-Pageau & Morales [51]	2022	Sexuality and Disability	Q2	50
Dekker et al. [52],	2023	Archives of Sexual Behavior	Q1	133
García-Barba et al. [53]	2024	Sexuality and Disability	Q2	50
Hancock et al [54].	2019	Sexuality and Disability	Q2	50
Genovese [55]	2021	Cureus Journal	Q3	64
Joyal et al. [56]	2021	Frontiers in Psychiatry	Q2	184
Lewis et al. [57]	2020	Journal of Autism and Developmental Disorders	Q1	208
Maggio et al. [58]	2022	Brain Sciences	Q2	66
Mogavero & Hsu [59]	2019	Sexuality and Disability	Q2	50
Noble et al. [60]	2023	The Family Journal	Q2	43
Pedgrift & Sparapani [61]	2022	Sexuality and Disability	Q2	50
Picard-Pageau et al. [62]	2023	Sexuality and Disability	Q2	50
Strang et al. [63]	2023	Journal of clinical child & adolescent psychology	Q1	157
Torralbas-Ortega et al. [64]	2023	BMC psychiatry	Q1	137
Rocha et al. [65]	2023	Sexuality and Disability	Q2	50
Kohn et al. [66]	2023	Journal of autism and developmental disorders	Q1	208

) provides information about the quartiles and H-Indexes of journals where the sources used in our review were published, as we consider them a measure of the rigour and precision of the peer review process that the published articles underwent before publication.

3. Results

From the analysis of the results of the selected studies, several themes and sub-themes emerged, which will be explored in more detail in the following paragraphs.

In reviewing the results, we intermittently used the term “ASD” (autism spectrum disorder). This choice has been made in reference to individuals formally diagnosed under DSM-5 criteria; however, we recognize that autism is not a disorder but rather a form of neurodiversity. As a form of neurodiversity, autism highlights the inherent diversity in human cognition, social interaction, and sensory processing, and the use of this term emphasises that autistic experiences are variations within the spectrum of human neurology rather than pathological deviation.

3.1. Intimacy, Sexuality, and Relationships Among Autistic People

3.1.1. Experiences of Intimacy: Similarities and Differences Between Autistic and Non-Autistic Participants

Many autistic adults have fewer friendships and fewer romantic relationships than their neurotypical counterparts [39]. Although autistic people have difficulties with social–emotional reciprocity, most still desire intimate romantic relationships. Sala, Hooley, and Stokes [39] found that both autistic and non-autistic participants were interested in romantic relationships, with most having prior relationship experience or expressing interest in future relationships. Research on the general population has shown that adolescent social competence is positively linked with various adult outcomes, including job status, relationships, and mental health. These associations appear to be similar for autistic young adults. A study conducted by Clarke and Lord [49] revealed that the likelihood of ever having been in a romantic relationship was only predicted by nonverbal IQ at the age of 9, highlighting the influence of cognitive abilities on social and romantic involvement for autistic individuals.

Dewinter et al. [46] indicated that the timing of puberty generally does not differ between autistic and non-autistic adolescents. Many autistic adolescents show an interest in sexuality and relationships, engaging in both solo and partnered sexual activities around the same age as their non-autistic counterparts. However, a notable proportion of autistic individuals, particularly males, tend to initiate partnered sexual activities later than their non-autistic peers. Autistic individuals with no partnered sexual experiences have reported higher levels of sexual anxiety, along with a diminished interest in sexuality and sexual desire [53]. According to Rocha et al. (2023), autistic individuals report significantly lower scores in sexual self-concept compared to neurotypical individuals, which can impact their ability to establish and maintain romantic relationships [37].

Other differences between autistic individuals and neurotypical individuals are related to sexual cognitions, and, although sexual cognitions are an important aspect of sexual well-being for all individuals, little is known about the sexual cognitions of autistic individuals [53]. Therefore, García-Barba and colleagues [53] conducted a study to examine the range, content, and frequency of positive and negative sexual thoughts among autistic individuals. The results showed that both autistic men and women have a wide variety of both positive and negative sexual cognitions, though these are less varied compared to those of neurotypical individuals. Possible reasons for this reduced diversity and frequency include lower sexual desire, sensory issues making sexual activity uncomfortable, and a preference for familiar routines, which may limit the exploration of new experiences. Autistic individuals might also find it challenging to imagine themselves in unfamiliar scenarios, and breaking from routine can cause anxiety, further reducing the motivation to seek new sexual experiences and fantasies. Common positive sexual cognitions among autistic individuals included intimacy and specific sexual activities, such as having intercourse with a loved partner or kissing passionately, which show their sexual interest and desire. In contrast, the least frequent positive sexual cognitions reported by participants, such as harming a partner or becoming aroused by watching someone urinate, align with earlier studies on neurotypical individuals and typically signify a breach of social norms. Rarely reported were paraphilic interests, challenging the stereotype that many autistic people have such interests [38]. Moreover, Sala et al. [38] noted that they shared similar understandings of intimacy, such as sharing and mutual respect, but there were differences in how they approached and maintained intimacy. Non-autistic participants emphasised attachment, mental health, and identity in their relationship functioning. Autistic individuals faced specific difficulties with communication and courting behaviour, which could be reinforced by stereotypes and concerns of parents and caregivers. Limited exposure to diverse relationships and sexualities may contribute to uncertainties about romance and relationship structures among autistic individuals [46]. Despite communication difficulties, autistic individuals made adaptations to navigate relationship challenges, such as clear communication and self-understanding, while non-autistic participants relied more on implicit understanding and familiarity. Enabling intimacy for both groups included communication, sharing and similarity, respect and safety for oneself and others, and working on the relationship. Barriers for both groups included intra- and interpersonal conflicts; autistic people specifically highlighted uncertainty about relationships and communication. As also confirmed in a study by Dewinter et al. [46], autistic adults reported valuing aspects of intimate relationships in a manner similar to those of their non-autistic peers, such as the importance of communication and dedication to working on the relationship. This indicates that, despite potential challenges, autistic individuals hold similar ideals and values regarding intimate partnerships. Moreover, findings suggest that autistic and non-autistic people have similar notions of intimacy but have different challenges in experiencing it [38].

3.1.2. Sensory Processing and Sexuality

People on the autism spectrum often perceive sensory inputs differently, which can significantly influence their sexual and relational engagements [47]. These autistic sensory features can include heightened sensitivities and a proclivity for seeking intense sensations. Gray and colleagues [47] conducted an analysis grounded in Dunn’s model of sensory processing, which categorises sensory experiences based on low or high neurological thresholds. This model suggests that individuals with low thresholds are more sensitive to sensory inputs, while those with high thresholds may seek more intense sensory experiences. Participants reported that their sensory sensitivities could lead to feelings of confusion, distress, or frustration during sexual encounters, often resulting in the avoidance of sexual activities. For instance, the typical sights, sounds, smells, and textures associated with dating and sexual activities could be overwhelming for individuals with heightened sensory sensitivities. Conversely, the study also revealed that some autistic individuals seek more intense sensory experiences in their sexual relationships or prefer intimate interactions that provide calming and regulatory sensory input. Another study that shed light on these difficulties was conducted by Lewis and colleagues in 2021 [57]. In this study, 67 autistic people were described through online interviews as having varying experiences with stressors such as anxiety, sensory overload, and social pressures that inhibited their ability to comfortably engage in sexual intimacy. Several participants viewed genitals and sexual intercourse as “gross”, “disgusting”, and “repulsive”. For some, this sex repulsion existed regardless of their own sexual drive and interest in sex in general. Many participants also described the impact of hypersensitivity to physical touch and sensory overload as complicating factors during sexual activities.

Participants described concerns about hygiene and cleanliness that affected their enjoyment of sexual activities. Autistic people explained that sensory and hygiene concerns were particularly difficult and even guilt-inducing when they wanted to be intimate with a partner [57]. Autistic people described various strategies and adaptations they employed to navigate their sensory preferences and needs in sexual contexts, such as open communication with partners or the use of substances to mitigate overwhelming sensations. Other people indicated that they avoided sexual activity because of their sensory features [47].

3.1.3. Insights from Long-Term Relationships Involving Autistic Individuals

Autistic individuals report similar levels of interest in romantic relationships to their non-autistic peers but experience greater challenges with the initiation and maintenance of these relationships [41]. Physical attractiveness, as perceived by partners and observers, was found to facilitate relationship opening, potentially compensating for social challenges initially [41]. Financial resources also seemed to provide an advantage in relationship initiation but may not benefit all autistic individuals due to high rates of under- or unemployment. Challenges in initiating romantic relationships were associated with low social and peer functioning, reflecting difficulties in understanding social interactions. Autistic people try to act as a function of the other person (e.g., trying to have similar interests, give them something nice), whereas non-autistic people tease them to receive attention; a greater proportion of autistic girls compared to their non-autistic peers would say things about themselves that they think the other person would like to hear [47]. An overall lower level of romantic functioning, more “stalking-type” or persistent courting behaviours, and more inappropriate courting behaviours were observed (but the differences were not statistically significant) [59]. No significant gender differences were found in terms of knowledge, experience, or courting behaviours. Autistic individuals have fewer resources available for learning how to acquire romantic dating skills and knowledge compared to their typically developed peers. They say they have not learned how; they don’t initiate; some use trial and error; and it is difficult to understand and communicate because of problems with verbal and nonverbal communication (know when a conversation should be ended, misunderstand signals, social cues, hard to see when they are not interested) [59]. They did not understand how relationships work, so it was difficult to recognize unhealthy or inappropriate behaviour when courting or being courted or how to handle dating situations in a healthy manner. Analysis revealed that neurodiverse relationships progressed along pathways similar to neurotypical ones, such as honeymoon, defining, and establishing [42]. The honeymoon phase, marked by initial excitement and discovery, involves positive communication and tolerance of partner faults. In particular, autistic people tend to value more implicit characteristics than extrinsic or social status (trustworthy, nice, funny vs. good-looking, popular, rich). They both look for similar people, who are similar in intrinsic status, but who are less similar in social status; autistics seek nicer people than neurotypical people. They want someone who is closer to their characteristics than neurotypical people; they adapt their desires to their own capabilities. On the other hand, they see themselves as being less of a good partner; autistics have lower self-esteem, and they believe that they are less suitable partners, possibly because of their awareness of their social difficulties [52]. As shown by an analysis by Smith et al. [42], when relationships progress, conflict and communication challenges emerge, particularly during the defining phase, characterised by increased intimacy and assertiveness. Neurodivergent couples face unique challenges in establishing mutual understanding and expectations due to differing communication styles and perspectives. While some autistic partners may initially use camouflaging techniques to navigate social interactions, maintaining this strategy long-term becomes challenging. Nonetheless, participants reported developing strategies to overcome communication barriers and strengthen their relationships, often with neurotypical partners playing a significant supportive role. Facilitators included the strength-based roles that each partner took on and their genuine support and care for each other. The establishment phase signifies increased stability and commitment, accompanied by positive communication strategies and reduced conflict. Receiving an autism diagnosis, often occurring later in the relationship, aids partners in understanding each other’s differences and seeking appropriate support. Viewing neurodiverse relationships through an intercultural lens highlights the need for cultural awareness and adaptation to intercultural couples. However, participants noted a lack of adequate support and resources tailored to neurodiverse couples, emphasising the need for health professionals to undergo further education to better assist these couples in navigating their unique challenges [52]. Participants have difficulty carving out quality time for connection, sometimes feeling that they are not a priority or that their partner makes unreasonable requests [60]. Insecurity can also create distance, as individuals may avoid adopting a partner’s bad habits or struggle to negotiate their needs effectively. The fear of a partner losing interest further complicates matters. These anxieties manifest in different ways. For example, some individuals experience a lack of awareness regarding their fears or uncertainty about appropriate ways to express themselves, or they may hesitate to introduce certain topics or communicate their needs directly. Consequently, autistic individuals have reported lower satisfaction in their romantic relationships than non-autistic individuals. Yew et al. [40] explored this topic to establish whether the barriers to relationship satisfaction identified in the literature (i.e., personality factors, poor social and communication skills, social loneliness, low partner support, and low sexual satisfaction) are experienced by autistic people in long-term relationships. Autistic participants reported higher levels of social loneliness and scored lower on each of the Big Five personality traits than non-autistic participants, consistent with previous research. Surprisingly, autistic participants reported greater perceived sexual and relationship satisfaction than non-autistic participants did, contrary to expectations based on sensory sensitivities and communication differences. Interestingly, some autistic individuals express greater satisfaction in relationships where their partner is also autistic [53]. This suggests a level of mutual understanding and shared experiences that might contribute to relationship satisfaction. Autistic participants also reported shorter relationships, possibly due to challenges in relationship maintenance or the younger age of the autistic group. In fact, those who do not perceive positivity from the relationship struggle to maintain the relationship as they struggle to connect with their partners. Consequently, bad relationship experiences produce loss and create deep concerns that influence all life aspects; they need to “fill the gap” created by the partner who left [60]. It is shown that partner responsiveness significantly predicted relationship satisfaction for both autistic and non-autistic partners, while personality traits were not significantly associated with relationship satisfaction in long-term relationships involving autistic individuals, suggesting that personality effects may be masked by partner accommodation or other factors [40]. Furthermore, it was found that communication differences, including responsiveness to partners, were linked to reduced relationship satisfaction, consistent with qualitative reports [41]. In contrast to these findings, another study by the same author reported that communication skills, social skills, and social loneliness were also not significantly associated with relationship satisfaction [40].

3.2. Gender Identity and Sexual Orientation

3.2.1. Gender Identity

Several studies have reported an interesting link between the autistic spectrum and a non-conforming gender identity. Autistic people, especially those who are assigned female at birth, have significantly greater rates of gender dysphoria and are less likely to identify with their assigned gender at birth [43,46,53,56]. Autistic women are also less likely to report heteronormative interests and identities, indicating a significant prevalence of gender diversity within the autistic population [53]. Autistic adolescents generally have a greater desire to belong to a different gender, there are higher rates of autism diagnosis in transgender and gender non-conforming adults than in their peers, and a significant correlation between autism and gender variance has been observed in both adolescents and adults; autistic-like characteristics are also highly present among gender -variant children and adolescents compared to their peers [58]. This growing body of evidence on the link between autism and gender variance and/or gender dysphoria has sparked interest in the issue. A 2020 study [38] hypothesised that this relation might be due to different factors, including prenatal testosterone levels, difficulties with implicit social learning about gender, rejection from one’s gendered group, and a rigid thinking style that interprets gender roles as inflexible. Interestingly, Pecora et al. [48] reported that while non-autistic transgender individuals reported more regretted sexual encounters than did their cisgender counterparts, transgender status did not correspond with an increased likelihood of negative sexual experiences among autistic females identifying as transgender.

3.2.2. Sexual Orientation

Several reviews show an ongoing debate on whether a non-heterosexual sexual orientation is more prevalent in autistic people, with some studies suggesting that there are no differences in sexual orientation and others observing higher rates of non-heterosexuality among the autistic population [33,56,58]. A 2022 review [58] found one study stating a higher prevalence of homosexuality, bisexuality, and asexuality among both autistic men and women. However, several studies suggest a trend regarding autistic women who identify as bisexual more often than autistic men [33,58]. Age has an interesting impact on sexual orientation experiences and expressions. Older autistic men tend to identify as bisexual, while younger men identify as homosexual more often than their non-autistic peers. This observed difference in sexual orientation identification between older and younger autistic individuals may be due to social attitudes toward sexuality becoming more open and accepting, encouraging autistic individuals to explore and express their sexual identities [33]. Sexual orientation also influences sexual experiences: autistic homosexual women experience a greater risk of unwanted sexual behaviour and regretted sexual activities than both autistic heterosexual women and non-autistic women. Conversely, autistic bisexual women have a lower risk of regretting sexual behaviour than non-autistic heterosexual women [48].

3.2.3. Asexuality

Recent studies suggest a connection between being on the autism spectrum and identifying as asexual [33]. However, research on this link is complex and ongoing. A 2020 study [44] revealed that a significant number of participants identified themselves as being within the asexual spectrum, including those who identified as asexual, questioning, grey-asexual, or demi-sexual. Interestingly, those on the asexual spectrum expressed greater sexual satisfaction, possibly because their gratification does not depend on sexual activity with a partner. They also show lower generalised anxiety: while autistic people may face obstacles in fulfilling their sexual desires, leading to greater anxiety, those on the asexual spectrum might not experience such barriers, contributing to lower anxiety levels and greater satisfaction. Maggio et al. [58] highlighted similarities between asexuality and autism, with both sharing a particular understanding of romantic and sexual dimensions and sexual desire not necessarily oriented toward one’s partner. Another study [35] found that some autistic people who identify as asexual may actually experience some level of sexual attraction; their identification might be more linked to a lack of desire or difficulty with interpersonal relationships than to a complete absence of attraction. The authors highlight the importance of a multifaceted approach to accurately assess sexual identity.

3.3. Challenges

Autistic individuals who identify as part of the queer community, due to their sexual orientation and/or sexual identity, face different challenges stemming from feelings of being different and experiences of stigmatisation about gender expression [53]. Hillier et al. [50] investigated this double minority status through a focus group with queer autistic individuals to identify multiple minority stresses. The LGBTQ+ community was reported to be unaware of different autism spectrum aspects and to have stereotypical views about autism, leading to isolation and exclusion from the queer community. Some people also attributed the participants’ sexual identity to their autism. This issue of double minority status is further complicated by the notable prevalence of autism among transgender adolescents [63]. Both autism and gender diversity independently elevate the risks of mental health issues. Autistic transgender adolescents exhibit markedly heightened internalising symptoms compared to their allistic transgender and autistic cisgender counterparts. Alongside stigma-related mental health associations, cognitive/neurodevelopmental factors linked to autism, such as poorer executive function (EF) and heightened social symptoms, are correlated with worse mental health outcomes. Specifically, social symptoms and EF-related gender barriers are associated with increased internalising symptoms and EF problems, while EF-related gender barriers are associated with heightened suicidality [63].

Disclosing sexual identity as an autistic person presents a specific set of challenges. Most participants felt that they lacked the necessary communication skills to effectively express their identity. Additionally, they struggled with anticipating how others would react to their coming out, fearing negativity and homophobic comments. A few shared the opposite perception, stating that their autism made them less concerned about others’ reactions to their disclosing. These findings align with another study by Genovese [55] that highlighted the challenges faced by autistic queer individuals in expressing themselves due to the stigmatisation of gender expression and autism-related social and communication skills.

Another interesting conclusion drawn from the research of Hillier and colleagues [50] concerns the difficulties faced by autistic LGBTQ+ individuals in finding services and/or health professionals who understand the interaction between autism and queer identity; many participants reported experiences of misgendering, lack of support, and intrusive questions. Exploring the experiences of autistic people who identify as a sexual minority, Lewis et al. [57] found that many autistic queer people process these identity aspects separately, often feeling more comfortable with one than the other, with one of the two bringing shame. Many participants felt that being autistic impacted their sexual identity by challenging them to recognize sexual feelings and attractions, complicating their overall sexual understanding. Moreover, autism-related social challenges complicate the possibility of having romantic and/or sexual experiences, hindering their ability to imagine being in a sexual situation. Despite perceiving autism’s impact on their sexual identity understanding, most participants felt that their sexual orientation was not related to their autism and resented when others assumed these were connected. One autistic woman linked her romantic attraction to her autism, explaining that she did not want to be in any intense relationship. Most of the participants emphasised the significance of negative reactions from others, leading them to feelings of isolation and pain, increasing confusion and preventing them from fully accepting themselves. Often, autistic individuals feel isolated from both the LGBTQ+ and autism communities; they especially struggle to understand dating norms since they lack a queer model to mirror. These findings concerning isolation by both communities align with those from the previously mentioned Hillier and colleagues’ study [50].

3.3.1. Hypothetical Explanations

The broader range of gender and sexual diversity within the autistic community is likely influenced by a combination of neurobiological factors and social factors [33]. Pecora et al. [48] explore different possible theories. From a neurobiological point of view, there might be a link between prenatal exposure to testosterone, autistic traits, and neural masculinization, leading to the development of more typically male traits and preferences in autistic individuals assigned female at birth. A more psychosocial framework hypothesises that certain autistic traits might cause autistic individuals to hold rigid views on gender roles, making it difficult for them to understand how social influences shape these roles; consequently, autistic individuals who do not conform to these stereotypical expectations may identify as transgender. Additionally, social interactions and reduced awareness of societal norms play a crucial role since they make the assigned gender at birth less relevant in connecting with a potential partner.

3.3.2. Challenges and Risks in Sexual Behaviour for Autistic Individuals

Findings reveal a growing awareness of the desire for sexual and intimate relationships in autistic individuals. However, the challenges associated with autism complicate the acquisition of knowledge and skills necessary for healthy sexuality and relationship building, leading to difficulties in initiating sexual interactions and relationships. Research highlights that autistic adolescents tend to exhibit fewer sexual behaviours, possess less knowledge about privacy rules, and receive inadequate sex education. Consequently, they may be more likely to engage in inappropriate sexual behaviours than their neurotypical peers. This lack of privacy awareness can result in difficulties in understanding and adhering to societal norms regarding sexual situations, potentially increasing the risk of inappropriate or even abusive behaviour [58].

Although autistic individuals may have a reduced amount of sexual experience due to challenges in relationship skills, they can also demonstrate a strong interest in relationships and engage in age-appropriate sexual behaviours. Studies indicate that a significant portion of autistic individuals are in romantic relationships, and sexual activity among autistic males occurs at rates comparable to those among non-autistic males. However, autistic young adults often express a greater need for privacy and engage in sexual behaviours that align with their preferences, yet they also face heightened risks of sexual victimisation [58].

Research by Joyal et al. [56] demonstrated that multiple factors, including gender, age at first diagnosis, self-reported knowledge about sexuality, and the desire for sexual relationships, influence both positive and negative sexual experiences among autistic individuals. This suggests an intricate interplay between these factors and how autistic individuals navigate and interpret their sexual experiences. The presence of both positive and negative outcomes in the same population highlights the necessity for targeted, supportive interventions that foster safe and fulfilling sexual experiences.

Despite these insights, concerns persist regarding problematic sexual behaviours in some autistic individuals. Research suggests that a subset of autistic individuals, particularly males, may engage in hypersexual behaviours, compulsive masturbation, and unique masturbation techniques. Additionally, some studies have explored the link between autism and certain paraphilic interests, including fetishism. However, it is crucial to approach this topic with a nuanced perspective, as many of these behaviours may stem from autism-related sensory sensitivities, social naïvety, or difficulties in understanding social norms, rather than inherent deviance [48,58].

Misinterpretations of autistic individuals’ behaviours may lead to legal consequences, particularly in cases of so-called “counterfeit deviance”, where actions are not driven by sexual deviance but rather by a lack of sexual knowledge, social misunderstandings, or difficulty recognizing boundaries. This issue is particularly concerning in the context of viewing child exploitation material, where isolation, social anxiety, and insufficient sexual education may play a significant role in such behaviours [48,50].

Therefore, researchers challenge the assumption that autistic individuals are less sexually active. Regarding the related risk of STIs, studies reveal no significant differences in the age of first sexual activity or STI rates between autistic and non-autistic groups, indicating that the lifetime STI risk is comparable across populations [33].

Although some autistic individuals identify as asexual or engage in fewer sexual experiences, this does not necessarily reduce their STI risk. Autistic individuals who are sexually active may engage in risky behaviours due to a lack of adequate sexual health education.

Studies on sexual experiences in autistic individuals have highlighted a greater risk of sexual victimisation and abuse, which is prevalent among both young people and adults [48], with a risk more than four times greater than that faced by non-autistic individuals [35,53]. This heightened vulnerability necessitates a nuanced understanding of the unique consequences and needs of autistic survivors of such victimisation, which may differ from those in the general population. The adverse effects of sexual victimisation on autistic individuals can be further intensified by prior negative experiences, social exclusion, and a lack of appropriate responses or support from others when they seek help [53]. There are sex differences in victimisation, with autistic females facing a greater risk of negative sexual experiences, such as regret and unwanted encounters, than their male counterparts. Several factors contribute to heightened vulnerability in autistic females, including a tendency toward naïve promiscuity to form desired relationships and poor partner choices that may lead to abusive situations. Additionally, homosexual females with ASD might experience increased vulnerability to regretted sexual experiences, possibly due to the added challenges of being a sexual minority. The same factors that contribute to an increased risk of offending in autistic individuals, such as deficits in social understanding, communication challenges, and impaired theory of mind, are also believed to increase the risk of sexual victimisation. These deficits can make it difficult for autistic individuals to interpret others’ intentions correctly and to distinguish between safe and unsafe people and situations. A lack of sexual knowledge exacerbates these issues, limiting their ability to protect themselves from risky situations and practices [53,64]. Studies on sexual experiences in autistic individuals have highlighted a significantly higher risk of sexual victimisation, which is prevalent among both young people and adults [48]. Research indicates that autistic individuals face a risk of sexual abuse that is more than four times greater than that of their non-autistic peers [35,53]. This heightened vulnerability necessitates tailored interventions that recognize the specific needs of autistic survivors and ensure appropriate support.

The adverse effects of sexual victimisation may be intensified by prior negative experiences, social exclusion, and a lack of appropriate responses from support networks when autistic individuals seek help. Additionally, research highlights gender differences, with autistic females facing a higher risk of regret and unwanted sexual encounters than autistic males. Certain factors, such as a tendency toward naïve promiscuity, difficulties in recognizing manipulative partners, and social pressures, contribute to this increased vulnerability.

Furthermore, autistic females who identify as LGBTQ+ may experience compounded risks of regretted sexual experiences, possibly due to the additional challenges associated with being both autistic and part of a sexual minority group. The same difficulties that increase the risk of offending in some autistic individuals—such as deficits in social cognition, impaired theory of mind, and communication challenges—also make them more vulnerable to victimisation. This highlights the urgent need for improved sex education, support networks, and accessible reporting mechanisms tailored to the autistic population.

3.3.3. Sex Education: Challenges, Facilitators, and Innovative Practices

Several recent studies have shed light on the intersection of autism, sexual orientation, and sexual health, advocating for more inclusive approaches to education, healthcare, and support tailored to the needs of autistic individuals. One key finding is that autistic individuals report significantly less learning about sex-related topics from their friends than non-autistic individuals [54]. This disparity in learning from peers contributes to the broader social engagement challenges faced by autistic individuals, since reduced social engagement may be partly attributed to differences in informal sexual education among peers [54]. Rocha et al. (2023) proposed a model analysing psychosexual well-being by comparing autistic and neurotypical individuals, revealing significant differences in self-perception as sexual beings and in access to adequate sexual information [37]. This trend is especially pronounced among boys, highlighting a gendered dimension to how sexual education is received [57]. Furthermore, social interaction difficulties inherent to autism decrease opportunities for obtaining sex-related information, leading to significant gaps in knowledge [34,45]. In fact, Kohn et al. (2023) observed that autistic individuals have fewer opportunities to acquire sexual knowledge through informal social interactions, such as discussions with friends or family members [38,66]. Research suggests that difficulties in pragmatic communication may impact their ability to engage in discussions about sexual health, potentially contributing to misunderstandings and challenges in social interactions [66]. There were reported gender differences in the levels and types of sexual health knowledge among students, with young men having fragmented knowledge about certain aspects of sexuality but lacking comprehensive understanding and opportunities to apply this knowledge in real-world contexts.

Moreover, a study by Weir et al. [33] highlighted disparities in healthcare satisfaction and self-efficacy among the autistic population, especially concerning LGBTQ+ individuals, who face compounded risks. This research also highlights lower rates of cervical cancer screening among autistic females. Moreover, this work sheds light on the importance of healthcare professionals adopting affirming language and approaches to address the specific needs and risks of autistic individuals in sexual health contexts. This includes heightened vigilance regarding the risks of sexual abuse, especially among autistic females and those with diverse sexual orientations. To address challenges related to victimisation, educative programs can be implemented, as seen in the next paragraph about innovative interventions.

Strnadovà and colleagues’ review [45] aimed to gather insights from parents, teachers, and students on sex education for high school-aged students diagnosed with intellectual disabilities and/or ASD, revealing a noteworthy gap: the direct involvement of students in shaping and evaluating sex education curricula is minimal. Specifically, students diagnosed with intellectual disabilities and/or ASD reported fewer formal opportunities for sex education [41,45]. There is a general lack of confidence among teachers and parents in delivering sex education due to their own limited knowledge [45]. Dewinter et al. [46] showed that teachers and parents generally held positive attitudes toward the necessity of sex education for students diagnosed with intellectual disabilities and/or ASD. However, they also acknowledged the critical need to balance protecting students’ autonomy and rights to participate in sexual relationships with preventing victimisation. Parents of autistic children often express concerns about their children’s sexual well-being and show a desire to support their sexual development, but they hesitate to provide sexual education themselves, highlighting a perceived need for professional guidance in these discussions. In contrast, professionals do not always address or support issues of sexuality consistently in their interactions with autistic youth and their families, creating a gap that underscores a need within the field of autism care and education. Broader community and cultural barriers also pose challenges, including societal stigmas and the trauma some students may have experienced [45].

Facilitators for better sex education include starting education at puberty, adopting a whole-school approach, ensuring that all staff are trained, and aligning teaching at school with discussions at home. Moreover, communication should be clear and explicit, while resources should be personalised, appropriate, and considerate of the individual’s needs [45]. In this regard, Kohn et al. (2023) highlight the importance of sex education programs that extend beyond factual knowledge to include explicit instruction in pragmatic language skills [66]. These skills play a crucial role in facilitating effective communication about sexual health, establishing personal boundaries, and navigating romantic relationships. Dewinter and colleagues [46] advocate for sex-positive education, clinical practice, research, and policy focusing. Their recommendations are organised around three main themes:

• Education and information: providing autistic individuals and their families with education and information regarding sexuality, relationships, and gender diversity, to ensure that autistic people have the necessary knowledge to navigate their sexual and relational health and gender identity confidently.
• Healthcare expertise and accessibility: calling for improvements in healthcare professionals’ expertise in, and the accessibility of, services related to sexuality, relationships, and gender diversity, including preventing sexual victimisation and offering support to those who have experienced it, acknowledging the heightened vulnerability within the autistic population.
• Research: ensuring that there is relevant, inclusive, and respectful research by including the autistic community in future research projects on sexual well-being.

3.3.4. Innovative Strategies for Sexual Education and Relationship Skills in Autistic Individuals

Pecora et al. [48] emphasised the importance of tailored sex education programs for autistic individuals. Innovative teaching strategies that cater to the diverse learning needs of students with diagnosed intellectual disabilities and/or ASD can include using diagrams, easy-to-understand language, pictures, auditory stimuli, role-playing, and practical demonstrations to make learning material more accessible and comprehensible. The necessity for group discussions with parents regarding the sex education their children receive, along with practical guides and workshops that involve both parents and their children, was highlighted. Such initiatives could foster open discussions about sexuality, enhancing trust and understanding between parents and children [66]. A 2022 review [51] explored different intervention programs focused on the sexual life of young autistic people, highlighting that teaching sessions alone can improve the knowledge of autistic youth, while programs incorporating practical approaches and homework also produce observable behavioural effects. These interventions tend to be more effective when they involve daily continuity and are implemented during early adolescence.

Intervention programs targeting school-based workers show mixed results: some workers achieve positive outcomes with youth, while others see no significant changes. On the other hand, interventions aimed at health professionals do not yield conclusive results. Several factors might explain why combining instruction with homework and professional interventions is more effective. Regular exposure to information may help youth integrate what they learn more thoroughly, and interventions that blend direct approaches with homework can be tailored to address the specific challenges and needs of individual participants. Additionally, autistic youth often struggle with generalising information across different contexts, which may limit the effectiveness of teaching sessions alone. The review also highlights the necessity of guiding parents in supporting their children. Many parents are uncertain about how to approach discussions with their youth but are willing to learn: parent-focused interventions slightly enhance parents’ comfort levels and their ability to interact effectively with their children, demonstrating a potential for significant improvement in parents’ ability and confidence to engage effectively with their children on these topics. Overall, the findings from this literature review suggest that sexuality interventions can successfully support personal, environmental, and occupational development in youth.

Evidence-based programs such as PEERS for Young Adults offer promising avenues for teaching the social skills necessary for establishing and maintaining relationships [62]. PEERS for Young Adults is an evidence-based program aimed at teaching the social skills needed to establish and maintain close relationships, including friendship and romantic relationships. Specifically, Platos et al. [36] conducted a randomised controlled trial of the PEERS program adapted for autistic young adults, demonstrating significant improvements in social skills, cognition, and knowledge among participants. It consists of 16 weekly sessions led by mental health professionals or educators, with a focus on cognitive–behavioural principles and behavioural rehearsal exercises. Participants are supported by a “social coach”, typically a parent or another adult, who undergoes parallel training to facilitate skill acquisition and homework completion [62]. Rothman et al. [37] explored the feasibility of an online class, HEARTS (Healthy Relationships on the Autism Spectrum), designed to improve relationship skills among autistic individuals. This collaborative effort involved autistic self-advocates and non-autistic professionals. Participants showed significant improvements in various areas, including decreased hostile thoughts and increased awareness of resources related to domestic violence. Participants appreciated interacting with other autistic students and having an autistic co-teacher, and found the activities and content valuable. Despite the promising outcomes of interventions, challenges remain, including the gap between skill acquisition and real-world application and the need for post-treatment support [62]. Additionally, some participants expressed dissatisfaction with traditional approaches to social skills training, highlighting the importance of incorporating neurodiversity perspectives into interventions. Pedgrift and Sparapani [61] developed the Social-Sexual Education program to address the educational gap for adults with neurodevelopmental disabilities, including intellectual disabilities and autism. This program aims to empower these individuals by teaching them how to build safe and healthy relationships and recognize and prevent abuse. The curriculum is inclusive of sexual and gender diversity and is based on input from individuals with disabilities. The program’s effectiveness was noted by educators and facilitators, although challenges included dealing with younger participants’ immaturity and older clients’ strong emotional reactions due to past trauma. Addressing sexual orientation and gender diversity also posed challenges, requiring facilitators to maintain neutrality and handle sensitive discussions. Despite these challenges, the program has been shown to be a valuable tool for professionals, increasing awareness and understanding of safe relationships and equipping participants with the knowledge to prevent abuse. To address sexual-related challenges in the autistic population, Picard-Pageau and collaborators [51] developed a toolkit aimed at supporting sexuality, sexual health, and sustainable sexual practices in autistic youth. This toolkit, created using a multimethod, co-creation approach, involves input from autistic youth, practitioners in specialised settings, and school-based practitioners. It aims to bridge the knowledge gap and provide accessible education on sexuality for young autistic people, starting as early as age 12. The toolkit’s teaching methods include visual aids, which are particularly appreciated by both the youth and specialists, helping convey essential information about sexuality in a way that is easy to understand and retain. The toolkit covers basic knowledge about sexual activities, consent, STIs, pregnancy prevention, sexual orientation, and gender identity, therefore addressing the primary areas in which autistic youth face difficulties. By providing a structured and accessible way to learn about sexuality, the toolkit helps prevent the development of inappropriate behaviours and supports the healthy sexual development of young autistic people. It also eases the burden on practitioners, many of whom may not feel comfortable teaching these topics. The toolkit serves as a valuable resource for both specialised and school-based practitioners, facilitating a more consistent and comprehensive approach to sexual education for autistic youth.

4. Discussion

This article offers a comprehensive and updated synthesis of the unique challenges faced by autistic individuals in the realms of sexuality and intimacy. Research provides valuable insights into the ongoing barriers these individuals encounter, such as social isolation, difficulty in communication, and lack of proper sexual education. This work builds on the existing literature by consolidating recent findings that explore the broader context of intimacy and sexuality in the autism spectrum, making it a relevant and timely contribution. The findings from various studies shed light on the complexities of intimacy, sexuality, and relationships among autistic individuals, highlighting both similarities and differences compared to their neurotypical counterparts. Understanding these nuances is crucial for providing tailored support and interventions to enhance the well-being and relational experiences of autistic individuals. First, regarding experiences of intimacy, it is evident that despite facing challenges in social–emotional reciprocity, many autistic individuals desire and engage in romantic relationships. Studies have indicated that autistic adults, similarly to their non-autistic peers, value communication, mutual respect, and dedication to relationship maintenance [47,53]. However, autistic individuals may encounter specific difficulties in communication and courting behaviours, influenced by stereotypes and limited exposure to diverse relationship models [38]. Moreover, cognitive abilities, such as nonverbal IQ, play a significant role in shaping romantic involvement in autistic individuals [39]. Interestingly, while both autistic and non-autistic individuals share similar notions of intimacy, they may approach and maintain intimacy differently. Autistic individuals tend to rely more on explicit communication and self-understanding, while non-autistic individuals may rely on implicit understanding and familiarity. Despite these differences, both groups identify communication, sharing, similarity, and respect as essential components of intimacy [47]. Second, differences in sensory processing significantly influence autistic individuals’ sexual and relational experiences. Autistic individuals may exhibit heightened sensory sensitivities, leading to feelings of distress or avoidance of sexual activities. Conversely, some autistic individuals may seek intense sensory experiences or prefer intimate interactions that provide calming sensations [57]. However, sensory sensitivities, including hypersensitivity to touch and concerns about hygiene, can complicate sexual intimacy and lead to avoidance of sexual activities [41]. Furthermore, long-term relationships involving autistic individuals face unique challenges, particularly in terms of their initiation and maintenance. Autistic individuals may struggle with social interactions and communication, which can impact relationship initiation [49]. Moreover, while autistic individuals report similar levels of interest in romantic relationships to those of their non-autistic peers, they may experience lower levels of relationship satisfaction, possibly influenced by social loneliness and communication differences [60]. Interestingly, some autistic individuals express greater satisfaction in relationships with autistic partners, indicating the importance of shared experiences and understanding [53]. The relationships among gender identity, sexual orientation, and autism are multifaceted and complex, as highlighted in recent studies. Individuals on the autistic spectrum, particularly those assigned female at birth, have shown significantly greater rates of gender dysphoria and a lower likelihood of identifying with their assigned gender at birth [33,46,53,56,58]. This deviation from normative gender identities is not limited to gender dysphoria but extends to a broader range of non-heteronormative interests and identities, suggesting a prevalent diversity of gender within the autistic community. The intersection of autism with sexual orientation also presents an interesting narrative. While the debate continues regarding the prevalence of non-heterosexuality among autistic individuals, several studies suggest a higher frequency of homosexuality, bisexuality, and asexuality within this population [33,48,56]. The impact of age on sexual orientation, particularly among autistic individuals, suggests a dynamic landscape influenced by changing societal attitudes toward sexuality, encouraging a more open exploration and expression of sexual identities over time [44]. Moreover, the discourse around asexuality within the autistic community unveils another layer of complexity. The linkage between autism and identifying as asexual suggests unique experiences and perceptions of sexual and romantic attractions, where sexual desires are not necessarily partner-oriented [44,48]. Interestingly, those on the asexual spectrum within the autistic community reported greater sexual satisfaction and lower generalised anxiety, highlighting the diversity and range of sexual experiences and orientations within this population. However, autistic individuals, especially those identifying as part of the queer community, face multifaceted challenges. These problems range from stigmatisation and feelings of difference due to gender expression and sexual orientation [53] to difficulties in expressing sexual identity and finding supportive services that understand the interplay between autism and queer identity [41,56,63]. The dual identity of being autistic and being part of the LGBTQ+ community often leads to additional minority stress, compounded by stereotypical views and a lack of awareness within both the autism and LGBTQ+ communities.

Furthermore, autistic individuals’ sexual behaviours and experiences are complex and often fraught with risks and challenges. The difficulty in acquiring the knowledge and skills necessary for healthy sexual relationships, combined with heightened risks of inappropriate or even abusive behaviour, underscores the need for tailored sex education and support [58]. Moreover, the review highlighted the disturbingly high rates of sexual victimisation among individuals with ASD [53,55,56]. These individuals face challenges such as deficits in social understanding and communication, which significantly increase their risk of being abused or exploited. The nuanced impact of these experiences calls for specialised support and interventions tailored to the autistic community’s specific needs.

Contrary to assumptions that lower sexual activity in autistic individuals might imply reduced STI risks, research has shown no significant difference in STI rates between autistic and non-autistic populations [44,48]. This revelation underlines the urgent need for comprehensive sexual education and health services that cater specifically to autistic individuals, recognizing their similar risk profiles while addressing their unique challenges.

This review further explored the disparities in sexual education between autistic individuals and their neurotypical peers [45,54,58]. A significant finding is the lack of peer-based sexual education for autistic individuals, which contributes to gaps in their sexual knowledge and understanding. This research calls for inclusive sex education that actively involves autistic students in the development and evaluation of curricula, aiming to bridge these educational gaps. The identified barriers to effective sex education include the lack of tailored curricula and the need for specialised educator training [45]. However, the review also points to facilitators such as starting education at puberty and adopting a whole-school approach, highlighting the importance of clear, explicit communication and personalised resources [45]. Innovative teaching strategies and programs such as PEERS for Young Adults [62] and the HEARTS online class [37] show promise in improving social and relationship skills among autistic individuals. These programs emphasise the importance of incorporating neurodiversity perspectives and supporting the real-world application of learned skills.

Limitations and Clinician Challenges

A major gap in the literature is the absence of research that directly assesses the long-term effects of the COVID-19 pandemic on the sexual and relational development of individuals with ASD. Future studies should aim to explore how the pandemic may have created new dynamics in intimacy, communication, and sexual health. Additionally, there is still insufficient understanding of the gender and sexual diversity within the autistic community, pointing to the need for research that addresses the intersectionality of autism, gender identity, and sexual orientation, particularly in post-pandemic contexts. The findings underscore the need for clinicians to focus on addressing the sexual health and relational challenges that autistic individuals face. Tailored interventions should be developed that account for sensory sensitivities, communication difficulties, and the heightened risks of victimisation.

5. Conclusions

Although there have been significant improvements and renewed knowledge about the lived experiences of autistic people, autistic individuals still face significant challenges in their sexual lives due to societal prejudices and a lack of appropriate education. Similarly to other marginalised groups and/or because of their belonging to multiple marginalised communities, they are vulnerable to victimisation [50]. Furthermore, from the studies analysed, there do not appear to be any elements or references to the COVID-19 pandemic and its influence on the psychosexual well-being of this segment of the population. Comprehensive education and support, as well as sexual education programs, are essential for addressing these barriers and improving overall well-being [45]. Further research on this topic needs to focus on investigating what would make sexual education for autistic individuals more effective, since scientific literature on this topic is rare.