A systematic review of sexual health, knowledge, and behavior in Autism Spectrum Disorder

Abstract

Background

Autism Spectrum Disorder (ASD) affects social interaction, communication, and behavior, with significant challenges in sexual experiences, relationships, and victimization. This review consolidates findings to improve understanding of sexual health in ASD.

Methods

Following PRISMA guidelines, studies from PubMed, Scopus, Web of Science, and PsycInfo (1991–2024) were reviewed. Data were extracted using EndNote 21, focusing on demographics, autism support needs, and sexual behaviors. Methodological quality was assessed using modified Cochrane and Effective Public Health Practice Project tools.

Results

Autistic individuals face unique challenges in romantic and sexual relationships, such as sensory sensitivities and communication difficulties. While they share typical sexual desires, these challenges can complicate their relationships and increase the risk of victimization. The review highlights the need for tailored sexual health education and supportive interventions, particularly for those at higher risk.

Conclusion

This review emphasizes the need for inclusive sexual health interventions for autistic individuals, considering the heterogeneity of ASD and its impact on sexual well-being. Further research should address current gaps, especially regarding non-Western contexts and individuals with co-occurring intellectual disabilities or gender diversity, to improve support and understanding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12888-025-06836-x.

Introduction

Autism Spectrum Disorder (ASD) is characterized by reciprocal social interaction and communication impairments and restricted repetitive behaviors based on the Diagnostic Statistical Manual of Mental Disorders (DSM- 5) [1].

For many years autism was mistakenly recognized as a childhood disorder, and most existing research focuses on children [2]. Approximately 1 in 100 children worldwide has been diagnosed with an ASD [3]. The prevalence of autism among adults is estimated to be one in 75 people of all [4], and in inpatient psychiatric services it is estimated to be between 2.4% and 9.9% [5]. Despite this, there is a lack of literature and information available about autistic individuals [6].

Autistic individuals often face challenges in interpersonal relationships, including communication, social cognition, and emotional processing [7]. These challenges can extend to aspects of intimacy and sexual relationships [8, 9]. Such experiences can be attributed to impairments in communication, stereotyped behaviors, deficits in theory of mind, difficulty expressing emotions, sensory processing problems, fine motor skill deficits, and issues with self-awareness [10]. Such challenges as regards to interpersonal relationships can also be attributed to mismatch between environment-person rather than lack of abilities in autistic individuals. Research shows that higher similarity in autistic traits between partners is associated with greater closeness and acceptance, suggesting that difficulties in relationships may result from differing social norms rather than inherent deficits [11]. Recognizing this dynamic can promote a more inclusive understanding and reduce stigmatization of autistic individuals.

Recent studies revealed that autistic adults without intellectual disability have a similar level of sexual interest and behavior as those without autism despite common misconceptions [12]. However, the quality of this relationship is affected by less relationship experience, more parental guidance, greater use of online materials, and less school-based sexual health education [13]. They may have difficulties initiating and maintaining romantic relationships [14]. Problems with intimacy, avoidance of sexual behavior due to oversensitivity, and overprotective parenting have been identified in this population [9]. While autistic people show typical sexual behaviors, they may be more prone to deviant sexual behaviors compared to those without autism [15].

Studies reveal that non-heterosexual orientation in ASDs is more prevalent than in the neurotypical population. This difference is particularly pronounced in autistic women [16, 17]. Furthermore, asexuality, which is a lack of sexual interest in any gender, is more expressed in autistic individuals [18, 19].

Unusual sexual behaviors are documented in autism, but these behaviors are not necessarily harmful. The rates of paraphilic behaviors, such as being aroused by smells (olfactophilia), feet (podophilia), and animals (zoophilia), are higher in autistic individuals [20, 21]. Restricted repetitive patterns of behaviors, deficits in social interactions, concordance of intellectual disability, interests in part of objects, early conditioning to deviant stimuli, and counterfeit deviant sexual behaviors are the probable aetiologies, and social deficits, intellectual disability, and education gaps influence sexual behaviors in children with ASD [22, 23]. Some other sexual behaviors are also prevalent in autism, which include hyper masturbation, public masturbation, inappropriate romantic gestures, inappropriate arousal, and exhibitionism. Lack of understanding about normal sexual development, insufficient sex education, support needs of autism, and other related issues may contribute to these behaviors; moreover, sexual behaviors in ASD, like public masturbation and fixation, arise from poor education and understanding. Therefore, providing proper sexual education may help reduce these behaviors [24–27].

Autistic people may be more likely to have issues with using pornography. Some autistic individuals may develop obsessive tendencies toward pornography, collecting and categorizing it rather than merely viewing it, which can lead to legal implications​. This is due to a variety of reasons outlined in the literature, including differences in social communication, sensory sensitivities, repetitive behaviors, emotional regulation problems, interpretation challenges, loneliness, and lack of comprehensive sexuality education [24, 28–30]. They may also be more likely to view child pornography because they have trouble recognizing the age and facial expressions of the children in the pornography [31]. Studies have found a positive correlation between autism and pornography addiction [24, 32]. Furthermore, autistic people have limited access to sexual education and may seek information from non-social sources such as the Internet, which may be less beneficial [15].

Inappropriate or deviant sexual behaviors, which may cause harm to oneself or others, require further examination. Research suggests that autistic individuals may be overrepresented among those who engage in sexually inappropriate behaviors. Several studies have indicated that autistic people may exhibit various offending behaviors, including sexual offending behaviors, which are associated with traits of autism [33–36]. Traits of ASD that may contribute to the vulnerability of exhibiting sexual offending behaviors include an impaired theory of mind, repetitive and stereotyped behavioral patterns, and persistent preoccupation with sexual themes [34, 37]. Unfortunately, the court environment can be unfamiliar and challenging for autistic people, and the jury may not have received the necessary training to understand their unique conditions [38]. Sexual education can play a crucial role in preventing sexual offending, and cognitive behavioral therapy has shown promise as an effective treatment for this issue [37].

Sexual victimization is more prevalent in autistic adults and children, and this has been stated in many articles [39, 40]. Limited sexual knowledge and experiences, social deficits and co-occurence of attention deficit hyperactivity disorder (ADHD), co-occurence of intellectual disability, and women and nonbinary gender identity are the risk factors [39, 41, 42]. The most frequent forms of sexual abuse reported were verbal sexual harassment and flashing/sexual exposure [43].

Several recent review articles have been conducted on the topic of sexualities in autistic adults, but there is inconsistency among them [15, 16, 38, 44, 45]. These inconsistencies stem from differences in study populations, methodologies, and the conceptual frameworks used to examine sexuality in autistic individuals. Given these discrepancies, a comprehensive and focused review is needed to provide a clearer understanding of this topic Gender dysphoria and sexual orientation are two aspects of sexuality that have been covered in many review articles and require special attention, so we will not include them in our review [9, 22, 8, 46–52].

Materials and methods

Instrument

We adhered to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [53, 54] checklist to carry out a systematic review. The databases selected for this research (Fig. 1) were PubMed, Scopus, Web of Science, and PsycInfo.

Fig. 1.

Selection of studies. preferred reporting items for systematic reviews and meta-analyses (prisma) flow diagram. of the 2311 identified studies, 56 were included in the synthesis after applying the inclusion and exclusion criteria [54]

Inclusion and exclusion criteria

Prior to the screening, the subsequent inclusion and exclusion criteria were definedInclusion Criteria:

• Human-based research only.

• Publications written in English.

• Studies focusing on sexual health, sexual knowledge, and behaviors in individuals with Autism Spectrum Disorder (ASD).

• Research following PRISMA guidelines and sourced from databases such as PubMed, Scopus, Web of Science, and PsycInfo (1991–2024).

• Studies including data on demographics, autism support needs, and sexual behaviors.

• Research assessed for methodological quality using modified Cochrane and Effective Public Health Practice Project (EPHPP) tools.

Exclusion Criteria:

• Research letters, editorials, reviews, and comments.

• Studies with incomplete data or insufficient analysis.

• Research focused on non-human subjects.

• Articles not directly addressing the sexual health, knowledge, or behavior of individuals with ASD.

Gender dysphoria and sexual orientation represent key aspects of sexuality that have been extensively addressed in prior review articles [8, 9, 22, 47–52, 55] and warrant focused consideration. In our preliminary search, we identified 78 articles specifically examining topics such as gender dysphoria and sexual orientation, indicating a substantial body of research dedicated to these areas. Given the volume and complexity of findings in this domain, we believe these topics would be best explored in a dedicated review that thoroughly analyzes their specific issues and trends. As such, we have chosen not to include these aspects in our current review, allowing us to focus more deeply on other aspects of sexuality in the autism population.

Search strategy

Eligible studies were identified using PubMed, Scopus, and PsycInfo search searches. Studies were published between January 1, 1991, to January 10, 2024.

Distinct search techniques were developed for each database. The search words used to extract data from each thesaurus started by combining general terms sourced from cognitive domains and those derived from our previous knowledge. A series of initial scoping searches were conducted, resulting in the identification of several key search keywords. An example of a definitive search procedure for the PubMed database is shown below.

1. (Autism spectrum*[Title/Abstract]*) OR (Autism[MeSH Terms]) OR (autistic disorder[MeSH Terms]) OR (Autis*[Title/Abstract])OR (autistic disorder[MeSH Terms])

2. (gender identity[MeSH Terms]) OR (gender identity[Title/Abstract]) OR (transgender[Title/Abstract]) OR (transgender[MeSH Terms]) OR (gender development*[MeSH Terms]) OR (gender development*[Title/Abstract]) OR (sexual awareness[Title/Abstract]) OR (sexual awareness[MeSH Terms]) OR (sexuality[MeSH Terms]) OR (sexuality[Title/Abstract]) OR (sexual development*[Title/Abstract]) OR (sexual development[MeSH Terms]) OR (sexual orientation[MeSH Terms]) OR (sexual orientation[Title/Abstract]) OR (sexual identity[Title/Abstract]) OR (sexual identity[MeSH Terms]) OR (hypersexual*[MeSH Terms]) OR (hypersexual*[Title/Abstract]) OR (paraphiliac behavior*[Title/Abstract]) OR (paraphiliac behavior[MeSH Terms]) OR (sexual relationship*[MeSH Terms]) OR (sexual relationship*[Title/Abstract]) OR (Intimacy[Title/Abstract]) OR (Intimacy[MeSH Terms]) OR (sexual Victimization[MeSH Terms]) OR (sexual Victim*[Title/Abstract]) OR (stalking[Title/Abstract]) OR (stalking[MeSH Terms])

3. “Review”[Publication Type] OR “Review Literature as Topic”[MeSH] OR “Systematic Review”[Publication Type] OR “Systematic Reviews as Topic”[MeSH] OR “Meta-Analysis”[Publication Type] OR “Meta-Analysis as Topic”[MeSH] OR “Network Meta-Analysis”[MeSH]

4. #1 AND #2 NOT #3 filters: from 1991–2024 Filters: Eng

The terms placed in brackets indicate whether the phrase is a search keyword or a Medical Subject Heading (MeSH). All search queries were analyzed for registration as MeSH keywords.

A search was conducted to determine whether, for example, the search term"Autism"should be searched as a MeSH term, or included as a Title/Abstract as specified.

This was used to simplify the search term while preserving identical search results since specific databases had difficulties processing extensive search phrases. Comparable experiments were conducted across all datasets.

Data screening

All references were inputted into EndNote 21, where duplicates, non-English languages, and irrelevant kinds not corresponding to the article titles were later identified and eliminated. In the data screening stage, two reviewers were involved in the process. Cross-checks were performed between the reviewers to ensure accuracy and consistency in the data selection and analysis.

Data charting process

A reviewer cooperatively developed a data-charting form to determine the variables to extract. The reviewer independently extracted data and analyzed the results in the case of a disagreement. Demographic data from articles (author, year, nation, journal, and citations) and population characteristics (autism support needs, autism diagnostic instruments) were retrieved, along with sample size (n), mean age, and sex distribution. The conclusion of data extraction was based on the research criteria of intervention, result, and effect.

The studies examined various outcomes, including autism and sexual diagnostic methods, sexual violence, atypical sexual behaviors, their relational dynamics, and sex differences. Different categories were used for different research designs: intervention studies focused on treatment outcomes and effectiveness, while observational studies assessed prevalence, risk factors, and relational dynamics. Additionally, the knowledge and information levels of individuals about different aspects of sex were evaluated across most of study designs to provide a comprehensive overview.

Quality assessment

The risk of bias was evaluated using approaches from the Cochrane Collaboration Risk of Bias Tool 2 (CCRBT) and the Effective Public Health Practice Project Quality Assessment Tool to assess the methodological quality of primary studies employing diverse research designs [56]. The six evaluated components are: (1) selection bias, (2) research design, (3) confounders, (4) blinding, (5) data collection methods, and (6) withdrawals and dropouts. Every component is categorized as strong, moderate, or weak. In the absence of weak ratings, the overall rating is deemed strong; one weak rating results in a moderate classification, and two or more weak ratings provide a weak overall classification. The tool was somewhat altered since the component domain'confounders'is especially pertinent to randomized controlled trials, where managing group differences is essential. In the current research, populations acted as their own controls, making this aspect less meaningful. Two separate evaluators appraised the research and resolved any discrepancies through discussion. Different quality assessment tools were used based on the study design; the CCRBT was primarily applied to randomized controlled trials, while the Effective Public Health Practice Project Quality Assessment Tool was used for observational and other study designs [57].

Results

We identified 56 articles relevant to this systematic review, highlighting the commonalities and differences in sexual behavior between autistic individuals and neurotypicals (Table 1).

Table 1.

Characteristics and main findings of studies included in the systematic review

Authorref	Year	Country	Age Range	Sample Size	Diagnosis	Intelligence Range	Autism Assessment Tools	Sexual Behavior Measures	Result
				Men-Women(%)
M.E. Van Bourgondien et al. [58]	1997	USA	16–59	89	ASD	Various levels of intellectual disabilities	N/A	Sexuality Questionnaire	The study highlighted sexual behaviors in autistic adults, with a need for systematic sexual education and better caregiver training on managing sexual behaviors
				81–19
H. Hellemans et al. [59]	2007	Belgium	15–21	24	ASD, AS, PDD-NOS	IQ: 71–113	N/A	ISA	Cognitively able adolescents with autism showed sexual interest but had difficulties with socio-sexual skills, leading to some inappropriate behaviors; emphasized the need for tailored sex education
				100–0
Ingudomnukul et al. [60]	2007	UK	Adult	311	ASC (54 women with ASC, 74 mothers with ASC children, 183 mothers with typically developing children)	N/A	AQ	Testosterone-related Medical Questionnaire, Sexual Preference and Behavior Questionnaire	Autistic women reported elevated rates of testosterone-related conditions like hirsutism, irregular menstrual cycles, and polycystic ovary syndrome compared to controls
				0–100
H. Hellemans et al. [61]	2010	Belgium	15–21	39	ASD, ID	IQ: 54–78 (ASD & MR)	N/A	ISA-R	Autistic individuals exhibit sexual behaviors similar to those with ID, though autistic people have unique challenges such as sensory fascinations and stereotyped sexual interests
				N/A
Pollmann, M. M., et al. [62]	2010	Netherlands	N/A	195 couples	Non-clinical Sample	N/A	AQ	Dyadic Adjustment Scale, Shortened version of the Experiences in Close Relationships Questionnaire, Perceived Relationship Quality Components	Higher autistic traits in husbands were linked to lower relationship satisfaction, but no such effect was found for wives
				N/A
Kalyva, E [23]	2010	N/A	N/A	76 children	ASD	N/A	N/A	SBS	Teachers perceived children with LFA as less socially aware, while those with HFA/AS were perceived with more concerns about sexual behavior and privacy rules
				N/A
L. Gilmour et al. [63]	2011	Canada	23.2–28.9	364	ASD	N/A	AQ	Sexual Experience Questionnaire, Sexual Vocabulary Test	Many autistic people show sexual interest and behaviors; however, higher asexuality and differences in sexual orientation were noted, highlighting the need for tailored education
				N/A
Mehzabin, P., et al. [64]	2011	Australia	18–30	60	HFA, AS	N/A	N/A	SBS	Young adults with HFA show low sexual experience and education, needing tailored sex education programs to address concerns and social anxieties
				39.7–60.3
Muller, J. L [65]	2011	Germany	16	1	ASD, Fetal Alcohol Syndrome, OCD, Low IQ	IQ:91	N/A	DSM-IV criteria for fetishism, sadism, and masochism	Amygdalohippocampal lesions in autism correlate with sadomasochism, hypersexuality, impaired empathy, and deviant sexual behaviors. Findings highlight neurobiological underpinnings, necessitating advanced imaging studies for understanding, treatment, and forensic assessment of such behaviors
				100% men
Byers, E. S., et al. [66]	2013	N/A	21–71	129	ASD-AS	Average to above-average intelligence	AQ: > 32	Sexual Knowledge Questionnaire, Sexual Arousabilty and Sexual Anxiety Inventory, Sexual Functioning Questionnaire, Sexual Desire Inventory, Sexual Activity Questionnaire, SCC	Cognitively able adults on autism spectrum often face sexual anxiety and lower sexual arousability; however, they show good sexual knowledge, highlighting the need for tailored interventions
				N/A
Byers, E. S., et al. [67]	2013	N/A	21–73	141	ASD, AS	Average/Above-average	AQ (28–49)	Global Measure of Sexual Satisfaction, Self-Esteem Subscale of the Sexuality Scale, Hurlbert Index of Sexual Assertiveness, Sexual Knowledge Questionnaire, Sexual Arousability and Sexual Anxiety Inventory, Sexual Functioning Questionnaire, Sexual Desire Inventory, Sexual Activity Questionnaire, SCC	Sexual well-being involves both dyadic and solitary experiences. Men and those with fewer ASD symptoms reported higher satisfaction, emphasizing tailored sexuality education
				39.7–60.3
Byers, E. S., et al. [68]	2014	N/A	21–62	205	ASD	Average Intelligence	AQ (26 or higher)	IEMSS Questionnaire, Global Measure of Sexual Satisfaction, Sexual Rewars/Costs Checklist Revised	Increased sexual satisfaction is linked to better sexual exchanges and communication, dispelling myths about the sexual experiences of those with HF-ASD
				37.5–62.5
Roth, M. E. et al. [69]	2014	N/A	19–50	17	Autistic	N/A	N/A	Online Dating Survey	53% of participants in the survey had engaged in online dating, consistent with general population estimates
				54.5–44.5
Lamport, D. et al. [70]	2014	N/A	18–42	249	Autistic	N/A	Empathy Quotient-Short, Broad Autism Phenotype Questionnaire	ECR-R	Higher BAP scores were linked to lower empathy and increased attachment anxiety and avoidance
				49–49.3–1.7(agender)
Brown-Lavoie, S. M., et al. [39]	2014	N/A	N/A	212	Autistic	N/A	AQ	The revised Knowledge of Sexual Health questionnaire, SES	Autistic people had less sexual knowledge from social sources and more victimization than controls
				44.8–55.2
J. Dewinter et al. [71]	2015	Netherlands	15–18	140	ASD	IQ: 76–142	ADOS, ADI-R	Sexual Health Survey	Autistic boys exhibit typical sexual behaviors, challenging previous misconceptions, though they showed a more tolerant attitude toward homosexuality
				100–0
Barnett, J. P. et al. [72]	2015	Canada	18–61	24	ASD	N/A	N/A	Internet Facilitated Interviews	Adults on the autism spectrum face challenges in sexual experiences, emphasizing the need for inclusive, sensory-aware, and gender-identity-sensitive sex education programs
				25–54.2–20.8(agender)
Palermo, M. T., et al. [73]	2015	N/A	18	1	Autistic	N/A	N/A	N/A	Autistic individuals sold themselves for money, raising questions about impaired capacity or sexual victimization
				100% men
J. Dewinter et al. [74]	2016	Netherlands	16.64–20.29	30	ASD-AS	IQ: 80–89 to 130 + (varied)	ADOS: Above autism cut-off (30%)	Computerized Survey on Sexuality	Autistic boys had fewer partnered sexual experiences than peers, and some were coerced into sexual activities, highlighting the need for comprehensive sexuality education and communication
				100% Male
L.C. Fernandes et al. [20]	2016	Sweden	15–39	184	ASD-AS	IQ < 70 to 104	DISCO	Author-made Questionnaire	Autistic people experience similar sexual needs but face barriers like sensory sensitivities and social impairments, increasing the risk of sexual victimization and inappropriate sexual behaviors
				78–22
J. Dewinter et al. [75]	2016	Netherlands	16–20	8	ASD-AS	Average to Superior	ADOS, ADI-R	Interview	Autistic adolescents experience diverse sexual behaviors and relationships, emphasizing the need for personalized sex education to address challenges in social and communication areas
				100% Male
L.P. Dekker et al. [76]	2017	Netherlands	13–21	210	ASD	IQ: 54–135 (ASD) vs 64–152 (TD)	ADOS, ADI-R	TTI	Autistic adolescents showed poorer psychosexual functioning, including lower self-esteem and social competence, highlighting the need for psychosexual training programs
				61–39
Visser, K., et al. [77]	2017	Netherlands	12–17	188	ASD	IQ: Normal range (> 85)	SRS, ADOS- 2	Flag System Assessment	Autistic adolescents can adequately judge sexual situations, challenging stereotypes and suggesting the need for better sexual education for healthy development
				50–50
Pearlman-Avnion, S., et al. [78]	2017	Israel	17–62	31	Autistic	N/A	N/A	Quality of Life Questionnaire, Sexual Wellbeing Questionnaire	Relationship status doesn't impact sexual well-being for autistic adults. Perceptions of sexual satisfaction vary, and social participation matters more
				58–35.5–6.5(agender)
May, T., et al. [79]	2017	Australia	14–15	3639	Autistic	N/A	Parent Interview	ACASI	Higher proportions of non-heterosexual attraction were found in autistic women compared to the non-ASD group
				48.3–51.7
Schottle, D., et al. [29]	2017	Germany	Mean age 39.2 (ASD)/37.9 (HC)	192	Autistic	N/A	AQ-SF	HBI- 19, QSEB	Autistic people show high interest in sexual behaviors but report difficulties in social and romantic functioning, leading to sexual peculiarities
				41.1–58.9
Aral, A., et al. [80]	2018	Turkey	15	1	Autistic	N/A	Interview	N/A	Persons with Asperger Syndrome may face wrongful accusations of pedophilic behavior due to inappropriate sexual conduct, leading to legal conflicts
				Women
Pryde, R. et al. [81]	2018	N/A	16–24	5 mothers	ASD	N/A	N/A	Parent Interview	Mothers of autistic sons acknowledged the importance of sexuality development but expressed concerns about exposure to explicit material, inappropriate behavior, and the future of their sons'sex lives
				N/A
K. Hartmann et al. [82]	2019	N/A	Mean = 22	100	ASD	IQ: Avg. to Below Avg	AQ- 10	SBS, SES, General Sexual Knowledge Questionnaire, Family Sex Communication Quotient	Autistic young adults desire and engage in sexual intimacy, but family communication gaps about sexuality hinder understanding, requiring tailored sex education to address their needs
				N/A
Cheak-Zamora, N. C., et al. [26]	2019	USA	16–25	24	ASD, AS	N/A	N/A	Interview	Autistic adolescents and young adults desire romantic relationships but face gaps in knowledge and skills. They need comprehensive sexuality and relationship education
				70.8–29.2
Turner, D., et al. [83]	2019	Germany	17–55	192	ASD	N/A	AQ- 10	Kinsey Scale, IIEF, FSFI, SIS/SES-SF	Autistic people experience significantly more sexual dysfunctions, especially in erectile function (men) and across FSFI domains (women) compared to controls
				58.8–41.2
Byers, E. S. et al. [84]	2019	N/A	21–73	331	Autistic	N/A	AQ	Online Sexual Experience Questionnaire	Almost two-thirds of participants had engaged in online sexual activity (OSA), with few differences based on sex, age, and sexual identity
				42.6–57.4
Kock, E., et al. [85]	2019	UK	20–40	8	Autistic	N/A	N/A	Interview	Autistic women face challenges in relationships and some benefit from post-diagnostic counseling for intimacy
				100% women
Pecora, L. A., et al. [86]	2019	N/A	N/A	231	Autistic	N/A	AQ	SBS-III	Autistic women reported less sexual interest but more sexual experiences compared to autistic men
				41.4–58.6
Bush, H. H [87]	2019	USA	N/A	427	Autistic/Non-Autistic(248 women/179 non-autistic women)	N/A	AQ- 10	Sexual History Questionnaire, Sexual Experience Questionnaire, Sexual Desire Inventory, Sexual Satisfaction Scale for Women, Sexual Awareness Questionnaire	Autistic people reported less sexual desire and fewer sexual behaviors but similar sexual satisfaction compared to non-ASD individuals
				100% women
Mogavero, M. C. et al. [88]	2020	USA	19–57	134	Autistic	N/A	N/A	CBS	There is a need for dating and relationship education to be incorporated into social skills and sexual education training
				47–74%—13 (agender)
Hancock, G., et al. [27]	2020	Australia	13–59	460	Autistic	N/A	AQ-Adolescent, AQ-Adult	SBS-III	Compared to neurotypical individuals, those on autism spectrum had shorter relationships, fewer opportunities, and more significant concerns about future relationships
				35,− 56.5–8.5(agender)
Sala, G., et al. [89]	2020	Australia	19–57	57	Autistic	N/A	AQ	Interview	Autistic and non-autistic individuals have similar views of intimacy but face different challenges in experiencing it
				26.3- 59.7–14(agender)
Dekker, L. P., et al. [90]	2020	N/A	N/A	136 dyads	Autistic	N/A	ADI-R, ADOS	TTI, Friendship Skill Scale	Informant discrepancies in psychosexual functioning were larger in ASD dyads than in the general population, except for body image, sexual behavior, and confidence in the future
				N/A
Holmes, L. G., et al. [91]	2020	N/A	18–12	298	Autistic	N/A	SRS- 2	Sexual Behavior Inventory, Parent Action Inventory	Most youth experienced sexual attraction, including same-sex attraction, with girls more likely to have romantic relationships and less likely to face consequences for sexual behavior
				52.7–47.3
Reese, S., et al. [92]	2020	N/A	N/A	1	Autistic	N/A	N/A	N/A	Autistic youths experienced compromised care after sexual assault due to system failures and gaps in trauma-informed care knowledge
				Woman
Pecora, L. A., et al. [93]	2020	N/A	N/A	134	Autistic	N/A	AQ	SBS-III	Autistic women displayed more diversity in sexual identities, with those identifying as homosexual at greater risk of adverse sexual experiences
				0–100
Brilhante, A. V. M., et al. [94]	2021	Brazil	15–17	14	ASD	N/A	N/A	Interview	Autistic adolescents'sexual experiences and needs are highlighted, emphasizing the importance of inclusive education and challenging misconceptions about their sexuality
				57.1, 35.7, 7.2(agender)
McMahon, C. M., et al. [95]	2021	USA	> 18, avg. 35.23	236	Autistic	N/A	AQ- 10	Dating Behaviors Questionnaire	Individuals with higher autistic traits showed a preference for dating those with rude, unattractive, and idiosyncratic behaviors
				51.7–48.3
V. Gibbs et al. [96]	2021	Australia	25–83	410	Autistic/non-autistic(301 Autistic adults, 109 non-Autistic adults)	N/A	Short AQ	CTES and RTES	Autistic adults face higher victimization rates in sexual contexts, highlighting the need for awareness and support to mitigate risks, as funded by the Autism (Cooperative Research Centre) CRC
				32.7–58.8
Brown, A., et al. [97]	2022	UK	> 18	4280	Autistic	N/A	AQ- 10	SFBI, Revised Sociosexual Orientation Inventory, Dyadic Sexual Communication Scale, Sexual Sensation Seeking and Sexual Compulsivity Scales	Autistic traits had little to no meaningful association with gender nonconformity or discomfort, though decreased autistic traits were linked to increased normophilic interest
				49–48.2 − 2.8(agender)
Masoudi, M., et al. [98]	2022	Iran	8–34	27 parents	ASD	IQ > 70	N/A	Parent Interview	Parents of autistic children experienced psychological distress from sexual vulnerability, unintended social consequences, and confusion about future sexual life
				N/A
García-Barba, M., et al. [99]	2023	Canada	21–73	332	ASD	N/A	AQ (26 +)	SCC	Autistic individuals experience a diverse range of positive and negative sexual cognitions, highlighting the importance of positive sexual experiences and gender-specific education
				42.5–57.5
Torralbas-Ortega, J., et al. [100]	2023	Spain	14–27	7	ASD	IQ: 76–121	ADI-R, ADOS- 2	Interview	Autistic young adults face barriers in developing affective-sexual relationships, highlighting the role of families in sex education and the need for adapted, supportive programs
				57, 43
Rocha, J., et al. [101]	2023	USA	18–58	108	ASD	N/A	AQ- 10	Online Survey	Autistic adults scored lower in psychosexual well-being and sexual self-concept compared to neurotypical adults, highlighting the need for tailored sex education
				35.2, 48.2, 16.6(agender)
Pearson, A. et al. [102]	2023	UK	27–52	6	Autistic	N/A	N/A	Interview	Engagement in BDSM/kink has a niche appeal for autistic adults, with certain aspects being inherently attractive
				N/A
Gibbs, V., et al. [103]	2023	Australia	19–70	228	Autistic	N/A	AQ	Questionnaire on Experiences of Violence	Lower social competence, higher compliance, and emotional regulation difficulties are associated with poly-victimization in autistic adults
				51.7–48.3
Gibbs, V., et al. [104]	2023	Australia	N/A	228	Autistic	N/A	AQ- SF	Questionnaire on Experiences of Violence	The study examined abnormal sex behavior, victimization, sexual dysfunction, relationship status, sexual differences, and knowledge. ADHD features were predictive of poly-victimization
				51.7–48.3
Libster, N., et al. [41]	2023	N/A	N/A	540	Autistic/Non-Autistic	N/A	N/A	Author-made questionnaire on Sexual Contact And Sexual Assault	Autistic students are equally as likely as non-autistic students to experience unwanted sexual contact and assault, with ADHD increasing vulnerability
				50–50
Pearson, A., et al. [105]	2023	UK	19–73	102	Autistic	N/A	N/A	Interview	The impact of victimization is categorized as usual of autism and cost of living, with challenges in finding appropriate words to express experiences
				N/A
Rothman, E. F., et al. [106]	2023	USA	N/A	219,841	Autistic/Non-Autistic(1,411 autistic/218,430 non-autistic)	N/A	N/A	Author-made questionnaire	Autistic students are more likely to experience emotional and physical victimization, with a higher academic impact from sexual assault than non-autistic students
				N/A

ACASI Audio Computer-Assisted Self-Interviewing, ADI-R Autism Diagnostic Interview-Revised, ADOS Autism Diagnostic Observation Schedule, AQ Autism, AQ- 10 Autism Quotient- 10 Spectrum Quotient, AQ-SF Autism Quotient-Short Form, AS Asperger Syndrome, ASC Autism Spectrum Conditions, ASD Autism Spectrum Disorder, BAP Broad Autism Phenotype, BDSM Bondage and Discipline, Dominance and Submission, Sadism and Masochism, CBS Courting Behavior Scale, CTES Childhood Traumatic Events Scale, DISCO Diagnostic Interview for Social and Communication Disorders, DSM-IV Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), ECR-R Experiences in Close Relationships-Revised, FSFI Female Sexual Function Index, HBI- 19 Hypersexual Behavior Inventory- 19, HFA High-Functioning Autism, IEMSS Interpersonal and Emotional Sexual Satisfaction, IIEF International Index of Erectile Function, ISA Interview about Sexuality in Autism, MR Mental Retardation, N/A Not Applicable, OCD Obsessive–Compulsive Disorder, PDD-NOS Pervasive Developmental Disorder-Not Otherwise Specified, QSEB Questionnaire on Sexual Experiences and Behaviors, SBS Sexual Behavior Scale, SES Sexual Experiences Survey, SFBI Sexual Fantasy and Behavior Inventory, SRS Social Responsiveness Scale, TTI Teen Transition Inventory

The studies included a wide range of age groups, spanning from early adolescence (12 years) to older adulthood (83 years), with the majority focusing on late adolescence to middle adulthood (15–59 years). The gender distribution varied, with some studies exclusively examining men or women, while others had a more balanced representation. Many studies included a higher proportion of men, reflecting historically higher autism diagnosis rates in males.

Most of these studies were conducted in developed western countries, and sample sizes ranged from small qualitative studies to large-scale cohort analyses (Fig. 2).

Fig. 2.

Overall view of the results

The most frequently used method for assessing sexual behavior was self-reported data collected through interviews or questionnaires. Some studies also utilized reports from parents or caregivers, including teachers and healthcare providers, to gather additional insights into sexual behaviors.

A diverse range of assessment tools has been utilized in studies (Table 1) to capture different aspects of their sexual health and safety.

Interest and desire

Most studies showed that autistic individuals experience sexuality as part of their development, and they often show sexual interest [20, 26, 59, 61, 66, 75], which is comparable to their neurotypical peers [63, 71, 76].

A study in 2023 exploring sexual cognitions among 332 autistic individuals revealed that nearly all participants experienced both positive and negative sexual thoughts, with positive sexual cognitions being more varied and frequent than negative ones. Intimacy-related thoughts were the most common type of sexual cognition for both men and women. Authors also compared the results to similar studies on neurotypical individuals and found that autistic individuals'sexual cognitions are mainly similar to those of their neurotypical counterparts, indicating that autistic and neurotypical individuals experience sexual thoughts in comparable ways [99].

However, some differences may exist; the rate of those identifying themselves as asexual is reported to be high in autistic individuals [63]; perceiving having a relationship as a trouble and problems with intimacy, discomfort with physical touching, some anxieties about having children has been reported by some individuals [26]. According to Byers et al., autistic individuals reported significantly greater sexual anxiety, less sexual arousal, lower interest in partnered sexual activity, and fewer positive perceptions of sex than neurotypical individuals [66].

Some stereotypical interest in sexual activities has also been found in this population. For instance in a study use of special objects for masturbation or fascination with objects with potentially sexual connotations was reported [59]. In another study autistic individuals highlighted a specific interest in objects, body parts, and sensory stimuli. Some found these interests sexually arousing, with partialism (arousal by body parts) being common. In contrast, individuals with intellectual disabilities (ID) were more aroused by conventional sexual stimuli, like images of naked women. Sexual fascinations with objects or sensory stimuli were only observed in the autistic group [61].

Experience

Despite having interests in sexual behavior, there may be some differences in sexual activity between autistic individuals and their neurotypical peers.

Some studies emphasized that there are no differences between sexual experience in ASD and non-ASD groups [63, 75] while some other studies reported that autistic individuals have fewer sexual behaviors [64]. A survey by Dewinter et al. compared autistic boys aged 16–20 to a matched group from the general population and found that most boys in both groups engaged in masturbation and experienced orgasms. However, autistic boys were significantly less likely to have had partnered sexual experiences compared to the control group [74]. As demonstrated by a study of 20 institutionalized male autistic adolescents and youths with borderline or mild intellectual disability and of 19 institutionalized male adolescents and young adults with borderline or mild intellectual disability without autism, participants with mild intellectual disability but without autism had more experience with relationships compared to those on autism spectrum [61].

A survey of 89 autistic adults living in group homes in North Carolina revealed that most participants were involved in some type of sexual activity, with masturbation being the most prevalent (67%). Additionally, one-third of the individuals displayed person-oriented sexual behaviors accompanied by clear signs of arousal [58].

According to a qualitative study, sensory dysregulation was a common issue among participants, with many experiencing sensory overload or discomfort from certain sensations related to sex, such as sounds or textures. For some, this made all sexual experiences, especially with partners, painful. Others had to manage overstimulation and sensitivity to enjoy sex carefully. However, this management was often hindered by delays in recognizing or communicating changing sensory needs during sexual activity [72].

Only one study explored sexual dysfunction in autistic men and women. Authors used the Kinsey scale, the International Index of Erectile Function, the Female Sexual Function Index (FSFI), and the Sexual Inhibition/Sexual Excitation Scales-Short Form to assess sexual dysfunction. Autistic men face more significant challenges with erectile functioning compared to the control group, and autistic women report significantly more sexual dysfunctions in all FSFI domains compared to women without autism. However, When comparing autistic women to autistic men, it was found that a higher percentage of autistic women were currently in a relationship (46.2% vs. 16.1%), more autistic women were satisfied with their current relationship (44.4% vs. 11.1%), and autistic women perceived themselves as more sexually attractive than autistic men (20.0% vs. 3.6%) [83].

Relationship

Although autistic people express similar interests in relationships as their neurotypical peers, their relationship experiences often differ significantly due to communication difficulties, social misunderstandings, and limited opportunities to form relationships. Numerous studies have explored these complexities, revealing both the barriers to intimacy and the factors that can enable more positive romantic and sexual experiences for those on autism spectrum.

Relationship initiation and experience

A survey of 134 participants (46 autistic, 88 non-autistic) found that while almost all were knowledgeable about sex and relationships, only 54.3% of those on autism spectrum knew how to initiate relationships compared to 87.7% of those without autism. Fewer autistic people were in romantic relationships (41.35% vs. 60.2%), and they had lower overall romantic functioning and more stalking-like or persistent courting behaviors [107]. In a study of 129 single adults (61 men, 68 women) with autism without intellectual disability, 53 participants (41%) had never been in a romantic relationship lasting three months or longer. In contrast, 76 participants (59%) had past relationship experience but were not currently in a relationship [66].

Similarly, Cheak-Zamora et al. found that most participants (over 80%) in the study reported that they were not currently in a relationship [26].

Barriers to relationships

Despite showing similar levels of interest in relationships as neurotypical individuals, autistic people had fewer opportunities to meet new partners (t(457) = 1.76, p < 0.05), experienced shorter relationships (t(321) = 2.79, p < 0.003), and expressed more significant concerns about their future romantic prospects (t(434) = 4.71, p < 0.001) [27]. A study involving interviews with 8 autistic women identified several relationship barriers: doubts about the relationship's future, difficulty with dating, a lack of understanding about dating, challenges in understanding partners, and the spontaneous nature of relationships [85]. Another study examined factors that enable and hinder emotional intimacy in 31 autistic and 26 non-autistic individuals through an online survey. Both groups identified communication, sharing and similarity, respect and safety, and relationship effort as enablers of intimacy. Barriers included intra- and interpersonal conflicts, with autistic participants specifically noting uncertainty about relationships and communication issues. The findings indicate that while autistic and non-autistic people have similar views on intimacy, they face different challenges in achieving it [89].

Emotional well-being

Autistic individuals reported a wide range of relationship experiences, from fulfilling connections to more challenging and distressing situations. While some adolescents and young adults highlighted positive aspects of their relationships, many others encountered confusion or stress, were unsure about the status of their relationships, and shared experiences of feeling exploited or hurt [26].

When asked about ideal partners, the emphasis on acceptance, kindness, and understanding in relationships was more commonly highlighted by autistic individuals [26], reflecting a deeper desire for meaningful connections based on mutual respect and empathy.

In contrast, higher autistic traits were associated with lower empathy (b = –0.37, p < 0.01), higher attachment anxiety and avoidance (b = 0.42, p < 0.01) [70], and lower relationship satisfaction for husbands, though this was not observed in wives [62].

Sexual satisfaction and psychosexual well-being

Several studies examined the impact of autism traits on sexual and relationship satisfaction. A study involving 205 autistic adults without intellectual disability (77 men and 128 women) found that those with more pronounced autism traits reported lower sexual and relationship satisfaction compared to neurotypical individuals in both long-term and dating relationships. They also experienced a less favorable balance between sexual rewards and costs and less equality in these aspects [68].

Another study found that cognitively able autistic individuals who were in relationships were more socially engaged and felt a greater sense of belonging compared to those who were not in relationships. These individuals also demonstrated a strong link between their sexual well-being and productive capacity (R = 0.776, p < 0.05), underscoring the important role that intimacy plays in enhancing an individual's life [78]. Lower psychosexual well-being in the autistic group compared to the neurotypical group was reported in another study [101]. Moreover, autistic participants had a significantly lower sexual self-concept.

Furthermore, a study of 141 autistic adults living in the community found that those in relationships reported more frequent affectionate and genital interactions with their partners, increased sexual assertiveness, and greater overall sexual satisfaction. Moreover, men and individuals with fewer autism traits, particularly in social and communication areas, generally experienced significantly better dyadic sexual well-being [67].

Overall, these studies reveal a complex interplay between the desire for romantic connections and the unique challenges faced by autistic people in achieving and maintaining fulfilling relationships.

Online sexual activity

As indicated by Dewinter et al., there were no significant differences between autistic participants and controls in their exposure to sexually explicit media and internet-based sexual content [71].

A study in 2014 conducted a survey on 17 autistic adults [69] supported the idea that autistic adults are motivated to date through online services. In the current survey, 53% of participants used online dating services, comparable to the 38% found in the general population. Notably, 44% of the sample formed long-term relationships through online dating, which is higher than the 22% of adults in the general population reported in the latest Pew Research survey [108]. Autistic individuals highlighted several benefits of online dating, noting that it offers a more convenient way to meet people without the need to engage in potentially stressful or aversive face-to-face situations. However, safety concerns were frequently mentioned as a significant drawback, reflecting some individuals'apprehensions regarding the risks involved in online interactions.

In another study in 2019, 141 men and 190 women on autism spectrum completed an online survey evaluating their recent engagement in non-arousal (information seeking, chatting), solitary-arousal, and partnered-arousal online sexual activities. Nearly two-thirds had participated in at least one type of online sexual activity, though infrequently on average. More men than women engaged in information-seeking and solitary-arousal online sexual activity, and they did so more frequently. However, men and women did not differ in their likelihood of engaging in chatting or partnered-arousal activities. The study suggests that sexual health education for autistic people should include online sexual activities as a source of information and expression, highlighting benefits while teaching how to identify reliable websites and providing safety guidelines for online interactions and meetings [84].

Knowledge

The sexual knowledge and experiences of autistic people have been a topic of increasing research focus, with many studies exploring how their understanding of sex education, privacy, and social interaction differs from their neurotypical peers. While autistic individuals often show similar levels of knowledge about certain aspects, such as privacy rules, other areas—such as practical socio-sexual skills—present more challenges.

In a study in 2011, autistic individuals showed less knowledge of sex education (partial ƞ2 = 0.29) but similar levels of knowledge about privacy rules (partial ƞ2 = 0.11) as compared to neurotypicals [64].

Using various illustrated sexual situations, Visser et al. assessed how 94 autistic cognitively-able adolescents and 94 typically developing adolescents judged their appropriateness and compared the differences between the two groups. The results showed that the judgments of both autistic people and their typically developing peers were similarly aligned with the consensus opinions of the expert panel [77].

In a study on 129 single cognitively-able autistic adults living in the community with and without prior relationship experience, participants demonstrated good sexual knowledge, correctly answering about 81% of the questions. However, this knowledge did not significantly correlate with most sexual functioning variables [66]. Similarly, in a survey of 24 autistic the theoretical knowledge of self-care and socio-sexual skills was rated adequate, while the actual practice was inadequate for several individuals. Some problems reported were talking too frankly about sexuality, touching the genitals in public, and masturbation in the presence of others [59].

Autistic individuals revealed no difference in comprehension of sexual language when contrasted with non-autistic participants [63]. However, difficulties in communication and social interaction hinder young adults from forming affective-sexual relationships, resulting in negative emotions and experiences that reinforce avoidance behaviors, worsening their social interaction challenges [100].

A study based on reports from 79 parents using the Teen Transition Inventory found that autistic people exhibited significantly lower levels of psychosexual knowledge compared to their typically developing peers. Both autistic adolescents and their parents also reported lower perceived social competence, fewer friendship skills, and less peer acceptance when compared to TD adolescents [76]. Autistic adolescents reported similar personal openness about psychosexual topics as their TD peers [76].

Autistic individuals sought practical guidance on sex and relationship development. Although many had trusted individuals, usually parents, to talk to about these issues, the discussions were often vague. Moreover, healthcare providers did not offer the necessary support in this area [26]. Autistic people reported fewer learning sources as to how they acquired romantic dating skills and knowledge [107] and reported learning less about sexuality from their peers or other social sources [27]. In a study involving in-depth, Internet-facilitated interviews with 24 adults on the autism spectrum, participants expressed that inadequate and disability-insensitive sex education played a significant role in their difficulties with courtship and sensory regulation. Most reported receiving little to no effective sex education from their parents, with several noting that their parents never discussed sexuality with them at all. This lack of guidance further exacerbated the challenges they faced in navigating relationships and understanding sexual development [72].

Rocha et al., found a significant correlation between sexual self-concept and sexual knowledge in neurotypical participants. However, this correlation was not observed in autistic participants. These group differences emphasize the importance of developing tailored sexuality and relationship education programs for autistic individuals [101].

Abnormal sexual behavior

Another key issue addressed in the reviewed studies was the atypical sexual behaviors exhibited by autistic individuals. It should be mentioned, however, that sometimes drawing a clear line between unusual and inappropriate sexual behaviors—especially those that may be harmful to others—can be challenging, as these behaviors are sometimes studied together rather than separately in research.

While some studies have reported comparable levels of public sexualized behaviors [64], others highlight a higher prevalence of inappropriate sexual behaviors among those on autism spectrum.

In a cohort of 184 adolescents and young adults (ages 15–39) diagnosed with autism in childhood, approximately 29% were reported to exhibit unusual sexual behaviors and paraphilias. The most frequently noted inappropriate behavior was public masturbation, occurring in 21% of the cases [20]. Almost a quarter (24%) of individuals confirmed having specific paraphilias when asked. The most frequently mentioned was fetishism, followed by voyeurism, with no reports of exhibitionism [20]. Another study conducted on a large number of non-clinical samples revealed that autistic traits were related to decreased normophilic interests [97]. A study in 2022 compared 96 autistic people with 96 healthy controls, showing that autistic patients had significantly higher hypersexual behavior scores than healthy controls (35.1 ± 13.7 vs 29.1 ± 8.7 p < 0.001). This difference was particularly notable among men, with more male autistic patients classified as hypersexual compared to male controls (30.4% vs 3.5%). However, no significant differences in hypersexuality were found between women patients and women controls. Paraphilic fantasies and behaviors were more commonly reported by male autistic patients compared to male healthy controls. Even after adjusting for multiple comparisons, significant differences remained in the frequency of masochistic, sadistic, voyeuristic, frotteuristic, and pedophilic fantasies [29].

Autistic people may encounter legal issues due to inappropriate sexual behavior and be wrongfully accused of pedophilic behavior.

Aral et al., described a 15-year-old girl who kept child pornography images and shared them on social media. After being assessed, it was revealed that she had impaired social judgment and had no arousal or pleasure in watching pornography [80].

Deviant or unlawful sexual behavior may result from a combination of circumscribed interests, a poor grasp of social moral standards, or an inability to interpret verbal and nonverbal cues.

In a study of six autistic adults involved in BDSM/kink, participants reported that the structured communication and clear boundaries in BDSM/kink helped them feel safer and reduce uncertainty. They also highlighted that the sensory aspects of kink were a key motivation, as it allowed them to experience sensory pleasure in a controlled way, which aligns with the concept of"sensory joy"in the autistic community [102].

However, biological underpinnings also should be considered in some cases. Muller reported a forensic psychiatric inpatient with autism and sadomasochism who had committed murder showing hypo-intensities in the amygdala-hippocampal complex bilaterally medial to both cornua inferiors corresponding to an amygdala-hippocampal atrophy in an MRI scan [65].

Victimization

Another area of focus highlighted in the reviewed studies was the victimization experienced by autistic individuals.

A study examining 1,411 autistic and 218,430 non-autistic students across 78 colleges revealed that autistic students reported significantly higher rates of emotional and physical victimization compared to non-autistic peers (44% vs. 26% and 8.4% vs. 5.7%). Autistic students who faced sexual assault were 2.23 times more likely to say it negatively affected their academic performance [106].

Similar to previous research, in a study involving 95 autistic adults and 117 adults without autism, findings revealed that autistic adults experienced higher rates of sexual victimization compared to non-autistic individuals (78% vs 47.4%). Additionally, the study found that the increased risk of victimization among autistic adults was partially mediated by their lower actual knowledge [39].

In a study conducted on a sample of 228 adults, consisting of 118 autistic and 110 non-autistic participants, autistic adults reported higher rates of various types of violence (76.3% vs 46.4%), including multiple forms and repeated instances of the same type. While typical gender differences in violence patterns—such as men reporting more physical violence and women reporting more sexual violence—were observed in the non-autistic group, these gender differences were not present among autistic adults [104].

A cross-sectional survey on 245 autistic adults without intellectual disability and 49 non-autistic adults showed that a higher percentage of autistic adults reported childhood experiences of sexual and physical violence (49.4% vs 22.4%). Autistic traits, rather than emotion regulation difficulties, were a significant predictor of experiencing violence [96].

In a further study, authors then focused on determining if specific traits commonly associated with autism, such as reduced social competence, increased compliance, emotion regulation issues, or heightened ADHD characteristics (like inattention, impulsivity, and hyperactivity), were linked to experiences of poly-victimization, which includes sexual harassment, stalking, sexual violence, and physical violence. After controlling for socio-demographic factors such as age and sexual orientation, the findings showed that only ADHD-related traits were significant predictors of poly-victimization [103]. In a similar vein, Libster et al. showed that the likelihood of experiencing unwanted sexual contact and sexual assault was similar between autistic students (n = 270) and non-autistic students (n = 270). However, students with ADHD, regardless of their autism diagnosis, were more susceptible to unwanted sexual contact and sexual assault than those without ADHD (22% vs 12%) [41].

An online survey of 135 adults using the Dating Behaviors Questionnaire revealed that participants with higher autistic traits were more inclined to date individuals exhibiting rude, unattractive, and idiosyncratic behaviors. Due to their limited social competence, this tendency increases the risk of sexual victimization in this population [95].

A qualitative study exploring the views of autistic individuals on victimization found that many see it as an inherent part of being autistic, leading them to mask their symptoms. To improve support and recovery, the study calls for reducing structural inequalities and enhancing frontline professionals'training on autism [105].

The two case reports found [73, 92], despite focusing on different cases—a man engaged in sex work and a girl who was sexually assaulted—both highlight the complexities of addressing these issues within this population. They emphasize concerns regarding the ability to consent to sexual activity for individuals with psychiatric conditions and the risks of victimization and exploitation. The reports also bring attention to the exploitation of disabled individuals, medico-legal responsibilities, and the inconsistent understanding among multidisciplinary teams regarding trauma-informed care for autistic youth.

Considerations in women

According to a study that compared the sexual functioning of 135 autistic women, 96 autistic men, and 161 typically developing women, autistic women reported lower sexual interest (72.6% vs 85.4%) but had more sexual experiences (40% vs 21.9%) than autistic men. Additionally, they were more likely to engage in unwanted sexual activities (60% vs 34.6%) and to face unwanted sexual advances (78.2% vs 57.7%) compared to typically developing women. Due to the discrepancy between their lower sexual interest and increased sexual behaviors, it can be suggested that autistic women are at a higher risk of negative sexual experiences, including victimization and abuse, compared to autistic men [86].

A study involving 134 autistic and 161 non-autistic women found that autistic homosexual women were more likely to encounter various negative sexual experiences compared to non-autistic women, regardless of their sexual orientation (OR ≥ 2.38; p < 0.05) [93].

In a research examining the experiences of women aged 18–30, both with autism (n = 248) and without (n = 179), most of whom identify as sexual minorities (i.e., non-heterosexual), women on autism spectrum reported lower levels of sexual desire, engaged in fewer sexual behaviors, and had less sexual awareness compared to those without autism. However, both groups reported similar levels of sexual satisfaction [87].

Caregivers viewpoints

Some studies have explored the sexual behavior of autistic individuals regarding parent's viewpoints, revealing a range of challenges and parental perceptions that vary depending on the support needs of the condition and other factors.

According to a study that surveyed parents of autistic adolescents aged 12–18 years (N = 298, 52.7% boys), a significant number of these youths expressed sexual attraction and an interest in relationships. The study found that girls were more likely than boys to have had a romantic relationship and less likely to face school or legal issues related to sexual behavior. Approximately 20% of the youth engaged in socially inappropriate sexual behavior, while 6.4% had a history of sexual abuse, and peers bullied 14.5% due to a lack of sexual knowledge. Nearly 40% of the participants had not received any sex education at school or in the community, a figure that rose to 60.9% among those with a reported IQ below 70. Some parents sought advice from school staff (36.4%) or healthcare providers (55.9%) on sexuality-related issues, but 19.5% only discussed the topic with their children and took no further action [91].

Parental perceptions of their children's sexual behaviors were often at odds with the children’s self-reports. For example, parents of autistic adolescents viewed their children as having lower friendship skills, less positive body image, and less peer acceptance than the children reported themselves. They also believed their children were more engaged in online sexual activities and exhibited more inappropriate sexual behavior than the adolescents admitted. By contrast, parents of typically developing (TD) adolescents reported greater involvement in online sexual activity and had more confidence in their children's future than what their children self-reported [90]. Furthermore, parents of autistic adolescents generally reported less sexual behavior in their children compared to the parents of TD adolescents, while the adolescents themselves did not note a significant difference. However, parents did report that their autistic children exhibited more inappropriate sexual behavior than their TD peers [90].

The societal perception of autistic individuals as innocent or asexual was also explored in a qualitative study of 14 autistic adolescents. The term"blue angel"was used to describe autistic people, a narrative that contributes to their infantilization and can obscure the reality of their sexual development [94].

The perception of autistic individuals as innocent or asexual can lead parents to underestimate or overlook the risks of victimization their children may face. However, at the same time, many parents express concerns about these very risks. For instance, Hartmann et al.'s study, which surveyed 100 young adults (ages 18–30) and their parents, revealed that while young adults reported more normative privacy and sexual behaviors, as well as higher instances of sexual victimization than their parents did on their behalf, parents still harbored concerns about their children's safety [82].

A separate study involving interviews with 27 parents of autistic children (aged 8–34 years) highlighted deep parental anxiety regarding their children's vulnerability to sexual abuse due to challenges in understanding social cues. Parents often reported emotional distress, including anxiety and guilt, over their child's sexual behaviors. They also expressed concerns about their child’s future sexual life, noting that society often rejects the sexual behaviors of autistic individuals, especially when these behaviors clash with cultural or religious values [98].

Similarly, interviews with five mothers of autistic sons and intellectual disabilities revealed their significant worries about their sons'sexual development. These mothers struggled with providing adequate sex education and expressed fears about their sons’ future care as they grew older [81]. Families, particularly mothers, often feel inadequate in offering sexual and emotional guidance, which can lead to feelings of anxiety and frustration [100].

Lastly, a study of teachers'perspectives on sexual behaviors in autistic children found that children with intellectual disability were less likely to demonstrate socially acceptable behaviors and had a poorer understanding of privacy and sexual norms. However, teachers expressed greater concern over the sexual behaviors of children with Asperger’s Syndrome [23].

Discussion

This systematic review explored the sexual behaviors, experiences, and relationships of autistic individuals, drawing attention to both commonalities and differences compared to their neurotypical peers. This area of research is likely to suffer from many common misconceptions about autism. Also, it seems to be relatively understudied, with many of such studies having limitations with their methods and designs. However, It is drawn from the existing literature that, in general, autistic individuals are no different in terms of their sexual interests and desires compared to neurotypicals. Yet, their sexual experiences seem to be impacted by their unique set of challenges, such as sensory sensitivities, communication difficulties, and social barriers that can all complicate romantic and sexual relationships. It also needs to be stressed that symptoms and challenges observed in autistic individuals may be influenced by mismatches between environment and person and this may explain, at least to some degree, the inconsistencies reported in various studies. In this paper, we systematically reviewed the studies exploring this complex set of human life experiences in autistic adults while keeping in mind that most of them are from western developed countries.

Our conclusions may come across as challenging this widely-believed misconception that autistic people are asexual or uninterested in romantic or sexual relationships, and some studies are reporting that autistic individuals are unlikely to engage in partnered sexual experiences [66, 74]. In contrast, our review suggests, however, that many autistic individuals report having sexual cognition, including thoughts and desires related to intimacy, that are comparable to those of neurotypicals [26, 20, 59, 61, 63, 66, 71, 75, 76]. Several factors, including intellectual disabilities, social and communication difficulties, and sensory sensitivities, can hinder the development of romantic and sexual relationships [26, 72].

Like most people, autistic individuals frequently desire relationships built on mutual respect, empathy, and understanding, and when such elements are present, they can experience fulfilling connections [26]. Yet, they may face many more challenges (Lamport and Turner 2014, Hancock, Stokes et al. 2020) and sustaining their relationships would require a great deal of proper support, communication tools, and education.

As for their most serious challenges, practical application of what they learn or are taught about sexual relationships seems to be a major obstacle [66]. This is perhaps explainable by their tendencies to be literal and also their underlying cognitive deficits in terms of the “pragmatism” aspect of language, among other explanations. While many possess an adequate understanding of privacy rules and sexual terminology [64], there is often a disconnection between this knowledge and real-life social skills [59]. This points to the need for more tailored, hands-on sexual education programs that take into account the unique cognitive and social processing differences in autistic individuals.

We did not address the role of technology in this paper, and like many other areas in medicine, it may provide us with new horizons in this area as well. Technology often provides both opportunities and risks simultaneously. Notably, the rise of online dating platforms has emerged as playing significant roles in the romantic and sexual lives of autistic individuals, among others. For many of them, online platforms perhaps provide a less stressful alternative to traditional, in-person dating by offering a controlled environment where social interactions can be managed more easily. Autistic individuals often find online dating appealing [69], as it reduces the pressures of face-to-face interaction, which can be particularly challenging for those with social anxiety or communication difficulties. On the other hand, despite the advantages, concerns about safety in online dating remain prevalent, and the findings underscore the importance of incorporating sexual health education that addresses the specific risks and challenges associated with online sexual activities.

In our review, we also found a range of abnormal sexual behaviors, such as hypersexuality, fetishism, partialism, use of objects during masturbation, and paraphilic behaviors, as being reported more frequently among autistic individuals, particularly men [20, 29, 64]. These behaviors may be linked to various causes such as sensory sensitivities, cognitive processing differences, or impaired social judgment [80, 102]. For example, some individuals may engage in inappropriate online activities, not out of deviant intent but because of a lack of understanding of social norms. This reinforces the need for explicit, structured guidance on navigating complex social and moral situations.

Another important issue highlighted in our review is the heightened risk of autistic individuals to be exposed to sexual victimization. There are many studies consistently showing that autistic individuals are at greater risk of being sexually victimized compared to their neurotypical peers [39, 104, 106]. This vulnerability is linked to several factors, including deficits in social competence, a heightened tendency toward compliance, and, in some cases, co-occurring conditions like ADHD [103]. The increased risk of victimization should be incorporated in any intervention package and also underscores the need for preventive measures, such as comprehensive sex education that empowers autistic individuals to recognize and avoid risky situations and for supportive interventions for those who have experienced victimization. The sexual experiences of autistic women are highlighted as an area of particular concern. Research shows that while autistic women often report lower levels of sexual interest compared to their male counterparts [86], they are more likely to engage in some sorts of sexual experiences, including unwanted sexual activities. This may be due to social vulnerabilities and impaired communication skills, which can make it difficult for autistic women to assert boundaries or recognize unsafe situations.

Caregivers, particularly parents, add another layer of complexity to understanding the sexual behaviors of autistic individuals. Their viewpoints follow different patterns; Many parents express deep concerns about their children’s vulnerability to sexual victimization and their ability to adhere to socially acceptable sexual behaviors [98]. While some parents underestimate their children’s sexual development due to societal perceptions of autistic individuals as asexual, others worry about their safety and future sexual lives [82, 90]. Caregivers of autistic children with intellectual disability are especially concerned about socially inappropriate behaviors such as masturbation, while parents of children with Asperger’s Syndrome are more focused on their children’s romantic relationships and sexual behaviors and [23] probably the possibility of marriage.

While our review provides valuable insights, several limitations should be acknowledged. First, most studies were conducted in Western, developed countries, limiting the generalizability of our findings to diverse cultural contexts.

The reliance on self-report data and small sample sizes in many studies also raises concerns about bias and representativeness. More longitudinal and large-scale studies are needed to better capture the developmental trajectory of sexual behavior in autistic individuals over time, as well as to identify potential shifts in experiences or needs throughout different life stages.

We also did not include data on gender dysphoria and sexual orientation, as these topics require a separate and more extensive review. Furthermore, while some studies addressed the experiences of sexual minorities, the intersectionality of autism with gender diversity remains underexplored. Future research should expand on these areas, particularly by focusing on more inclusive, cross-cultural, and gender-diverse perspectives.

There is a notable chronological discrepancy in research on autistic individuals mainly due to changes in the conceptualization of autism. Older studies primarily focused on those with co-occurring intellectual disabilities and some living in nursing homes, while more recent research has shifted toward individuals with average or above-average cognitive abilities. The heterogeneity of autism is another consideration as it may be inappropriate to generalize findings with heterogeneous origins across the spectrum. Notably, some newer studies suggest minimal differences between autistic individuals and neurotypicals in certain areas. Moving forward, it is crucial that research explores how varying degrees of support needs and specific features of autism influence sexual experiences, relationship dynamics, and sexual health education.

The practical implications of this review is significant. In general, our findings emphasize the importance of developing tailored educational programs that bridge the gap between theoretical sexual knowledge and practical socio-sexual skills. We did not include studies that evaluated interventions in this area. Future research should focus on reviewing interventions designed to enhance sexual health and relationships among autistic individuals.

Conclusion

This systematic review sheds light on the unique sexual behaviors, experiences, and relationships of autistic individuals, emphasizing both the similarities and differences compared to their neurotypical peers. Autistic individuals share common sexual interests and desires yet face distinct challenges, such as sensory sensitivities, communication difficulties, and social barriers, which can complicate their romantic and sexual relationships.

The review underscores the importance of tailored sexual health education that addresses these challenges and highlights the need for supportive interventions, particularly for those at increased risk of victimization. Clinicians, educators, and caregivers must prioritize comprehensive, neurodiversity-affirming sexual education that accounts for the unique social, cognitive, and sensory processing differences in autistic individuals.

One key recommendation is the development of structured, individualized sexual education programs that bridge the gap between theoretical knowledge and practical socio-sexual skills. Many autistic individuals understand sexual terminology and privacy concepts but struggle with real-life application, highlighting the need for explicit teaching of relationship-building, boundary-setting, and consent negotiation. Digital resources and gamified learning tools may be particularly beneficial, given the preference of many autistic individuals for structured, rule-based learning environments.

Furthermore, the review reveals critical gaps in current research, particularly in non-Western contexts and in relation to autistic individuals with co-occurring intellectual disabilities and gender diversity. Future research must address these gaps to ensure more inclusive, comprehensive insights into the sexual well-being of autistic individuals. Discussions on sexuality should be incorporated into routine mental health care for autistic individuals, creating a supportive space where topics like relationships, sexual identity, and personal safety can be explored comfortably and without stigma.Finally, Issues of heterogeneity, changing conceptualization of autism, and support needs of clinical presentation are important considerations in studying sex-related issues of autism.

Authors’ contributions

M.M. and J.A-r. designed and supervised the study. A.S. and A.H-H. carried out the literature search. M.M. and A.H-H. worked on interpreting the results and writing the manuscript. M.M. and J.A-r. critically revised the manuscript. All the co-authors reviewed the manuscript and approved the final version.

Funding

This article does not use any funds.

Data availability

The results of this review article are based on data obtained from publicly accessible sources, including peer-reviewed publications, databases, and other academic resources. All pertinent data and sources mentioned in this work are duly cited. No new primary data were created or analyzed due to this review's nature. Readers are advised to refer to the references section of the paper for further information on the sources of the evaluated data. Supplementary materials or datasets necessary for further inquiry may be acquired from the corresponding authors or repositories indicated in the referenced papers.

Declarations

Ethics approval and consent to participate

This systematic review did not include collecting original data from human or animal participants. Therefore, ethical clearance and permission for participation were not required for this study. All assessed data were obtained from publicly accessible, previously published research. The review adhered to the ethical norms for systematic research and reporting.

Consent for publication

Not relevant. This work does not include any individual or identifiable personal data necessitating permission for publishing.

Competing interests

The authors declare no competing interests.