The aim of the current study was to explore the representation of transgender gender identities or non-heterosexual sexual orientations in autistic females, in addition to the prevalence of negative sexual experiences among autistic females within these minority groups. As hypothesised, autistic females were more likely to identify with both a transgender gender identity, and non-heterosexual sexual orientation than non-autistic peers. Frequency analyses also identified that a greater proportion of autistic females reported having experienced unwanted sex and sexual advances compared to non-autistic females.
Contrary to expectations, identifying as transgender did not appear to influence the likelihood of having a negative experience in autistic individuals. However, non-autistic transgender individuals were more likely to report a regretted sexual experience than cisgender non-autistic participants. This finding should be interpreted in the context of the small numbers of participants identifying as transgender within both autistic and non-autistic samples.
The hypothesis that autistic non-heterosexual females would be more likely to report a negative sexual experience than autistic heterosexual females and non-autistic females irrespective of sexual orientation was partially supported. Autistic homosexual females had an increased risk of (i) unwanted sexual behaviour compared to heterosexual females with and without autism and (ii) regretted sexual behaviours compared to autistic heterosexual females. Surprisingly, autistic bisexual females had a reduced risk of regretted sexual behaviour compared to non-autistic heterosexual females. No differences were found in all remaining comparisons between autistic females identifying with a non-heterosexual sexual orientation and non-autistic peers. For non-autistic females, we found that identifying as homosexual increased the risk of unwanted advances, but not of unwanted or regretted sex compared to non-autistic heterosexual females. Bisexuality also provided a protective effect in females without autism, reducing risk of regretted sexual experiences but not of unwanted sexual experiences or advances, compared to non-autistic heterosexual females. These findings support the hypotheses predicting an increased risk of negative sexual experiences among autistic homosexual females, yet not for transgender females, and bisexual females. However, findings pertaining to negative sexual experiences across sexual orientation should be interpreted in the context of the increased proportion of participants identifying as homosexual (45.6%) in the non-autistic group.
The results of this study contribute to emerging insights of a higher proportion of transgender gender identities among autistic female populations compared to non-autistic populations [2, 22] and support proposed relationships between autism and GD [3, 5, 22]. Study findings also provide further evidence of an increased sexual diversity (i.e. higher incidence of homosexual or bisexual orientation, and lower incidence of heterosexual orientation) in autistic female groups, compared to the general population. This is consistent with existing research [18, 20,21,22].
Various hypotheses have been proposed to explain the increased diversity in both gender identity and sexual orientation among autistic females. These include a prominent neurobiological perspective, which suggests that an overexposure to foetal testosterone may lead to an increased development of male-based traits, and a preference towards masculinised gendered behaviours and activities within females [60]. Foetal exposure to testosterone affects aspects of adult personality including a male-oriented gender identity [61] and sexual orientation within the broader population [62]. As evidence of elevated testosterone has been found in autistic females [63, 64], greater exposure to foetal testosterone has been conceptually linked to increased likeliness of developing a male gender identity, a sexual preference towards females, and thus a homosexual and/or bisexual sexual orientation among autistic females [64].
Although foetal testosterone theory would account for variation in gender identity and sexual orientation in females, autistic males also present with more diverse sexual identities than non-autistic males [21, 65]. There is some weak evidence that suggests that increased exposure to foetal testosterone may be implicated in the development of a homosexual orientation in cisgender males [66, 67]. Other studies have also suggested excessively high foetal testosterone may predispose males to develop a homosexual sexual orientation [68], and feminise autistic males [69]. Despite these findings, conclusions drawn from two more recent reviews of current data examining prenatal influences on sexual orientation suggest that there are no meaningful differences in the level of exposure to foetal testosterone between heterosexual and homosexual males [70, 71]. Rather, the evidence suggests that the differences in sexual orientation among males are due to the variation in each individual’s response to prenatal testosterone, rather than level of exposure to it [70]. Interestingly, the review also suggests that the variation in exposure to prenatal testosterone is more consistently associated with sexual orientation in females rather than males [70, 72]. Considering these inconsistencies, it is likely that different prenatal and biological mechanisms play a role in the development of sexual orientation for both males and females [72]. Thus, further research is required to decipher the links between foetal testosterone and sexual identity between autistic and non-autistic individuals of both sexes.
Other explanations are consistent with social motivation theories [73, 74]. For example, features of autism include rigid thought processes and obsessional interests, and these may lead to inflexible interpretations of gender roles and increased likelihood of developing a gender identity that is not consistent with one’s birth sex if interests/attributes do not fit with stereotypes [5, 11]. Other features of autism, including lower sensitivity to social norms [74] together with reduced access to sexual and romantic partners experienced by many autistic people [22, 25], have also been proposed to reduce the relevance of birth sex when choosing or responding to potential partners [75], and increase the fluidity of sexual preferences and practices [14]. The complexities surrounding the relationship between autism and variations in gender identity and sexual orientation are likely to involve a number of interacting mechanisms rather than a single factor, and so multivariate hypotheses [6] may provide a more accurate explanation for our observations.
In addition to the increased variation in gender identity and sexual orientation within autism, insight into the nature of sexual experiences of transgender individuals is an important contribution of this study. This study found that identifying with a transgender identity increased the risk of negative sexual experiences, specifically, regretted sexual experiences for non-autistic individuals only. To date, research is yet to investigate the nature and circumstance of regretted and unwanted sexual behaviours across gender identity in either autistic or non-autistic samples. However, the finding of an increased risk of regretted sexual experience among non-autistic transgender individuals partially aligns with research showing increased risks for sexual victimisation [76] and intimate partner violence [34] among transgender females in the broader population. As the non-significant differences between transgender and cisgender autistic individuals across all negative sexual experiences in this study contrast against this research, clarification of the nature of sexual victimisation among minority and mainstream populations identifying with transgender gender identities should be a priority for future research.
The patterns of findings across the different negative sexual experiences measured provide some information about the nature of adverse sexual experiences of individuals with and without autism, and about how sexual orientation is an additional risk and protective factor. Our findings show that a homosexual sexual orientation is linked to increased risk of having experienced both regretted and unwanted sexual behaviour, but not unwanted advances, in autistic females, and an increased risk of unwanted sexual advance in non-autistic females. We also found that autistic homosexual females present with an increased risk of experiencing unwanted sexual behaviours than non-autistic heterosexual females, and are at an increased risk of unwanted advances than both non-autistic homosexual and heterosexual females. Bisexual females irrespective of diagnosis are at a lower risk of a regretted sexual behaviour than non-autistic heterosexual peers. These results align with findings of broader literature reporting higher prevalence of sexual victimisation between homosexual females than the general population [32, 77]. They likewise agree with research involving female-only samples, in which sexual victimisation has been found to be twice as likely between homosexual, compared to heterosexual women (e.g. 66% vs 38% respectively [78, 79]).
The results contrast with research investigating sexual victimisation in bisexual females in the broader population, where bisexual females have reported a higher rate of sexual victimisation [78]. Specifically, bisexual females reported a higher lifetime prevalence of sexual violence and victimisation (74.9–78%) than heterosexual (38–43.3%) and homosexual females (46.4–66% [78, 79]). Bisexual females have also been found to be up to 1.9 and 2.6 times more likely to have experienced intimate partner violence than homosexual and heterosexual peers, respectively [80], and have experienced more frequent and severe cases of sexual victimisation and abuse than females identifying with a heterosexual or homosexual sexual orientation [78, 81]. The reason for the differences in rates of negative sexual experiences between homosexual and bisexual females within this study and inconsistencies with previous research remain unclear. However, the most commonly identified risk factors for sexual victimisation among bisexual females include an increased prevalence of risky alcohol use [79], and a greater number of lifetime sexual partners, which increase the likelihood of exposure to potential sexual aggressors [78, 79]. Given that autistic individuals report less sexual experience [27, 82] and fewer sexual partners [27] than non-autistic counterparts, it is possible that the bisexual autistic participants in this study may have had less exposure to some of these risk factors than the bisexual females in previous research. Moreover, as homosexual females in the general population are more likely to report negative sexual consequences related to alcohol consumption [83] and are more likely to meet the diagnostic criteria for substance use (see [49]) than bisexual females [83], it is also possible that risky alcohol consumption may have also been a factor that played a role in some of the negative experiences reported by homosexual females in this study. Finally, as this study examined constructs of regretted and unwanted sexual experiences and advances, yet previous research has investigated rates of sexual victimisation [79], sexual abuse [78], and intimate partner violence [80] across sexual orientation, it is also possible that inconsistencies with previous research may be partially due to the differences in the specific variables measured across studies. Despite this, research is still required to determine the factors that increase risks to negative sexual experiences, and the contexts to which these occur for non-heterosexual females with and without autism.
The increased risk of negative sexual experiences between homosexual females with and without autism found here is concerning. Research is yet to explore the nature of adverse sexual experiences across sexual orientation within autism. In the general population, literature examining these variables is limited to prevalence data [78, 84] that do not offer explanations for the increased rates of sexual victimisation among homosexual females. The studies do highlight that cases of sexual victimisation (81% [78]) and unwanted sexual contact (85.2% [84]) among homosexual females often involve male perpetrators. Moreover, homosexual females also report aversive experiences with the opposite sex at younger ages and more negative attitudes towards previous sexual interactions with males than heterosexual counterparts [85]. Although still in need of empirical validation, Harrison et al. [85] have considered the possibility that the increased rates of unwanted sexual experiences among homosexual females may have occurred with those of the opposite sex during critical periods of sexual identity development. Thus, it is possible that the regretted or unwanted sexual experiences cited among homosexual females in this study may have occurred with individuals of the opposite sex before a clear sexual identity was developed. However, research that aims to determine if negative sexual experiences, or a vulnerability to unwanted sexual events, may shape the development of an individuals’ sexual orientation development in autistic and non-autistic circles is still necessary.
Limitations
The results of this study should be interpreted in light of their limitations, which carry important implications for future research. As this was a quantitative study, participant responses were based on a series of predetermined test items and response options. As such, response options that allowed for participants to qualitatively expand on their reported gender identities or sexual orientations were not available when completing the survey. If participants identified with a specific gender identity (i.e. non-binary, transmale) or sexual orientation (i.e. demisexual, pansexual) that was not included as a response option, this may have prevented participants from selecting or expanding on the specific sexual identity that they identified with.
Similarly, the design of test responses also limited abilities to expand on the nature, conditions, or frequency of each negative experience. Thus, findings cannot provide insight into the reasons why, and under what conditions these experiences occurred, as well as the factors that led participants to view these experiences as regretted or unwanted. This also limits the extent to which age-related patterns could be explored and how the development of a clear sexual identity or long-term relationships may shape perceptions of previous sexual interactions with former partners. Such data would provide valuable information that could facilitate a more sensitive comparison between autistic and non-autistic females of different gender identities and sexual orientations. Findings would also inform interventions to help females of minority groups avoid and manage the outcomes of negative sexual experiences.
Secondly, while sexual orientation was measured via participants’ self-reported sexual identity, sexual orientation also encompasses an individual’s sexual attraction and contact with others [14]. Thus, this study did not consider participants’ sexual attractions or behaviours when distinguishing between sexual orientation labels. As there can be some inconsistency between an individuals’ sexual identity, attractions and behaviours [86], participants’ sexual identity may or may not truly align with their attractions and behavioural experiences. Thus, while relying on participants’ self-reported sexual identity may be related to an individual’s attractions and behaviours, measuring all three domains of identity, attraction, and behaviours would be more informative.
Given the limited number of autistic (n = 26) and non-autistic (n = 14) transgender females in this study, the comparisons made using smaller participant subgroups may be limited by poor power. Consequently, our attempt to draw conclusions about the links between an individuals’ gender identity and their risks to adverse sexual experiences in both the autistic and non-autistic groups is tentative. Although the data in this study should be interpreted cautiously, findings highlight the importance for future research to clarify the role of gender identity in risks and rates of negative sexual experiences among females irrespective of diagnosis.
A large proportion of participants in the non-autistic group (45.6%) reported a non-heterosexual sexual orientation. This figure is substantially higher than that observed in the broader population, which ranges from 2 to 5% [87, 88]. Although participants were recruited via a range of various online platforms, the use of social media advertisements and snowballing techniques, which were used to recruit autistic participants, do not completely ensure that a representative sample was attained. As it is possible that the sample is not entirely representative of the broader population, the rates of sexual orientation in this study should be interpreted with caution. Moreover, it is also possible that some may have had a pre-existing interest in sexuality when volunteering to participate in this study, the overrepresentation of non-heterosexuality in this group may have been due to a bias in participant selection. Despite this, the increased rates of a non-heterosexual orientation between autistic females when compared to non-autistic females in this study may have been even more pronounced if the prevalence of non-heterosexuality within the non-autistic group (45.6%) reflected estimates observed within the wider population (2–5%).
As this study examined patterns of sexuality and sexual victimisation among autistic females, study conclusions cannot be generalised to the broader autistic population irrespective of sex. Given that transgender and gay males experience forms of sexual violence and coercive behaviours [77], the increased rates of adverse sexual experiences in this study cannot be fully attributed to an autism diagnosis or female birth sex. It would therefore be valuable to examine whether rates of negative sexual experiences are also elevated among autistic males who identify as transgender, or with a non-heterosexual orientation when compared to non-autistic male counterparts. These findings would clarify whether increased sexual risks are unique to autistic females who present with diverse sexual identities, or if these vulnerabilities are apparent among the autistic transgender or autistic non-heterosexual population overall.
Finally, this study did not test for dependence between the dependent variables of each negative sexual experience. As such, whether participants who endorsed a regretted, an unwanted sexual event, or an unwanted sexual advance would be more likely to also report another negative sexual experience was not examined in this study. This may bias the results, increasing the likelihood of us finding a result where a regretted event was reported because of an unwanted event.
Future directions
The findings of this study assert the importance of continuing to further understand the sexuality of autistic females, and the factors that shape their sexual identities and sexual experiences. Further research is required to continue investigating the links between sexual diversity and autism, as well as the mechanisms underlying the development of identity and attraction for autistic females. Although this study identified an increased prevalence of negative sexual experiences among autistic, homosexual females, the reasons behind these elevated rates remain unclear. Accordingly, research that explores the nature and characteristics of regretted and unwanted sexual experiences between autistic females across sexual orientation may identify the causal mechanisms leading to these increased sexual vulnerabilities.
Additionally, this study did measure the construct of regretted sexual experiences using definitions from prior literature that conceptualised such experiences as the (consensual) engagement in sexual behaviours that are later associated with negative emotions [45, 46]. However, the potential reasons that sexual behaviours were viewed and reported as regretted by participants were not examined in this study. While there are a number of reasons why a sexual behaviour could be viewed as regretted [89], it is possible that some of these experiences are due to an individual not knowing what to expect when initially consenting to engage in a (later regretted) sexual behaviour [89]. Other times, sexual interactions can be spontaneous, evolving so quickly that an individual may only realise that they did not want, or enjoy the experience until after it had ended [89, 90]. As such, future research would benefit from exploring the emotion of regret in relation to past sexual behaviours, as well as the factors that have led each individual to perceive a particular experience as regretted. Moreover, as regretted experiences have been associated with poor psychological health and wellbeing [90] and may also influence both future sexual behaviours and choices of sexual partners [89], exploring the links between these variables in both autistic and non-autistic samples is necessary.
Finally, although evidence of poor mental health outcomes has been observed among individuals who identify with a sexual minority that have experienced sexual victimisation within the broader population [39], they are yet to be examined within autism. Thus, further research is required to determine the specific mental health challenges that are and are not unique to autistic females who identify with a sexual minority, and have also been subject to a negative sexual experience. These findings may identify the extent to which negative sexual experiences may be amplifying the mental health difficulties already apparent for autistic individuals [41, 42], while also identifying the most effective practices to prevent these outcomes.
Clinical implications
In light of the sexual vulnerabilities that are already apparent for autistic females, the additional risks identified in this study signal the importance of addressing the needs of autistic females with a homosexual sexual orientation. The results of this study therefore hold practical and clinical implications for health care providers supporting both autistic females and those that identify with a sexual minority. It is apparent that there is a need to increase clinical awareness of the higher representation of gender and sexual diversity in autism, particularly among autistic females. Clinicians should be prepared to provide opportunities to share the concerns and uncertainties these individuals may be experiencing as they develop and express their sexual and gender identities. Professionals should likewise be aware of the unique challenges and health care needs that autistic females may experience when identifying within a gender or sexual minority. These include poorer levels of psychological wellbeing and higher rates of internalising problems [26, 91], which are also compounded by increased risks of complex mental health issues and socioemotional problems that individuals identifying with a sexual minority are often subject to [37, 38, 92]. Through increased understanding, this knowledge can also be used to develop strategies and services that aim to provide these females with the skills required to develop a clear and fulfilling gender and sexual identity.
The findings of increased rates of regretted and unwanted sexual experiences among autistic homosexual females raise a number of immediate concerns. Results highlight the importance of increasing professional awareness of the increased risks to adverse sexual experiences among individuals identifying within a multiple minority group. Findings assert the need for clinicians to understand the specific types of negative sexual experiences that autistic and non-autistic females are at risk of experiencing, and the role that sexual orientation plays in increasing or reducing this level of risk. Given that irrespective of diagnosis, homosexual females were more likely to have engaged in unwanted sexual behaviours, and autistic homosexual females also cited increased regretted experiences, findings highlight the importance of clinicians to assess the sexual history of autistic, and homosexual, females in sensitive ways. Thus, it would be helpful to explore the extent to which engagement in unwanted behaviours may influence feelings of regret with clients and address reasons why individuals may be engaging in unwanted and regretted sexual behaviours. Moreover, as homosexual females with and without autism also present with increased risks of unwanted sexual advances than non-autistic heterosexual peers, clinicians could also work with clients to explore their feelings around these experiences and develop personal boundaries to protect their safety.
Professionals should likewise be attuned to recognise the risk factors, warning signs, and symptoms of sexual victimisation, and previous unwanted sexual experiences within their clients. Tailored support programmes would benefit from greater understanding of multiple levels of risk, and unwanted sexual experiences that autistic, and sexual minority females may be subject to. These educational efforts could aim to promote the sexual health and safety of autistic, and non-heterosexual females, to enhance personal skills required to make safe and positive decisions in sexual situations. Thus, these programmes may be one of the first steps in reducing the sexual risks and vulnerabilities among autistic and non-autistic homosexual females and may also allow these females to cope with the adverse psychological and interpersonal outcomes that often accompany aversive negative events.