Will autistic people experience abuse
Sexuality in people with autism spectrum disorder and its relevance to forensic psychiatry and psychotherapy
People with an autism spectrum disorder display the full range of sexual fantasies and behavior, as do their unaffected peers. However, there are also some peculiarities in sexual experience and behavior in people with an autism spectrum disorder, which can largely be traced back to the disorder-specific symptoms. This includes a higher diversity in terms of one's own sexual orientation and understanding of one's own gender role, but also problems with regard to entering into stable partnerships or with regard to one's own sexual functioning. In addition, some people with an autism spectrum disorder (especially men) have evidence of hypersexual behaviors and paraphilic sexual fantasies and behaviors. To date, there is no empirical evidence to suggest that an autism spectrum disorder is a risk factor for general or sexual delinquency. Based on case studies, however, some explanatory approaches have been published that describe how in a few cases the autism-specific symptoms could have contributed to the commission of a criminal offense, which could also be taken into account in the assessment of criminal liability. These include a lack of victim empathy, the presence of cognitive distortions or deficient communication and interaction skills. Offenders with an autism spectrum disorder should be given individually tailored psycho- and pharmacotherapeutic interventions to prevent reoffending in the best case scenario.
Individuals with autism spectrum disorder (ASD) show the whole range of sexual fantasies and sexual behavior just like their non-affected counterparts. Nevertheless, individuals with ASD show some peculiarities concerning sexual experiences and sexual behavior that can mainly be traced back to the disorder-inherent symptoms. Among these peculiarities are an increased diversity concerning their own sexual orientation and their understanding of gender roles as well as problems concerning the initiation of romantic or sexual partnerships or problems with sexual functioning. Furthermore, some individuals with ASD (especially men) show signs of hypersexual and / or paraphilic fantasies and behavior. So far, there exist no empirical results that would suggest that ASD is a specific risk factor for general or sexual offending; However, based on case studies some authors outlined in how far the disorder-inherent symptoms could have contributed to offending behavior in special cases, which could also be taken into account when assessing criminal responsibility. These include reduced victim empathy, cognitive distortions or deficits in communication or social interaction abilities. Specialized psychotherapeutic and pharmacotherapeutic interventions should be provided for individuals with ASD in order to prevent criminal recidivism.
In some people with an autism spectrum disorder, there are peculiarities in behavior, emotions and cognitions that can have a significant influence on the experienced and lived sexuality and which should therefore also be taken into account in the assessment, therapy and prevention of sexual offenses . The core symptoms of an autism spectrum disorder include a qualitative impairment of mutual social interaction, qualitative abnormalities in communication and limited, repetitive and stereotypical behavior, interests and activities (American Psychiatric Association 2013). The ICD-10 (International Classification of Diseases — 10th revision) differentiates between early childhood autism (F84.0), atypical autism (F84.1) and Asperger's syndrome (F84.5 ) (World Health Organization 1993). While symptoms in early childhood autism appear before the age of three and are often associated with considerable developmental delay, symptoms in atypical autism either only appear after the age of three or the diagnostic criteria for early childhood autism are not fully met. In addition, around 30–50% of those affected have limited intellectual capacity (World Health Organization 1993). In people with Asperger's syndrome, in contrast to early childhood and atypical autism, there is no delay in language and cognitive development and sometimes apparently less pronounced symptoms, which means that Asperger's syndrome often only occurs in adolescence or adulthood the rise in social demands is diagnosed (World Health Organization 1993). A closer look at the social development of an affected person reveals specific abnormalities in the retrospective, often already in childhood. B. were overlooked by fulfilling role clichés ("the reserved shy girl"). In the ICD-11, this diagnostic tripartition based on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders — 5th revision) is abandoned, and all disorders are grouped under the term autism spectrum disorder. Furthermore, it should be possible to subdivide this new diagnostic category with regard to the presence of an intellectual disability and a delay in speech development (Matthies and Frauenknecht 2019).
The lifetime prevalence of autism spectrum disorders is around 1%, with men being affected significantly more often than women in a ratio of 2–3: 1 (Fombonne 2009). Frequently occurring comorbid mental illnesses are attention deficit / hyperactivity disorder (ADHD), tic disorders, obsessive-compulsive disorder, depressive syndromes and personality disorders (especially schizoid and schizotypic personality disorders) (Matthies and Frauenknecht 2019). These frequently encountered comorbid diseases show numerous overlapping symptoms with disorders from the autism spectrum, so that the assignment of the existing symptoms to the individual disorders is a major diagnostic challenge and requires comprehensive knowledge of the diagnostic criteria of the individual disorders. In the best case, a diagnosis should be made in a specialized center, especially in adulthood and with average intellectual ability, including standardized test procedures (e.g. the Diagnostic Observation Scale for Autistic Disorders [ADOS; Poustka et al. 2015] or the Diagnostic Interview for Autism-Revised [ADI ‑ R; Bölte et al. 2006]) and the use of external anamnestic information. Since the treatment of the individual disorders can differ significantly despite their similarities, a precise diagnostic classification is all the more important.
Sexuality and Autism Spectrum Disorders
Well-developed skills in social communication, interaction and emotion regulation, sharing interests and activities with others as well as well-developed theory-of-mind skills are essential prerequisites for satisfactory and respectfully designed sexuality. Spectrum disorder can find abnormalities in all of these areas, there have long been numerous prejudices about the sexuality of people with autism spectrum disorder. For example, it has been assumed that people with an autism spectrum disorder show little to no interest in intimate relationships, or that their own sexuality is mainly lived out in the form of masturbation (Koller 2000; Konstantareas and Lunsky 1997). In recent years, however, numerous empirical studies have shown that, contrary to these earlier ideas, people with an autism spectrum disorder show an interest in partner-like and solo sexuality and that the entire range of sexual behaviors can be found in the same way as in unaffected people (Strunz et al. 2017; Turner et al. 2017). Nevertheless, the influence of disease-specific behavioral problems on sexual behavior cannot be ignored. The following is an overview of the specifics of the sexual preferences, fantasies and behaviors of people with an autism spectrum disorder. Finally, the importance of an autism spectrum disorder in connection with (sexual) delinquency is discussed. The focus here is on people with a normal intellectual capacity (Asperger's syndrome or highly functional autism).
Sexual orientation and personal gender perception
There are now numerous indications that people with Asperger's syndrome are more likely to describe themselves as non-heterosexual compared to the general population. Although there is largely a lack of representative information on the distribution and frequency of different sexual orientations in the general population, it is estimated that between 5 and 10% of men and women describe themselves as non-heterosexual, including homosexual and bisexual people, and People who do not feel they belong to any of these three categories (Shaeer and Sheer 2015). In contrast, the prevalence of a non-heterosexual orientation in people with an autism spectrum disorder is estimated to be around 15–35% (Hellemans et al. 2007; Turner et al. 2017). Women with an autism spectrum disorder seem to report a non-heterosexual orientation significantly more often than men (Turner et al. 2017). It is assumed that people with an autism spectrum disorder orient their behavior less towards social norms and thus also show themselves to be more tolerant of non-heterosexual partnerships. In this case, the choice of partner depends to a greater extent on the genuine interest in the other person, regardless of his or her gender (Turner et al. 2017).
A systematic review article showed that children and adolescents as well as adults with gender dysphoria have a higher prevalence of comorbid autism spectrum disorder than would be expected compared to the general population (Glidden et al. 2016) . Possible explanations for this connection include the theory of a particularly masculine brain, increased prenatal androgen serum levels as well as increased androgen serum levels in childhood and adolescence (in people who were assigned a female gender), impairments in the maternal Child attachment, the low personal importance of traditional gender roles in defining the self and an often low orientation towards social norms (Glidden et al. 2016). However, there are also findings that speak against the relationship postulated above, so that it should not be considered as certain that an increased prevalence of autism spectrum disorders can be found in populations of adults with gender dysphoria (Oien et al. 2018).
Sexual and romantic relationships
As discussed above, there has long been a belief that people with an autism spectrum disorder show little interest in sexual and romantic relationships (Koller 2000; Konstantareas and Lunsky 1997). In contrast, both men and women with an autism spectrum disorder show a clear interest in and desire for a stable partnership, and in the various studies it was generally less than 10% of those surveyed who did not have a partnership relationship for themselves considered (e.g. Strunz et al. 2017). Nevertheless, people with an autism spectrum disorder are less likely to be in a steady relationship than people from the general population without a mental illness (Schöttle et al. 2017). This could be a consequence of the ultimately limited skills in social interaction and communication, which could make it difficult to enter into and maintain a partnership. It is therefore not surprising that relationships are often found in which both people show autistic traits and who rate their relationship as happier than people in relationships in which only one partner shows autistic traits (Strunz et al. 2017).
There are significant gender differences in the frequency of relationships between people with an autism spectrum disorder. While affected men want a steady relationship more often compared to women with an autism spectrum disorder, women are significantly more likely to be in a steady relationship (Turner et al. 2017). The limitations in social interaction and communication skills are usually much less pronounced in women with an autism spectrum disorder, and women sometimes have better coping strategies to compensate for the deficits that exist in daily life, such as a pronounced ability to social Mimicking the behavior of peers not suffering from an autism spectrum disorder (“social mimicry”) (Dean et al. 2017). This could make it easier for women with autism spectrum disorder to enter into a sexual relationship.
Sexual behaviors and sexual disorders
Overall, both men and women with an autism spectrum disorder reported less regular sexual intercourse compared to people from the general population in several studies (Byers et al. 2013a, 2013b; Schöttle et al. 2017). This could be viewed as a direct result of the lower number of people with Autism Spectrum Disorder living in stable relationships. In addition, both men and women with an autism spectrum disorder are more likely to find indications of sexual dysfunction, which could also impair their sexual life as a partner (Turner et al. 2019). The frequency of sexual dysfunctions seems to be increased, especially in female subjects, and includes all areas of the sexual reaction cycle (e.g. decreased sexual desire, decreased sexual arousal, decreased frequency of orgasms, decreased general sexual satisfaction and increased sexual pain) (Turner et al. 2019). To explain this connection, it was stated that in particular the pronounced hypo- and / or hypersensitivities in various sensory areas, which can usually be found in people with an autism spectrum disorder, could be responsible for the development of the sexual dysfunction. While certain stimuli, e.g. B. olfactory stimuli are perceived particularly intensely, other stimuli, z. B. tactile stimuli, perceived only very weakly, whereby the severity can vary from person to person (Pellicano 2013). Furthermore, the deficits in social communication and interaction could make it difficult not only to lead a stable partnership, but also to initiate short sexual contacts.
In contrast, in several studies, at least men with an autism spectrum disorder reported a higher frequency of masturbation compared to men from the general population (Fernandes et al. 2016; Schöttle et al. 2017). The tendency towards repetitive and stereotypical interests and behaviors may contribute to this. This tendency is often much more pronounced in men, which could also explain the gender difference here. At its maximum, the higher masturbation frequency on the part of men with an autism spectrum disorder could lead to the development of hypersexual behavior. If additional criteria such as personal distress can be found on the part of the person concerned, this justifies the diagnosis of a hypersexual disorder or, according to the ICD-11, an "obsessive-compulsive sexual behavior disorder". Here, sexual behavior can be expressed in any type of behavior that leads to sexual arousal in the person concerned and is carried out with the aim of experiencing an orgasm (Turner and Briken 2017). In a first own study with 56 men with Asperger's syndrome and 56 men from the general population (matched according to age and level of education), men with Asperger's syndrome reported more frequently about hypersexual behavior. While 30% of men with an autism spectrum disorder were above the suggested “cut-off” value for hypersexual disorder in the Hypersexual Behavior Inventory (Reid et al. 2011), this was only 4% of men from the general population.In contrast, there were no differences in the self-reported frequency of hypersexual behavior among the 80 study participants with an autism spectrum disorder and the general population (Schöttle et al. 2017).
In addition to the pronounced tendency to repetitive behavior, as already mentioned above, people with an autism spectrum disorder often also have pronounced hypo- or hypersensitivities in the various sensory systems. The particularly intense perception of sexual stimulation (up to promoting an addictive character with regard to sexual stimuli) as well as only weak perception (particularly intense and frequent sexual stimulation is required so that it is perceived as sufficient) could lead to hypersexual behavior (Schöttle et al. 2017).
There are not only quantitative but also qualitative differences in sexuality between people with and without autism spectrum disorder. In the study presented above, men with an autism spectrum disorder reported more frequently paraphilic sexual fantasies, such as masochistic, sadistic, voyeuristic, frotteuristic and pedophilic sexual fantasies. These differences were mostly found at the level of sexual fantasies, while no differences were found at the behavioral level (with the exception of voyeuristic and frotteuristic behaviors, which were equally more common in men with an autism spectrum disorder). Again, no differences in this regard could be found in women with and without autism spectrum disorder (Schöttle et al. 2017). It is conceivable that the higher frequency of (hyper) sexual behaviors leads to habituation related to sexual stimuli, which could make increasingly unusual and specific sexual stimuli necessary for sufficient arousal. Added to this is the already above-average tendency to repetitive and stereotypical behaviors as well as hypo- and hypersensitivities, which could further increase the likelihood of developing paraphilic sexual interests in an individual with an autism spectrum disorder (Schöttle et al. 2017).
Importance of Autism Spectrum Disorders in Forensic Psychiatry
So far there is no evidence that an increased prevalence of people with an autism spectrum disorder can be found in criminal populations (King and Murphy 2014; Mouridsen 2012; Woodbury-Smith et al. 2006). There is also no increased prevalence of an autism spectrum disorder within the group of sex offenders, but systematic studies on this are largely lacking. So far there have mainly been case descriptions in which the sexually abusive behavior ranges from “kissing a stranger” (Clements and Zarkowska 2000) to sexually violent assault (Murrie et al. 2002). The patients presented also show very different cognitive limitations (Brendel et al. 2002; Chan and Saluja 2011), so that the attempt to uncover tenable similarities between the individual case reports is hardly possible.
The few systematic studies that have been carried out to date have shown that people with an autism spectrum disorder who have committed a sexual offense were more likely to experience emotional and physical abuse and neglect in their childhood, often already exhibiting abnormal sexual behavior in childhood and adolescence have (including excessive masturbating, masturbating or exposing their own genitals in public places), have more frequent cognitive and intellectual impairments and, less often, have received adequate sexual education and training. In addition, sexual assaults committed by people with an autism spectrum disorder are more likely to be impulsive acts (Søndenaa et al. 2014).
In the literature there are individual approaches to explaining a possible connection between an autism spectrum disorder and sexually assaulting behavior, which, however, were mainly derived from case studies:
Excessive fixation on certain interests (e.g. pornography) or certain body features (e.g. hair, shoes) could represent a risk factor for committing a sexual offense via the development of a hypersexual disorder or a paraphilic disorder (Brendel et al. 2002; Chan and Saluja 2011; Haskins and Silva 2006).
The lack of or reduced social and communication skills could make it difficult to initiate a mutual sexual relationship, so that other paths, e.g. sexual violence, must be resorted to (Griffin-Shelley 2010).
The lack of or only minimally developed theory-of-mind skills could lead to reduced empathy for the victims of sexual offenses, which could lower one's own inhibition threshold for committing a sexual offense (Murrie et al. 2002).
A reduced understanding of social norms could lead to more cognitive distortions, which are also a prognostically unfavorable factor for sexual delinquency (Milton et al. 2002).
As a result of the sexual education and upbringing, which is not tailored to the specifics of people with an autism spectrum disorder, there is a lack of basic knowledge and skills for sexual behavior in accordance with criminal law (Schöttle et al. 2017).
Even if these explanatory approaches have not yet been adequately investigated empirically, they do represent a possible starting point for therapeutic interventions with people with an autism spectrum disorder who have committed a sexual offense. It has been suggested that psychotherapeutic interventions as opposed to therapy programs with non-autistic sex offenders should rather be carried out in an individual setting (Sutton et al. 2013). In individual therapy, depending on the intellectual performance level and the existing individual deficits derived from the explanatory approaches mentioned above, inter alia. The following subject areas are dealt with: building up sufficient knowledge about sexuality, building up criminal law-compliant sexual behavior, social competence training with a focus on improving verbal and non-verbal communication skills, building a sufficient sense of empathy, processing cognitive distortions and improving impulse control (Allely and Creaby-Attwood 2016 ). Due to the addictive nature of sexual behavior described in some case reports and the sometimes quite considerable limitations of intellectual performance, it is also conceivable that some sex offenders with an autism spectrum disorder could benefit in particular from drug-based, drive-suppressing therapy (Turner et al. 2014; Turner and Briken 2018).
Internationally, there are authors who discuss the influence of autism-specific symptoms on the ability to form judgments and on self-control, which in selected cases could also be of importance for the assessment of the ability to understand and control in the context of the assessment of culpability within the German criminal law system. A direct transfer to the criminal liability assessment in Germany should be avoided at all costs due to the existing differences between the individual legal systems. Nevertheless, the examination of the international literature can provide some food for thought.
Katz and Zemishlany (2006) described that autistic development could lead to a psychosis-like narrowing of cognitions and emotions as well as faulty reasoning. Combined with the clear deficits in grasping social situations and taking the point of view of the other person, this could, at least within the framework of Israeli criminal law, result in a reduced ability to see the injustice of an act (Katz and Zemishlany 2006). In a current review article, which relates to the Canadian legal system, it was shown that the pronounced empathy deficits in people with an autism spectrum disorder lead on the one hand to an incorrect understanding of the consequences of their own actions and on the other to misinterpret their behavior and psychological well-being of the counterpart (e.g. the counterpart is falsely classified as threatening, and the criminally relevant act of the person with an autism spectrum disorder represents a reaction to the falsely perceived threat) (Grant et al. 2018). Conversely, the rigid adherence to and the inflexible interpretation of moral values in people with an autism spectrum disorder could express itself in a strict adherence to and apodictic insistence on the social norms of the rule of law, which ultimately even represent a protective factor with regard to future delinquency could (Lindsay et al. 2014; Grant et al. 2018). More complex social situations, in which a flexible adjustment of one's own moral ideas and attitudes is necessary, could, however, lead to a collapse of the strict moral values, which in the individual case could be expressed in the impulsive-criminal behavior of the person concerned (Grant et al. 2018) .
In Germany, an Asperger's syndrome or a highly functional autism spectrum disorder can be assigned to the fourth input characteristic according to Section 20 of the Criminal Code, the “other serious mental abnormality” within the scope of the assessment of culpability. In the case of people with early childhood or atypical autism, depending on the intellectual performance level, the presence of the third input characteristic, “nonsense”, must also be discussed. The authors of the current German-language forensic-psychiatric textbooks recommend that a criminal with a diagnosis of an autism spectrum disorder and at least average intellectual performance (Asperger's syndrome or highly functional autism) should generally be considered to have insight (Günter 2015). . The determination of a significant impairment of the ability to steer should also be applied rather cautiously (Günter 2015). Nevertheless, in the case of criminal offenses that can be inferred from a lack of understanding of the social circumstances (e.g. a test person with an autism spectrum disorder misinterprets the behavior of his counterpart as offensive or as an attack on himself) and therefore reacts aggressively and violent) or arise as a result of rigid and stereotypical clinging to certain routines (e.g. a routine course of action is disrupted by an unexpected event and the test subject reacts with clear inner restlessness and a psychomotor state of excitement in which another person is injured) an impairment of the ability to control can at least be discussed (Günter 2012, 2015; Remschmidt 2016). As in all cases, however, an individualized approach to the forensic-psychiatric assessment is necessary in order to do justice to the individual case. This is particularly the case against the background of the frequent comorbid mental illnesses, which could also have an impact on possible delinquency (Palermo 2004; Remschmidt 2016).
In conclusion, it can be stated that the current state of research regarding the connection between delinquency and an autism spectrum disorder is still very manageable. Future studies should therefore focus in particular on the relationship between the disorder-specific symptoms (e.g. repetitive interests, hypo- or hypersensitivities, lack of theory-of-mind skills or cognitive distortions) and delinquency. In this way, important knowledge can be obtained not only with regard to a crime-preventive and disorder-specific therapy, but also with regard to the forensic-psychiatric assessment.
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