“I'm Human After All”: Autism, Trauma, and Affective Empathy

Abstract

Academic literature has long associated autism with empathy deficits. Although this view has been attenuated over time to include only cognitive empathy, earlier perceptions continue to influence popular representations of autism and screening/diagnostic tools. As a result, empathetic autistics may be prevented from accessing diagnosis, and those with a diagnosis may experience internalized stigma or violence under the guise of therapy. There are, however, some autistics who do self-identify as having empathy difficulties. The purpose of this perspective piece was to first trouble the view of empathy “deficit” as intrinsic within autism and consider alternative explanations and, second, to more deeply consider post-traumatic stress disorder (PTSD) as a factor for autistic people who self-identify as having empathy difficulties. Using both literature and author narrative, we argue that autistics are more likely to experience trauma and more vulnerable to developing PTSD, but less likely to receive a diagnosis of PTSD than nonautistics, as their PTSD-related symptoms, such as a lack of affective empathy, may be conflated with autism traits. Our main recommendations are: (1) future studies should investigate the possible interactions between autism, trauma, PTSD, and affective empathy, determining whether autistic adults with PTSD may recover affective empathy following therapy; (2) clinicians should look beyond autism if their client identifies a lack of affective empathy as part of their challenges; (3) and clinicians should adapt diagnostic procedures for PTSD in autistic adults to accommodate those with alexithymia, and exercise caution when using screening tools for autism, allowing empathic autistic adults to access diagnosis.

Lay summary

What is the topic of this article and why is it important?

Many people believe that autism causes a lack of empathy. This belief is a problem because it denies the lived experience of autistic adults and makes them appear as less than human. It can also lead to violence against autistics, and it can mean that empathic autistic adults miss out on an autism diagnosis. As a result, they may not be able to access necessary supports. This situation may cause suffering for autistic adults.

What is the perspective of the authors?

R.H. is an autistic woman diagnosed in adulthood, who is often overwhelmed by too much empathy. She worked as an employment mentor for autistics and is now a PhD candidate researching relationship-building between autistic service users and their support professionals. H.B. is an autistic man diagnosed in childhood. As a teenager, he was also diagnosed with post-traumatic stress disorder (PTSD), a mental disorder caused by trauma. He did not feel any empathy for most of his life and felt very distressed by this, as he thought that it was a permanent trait of his autism. However, he started feeling empathy after trauma therapy and falling in love. Both authors believe that autistic adults can experience all forms of empathy.

What arguments do the authors make?

The authors cite research that shows other reasons which may explain the autism–empathy myth: (1) nonautistics may not recognize empathy in autistics because of mutual differences, (2) nonautistics may not believe autistics who say they have empathy because old research suggested that this is impossible, and (3) empathy research on autistics may not be correct because it uses inappropriate methods. The authors then suggest that unrecognized PTSD may be the reason why some autistics have difficulties in this area. They think so because PTSD can shut down emotional empathy. Autistics are more likely to experience trauma, more vulnerable to developing PTSD, and less likely to receive a diagnosis of PTSD than nonautistics.

What do the authors recommend?

• 1.Researchers should work with autistic adults who report difficulty in feeling empathy to determine whether they may have PTSD and/or recover empathy after trauma therapy.
• 2.Professionals who support autistic adults should look beyond autism if their client identifies a lack of empathy as part of their challenges.
• 3.Clinicians should treat questions relating to empathy with caution when using autism screening/diagnostic tools, allowing empathic autistic adults to access diagnosis and appropriate supports.

How will these recommendations help autistic adults now or in the future?

We hope that this will lead to better support for autistics who have PTSD, and less biased referral and diagnostic procedures for those who do not. We also hope that autistic adults might feel less stigma by suggesting PTSD, not autism, as the underlying cause if they have difficulties feeling empathy.

Introduction

This article integrates the perspectives of two autistic adults who, while sharing the experience of neurodivergence, have disparate cultural and emotional backgrounds. R.H. spent the first 11 years of her life in communist East Germany in a constant state of overwhelm due to excruciating amounts of affective empathy and sensory issues. She received an autism diagnosis in adulthood and is now a doctoral candidate researching the relationship-building experiences of autistic adults with their health care and support providers. H.B. grew up in New Zealand in a constant state of detachment due to a total lack of affective empathy, receiving a diagnosis of Asperger's in childhood and of post-traumatic stress disorder (PTSD) at age 17. He is now a bouldering enthusiast and part-time cleaner.

Having known each other since 2014, we often returned to discussions of our biggest difference, affective empathy. In R.H.'s professional experience as an employment mentor for autistic adults, an affective empathy deficit was not a feature of autism; yet, here was H.B. who vehemently contradicted her viewpoint. This article is the result of our persistent grappling with the tension produced by these discussions, each trying to explore the other's viewpoint without being able to inhabit it. This tension was resolved after H.B.'s epiphany and subsequent emergence of affective empathy, which he describes in the second part of this article. In telling H.B.'s story, we want to reconcile the viewpoints of autistic advocates and autism researchers, admitting that autistics may indeed experience decreased affective empathy but rejecting autism as the “cause.” Instead, we draw attention to PTSD as a possible factor mediating the ability to access affective empathy, aiming to encourage the assumption that the potential for affective empathy may always exist—in every person, regardless of their neurotype and regardless of how they may present in the moment.

Autism and Empathy

Academic literature has long associated autism with empathy deficits,^1–3 even identifying it as a “subclass of empathy disorders”⁴ despite the fact that empirical evidence is inconclusive^5,6 and self-report measures flawed.⁷ Frith, for instance, portrayed autism “as an extreme form of egocentrism with the resulting lack of consideration for […] and disregard of others” caused by a “failure of empathy.”⁸ While early theories posited a global empathy deficit in autistic people,⁹ contemporary researchers limit assumed empathy impairments to the cognitive domain, also known as impaired theory of mind or mindblindness.^3,10 Cognitive empathy refers to the ability to guess others' mental states based on nonverbal cues such as facial expressions,³ and it may be summed up with, “I can tell what you think.” Affective empathy and motor empathy, however, have been demonstrated as intact or heightened in autistic people.^5,11–16 Affective empathy refers to the capacity to be emotionally affected by others' feelings¹⁷ and may be summed up with, “I feel what you feel.” Motor empathy refers to the unconscious imitation of others' movements or body language¹⁸ and may be summed up with, “I'm yawning because I saw you yawn.”

Empathy-deficit theories of autism have thus been attenuated over time; however, the assumption of a cognitive empathy deficit as an intrinsic trait of autism remains problematic for several reasons. First, popular representations of autistic people tend to simplify and distort academic discourse, conflating different types of empathy and portraying autistics as “psychopaths”¹⁹ or “monsters,”²⁰ a stereotype that “Western popular culture's understanding of autism spectrum diagnoses largely relies on.”²⁰ These representations not only stigmatize autistic people but also ignore the many voices from the autistic community who insist that a lack of empathy is not part of their neurotype.^21–24 Indeed, resources created by autistic adults describe their often intense experience of all types of empathy^25–28 and criticize empathy-deficit theories as the most harmful and stigmatizing of all theories of autism.^29,30 This stigma is primarily rooted in autism orthodoxies that spring from the medical model of disability, which has traditionally dominated autism research, delivery of services, and interventions, and has been widely critiqued for being “exclusively etic and explicitly oriented to finding and eradicating flaws through therapy, treatment, or training.”³¹ It disempowers autistic people, defining them by their “deviation from statistical or idealised norms of observed behaviour”³² and placing the onus of change on them. What is more, in the context of empathy research, some authors appear to have elevated these idealized norms to proxies for humanness. For instance, in an article discussing the “mindreading deficits” of autistics, we find the statement that “a theory of mind remains one of the quintessential abilities that makes us human.”³³ With autistics thus established as not quite human, the path was clear for rationalizing violence against them under the guise of therapy or, ultimately, of release from a life not worth living: as Yergeau has cogently argued, empathy-deficit theories of autism create “a meta-narrative for such violence,” which “subjugates and discards autistic bodies.”³⁴ In other words, these theories provide a storyline to justify why autistic people should either be trained to hide their autism, or be hidden away in institutions.

In addition to sanctioning violence from others, empathy-deficit theories may also encourage the development of a negative self-image within the person so theorized. As was the case with H.B., autistic people may internalize assumptions of their diminished humanity: for how we are classified changes “how we can think of ourselves, […] our sense of self-worth, even how we remember our own past.”³⁵ In short, theories about “our kind” feed back into our self-image. Illustrating this effect, a commentator on an article linking empathy with being “truly human” wrote, “I am on the autism spectrum. Since it is empathy that makes YOU all ‘truly human,’ I cannot be human.”³⁶ Although the article did not mention autism, the commentator felt that the link was implicit and saw his own humanity under attack as a result.

Finally, empathy-deficit theories of autism not only harm those already diagnosed, but they may also prevent autistic adults from accessing diagnosis unless they perform their disability according to theoretical expectations manifest in autism screening tools and standardized diagnostic instruments. For adults, these comprise the Empathy Quotient (EQ), the Autism Quotient (AQ), the Adult Asperger Assessment (AAA), and the Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R).³⁷ The EQ exclusively screens for empathic traits, and primary care physicians may use it to verify whether a referral for a more complex diagnostic autism assessment is warranted.³⁸ In the AQ, which its creators, Baron-Cohen et al., described as “a valuable instrument for rapidly quantifying where any given individual is situated on the continuum from autism to normality [sic],”³⁹ 10% of questions focus on empathy.⁴⁰ The AAA combines elements of the AQ and the EQ and specifically includes “lack of empathy”⁴¹ as a criterion, whereas in the RAADS-R, approximately one quarter of questions focus on empathy.⁴²

While the pressure to perform one's stigma is a pan-disability issue,⁴³ it becomes particularly overwhelming in the context of autism diagnosis, which is based on the observation of traits via the standardized tools described above.⁴⁴ This expected performance is further complicated by the fact that available tools fail to distinguish between different types of empathy, reflecting early understandings of autism. Despite the narrowing of contemporary empathy-deficit theories to include only cognitive empathy, all autism screening tools include statements relating to affective empathy; such as, “[s]eeing people cry doesn't really upset me.”³⁸ This leaves the person being screened with two options: lie and be referred for diagnosis but risk being marked as inhuman or tell the truth and risk being disqualified from an autism diagnosis, losing all potential supports.

Possible Causes for Perceived Empathy “Deficit” in Autistic People

Why is it that, despite protests from the autistic community, screening tools continue to include a global empathy deficit as a criterion for referral for a formal autism assessment? The mechanism at work may be rooted in epistemic injustices; for instance, “epistemic erasure,”⁴⁵ by which any empathy-related resources created by autistic people may be metaphorically erased by clinicians and researchers who assume that autistics, due to their lack of empathy, are not qualified to speak about it. Similarly, testimonial injustice⁴⁶ and willful hermeneutical ignorance⁴⁷ may prevent clinicians from recognizing the validity of autistic testimony, discounting it as “confusing and even bizarre,”⁴⁸ or judging that autistic people “misperceive their circumstances.”⁴⁸

However, epistemic injustices cannot account for the plethora of studies that originally identified a lack of empathy as a trait of autism. Several additional factors may play a part: first, outcomes of clinical experiments designed to test cognitive empathy may not be transferable to real-life scenarios if procedures rely on the presentation of isolated stimuli such as black-and-white photographs showing only a person's eyes, which remove crucial nonverbal cues participants may otherwise use to identify emotion in others.²⁹ Second, even tests using rich audiovisual material may distort outcomes due to alexithymia, a co-occurring condition that may prevent autistic participants from identifying an emotion despite feeling it.^49,50 Third, affective hyper-empathy, along with sensory and emotional overload,^13,51–53 may lead to “increased reappraisal, probably to overcome overarousal and personal distress,”¹⁴ preventing expected empathic behaviors despite the subjective experience of empathy, as R.H. has experienced. And fourth, neurotypical observers may not recognize any type of empathy in autistic people if it is expressed in nonnormative ways,^29,54,55 as H.B. has experienced. Indeed, normative interpretations of autistic practices are “often felt as invasive, imposing and threatening by an autistic person”⁵⁶ and thus may themselves trigger trauma-related responses along with a shutdown of empathy in the autistic person.

Our own positioning regarding perceived empathy deficits in autistic people aligns with what Milton called the “double empathy problem,” positing a bilateral breakdown in understanding between autistics and neurotypicals.^32,56,57 In other words, lack of empathy goes both ways as neither group is equipped to imagine what the other's life experiences entail. While Milton was the first to define the double empathy problem formally as “a disjuncture in reciprocity between two differently disposed social actors,”⁵⁶ other scholars had previously drawn attention to the issue. Gernsbacher, for instance, advised that “reciprocity needs to be developed more purposefully by non-autistics and applied more generously toward autistics,”⁵⁸ whereas Shore concluded that “the theory of mind issue cuts both ways.”⁵⁹ Recent research adds weight to the double empathy interpretation: for instance, when tasked with relaying a story, pairs of autistic people reported significantly better rapport and demonstrated more empathy and understanding than mixed autistic/neurotypical pairs, as well as retaining and passing on more information.⁶⁰ In other studies, neurotypical observers showed no more empathy with autistics than autistics did with neurotypicals,^61,62 and had as much^63,64 or more⁶⁵ difficulty in interpreting their mental and emotional states than autistics did in return. To address the double empathy problem, we follow Price and Kerschbaum's take on critical disability studies, considering it as “not about studying the supposedly broken bodyminds of the abject. Rather, it is about studying broken systems, broken attitudes, broken gazes.”⁶⁶ Accordingly, we situate breakdowns of empathy not within the autistic person but within “broken” social environments. At the same time, however, we do not want to ignore those in the autistic community who do self-identify a difficulty in empathizing with others, as was the case with H.B. The following section represents our attempt at sense-making of his experience.

Trauma, PTSD, and Affective Empathy

It could be argued that epistemic injustices, flawed methodologies, emotional overload, nonnormative expression, and the double empathy problem cannot explain all instances where decreased empathy is postulated in, or self-identified by, autistic people. Assuming that empathy “deficits” are not intrinsic to autism, we suggest that PTSD may instead play a part. While several mental health conditions and divergent neurologies have been theorized to impact empathy,^67–70 we focus here on the role of PTSD.^71–73 This focus is inspired by H.B.'s experience and by the fact that PTSD is characterized by “detachment or estrangement from others”⁴⁴ and “avoidance/emotional numbness or social withdrawal and emotional paralysis,”⁷² creating overlaps with traits often postulated in autism.⁴⁴

Brain imaging has demonstrated that “trauma alters neural responses that underpin the affective and cognitive components of empathy,”⁷¹ changing the parts of our brains responsible for processing empathy. Studies on the precise nature of these changes are inconclusive: while childhood trauma without consequent PTSD may increase affective empathy in adults,⁷⁴ if PTSD develops, affective empathy is impaired and empathic resonance lowered.^72,73 Some debate exists around whether PTSD also impairs cognitive empathy; however, if present, this impairment appears to be nonsignificant.⁷³ The main point of difference between empathy-related difficulties theorized in PTSD and autism, then, is the focus on impaired affective empathy in PTSD versus impaired cognitive empathy in autism. H.B. was confronted with both types of empathy impairment: a psychologist's assessment drew attention to his “lack of” cognitive empathy when he was a teenager, and deep introspection revealed an inability to feel affective empathy. He responded to the assessment by dedicating himself to the study of cognitive empathy until he could perform it to normative standards. However, despite equal efforts toward affective empathy, H.B. continued to identify with accounts of impaired affective empathy shared by PTSD sufferers online; for example, “I, to my own dismay, had the urge to laugh about [friends'] perceived traumas […] I could not empathise,”⁷⁵ and, “[f]earing that I don't really care is the worst.”⁷⁶

Factors mediating vulnerability to PTSD following trauma—and therefore vulnerability to decreased affective empathy—remain unclear, with likely variables including “temperamental reactivity, and anxiety disorders,”⁷¹ other “prior mental disorders,”⁴⁴ frequency of traumatic events,⁷⁷ as well as availability of social support structures.⁴⁴ Even more uncertainty marks research on trauma and autism, which is still “in its infancy, leaving more questions than answers.”⁷⁸ We do know, however, that autistics experience all the above vulnerability factors and may, therefore, be more prone to developing PTSD than neurotypicals. First, atypical communication and poor social networks may prevent autistic trauma survivors from reporting abuse and accessing assistance⁷⁷; second, they are affected by anxiety disorders and other mental health conditions at a higher rate than their nonautistic peers^79–84; third, hyperreactivity of the hypothalamic–pituitary–adrenal axis, which is common in autistics, causes heightened stress responses to sensory and social stimuli that are not recognized as traumatic for neurotypicals⁸⁵; and fourth, autistic children experience recognized sources of trauma, such as peer victimization or abuse, more frequently than their nonautistic peers.^86,87 They may also be exposed to an additional source of trauma related to applied behavior analysis (ABA). Considered the “gold standard”⁸⁸ in autism therapy, ABA is correlated with a significantly increased risk of developing PTSD: 46% of exposed autistic participants (n = 460) in one study met diagnostic criteria for PTSD.⁸⁹ Accordingly, the lifetime prevalence of diagnosed PTSD among autistics is at least double that of neurotypicals (17% compared with 6%–9%),^44,90 with lifetime prevalence of probable PTSD (meeting diagnostic criteria but not officially diagnosed) at a staggering 64% compared with 8%–12%.⁹¹ It comes as no surprise, then, that many autistic blogger/activist sites and forums reference PTSD caused by institutionalization, ABA, bullying, assault, or abuse,^92–99 with one contributor considering PTSD “inevitable”¹⁰⁰ for autistics without access to supports.

Considering both the increased vulnerability of autistics to PTSD⁹⁰ and the increased lifetime prevalence of PTSD in this population, we argue that PTSD may be present in those experiencing decreased affective empathy. Although we could not find specific mention of the relationship between empathy, autism, and PTSD, the attempt to unravel intertwining traits and symptoms of the two conditions is a common theme in autistic online spaces.^101–103 Blogger Urocyon, for instance, condemned “the lasting effects of ill treatment being attributed to autism itself.”¹⁰⁴ Daxer asserted that “[s]ome of the problems we blame on autism are not due to autism at all, but due to the experiences we've had in life,” including “PTSD; after-effects of abuse, neglect, institutional maltreatment, or bullying.”¹⁰⁵ “Theuninspirational” came closest to our argument when she wrote about her “difficulties of being close to other people” as “probably” part of her complex PTSD instead of autism.¹⁰⁶

The following narrative by H.B. illustrates our argument: unrecognized PTSD may explain decreased affective empathy in some autistic people. His story reflects the voices of autistic advocates discussed above, who criticized empathy-deficit theories as the most stigmatizing of all theories of autism.

I Guess I'm Human After All

I can't remember having emotional empathy at any point in my life, and I believed this would be my reality forever. Because I'm autistic. For a long time, I had forgotten that my life began with trauma—barely sleeping until I was 4 months old and finally received lifesaving surgery, then my parents force-feeding me pink antibiotic sludge through a syringe every day for 3 years. I remember the syringe. That pink syringe. I experienced trauma again at 17. I got great help following that: a trauma therapist, cognitive behavioral therapy, and later an autistic peer mentor. But for a long time, I was dead inside, no feelings at all. In a way, it was good; all the bad feelings were gone. But when I was with other people, I felt like a ghost among the living.

Many autistics seem to have too much empathy; it overwhelms them. They might not be able to express it in a way that neurotypicals can see, but they have it. I didn't. And in that way, I felt alienated from most autistics. It made me feel less—less than. In some ways, I thought, maybe I was a bit evil.

Psychopath?

Not quite human?

If people knew the things I've done, they'd call me nasty, hurtful names. “Monster” was the one that scared me the most. That shot right through to my core. When I saw people connecting with each other, I knew: I couldn't feel that. And that made me sad. I wanted a relationship, but it had to be real. I wanted to care about someone, but I couldn't. It felt impossible to be interested in someone else's well-being more than a casual curiosity into how their mind works. I thought that was selfish—trying to care for someone else was exhausting.

I started learning cognitive empathy as a teenager, after it was pointed out as a problem in a psychologist's assessment. My “special interest” became improving myself. I was around many people observing their behavior, learning the rules of socializing, mostly by doing it and people reacting badly. It was tough. I was still in my own head. I kept trying and eventually I learned how to behave. I'd often help people with their problems, and they told me I was great at it! I was good at active listening and problem-solving without getting clouded by emotions. I was doing the right things, but without feeling the right things.

Then I met Jess.*

We were having a conversation,

an honest conversation.

She's great at that.

It's the reason we connected in the first place.

I just felt … holy shit!

I could feel things! I cared!

I'd never said the word “love” to anyone.

I knew I couldn't say “I love you.”

I said,

“I want to give my love to you.”

It surprised the hell out of me.

It was magical.

I'd suddenly hit emotional empathy.

That was without a doubt the most valuable experience of my life, but also one of the hardest. I didn't handle it well at first. Suddenly, my life was ruled by my feelings and empathy for Jess. I couldn't think about anything else—it was all-consuming. My heart yearned for her.

I'm glad I learned cognitive empathy first and that I could already do the nonjudgmental, compassionate thing well, both for others and myself. If I had got into that sort of emotional space any earlier, it would have killed me.

Over time, with lots of self-awareness and talking about my feelings with Jess, I learned to handle it better. I still feel the same intensity of emotions, but I've learned to selectively empathize and pull back when I must. I found a healthier version of love. In the end, I accepted that we weren't going to be together. We've developed a healthy friendship.

Before, there was nothing.

Now, I could feel.

I'm changed.

It feels like anything in the world could affect me now.

I feel a lot more vulnerable.

I'm scared, because not having emotional empathy was a key feature of my life. It enabled me to think purely logically. I liked that it felt cold and calculated, and I'm afraid of losing that part of me. I now feel all sorts of emotions—frustration, sadness, peacefulness, hope, distant happiness—mixing together as intense physical sensations. I don't know how to harness this energy, or whether I will forever lose my pure logical thinking in exchange for emotional empathy. But at least I know that relationships are possible.

I will always treasure this experience and the woman who made it happen. She is a true heart surgeon and I will always love her for it.

I guess I'm human after all.

Conclusion

H.B.'s narrative demonstrates the dehumanizing effect of associating decreased empathy with autism, tracing his difficulties with both cognitive and affective empathy. While he describes learning cognitive empathy in a process of trial and error, affective empathy remained absent—causing a sense of alienation not only from neurotypicals but also from other autistics. In sharing H.B.'s anguish about his perceived inhumanity, we want to remind autistic readers that they are not alone and, indeed, the “experience that one is unable to establish meaningful connections with others is a common source of distress for the traumatized individual.”¹⁰⁷ Furthermore, if researchers and autism advocates are correct that lack of affective empathy is unrelated to the autistic neurotype, the disconnect may pass: H.B.'s story shows that even someone who believes that their autism permanently prevents them from experiencing affective empathy has the capacity to develop it. He eloquently describes regaining affective empathy as a result of falling in love, a process he compares to open-heart surgery. H.B. points out, however, that the timing was right for him to undergo this “heart surgery” without dying on the metaphorical operating table: having spent years working on his PTSD with the support of mental health professionals, he had the tools to manage the intense emotions that followed.

Recommendations

In this perspective piece, we are not aiming to generalize one person's experience to the entire autistic population, but to prompt research that may prove or disprove our idea. Until this research is conducted, we hope that our recommendations may still inspire new conversations and approaches for anyone who resonates with this piece.

For autistic adults:

• We hope that any autistic adults who feel that they have difficulty in empathizing can take heart from H.B.'s journey—knowing that what feels like a permanent trait may be a temporary response to trauma.

• We would like to encourage them to address the possibility of support for PTSD with their mental health professional. If they, like H.B. before his epiphany, do not recall any early childhood trauma, it may be valuable to ask parents and caregivers about possible events known as potential sources of trauma, such as surgery, ABA, or bullying.

For researchers:

• We recommend a rigorous investigation of the possible interactions between autism, trauma, PTSD, and affective empathy.

• Future studies should involve autistic adults from diverse backgrounds who report difficulty in feeling affective empathy and determine whether they may have PTSD.

• Longitudinal studies should investigate if autistic participants recover affective empathy following therapy for PSTD.

For clinical and support professionals:

• As many autistic adults may meet the diagnostic criteria for PTSD but miss out on appropriate support because their PTSD-related symptoms are erroneously conflated with autism traits, professionals should look beyond autism if their client identifies a lack of affective empathy as part of their challenges.

• Clinical assessment tools for PTSD, being designed for use with neurotypical clients, may need to be adapted or used more flexibly for accurate identification of PTSD in autistic adults, particularly those with alexithymia who may have difficulty describing trauma-related emotions.

• When using screening tools for autism, clinicians should treat questions relating to affective empathy with caution, allowing empathic autistic adults to access diagnosis and appropriate supports.

Authorship Confirmation Statement

R.H. conceived of the article and was responsible for the literature review, recommendations, and conclusions. H.B. is the owner of the story and collaborated with R.H. on the construction of its narrative, as well as advising on clarity of language in the entire article. Both co-authors have reviewed and approved the article before submission. The article has been submitted solely to this journal and is not published, in press, or submitted elsewhere.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received.