Should we continue to refer to autism as a ‘disease’ or ‘disorder’, or is the framework of ‘neurodiversity’ a more humane and accurate lens through which to view people with autism? Evidence at the ...genetic, neural, behavioural and cognitive levels reveals people with autism show both differences, and signs of disability, but not disorder. Disability requires societal support, acceptance of difference and diversity, and societal “reasonable adjustment”, whilst disorder is usually taken to require cure or treatment. These are very different frameworks. It will be important to see how the concept of neurodiversity is applied to the 300 diagnoses in DSM‐5, and if it revolutionizes both the science and the practice of psychiatry.
The mind‐blindness theory of autism spectrum conditions has been successful in explaining the social and communication difficulties that characterize these conditions but cannot explain the nonsocial ...features (the narrow interests, need for sameness, and attention to detail). A new theory, the empathizing–systemizing (E‐S) theory, is summarized, which argues two factors are needed to explain the social and nonsocial features of the condition. This is related to other cognitive theories such as the weak central coherence theory and the executive dysfunction theory. The E‐S theory is also extended to the extreme male brain theory as a way of understanding the biased sex ratio in autism. Etiological predictions are discussed, as are the clinical applications arising from the E‐S theory.
Females in the general population on average have a stronger drive to empathize, and males in the general population on average have a stronger drive to systemize. Evidence related to these claims is ...reviewed. People with autism spectrum conditions have below average empathy alongside intact or even above average interest in systems. As such, they can be conceptualized as an extreme of the typical male brain.
Summary Autism is a set of heterogeneous neurodevelopmental conditions, characterised by early-onset difficulties in social communication and unusually restricted, repetitive behaviour and interests. ...The worldwide population prevalence is about 1%. Autism affects more male than female individuals, and comorbidity is common (>70% have concurrent conditions). Individuals with autism have atypical cognitive profiles, such as impaired social cognition and social perception, executive dysfunction, and atypical perceptual and information processing. These profiles are underpinned by atypical neural development at the systems level. Genetics has a key role in the aetiology of autism, in conjunction with developmentally early environmental factors. Large-effect rare mutations and small-effect common variants contribute to risk. Assessment needs to be multidisciplinary and developmental, and early detection is essential for early intervention. Early comprehensive and targeted behavioural interventions can improve social communication and reduce anxiety and aggression. Drugs can reduce comorbid symptoms, but do not directly improve social communication. Creation of a supportive environment that accepts and respects that the individual is different is crucial.
Small studies suggest significant differences between autistic and nonautistic individuals regarding sexual orientation and behavior. We administered an anonymized, online survey to n = 2386 adults ...(n = 1183 autistic) aged 16–90 years to describe sexual activity, risk of sexually transmitted infections (STIs), and sexual orientation. Autistic individuals are less likely to report sexually activity or heterosexuality compared to nonautistic individuals, but more likely to self‐report asexuality or an ‘other’ sexuality. Overall, autistic, and nonautistic groups did not differ in age of sexual activity onset or contraction of STIs. When evaluating sex differences, autistic males are uniquely more likely to be bisexual (compared to nonautistic males); conversely, autistic females are uniquely more likely to be homosexual (compared to nonautistic females). Thus, both autistic males and females may express a wider range of sexual orientations in different sex‐specific patterns than general population peers. When comparing autistic males and females directly, females are more likely to have diverse sexual orientations (except for homosexuality) and engage in sexual activity, are less likely to identify as heterosexual, and have a lower mean age at which they first begin engaging in sexual activity. This is the largest study of sexual orientation of autistic adults. Sexual education and sexual health screenings of all children, adolescents, and adults (including autistic individuals) must remain priorities; healthcare professionals should use language that affirms a diversity of sexual orientations and supports autistic individuals who may have increased risks (affecting mental health, physical health, and healthcare quality) due to stress and discrimination from this intersectionality.
Lay Summary
This is the largest study on the sexual activity, orientation, and health of autistic adults. This study reaffirms that the majority of autistic adults are interested in sexual relationships and engage in sexual activity. Sexual education and sexual health screenings must remain a priority for all individuals, including those with autism; healthcare professionals should be aware that autistic patients may be more likely to identify as Lesbian, Gay, Bisexual, Trans, Queer, Asexual, and other identities not listed here (LGBTQA+) which may put them at greater risk of mental and physical health difficulties due to discrimination.
Autism spectrum conditions comprise a set of early-onset neurodevelopmental syndromes with a prevalence of 1% across all ages. First diagnosis in adulthood has finally become recognised as an ...important clinical issue due to the increasing awareness of autism, broadening of diagnostic criteria, and the introduction of the spectrum concept. Thus, the idea of a lost generation of people who were previously excluded from a diagnosis of classic autism has arisen. Making a first diagnosis of autism spectrum conditions in adults can be challenging for practical reasons (eg, no person to provide a developmental history), developmental reasons (eg, the acquisition of learnt or camouflaging strategies), and clinical reasons (eg, high frequency of co-occurring disorders). The diagnostic process includes referral, screening, interviews with informants and patients, and functional assessments. In delineating differential diagnoses, true comorbidities, and overlapping behaviour with other psychiatric diagnoses, particular attention should be paid to anxiety, depression, obsessive-compulsive disorder, psychosis, personality disorders, and other neurodevelopmental disorders. Possible misdiagnosis, especially in women, should be explored. The creation of supportive, accepting, and autism-friendly social and physical environments is important and requires a coordinated effort across agencies and needs support from government policies.
The relationship between sex/gender differences and autism has attracted a variety of research ranging from clinical and neurobiological to etiological, stimulated by the male bias in autism ...prevalence. Findings are complex and do not always relate to each other in a straightforward manner. Distinct but interlinked questions on the relationship between sex/gender differences and autism remain underaddressed. To better understand the implications from existing research and to help design future studies, we propose a 4-level conceptual framework to clarify the embedded themes.
We searched PubMed for publications before September 2014 using search terms “‘sex OR gender OR females’ AND autism.” A total of 1,906 articles were screened for relevance, along with publications identified via additional literature reviews, resulting in 329 articles that were reviewed.
Level 1, “Nosological and diagnostic challenges,” concerns the question, “How should autism be defined and diagnosed in males and females?” Level 2, “Sex/gender-independent and sex/gender-dependent characteristics,” addresses the question, “What are the similarities and differences between males and females with autism?” Level 3, “General models of etiology: liability and threshold,” asks the question, “How is the liability for developing autism linked to sex/gender?” Level 4, “Specific etiological–developmental mechanisms,” focuses on the question, “What etiological–developmental mechanisms of autism are implicated by sex/gender and/or sexual/gender differentiation?”
Using this conceptual framework, findings can be more clearly summarized, and the implications of the links between findings from different levels can become clearer. Based on this 4-level framework, we suggest future research directions, methodology, and specific topics in sex/gender differences and autism.
Fombonne’s (2020) editorial is a thought‐provoking appraisal of the literature on ‘camouflaging’, whereby some autistic people mask or compensate for their autistic characteristics as an attempt to ...fit in and to cope with disabilities under neurotypical social norms. Fombonne (2020) highlights three issues of contention: (a) construct validity and measurement of camouflaging; (b) camouflaging as a reason for late autism diagnosis in adolescence/adulthood; and (c) camouflaging as a feature of the ‘female autism phenotype’. Here, we argue that (a) establishing construct validity and measurement of different aspects of camouflaging is warranted; (b) subjective experiences are important for the differential diagnosis of autism in adolescence/adulthood; and (c) camouflaging is not necessarily a feature of autism in female individuals – nevertheless, taking into account sex and gender influences in development is crucial to understand behavioural manifestations of autism. Future research and clinical directions should involve clarification of associated constructs and measurements, demography, mechanisms, impact (including harms and benefits) and tailored support.
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