Sexuality in High-Functioning Autism A Systematic Review

Prévia do material em texto

ORIGINAL PAPER
Sexuality in High-Functioning Autism: A Systematic Review
and Meta-analysis
Laura A. Pecora1 • Gary B. Mesibov2 • Mark A. Stokes1
� Springer Science+Business Media New York 2016
Abstract Preliminary research examining sexuality within
High-Functioning Autism (HFA) has been yet to consider
the impact sex may have on the sexual/romantic func-
tioning of this population. A systematic database search
was carried out to identify 27 observational and cross-
sectional publications meeting predetermined inclusion
criteria. Using standardised mean differences, a random-
effects meta-analysis pooled data from 9 eligible studies.
Exhibiting higher levels of sexual understanding, females
with HFA were subject to more adverse sexual experiences
than males with HFA and neurotypical counterparts. Males
reported greater desire for, and engagement in both solitary
and dyadic sexual contact. Findings have provided initial
insight into characterising the sexuality of males and
females with HFA, yet also necessitated the need for future
research in the field.
Keywords Autism spectrum disorder � High-functioning
autism � Sexuality � Female profile � Systematic review and
meta-analysis
Introduction
Autism Spectrum Disorders (ASD) are a heterogeneous
group of neurodevelopmental conditions with preva-
lence estimates that have risen 100-fold since its initial
conception (Blumberg et al. 2013). Within phe-
nomenological literature, one of the most consistently
cited, yet widely unexplained observations has been the
overrepresentation of males in ASD, with a male:
female sex ratio that currently ranges from 2:1 to 3:1
(Goldman 2013; Lai et al. 2013). Recognising that
previous diagnostic classification systems and the
majority of research has been primarily focused on the
symptom characteristics of the male phenotype; more
recent literature aiming to uncover the unique presen-
tation of ASD in females has identified marked sex
differences in a range of social, emotional, and cogni-
tive domains in child and adolescent samples (Carter
et al. 2007; Mandy et al. 2012; Head et al. 2014;
Nichols 2009). Some of these include less severe social
and communicative impairments in females, and
restricted special interests that are more closely aligned
with those seen in typically developing (TD) peers
(Gould and Ashton-Smith 2011; Head et al. 2014;
Mandy et al. 2012; Van Wijngaarden-Cremers et al.
2014). Moreover, females have also been found to cope
and apply adjustment strategies in such a way that they
imitate appropriate social skills in neurotypical (NT)
circles, seeing that they are more likely to effectively
mask their symptoms, and thus evade diagnosis (Att-
wood 2009, 2013; Head et al. 2014). This has inter-
vention implications particularly for those affected
females that exhibit milder symptoms and higher IQs
(recognised as High-Functioning Autism; HFA), who
do not fit into this typical male-oriented clinical
& Laura A. Pecora
lpecora@deakin.edu.au
1 School of Psychology, Faculty of Health, Deakin University,
221 Burwood Hwy, Burwood 3125, Australia
2 Division TEACCH, University of North Carolina,
Chapel Hill, NC, USA
123
J Autism Dev Disord
DOI 10.1007/s10803-016-2892-4
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description, often fail to reach current diagnostic
thresholds, and thus receive much-needed support.1
The difficulty in gaining a clear understanding of
females with HFA may have been further compounded by
the sex differences in sociability and friendship skills that
have been found in adolescents and adults in recent years
(Head et al. 2014; Nichols 2009). While broader ASD lit-
erature has clearly demonstrated that the social and emo-
tional deficits typical to the disorder often see that
individuals of both sexes lack the critical skills necessary to
establish peer interactions and friendships through child-
hood (Bauminger et al. 2008; Chan and John 2012; Ors-
mund et al. 2014); a small series of empirical studies are
suggesting that the extent to which these deficits manifest
themselves may also be dependent on sex. Using Baron-
Cohen and Wheelwright (2003) Friendship Questionnaire
(FQ), both the original authors and Head et al. (2014)’s
recent research have all observed not only higher levels of
sociability and more advanced friendship skills in HFA
females but similar understandings and experiences of key
friendship characteristics between females with HFA and
TD males. These findings are in line with Attwood’s (2007)
and Nichols’ (2009) clinical observations of which have
cited comparative levels of social knowledge and com-
munication in HFA female when compared to TD male
groups. Although the reliable interpretation of these find-
ings is hindered by the low internal consistency of the FQ
(Head et al. 2014), when taken together, these results high-
light the possible existence of sex differences in the social
and emotional functioning of individuals with HFA; the
potential for a female phenotype that corresponds with TD
male characteristics; and plausible new approaches to the
assessment and diagnosis of the disorder (Nichols 2009).
As individuals with HFA mature into adolescence, the
social and communicative difficulties that accompany
diagnosis have a profound effect on the areas of sexual
development of sexuality; and often create challenges in
the initiation and maintenance of intimate and sexual
relationships (Bauminger et al. 2008; Gougeon 2010).
While current definitions of sexuality are broad and often
ill-defined, the World Health Organization (WHO 2006)
recognises sexuality as a central aspect of humanity that
encompasses sex, intimacy, and sexual identity; and is
experienced through thoughts, desires, attitudes, beha-
viours and relationships. Thus, sexuality is an integral
aspect of healthy human development, having been closely
linked to high relationship quality and psychological
wellbeing across the entire course of adulthood (Byers
et al. 2013b; Byers and Nichols 2014).
To date, no existing empirical literature has investigated
the sexuality of females with HFA independently. How-
ever, in recent years, new bodies of research have begun to
uncover a unique sexual profile of the wider HFA popu-
lation irrespective of sex, shedding some light on the
sexual functioning of both males and females in this group.
Such research has demonstrated that despite displaying
age-appropriate developmental trajectories and an interest
in sexuality at levels corresponding to those found in the
TD population; poor social competence and limited peer
relationships often means that individuals with HFA have
fewer social sources and opportunities to obtain accurate
information concerning sexuality (Gilmour et al. 2012;
Mehzabin and Stokes 2011; Ousley and Mesibov 1991;
Stokes and Kaur 2005; Stokes et al. 2007). As a conse-
quence, many individuals lack the appropriate knowledge
and skills required to successfully express their sexuality
and initiate desired relationships. While this has led some
to naively engage in inappropriate sexual and courting
behaviours, it also places those on the spectrum at a higher
risk of unintentional sexual offending and victimisation
(Howlin 1997; Sevlever et al. 2013; Stokes et al. 2007).
Upon recognition of these difficulties, parent reports and
research findings both suggest the development of struc-
tured programs and services specifically tailored towards
supporting and educating individuals with HFA to facilitate
the development of a fulfilling romantic and sexual life
(Hayward and Saunders 2010; Sevlever et al. 2013).
To date, only three published articles have examined
sexuality in males and females independently (Byers et al.
2013a, b; Hénault and Attwood 2006). Mirroring obser-
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J Autism Dev Disord
123
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A
J Autism Dev Disord
123
(n = 9), included alternative comparison groups other than
HFA versus TD (n = 3), reported data on the all-inclusive
ASD population (and thus examined ASD symptoms that
could be compounded by ID, n = 3), and measured a
variable of sexuality that was not included in other studies,
seeing that it was incomparable with existing variables
included for quantitative synthesis (n = 3). A total of nine
publications examining sexuality in HFA were deemed to
meet study eligibility criteria, and thus retained for meta-
analysis.
Study Characteristics: Methods and Participants
All quantitative studies examining sexuality in the HFA
populationwere published from 2005 to 2015, and employed
the use of cross-sectional designs. Collectively, these studies
provided self, parent, or carers reports on 1031 participants,
with sample sizes that ranged from 28 to 300. Within this
sample, 528 (289 males, 239 females) participants were
diagnosed with either HFA or AS; 447 (250 males, 197
females) were TD, and the remaining 56 were a Down syn-
drome comparative group included in Kaur’s (2009) study.
All participants (excluding parents) were adolescents or
adults, and ranged from 10 to 39 years of age. Of the six
studies that assessed self-report data, four employed an adult
sample (M = 33.9 years), while two examined adolescents
(M = 18.9 years). The three remaining studies included for
meta-analysis examined parent/carer’s reports of adoles-
cents with ASD (M = 17.5 years).
All subjects in included studies had received a formal
diagnosis of AS/HFA or equivalent prior to participation.
The initial diagnostic criteria and methods used to ascertain
cases of ASD ranged from professional diagnosis from a
mental health or medical professional using DSM-IV
(n = 3), or DSM-IV-TR (n = 5) criteria. One included
study did not specify the diagnostic criteria or means of
initial diagnosis of the sample. Four of the included studies
also offered some confirmation of ASD diagnosis through
the use of the AQ.
Study Characteristics: Interventions and Outcomes
Individual meta-analyses were conducted on each of the
DVs measured by two or more included studies in this
review. In the set of meta-analyses examining sex differ-
ences in sexuality within the HFA population, eight DVs
were identified. These included: (1) sexual knowledge, (2)
sexual anxiety, (3) sexual arousability, (4) desire for soli-
tary sexual activity, (5) dyadic desire, (6) frequency of
solitary genital activity, (7) level of sexual problems, and
(8) incidence/frequency of positive sexual cognitions.
While levels of sexual knowledge were also examined in
the exploratory meta-analyses investigating sexuality in the
wider HFA population against TD individuals, these anal-
yses also measured an additional five sexuality variables,
which included (1) sources of sexual knowledge, (2)
engagement in social behaviours, (3) engagement in
(inappropriate and appropriate) sexual behaviours, (4)
privacyrelated issues, and (5) level of parental concern. All
included studies investigated each DV through a range of
self-report questionnaires and scales that were either
developed for study purposes, or used successfully in
previous investigations on TD samples. Table 1 reports a
detailed description of each study reviewed via qualitative
and quantitative synthesis (Table 1).
Synthesis of Results
The meta-analyses examining sexuality in males and
females in the HFA population found significant sex dif-
ferences on six of the eight dependent variables measured.
While several important conclusions regarding overall
gender differences in sexuality can be drawn from the lit-
erature and are worthy of consideration; a comprehensive
discussion of the variables measured in all meta-analyses is
beyond the scope of this paper. As such, this section of the
review will synthesise findings on the DVs that were
observed exclusively in HFA female samples; and will
draw from both additional analyses performed in this study,
and existing research on gender differences in sexuality
within the TD population for comparison purposes only.
Sexual Understanding
Sexual Anxiety and Problems Overall, females with HFA
reported experiencing higher levels of sexual anxiety
(d = -0.78; p\ .05; 95 % CI -1.50 to -0.05; k = 2),
and a greater number of sexual problems than males with
HFA (d = -0.71; p\ .001; 95 % CI -1.10 to -0.33;
k = 2). The magnitude of these sex differences was mod-
erate, approaching a large effect (d[ 0.71). Nichols’
(2009) clinical observations noting greater endorsement
and experiences of affective factors related to sexuality-
related distress, anxiety and problems amongst females
than males with HFA further support these findings.
Sexual Knowledge Inconsistencies were observed in
levels of sexual knowledge, where higher rates in both
males (Byers et al. 2013b), and females (Byers et al. 2013a;
Hénault and Attwood 2006) were reported by included
studies. To date, Attwood’s (2009) clinical accounts exists
as the only identifiable literature examining sources of
sexual knowledge in HFA females. Like the wider HFA
population, these observations have also cited that media
outlets (i.e.: soap operas, films etc.) exist as the most
prominent source of sexual knowledge for females with
J Autism Dev Disord
123
HFA, which are thus often misinterpreted as social scripts
of appropriate behaviours to engage in when pursuing
relationships. No significant sex differences were observed
in frequency of sexual cognitions, although two of the three
included studies reported higher rates in males with HFA
(Byers et al. 2013a, b).
Sexual Identity and Orientation While not examined via
quantitative synthesis, nine included studies investigated or
reviewed existing findings on measures relating to sex-
ual/gender identity and sexual orientation amongst both
HFA and wider ASD groups (Bejerot and Eriksson 2014;
Byers et al. 2013b; Dewinter et al. 2013a; Gilmour et al.
2012; Glidden et al. 2015; Haracopos and Pederson 1992;
Hellemans et al. 2007). Focusing on persons with HFA
living in institutionalised settings, Haracopos and Pederson
(1992) and Hellemans et al. (2007) collectively examined
caregiver’s reports of the sexual orientation of 66 adoles-
cents using use of nation-wide and experimental surveys.
Taken together, 15–35 % of all participants displayed
exclusive homosexual or bisexual orientations, which when
contrasted to the estimates of homosexuality in TD
American and British populations (4.6, 5.4 %), demon-
strate considerable differences between the two groups
(Chandra et al. 2011; Johnson et al. 2001). Similarly,
Gilmour et al. (2012) and Byers et al. (2013b) found higher
scores on dimensional measures of homosexuality and
bisexuality, and lower on measures of heterosexuality in
adults with HFA when compared to TD controls. Extend-
ing onto examinations of gender identity in wider ASD
groups, Glidden et al.’s (2015) systematic review of case
control studies and clinical reports (n = 7) also identified
both significantly higher group means on AQ scores in
transgendered patients; and a co-occurrence of a-typical
gender identity and gender dysphoria amongst adults with
ASD (11.5 %) when compared to matched control groups
(3.6 %).
Gilmour’s community-based study was the only identi-
fiable source to exclusively examine gender differences in
reported sexual identity and orientation in HFA (n = 82),
and the first to demonstrate significantly lower levels of
heterosexuality in females despite no significant gender
differences in identified sexual orientation in the study’s
comparative sample of 282 TD controls. Bejerot and
Eriksson (2014) examination of sexuality and gender role
in ASD, which found rates of bisexuality to be four times
more frequent in females with ASD than female controls
and an overrepresentation of masculinised gender beha-
viour and identity in this group, also support notions lower
rates of heterosexuality in females with HFA. However, as
this study was performed on individuals across the spec-
trum of ASD, findings cannot be applied to conclusions
drawn on the HFA population only.
Sexual Contact
Sexual Desire and Arousability Significant gender dif-
ferences were observed in levels of sexual desire and
arousability (d = 2.09; p\ .001; 95 % CI 0.31–3.86;
k = 2), desire for both solitary sexual activity (d = 0.81;
p\ .001; 95 % CI 0.55–1.06; k = 2) and a dyadic
romantic or sexual relationship (d = 1.29; p\ .05; 95 %
CI 0.23–2.36; k = 3); which were reported as significantly
higher in males in all quantitative studies included in this
review. Moderately large d values ([.80) were obtained for
the three reported measures, suggesting considerable sex
differences in these areas of sexuality. Examining general
levels of sexual arousability, and then desire to engage in
solitary sexual activity (masturbation), Byers et al.’s
(2013a, b) canonical and zero-order correlations indicated
significantly higher self-reported levels in males with HFA
across both measures of sexuality. Consistent with these
findings, Hénault and Attwood’s (2006) cross-sectional
research also identified large gender differences in levels of
sexual desire amongst individuals with HFA, with males
reporting a greater desire for the engagement in both sexual
and romantic relations than females.
Engagement in Sexual Behaviour Examination of gender
differences in levels of engagement in sexual behaviour is
limited to a single quantitive analysis (Hénault and Att-
wood 2006), and thus was not examined via meta-analysis
in this review. This study did however identify a greater
proportion of females (76 %) had engaged in some form of
sexual behaviour than males (68 %) with HFA.
Masturbation Of the five studies that examined rates of
masturbation according to gender (Byers et al. 2013a, b;
Dewinter et al. 2013b; Haracopos and Pederson 1992;
Ousley and Mesibov 1991); significantly higher levels of
both observed and reported incidence and frequency of
masturbation were found amongst males with HFA
(20–77.8 %) when compared to females [(1–54.2 %)
d = 1.45; p\ .001; 95 % CI 0.76–2.13; k = 2] (Fig. 1).
Homogeneity Analysis
Homogeneity analysis (using v2) indicated significant
levels of heterogeneity (p\ .10) for six of the meta-anal-
yses conducted on sex differences in HFA. Levels of true
heterogeneity (I2) in these meta-analyses were high, rang-
ing from 84 to 97 %. This is most likely due to the limited
number of included studies in each meta-analysis, which
restrict Q statistic’s power to detect true heterogeneity
(Liberati et al. 2009). However, these studies represent the
entire published literature on these topics, and were gen-
erally consistent in direction and trend suggesting the
J Autism Dev Disord
123
results be accepted, though interpreted with some caution.
Moderate and low levels ofheterogeneity were also
observed in two of the meta-analyses performed; where
examination of levels of sexual problems and levels of
desire for solitary sexual activity gave I2 statistics of 60 and
0 % respectively. Average (pooled) effect sizes (d), 95 %
confidence intervals, and tests of heterogeneity for all
meta-analyses are reported as forest plots in Figs. 2 and 3.
Results of Qualitative Synthesis: Gender Differences
in Sexuality and the HFA Female Profile
Three publications retained for qualitative synthesis
reported descriptions of the HFA female sexual profile
drawn from clinical observations and case reports (Att-
wood 2009; Haracopos and Pederson 1992; Nichols 2009).
These articles collaboratively affirmed that females with
Fig. 1 PRISMA flow diagram
of study selection of sources
examining sexuality in HFA
population
J Autism Dev Disord
123
Fig. 2 Forest plot of sex differences in sexuality: HFA population
J Autism Dev Disord
123
HFA were found to experience puberty, and develop an
interest in sex and sexuality during the same developmental
period, yet experience greater levels of frustration, anxiety,
and social isolation as TD females.
Limited peer relationships and less access to social
sources to gain sexual knowledge than TD peers was noted
to result in HFA females seeking information from inap-
propriate non-social sources; leading to poor character
judgment of potential sexual predators, promiscuity, and a
higher susceptibility to sexual abuse. Two case reports
within the literature have cited higher rates of sexual abuse,
or the sexual misuse of females with HFA/AS, particularly
by TD males (Attwood 2009; Haracopos and Pederson
1992). These sources have indicated that following the
physical changes that accompany puberty, previously
socially excluded teenage females have begun to receive,
and thus positively respond to sexual interests from TD
teenage boys. Due to limited peers to provide appropriate
Fig. 3 Forest plot of differences in sexuality by diagnosis: HFA versus TD
J Autism Dev Disord
123
information on dating protocols and appropriate sexual
codes, the naivety that accompanies the HFA female profile
has led females to fail to recognise the interests of TD boys
as purely sexual, increasing susceptibility to sexual abuse,
and increased levels of parental concern. Consequentially,
results suggest that females with HFA appear to be at
greater risk of a number of adverse sexual experiences than
HFA male counterparts and TD females (Haracopos and
Pederson 1992).
Exploratory Analyses: Differences in Sexuality
by Diagnosis (HFA vs TD)
Exploratory analyses of publications examining sexuality
in the all-inclusive population confirmed previous research
that individuals with HFA develop, and possess the same
levels of interest in sex and sexuality as TD individuals
(Hellemans et al. 2007; Stokes et al. 2007; Ousley and
Mesibov 1991). This was further supported by Hénault and
Attwood’s (2006) study of 28 adults with HFA, who
reported a mean age of developing an interest in sexuality
as 14 years; an average also cited by two narrative syn-
theses of sexuality in TD groups (Baumeister et al. 2001;
Peplau 2003). Overall, this set of analyses identified sig-
nificant differences on the three of the six DVs measured
(see Fig. 3). Findings revealed that individuals with HFA
have significantly lower levels of sexual knowledge
(d = -1.11; p\ .001; 95 % CI -1.44 to -0.88; k = 4);
have less social contact and engage in fewer social beha-
viours (d = 0.12; p\ .01; 95 % CI -1.07 to 1.30; k = 4);
engage in more inappropriate sexual behaviours (d = 0.58;
p\ 0.05; CI 0.07–1.09; 3); and are the subject of greater
parental concern (d = 1.16; p\ .05; 95 % CI 0.15–2.16;
k = 3) than TD individuals. While the magnitude of levels
of sexual knowledge, social contact, and parental concern
were considerably larger (d[ 0.81), engagement in inap-
propriate sexual behaviours was also approaching a mod-
erate to large effect. Although individuals with HFA were
reported to be less likely to obtain sexual knowledge from
social sources such as peers and parents, this effect failed
to approach significance. No significant differences were
found between levels of awareness, and engagement in
privacy-seeking behaviours between HFA and TD samples.
Significant heterogeneity (p\ .10) was detected in all
DVs examined in the exploratory analyses. The degree of
true heterogeneity in these studies was large, with I2
statistics that ranged from 70 to 94 %.
Risk of Bias Across Studies: Publication Bias
Strong evidence of heterogeneity was observed in the
meta-analyses examining gender differences HFA
(I2 = 97 %; p\ .001); as well as the exploratory analyses
investigating differences in measures of sexuality across
diagnosis (I2 = 95 %; p\ .001). In order to further
explore this heterogeneity, funnel plots of subgroup dif-
ferences were examined for asymmetry. All funnel plots
showed evidence of considerable asymmetry, and thus
susceptibility to publication bias. As this effect was most
likely due to the few available studies, studies were not
excluded on this basis. Consequently, the high levels of
heterogeneity reported here should militate against strong
conclusions when interpreting these results. This was
despite stringent measures to include all possible studies.
Discussion
This systematic review identified a total of 13 different
measures of sexuality in HFA across a range of qualitative
and empirical sources. Overall, findings have confirmed that
sexuality and romantic relationships are important to indi-
viduals with HFA. For this population, sexuality is a nor-
mative aspect of adolescent development,where the physical
and sexual changes that accompany puberty, and a clear
interest in sexuality and dyadic relationships occur at com-
parable levels to that of the TD population. However, due to
socio-communication deficits, a corresponding growth in
social and emotional insight was not found to accompany
this development of sexual interest, and has frequently led to
significant problems in the appropriate expression of sexu-
ality and the initiation of successful relationships in this
group (Hayward and Saunders 2010; Stokes et al. 2007).
Sexual Understanding
Development of Sexuality in Adolescence and Sexual
Anxiety
Both caregiver’s and self-reports have indicated that persons
with HFA experience greater difficulties adapting to the
physical changes of puberty, and are thusmore susceptible to
increased psychological symptoms such as anxiety, distress,
and loneliness thanTDpeers (Hellemans et al. 2007;Hénault
and Attwood 2006). Clinical accounts have cited that nega-
tive experiences are even more pronounced for females with
HFA (Attwood 2009; Nichols 2009) because of their greater
interest in social relations and recognition that they do not fit
into the socially acceptable profile of the TD female (Van
Wijngaarden-Cremers et al. 2014). The results of the meta-
analysis investigating gender differences in sexual anxiety,
which revealed higher levels of anxiety and thus poorer
overall sexual wellbeing in HFA females converge with
these observations.
Due to limited peer relationships and reduced levels of
social contact; both parents of, and individuals with HFA
J Autism Dev Disord
123
reported fewer opportunities to acquire the accurate
knowledge and skills to initiate relationships and practice
safe sexual behaviours than TD peers (Dewinter et al.
2013b; Stokes 2012). Consequentially, evidence of con-
siderable differences in the information sources individuals
with HFA utilise to obtain knowledge on sexuality and
relationships when compared to TD controls (Attwood
2009; Brown-Lavoie et al. 2014; Dewinter et al. 2013b;
Stokes 2012; Stokes et al. 2007). Taken together, these
results suggest that the combination of heightened stress
and anxiety that accompaniesnot only a HFA, but a female
HFA diagnosis, is significantly greater than that of TD
males. While this has significant implications for the
healthy development of a fulfilling sexual life in adulthood,
it also highlights the psychological challenges such indi-
viduals face not only as they approach puberty, but as they
continually progress over the entire course of the lifespan.
Sexual Knowledge
Results on sexual knowledge are inconclusive. While
exploratory meta-analyses identified poorer understanding
and lower levels of sexual knowledge in HFA samples
when compared to TD controls, gender differences in both
HFA and TD groups have yielded inconsistent results.
These findings were consistent with the results of the meta-
analysis examining sexual knowledge in the TD popula-
tion, which also identified inconsistencies between studies,
and relatively small individual effect sizes. It is worth
considering that Byers et al.’s (2013a, b) studies examining
gender differences in HFA used an overlapping sample of
predominantly highly-educated female participants (53 %),
and measures of sexual knowledge that had not been
administered or tested previously on HFA. While this may
suggest implications on the potential of practice effects and
poor methodological quality of particular test items, over-
all, too few studies were included in the meta-analyses to
draw firm, conclusions on gender differences in this
measure.
Sexual Identity and Orientation
One of the most interesting observations in numerous
studies retained for qualitative synthesis was the higher
than expected rate of homosexual, bisexual interest and
asexual interest in individuals with HFA when compared to
TD adolescents and adults; and an overrepresentation of
gender dysphoria in the wider ASD group (Bejerot and
Eriksson 2014; Byers et al. 2013b; Dewinter et al. 2013a;
Gilmour et al. 2012; Glidden et al. 2015). These results
agree with anecdotal reports suggesting that due to limited
access to romantic partners in this group, many individuals
with HFA do not identify gender as a relevant
characteristic upon the process of partner selection, and
that limited relationship experience in this group often
hinders understandings of what is meant by sexual orien-
tation, and the normative sexual preferences amongst TD
peers (Lai et al. 2013; Mandy et al. 2012).
Warranting even further investigation in the field, is
both Gilmour et al.’s (2012) and Bejerot and Eriksson
(2014) respective findings of lower reported levels of
heterosexuality, and higher rates of same-sexual attraction
in HFA and wider ASD female groups. Upon consideration
of broader TD literature, which consistently cites greater
erotic plasticity, particularly in the areas of sexual orien-
tation in females, these findings validate the possibility that
such gendered observations may too be reflected in the
HFA population (Baumeister et al. 2001; Peplau 2003).
Moreover, new hypotheses suggesting the co-occurrence of
ASD and alternative sexual orientations in affected females
may also be a reflection of the neural basis of the condition,
and potential links between elevated fetal testosterone and
the development of both masculine brain development and
ASD-related traits may also partly attribute to this finding
(Gilmour et al. 2012; Glidden et al. 2015). While worthy of
future clarification, these initial results suggest that despite
the underlying mechanism driving the expression of gender
identity and sexual orientation within this population, sex
education is required to assist such individuals in their
development of a healthy sexual identity that best fits their
self-concept and is not shaped by perceptions of what is
socially acceptable in the TD population.
Sexual Contact
Sexual Desire and Arousability
The results of these meta-analyses emulate the broader and
well-documented literature of gender differences that exists
on these measures within the TD population. This litera-
ture, which includes a combination of large-scale meta-
analyses, cross-sectional studies, and narrative reviews, has
consistently demonstrated that physiological sex drive and
thus levels of sexual desire are higher, more intense, and
experienced more frequently in TD males than females
across all stages of the lifespan (Baumeister et al. 2001;
Carvalho and Nobre 2011; Peplau 2003; Petersen and Hyde
2010). Thus, when taken together, these findings demon-
strate that the effects of gender on sexual desire and
arousability appear to be consistent with those traditionally
observed in the TD population.
Engagement in Sexual Behaviour
The literature demonstrates that individuals with HFA
demonstrate some form of sexual behaviour, with over half
J Autism Dev Disord
123
of individuals reporting to have participated in sexual
encounters with others including intercourse (Byers et al.
2013a; Dewinter et al. 2013b; Hellemans et al. 2007;
Ousley and Mesibov 1991). Results from all analyses
revealed that overall, parents of adolescents with HFA
reported that their children engage in fewer appropriate
sexual behaviours and have fewer sexual and romantic
experiences than their TD peers. In addition, the average
age of first sexual intercourse for individuals with HFA
(22 years; Hénault and Attwood 2006) was over four years
higher than the mean age reported by TD studies
([17.64 years] Fischtein et al. 2007; Gökengin et al. 2003;
Sohn and Chun 2007; Valenzuela et al. 1990). This suggests
that there may be evidence of a delay in normal sexual
developmental trends in this group (cf. Stokes et al. 2007).
Hénault and Attwood (2006)’s study is the only publi-
cation to examine gender differences in sexual behaviours
and experiences in 19 adult males and 9 adult females
diagnosed with HFA. Despite their small sample size and
under-representation of female participants, their results
suggested that females reported a greater number of sexual
experiences than males. While more research is still needed
to confirm these findings, these results conflict with levels
of sexual behaviour in the TD population, which are sig-
nificantly higher in males of all age groups (Chandra et al.
2011; Gökengin et al. 2003; Mitchell et al. 2014).
Masturbation
One of the largest gender differences observed in this
review was in the incidence and frequency of masturbation.
While observed rates of frequent masturbation in individ-
uals with HFA were lower than those self-reported in
respective TD groups (75–95 %); the gendered pattern of
results was also reflected in studies performed on the TD
population, which consistently cite large gender differences
and more frequent masturbation in males (45–80 %) than
females ([15–41.7 %]; Baumeister et al. 2001; Oliver and
Hyde 1993; Petersen and Hyde 2010). Although reasons for
engaging in masturbation are yet to be examined in the HFA
population, Baumeister et al. (2001) systematic review of
20 cross-sectional publications concluded that the pre-
dominant motive for engaging in masturbation in males was
to achieve sexual gratification. Given that previously cited
meta-analyses reported higher rates of sexual desire, and a
desire to engage in masturbation in males with HFA, it
seems reasonable to assume that like the sexual motives of
neurotypical individuals, masturbation may also be linked
to the strength of sex drive in this diagnostic group.
Moreover, it is possible that the marked gender differ-
ences may also be attributable to male-dominated focus of
sex education programs available for individuals with HFA
at the time included studies were published. While largely
in response to cases of problematic masturbatory beha-
viours, typical sexuality interventions were predominantly
based upon the provision of instructions for the engage-
ment in masturbation within appropriate settings (Cam-
bridge et al. 2003). However, the case studies that report
the useof such teaching approaches have cited greater
concern for, and thus, exclusively male samples (Realmuto
and Ruble 1999; Ruble and Dalrymple 1993), seeing that to
date, there is no existing data confirming the application of
a masturbation-related intervention upon any female with
HFA. This suggests that many females with HFA may not
have had access to formal modes of sex education sur-
rounding masturbation, and perhaps due to a having less
awareness of the purpose of masturbation than the males
who received these approaches, may partially account for
the low frequency of masturbation cited in this review.
While this does raise a number of key questions sur-
rounding the administration of gender-specific sexuality
interventions for the HFA population, this also highlights
the potential of additional factors including higher inci-
dence of overall negative experiences and poorer sexual
wellbeing identified in females, which may also be the
partial consequence of a lack of access to sexuality edu-
cation and support services aiming to specifically address
and prevent these concerns.
Sexual Frustration and Problems
As a large proportion of sexually inexperienced persons
still reported comparative levels of interest in sexual
behaviours, the discrepancy between desire for sexual
activity and sexual experience may partly account for the
higher levels of sexual frustration and poorer sexual and
relationship satisfaction reported generally in HFA, and
particularly in males with HFA (Byers and Nichols 2014;
Ousley and Mesibov 1991). The more frequent and more
intense desire for sexual behaviour in both TD males and
males with HFA may give rise to higher levels of sexual
frustration in part explaining the observed gender differ-
ences in levels of sexual frustration in HFA.
Experiences of Sexuality that are Unique
to the High-Functioning Female
Review of the literature pertaining to the sexuality of
females with HFA is limited to three qualitative studies
(Attwood 2009; Haracopos and Pederson 1992; Nichols
2009). While quantitative analysis has revealed poorer
levels of overall sexual functioning and wellbeing in
females across a range of measures, clinical accounts assist
in capturing a clearer picture of the additional difficulties
and adverse experiences that are particular to this unique
diagnostic profile (Nichols 2009).
J Autism Dev Disord
123
Attwood’s (2007, 2009, 2013) clinical experience with
individuals with HFA/AS indicates that due to limited
social relationships, and the misinterpretation of non-social
sources of sexual information as social scripts for appro-
priate sexual behaviour; females’ inabilities to make
character judgments of potential sexual predators, may
leave them vulnerable, and forlornly raise promiscuity in
an attempt to formulate a relationship. Furthermore, due to
low levels of self-esteem commonly cited in Attwood
(2009) accounts of females with HFA/AS, poor choices of
abusive romantic partners has put increased vulnerability to
various forms of physical and sexual abuse in the pursuit of
a healthy and fulfilling romantic life.
Given that females are at higher risk of negative sexual
experiences (Attwood 2009, 2013), and that results suggest
levels of sexual desire, and masturbation are lower for
females than males with ASD, while overall engagement in
sexual behaviours by females is higher than for males, as
revealed above, this raises some pressing concerns for the
sexual health and welfare of females with HFA. Despite
having poorer overall sexual wellbeing, and less interest in
both sexuality and a desire engaging in sexual behaviours,
females with HFA are doing so at higher rates than their
male counterparts. To date, the motives for engaging in
sexual behaviours have not been the subject of empirical
investigation. However, that desire is lower among
females, but behaviour is increased suggests some other
mechanism than desire is driving this behaviour. This rai-
ses possibility of misplaced transactions, and implies that
additional factors, including the possibility of sexual
coercion may be apparent within the sexual experiences of
females with HFA. While this may work to partially
explain why qualitative research has finds greater suscep-
tibility to negative sexual experiences among females with
HFA (Attwood 2009; Haracopos and Pederson 1992;
Nichols 2009), if any form of coercion is implied, this is an
urgent topic of future study.
Strengths and Limitations
This study has worked to synthesise all existing qualitative
and quantitative research of sexuality for both males and
females with HFA, offering an initial, and much needed
understanding of the gender specific issues many affected
individuals face as they approach adolescence and adult-
hood. In light of these strengths, it is important that they
too, are interpreted in conjunction with the limitations of
this study, which have implications for future research.
Overall, the most significant limitation of this review is the
lack of empirical research on the sexuality of individuals
with HFA, and thus, the extremely limited number of
studies that could be included in each respective meta-
analysis. In addition to the small sample sizes in included
studies, these methodological issues suggest some evidence
of poor statistical power, and thus a limited generalisability
of study findings. Additionally, a well-acknowledged crit-
icism in the area of HFA that may have also impacted on
this research is the majority of studies that have used a
smaller number of HFA participants when compared to TD
controls, and included sex ratios that did not correspond to
those found in the wider HFA population.
Furthermore, as females with HFA are believed to be
under-diagnosed, the large proportion of females who have
exhibited mild symptoms and thus evaded a diagnosis are
not represented in this sample. This possibility of failing to
fully capture a representative sample of the wider ASD
population may also be due to the exclusion of individuals
who do not meet the high-functioning IQ cut-off score;
which limits understandings of the impact that more severe
ASD symptoms may have on sexual development and
sexuality. As such, issues associated with ascertainment
bias may have also impacted the findings of meta-analyses
presented in this paper.
Another factor limiting the conclusions of this review
was the large number of separate sexuality variables
measured by each study, which saw that few studies con-
tributed to the majority of these different variables. As
such, studies were difficult to compare, and in some cases
were the only source to examine a specific variable of
sexuality in HFA, and thus excluded from meta-analysis.
Due to small study sample sizes, considerable hetero-
geneity, and thus evidence of publication bias was
observed in these meta-analyses. As greater differences
may have emerged for some of the variables that contained
more available data, and misdiagnosed females with less
severe impairments may have not been represented in
participant groups of included studies, these findings
should be interpreted with caution.
In addition, the diagnostic methods and instruments to
confirm HFA features and previous diagnoses ranged from
short questionnaires to formal diagnoses, and were thus of
varying methodological quality. HFA was also labelled in
different ways, and diagnosed with a range of diagnostic
criteria. As a result there may have been participants
included in some studies that would not meet the criteria
specified in others. Furthermore, a large proportion of
studies used the perspectives of parents or caregivers as
primary data sources via self-administered questionnaires
or interviews. As parents may have limited and thus
inaccurate knowledge of their child’s social life and
behaviours engaged in when in privacy, data may be
reflective of either underreportingof, or confabulated or
hypothetical assumptions concerning their child’s sexual
experiences and behaviours. Consequently, issues with
reliability associated with reporting the perceived beha-
viours and experiences may be present in this data. Despite
J Autism Dev Disord
123
these limitations, this report has been one of the first to
demonstrate significant gender differences between males
and females with HFA, and offer limited, yet a more
complete picture of the HFA female profile.
Implications
This review has highlighted that to date, sexuality exists as
one of the most critical areas within HFA and the wider
ASD field that still remains largely neglected and under
researched. Nonetheless, results have affirmed that for this
population, sexuality is real, and an integral aspect of one’s
self-identity and overall quality of life irrespective of
diagnosis or gender. Despite this, evidence of poorer health
outcomes and higher rates of negative sexual experiences
cited within the HFA, and in particular, HFA female
population, suggest that along with the pervasive deficits
inherent to the disorder, being of the female gender may
also be interfering with the ability to pursue and enjoy the
level of desired sexuality that best meets their needs
(Danson 2015).
Overall, it appears that enhancing the knowledge of
clinicians, education providers, parents, and most impor-
tantly, persons with HFA, may be particularly important in
terms of the assessment, treatment, and overall sexual-
health outcomes of individuals on the spectrum. Given that
current sexual education programs have been largely
developed for either mainstream or ID populations, levels
of poorer sexual knowledge in the HFA population cited in
this paper suggest that the sexuality education needs and
difficulties of this population are not being addressed by
current educational frameworks (Danson 2015; Travers and
Tincani 2010). Consequentially, the findings of this review
support growing bodies of research urging the provision of
specialised sexual education and appropriate intervention
programs that target the specific social, cognitive, and
emotional capabilities of those females on the Autism
Spectrum (Chan and John 2012; Nichols 2009; Stokes
2012; Stokes and Kaur 2005; Ginevra et al. 2015).
Finally, the results of this study also highlight the
ongoing challenge that our legal and judicial systems may
face as they encounter individuals with HFA being either
the victim of, or perpetrator of sexual offences. Lower
levels of sexual knowledge and increased inappropriate
sexual behaviours cited in this review lead to the conclu-
sion that many affected individuals are likely to have a
poorer understanding of the legalities around sexual rights
and appropriate behaviours (Urbano et al. 2013). Alongside
the common citation of an overrepresentation of wider
ASD groups currently found within forensic samples
(Browning and Caulfield 2011; Loftin and Hartlage 2015);
it appears that individuals on the spectrum may be at an
increased risk of coming into contact with the criminal
justice system due to their difficulties with discerning and
following appropriate behaviour. Consequentially, this
raises a number of key issues surrounding the level of
education such individuals may require in order to min-
imise their risk of legal problems and abuse; and the extent
to which there is an adequate understanding of the com-
plexities that surround this disorder in these sectors. It is
anticipated that in order to begin to tackle these issues,
educational efforts aimed at teaching those with ASD the
differences between what is right and what is wrong in
sexual relationships with others, increasing the level of
understanding of both the legalities of sex and sexuality for
the HFA population, and clarifying the diagnostic para-
digms of the disorder within these legal systems, will be
most useful for achieving the best possible outcomes for
all.
Future Directions
In spite of the increasing number of published articles
dedicated to HFA in general, the lack of research relevant
to the current review highlights the neglected status of
gender-based differences in HFA and the sexual profile of
females within this group. Not only has this been a gap in
the research but also in clinical work with HFA males and
females. In fact the lack of programs to help males and
females with HFA with the needs identified in this study is
one of the biggest gaps in our services to these individuals
and one of the biggest obstacles to their chances of living
richer and fuller lives.
As such, the challenge remains in research and clinical
work to quantitatively explore the many aspects of sexual
development and sexuality in HFA in order to establish
greater insight into the unique sexual experiences and
needs of both the high-functioning male and female. This
could be performed through the use of larger-scale, trian-
gulated studies examining perspectives of the individual
themselves, parental or caregivers reports, and clinical
accounts; which would work to replicate and expand upon
current research findings and address the limitations iden-
tified by this meta-analysis. Moreover, it would be
advantageous of future research to extend beyond the
examination of sexual functioning in HFA to the devel-
opment and nature of romantic relationships in males and
females independently. As clinical accounts suggest that
some individuals with HFA can develop successful long
term relationships (Attwood 2009), a better understanding
of these successful relationships as well as the difficulties
in relationship formation, quality, and functioning that
persist well into adulthood are worthy of future research
attention. While this would allow for the provision of
sex/gender-specific sex education and target interventions
that can work to address the needs not currently met by
J Autism Dev Disord
123
existing support services, it also would improve the long-
term sexual outcomes, and thus the overall quality of life
for males and females with HFA.
Conclusion
Review of the literature pertaining to the sexual profile of
females with HFA suggests that sexuality, as a develop-
mental domain, is as it appears in neurotypical population.
However, being characterised by a condition with deficits
in the very skills required to understand, develop, and
maintain the healthy romantic and sexual relationships
many individuals with HFA so strongly desire, these sexual
relationships often result in a number of unforseen chal-
lenges in the pursuit of a healthy romantic and sexual life.
These difficulties have been found to be even more
apparent for the HFA female, who have not only been
reported to have poorer levels of overall sexual functioning
and wellbeing than males with HFA; but also are at greater
risk of adverse sexual experiences including naı̈ve
promiscuity, sexual assault, and abuse. While the current
literature provides insights into, and thus represent an
important step in characterising the sexuality of females
with HFA and the sex differences that exist between males
and females on the higher-functioning end of the spectrum;
it also leaves many of the most critical questions in this
area unanswered. Thus, further research is needed to
inform and create a society that works to provide the
support this unique diagnostic group needs to successfully
navigate throughout adolescence and beyond to achieve the
same physical, sexual and life fulfilment as their TD peers.
Acknowledgments
Author Contributions All authors contributed to the analytic
methods and written work presented in this paper. LP and MS con-
ceived, and participated in the design of the study. LP conducted all
systematic search and meta-analysis procedures, and drafted the
original manuscript. GM provided expertise regarding the study,
critically evaluated all key sections of the review, andassisted in
drafting the manuscript. MS oversaw all analyses, participated in the
interpretation of data, reviewed, and was involved in the write up of
all drafts. All authors were involved in the final revisions and
approval of the published manuscript.
Compliance with Ethical Standards
Research Involving Human Participants and/or Animals This
study has been approved by the Deakin University Human Research
Ethics Committee (Project ID: 2014-210). As this article was a review
of a number of primary publications, it did not directly conduct
research on human participants. However, of the procedures per-
formed in included studies that did involve human participants, all
were in accordance with the ethical standards of the institutional and/
or national research committee and with the 1964 Helsinki declaration
and its later amendments or comparable ethical standards. This article
does not contain any studies with animals performed by any of the
authors.
Informed Consent As this was a review article, formal consent of
participants was not required. However, informed consent was
obtained from all parents and carers of/individual participants in each
of the studies reviewed in this article.
Appendix: Complete Search Strategy and Search
Terms Used for Database Searching
See Table 2.
Table 2 Complete search strategy for all included studies: sex dif-
ferences in sexuality (HFA and TD)
1 Autis*
2 Autism spectrum disorder
3 ASD
4 Asperger
5 Social*
6 Sex*
7 Sexuality
8 Sexual behav*
9 Gender
10 Male* and female*
11 Difference*
12 Typically developing
13 Boy and girl
14 1 and 5
15 1 and 5 and 9
16 1 and 5 and 9 and 11
17 1 and 5 and 10 and 11
18 2 and 5
19 2 and 5 and 9
20 2 and 5 and 9 and 11
21 2 and 5 and 10 and 11
22 1 and 6
23 1 and 6 and 9
24 1 and 6 and 9 and 11
25 2 and 6 and 9
26 2 and 6 and 9 and 11
27 2 and 6 and 10 and 11
28 7 and 9 and 11
29 7 and 10 and 11
30 7 and 10 and 11 and 12
31 5 and 7 and 9 and 11
32 2 and 8 and 9
33 2 and 8 and 10
34 2 and 8 and 10 and 11
* Truncation; ‘‘ ’’ = Truncate within phrase; Limiters used: English
Language
Double quotation marks indicate exact phrase searching
J Autism Dev Disord
123
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	Sexuality in High-Functioning Autism: A Systematic Review and Meta-analysis
	Abstract
	Introduction
	Method
	Study Eligibility Criteria
	Information Sources
	Study Selection and Data Extraction
	Summary Measures and Statistical Analysis
	Results
	Study Selection
	Study Characteristics: Methods and Participants
	Study Characteristics: Interventions and Outcomes
	Synthesis of Results
	Sexual Understanding
	Sexual Anxiety and Problems
	Sexual Knowledge
	Sexual Identity and Orientation
	Sexual Contact
	Sexual Desire and Arousability
	Engagement in Sexual Behaviour
	Masturbation
	Homogeneity Analysis
	Results of Qualitative Synthesis: Gender Differences in Sexuality and the HFA Female Profile
	Exploratory Analyses: Differences in Sexuality by Diagnosis (HFA vs TD)
	Risk of Bias Across Studies: Publication Bias
	Discussion
	Sexual Understanding
	Development of Sexuality in Adolescence and Sexual Anxiety
	Sexual Knowledge
	Sexual Identity and Orientation
	Sexual Contact
	Sexual Desire and Arousability
	Engagement in Sexual Behaviour
	Masturbation
	Sexual Frustration and Problems
	Experiences of Sexuality that are Unique to the High-Functioning Female
	Strengths and Limitations
	Implications
	Future Directions
	Conclusion
	Acknowledgments
	Appendix: Complete Search Strategy and Search Terms Used for Database Searching
	Referencescited in the TD population (De Gaston and Weed
1996; Ellis and Symons 1990), these studies have been the
first to unanimously report lower levels of sexual desire
and less engagement in sexual behaviour in HFA females.
However, as inconsistencies were also reported on a
number of key variables, and females were poorly repre-
sented in Hénault and Attwood’s study (female n = 9),
methodological issues render it difficult to synthesize
conclusions from research on the experiences that are
unique to HFA females, and thus necessitate the conduct of
further research.
An additional unresolved issue in the sexuality of
females with HFA is whether normative sex differences in
1 (Note: Adopting definitions from the World Health Organisation
(WHO 2016), all references to ‘‘sex’’ in this paper refer to the
biological and physiological characteristics that define and differen-
tiate males and females. ‘‘Gender’’ refers to the socially constructed
norms, beliefs, and behaviours that a given culture associates with a
person’s biological sex. As the studies included in this meta-analysis
focus on adolescents and adults, the difficulty in separating out the
effect of sex and gendered socialisation has seen that some articles
refer to ‘‘sex’’, ‘‘gender’’ (WHO 2016, para. 3), or use the concepts
interchangeably. In order to acknowledge both this issue, and the
purpose of this meta-analysis, which was to examine the impact of
‘‘sex’’ (as a biological construct) on sexuality in HFA; all references
to ‘‘sex/gender’’ differences cited in included studies will be referred
to as ‘‘sex’’ in this paper).
J Autism Dev Disord
123
the TD population are also observed in clinically diagnosed
males and females (Baron-Cohen et al. 2014). The study of
sexuality within the TD population has been extensive,
with common and consistent findings. Results of two large-
scale meta-analyses collectively synthesising results from
907 studies have revealed that males not only report more
interest and desire in sexuality and more permissive sexual
attitudes; they also engage in sexual behaviours at an ear-
lier age, more frequently, and with a greater number of
partners than females (Oliver and Hyde 1993; Petersen and
Hyde 2010). Interestingly, despite holding less permissive
attitudes, females often exhibit greater flexibility in their
sexual orientation, and more sexual plasticity than males,
where their expression of sexuality is highly influenced by
the changing gender norms that occur over time (Peplau
2003; The Society for the Scientific Study of Sexuality
2012). To date, whether these differences are also reflected
in the HFA population is still yet to become the focus of
empirical investigations. However, considering that sex has
been found to influence both the expression of HFA
characteristics and aspects of development and sexuality in
the TD population, it seems reasonable to assume that it
would also play a role in the development and sexuality in
this diagnostic group.
In addition to the few aforementioned publications
investigating the sex differences between individuals with
HFA (Byers et al. 2013a, b; Hénault and Attwood 2006);
the only existing research that further contributes to
understandings of the sexuality of females with HFA are
excerpts from three qualitative reports (Attwood 2009;
Haracopos and Pederson 1992; Nichols 2009). As such, it
is evident that there is a paucity of research on both the sex
differences, and sexuality of high-functioning females on
the spectrum, and the sex differences that exist between
males and females in this population. As the large vari-
ability within existing research currently obscures under-
standings of sexuality and the HFA female profile,
integrating existing literature on all aspects of sexuality
will assist in gaining greater insight into the development
and experiences of sexuality that are unique to this diag-
nostic group.
Thus, the aim of this paper is to conduct a systematic
review and meta-analysis on current knowledge of the
sexual development and expression of sexuality of females
with HFA in order to uncover the unique female sexual
profile and the sex differences that exist among individuals
in this group. Given that to date, no empirical literature
exists specifically examining the female profile indepen-
dently, this review will evaluate evidence of sex differ-
ences in the presentation of sexuality variables in the HFA
population, and contrast these results to known differences
found in the TD population. As a quantitative analysis has
yet to integrate and confirm existing research on sexuality
in HFA, this review will also conduct an exploratory meta-
analysis synthesising research on the differences in the
wider HFA population against TD individuals, and link
these results to the conclusions of this report.
Method
This systematic review was conducted on all existing lit-
erature examining measures of sexuality in males and
females diagnosed with HFA. Sources included books,
peer-reviewed journal articles, and theses of varying
methodological quality. All papers were written in English,
with no restrictions on publication date and status.
Study Eligibility Criteria
All quantitative studies of varying design (cross-sectional,
cohort etc.) and qualitative publications were included in
this review. In order to distinguish the contribution of ASD
symptomology from the potentially confounding effects of
intellectual disability [defined as an average Intelligence
Quotient (IQ)\70], and thus examine the impact of ASD
on sexuality exclusively, studies examining either partici-
pants with either Autistic Disorder, or a wider ASD diag-
nosis without specifying level of functioning were
excluded from the review. Studies with participants who
had received a diagnosis of HFA or Asperger Syndrome
(AS) independent from ASD were retained for inclusion. In
studies that specified participants with an ASD diagnosis,
groups with an average IQ of above 70 were classified as
HFA, and therefore also considered for inclusion. Although
healthy cases of puberty onset have been reported in
females as young as 6 years of age (Nakamoto 2000), in
line with global trends suggesting an average age of
pubertal development of 10 years (WHO 2015), the age of
all included participants was restricted to over 10 years.
Studies with comparative groups were limited to those
examining sexuality either between males and females with
HFA, or wider-HFA populations of both sexes against TD
comparison groups. In addition to meeting these criteria,
only those studies reporting primary research, or sufficient
data to extract effect sizes of variables on individuals with
HFA (including respective parental or carers reports) were
then retained further for meta-analysis.
Information Sources
A systematic database search was conducted on Academic
Search Complete, eBook Collection (EBSCOhost), MED-
LINE Complete, PsychARTICLES, PsychBOOKS, Psy-
chEXTRA, PsychINFO, Psychology and Behavioral
Sciences Collection, PubMed, The Networked Digital
J Autism Dev Disord
123
Library of Theses and Dissertations and Trove Libraries
Australia to retrieve all relevant publications and theses.
Further searching was conducted to identify any additional
articles and government publications using Google Scholar
and through the inspection of references lists of included
sources. Articles were obtained using permutations of the
key words ‘Autism Spectrum Disorder’ paired with either
‘Socialisation’, or ‘Sexuality’, and ‘Gender’ ‘Differences’.
The initial systematic search was undertaken by the first
author in March, 2015, and updated to identify recent
publications that met inclusion criteria in April, 2016. All
decisions concerning which papers to include or exclude
were reviewed by another of the authors. The full elec-
tronic search strategy used for all database searches is
reported inthe Table 2.
Study Selection and Data Extraction
Each identified source was screened and then examined via
full text for inclusion in both the quantitative and qualita-
tive syntheses. From each paper that met eligibility criteria
for inclusion in the review, the first author manually col-
lected and summarised all relevant descriptive information,
demographic characteristics, study results, and effect size
data used to conduct both the qualitative and quantitative
synthesis in tabular form by the first author (Table 1) All
study search, selection, and data extraction methods and
results were reviewed by the remaining authors.
Summary Measures and Statistical Analysis
As the dependent variables (DV) of studies retained for
quantitative syntheses varied widely and thus were
incomparable via a single meta-analysis, individual anal-
yses were instead conducted on each variable of sexuality
that was examined by two or more studies. However, it is
important to note that due to the limited number of studies
examining sexuality in the HFA population, the majority of
these meta-analyses often included only two to three
studies. As Liberati et al. (2009) suggest that power to
detect heterogeneity in meta-analysis is low when a small
number of studies are included; the conservative approach
of a random-effects model was used in all analyses in this
paper.
Extracted effect sizes of all relevant variables were
converted to the common metric of ‘standardised mean
group difference’ (SMD; Cohen’s d). In studies that did not
report an effect size, the first and second authors were
equally involved in the computation of effect sizes. All
effect size conversions and calculations were performed
following Borenstein et al. (2009) conversion formulae to
transform and compute raw and standardised summary
effect measures. In the meta-analyses examining sexuality
in males and females with HFA, a SMD above zero indi-
cated that males scored higher on the measure of sexuality
under study, while a SMD below zero indicated that
females reported significantly higher scores. In the
exploratory meta-analyses investigating sexuality in HFA
versus TD individuals, an SMD above zero indicated that
the measure of sexuality was reported at higher rates in
individuals diagnosed with HFA, with the variable being
favoured towards the TD population in SMDs below zero.
When interpreting the magnitude of effect sizes, this
review adopted the Cohen’s (1969) guidelines, which
suggest a d value of .20, .50, and .80 equate to small,
moderate, and large effect sizes respectively. All 95 %
confidence intervals and standard errors of variables
examined in this review were computed using Compre-
hensive Meta-analysis, version 2 (Biostat Inc. 2010).
The individual effect sizes of each measure of sexuality,
standard errors, and sample size of the study examining the
variable of consideration were pooled into Review Man-
ager, version 5.3 ([Revman]; The Cochrane Collaboration
2014). All remaining analyses were conducted using Rev-
Man. Tests for heterogeneity were determined through
interpretation of the Cochrane’s Q (reported as v2) and I-
squared (I2) statistics. When assessing for heterogeneity
with the Q statistic, p values\.10 reject the null hypotheses
of homogeneity, indicating significant differences between
the mean scores of studies. While the Q statistic indicates
whether evidence heterogeneity is present, the I2 quantifies
this degree of total variation across studies. Describing this
variability as a proportion of total variance, I2 values[25,
[50, and[75 % suggest low, moderate, and high levels of
heterogeneity, respectively (Higgins et al. 2003).
Results
Study Selection
The initial database search examining sexuality in HFA
identified a total of 11,654 publications with an additional
65 retrieved through hand searching. After 5760 duplicates
were removed and the title and abstracts were screened,
159 articles were retained for full-text examination. Fol-
lowing exclusion of studies that were not relevant to the
specific research question (n = 27), examined socialisation
or sex differences in HFA without specifically investigating
aspects of sexuality (n = 47), compared sex differences in
the TD population only (n = 46), or included participants
outside of the appropriate age range (n = 11), 27 publi-
cations were retained for qualitative synthesis. In line with
the inclusion criteria specified in ‘‘Study Eligibility Crite-
ria’’ section, remaining papers were excluded if the article
was a review and thus did not produce new empirical data
J Autism Dev Disord
123
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ci
p
an
ts
h
ad
ac
h
ie
v
ed
a
u
n
iv
er
si
ty
ed
u
ca
ti
o
n
,
an
d
w
er
e
p
ar
en
ts
.
F
in
d
in
g
s
n
o
t
g
en
er
al
is
ab
le
to
w
id
er
A
S
D
p
o
p
u
la
ti
o
n
In
cl
u
d
ed
A
S
D
p
ar
ti
ci
p
an
ts
,
n
o
t
H
F
A
o
n
ly
B
ro
w
n
-L
av
o
ie
et
al
.
(2
0
1
4
)
U
S
A
,
C
an
ad
a
n
=
2
1
2
H
F
A
(n
=
9
5
)
5
8
m
,
3
7
f
(M
=
2
7
.8
3
y
ea
rs
,
S
D
=
4
.3
3
)
T
D
(n
=
1
1
7
)
6
6
m
,
5
1
f
(M
=
2
7
.6
0
y
ea
rs
,
S
D
=
4
.7
4
)
D
ia
g
n
o
st
ic
cr
it
er
ia
u
se
d
fo
r
in
it
ia
l
d
ia
g
n
o
si
s
n
o
t
sp
ec
ifi
ed
A
Q
u
se
d
to
co
n
fi
rm
d
ia
g
n
o
si
s
in
st
u
d
y
(A
Q
[
2
6
)
K
n
o
w
le
d
g
e
o
f
S
ex
u
a
l
H
ea
lt
h
Q
u
es
ti
o
n
n
a
ir
e,
re
vi
se
d
S
ex
u
a
l
E
xp
er
ie
n
ce
s
S
u
rv
ey
,
V
ic
ti
m
iz
a
ti
o
n
ve
rs
io
n
S
el
f-
ad
m
in
is
te
re
d
w
ri
tt
en
q
u
es
ti
o
n
n
ai
re
u
se
d
to
m
ea
su
re
p
er
ce
iv
ed
se
x
u
al
k
n
o
w
le
d
g
e
o
f
se
x
u
al
h
ea
lt
h
,
co
n
tr
ac
ep
ti
o
n
an
d
ri
sk
ta
k
in
g
b
eh
av
io
u
r
S
o
u
rc
es
o
f
se
x
u
al
k
n
o
w
le
d
g
e
S
ex
u
al
k
n
o
w
le
d
g
e
(a
ct
u
al
an
d
p
er
ce
iv
ed
)
S
ex
u
al
v
ic
ti
m
is
at
io
n
L
es
s
li
k
el
y
to
o
b
ta
in
se
x
u
al
k
n
o
w
le
d
g
e
p
ee
rs
,
te
ac
h
er
s,
p
ar
en
ts
M
o
re
li
k
el
y
to
g
ai
n
k
n
o
w
le
d
g
e
fr
o
m
te
le
v
is
io
n
an
d
p
o
rn
o
g
ra
p
h
y
L
es
s
se
x
u
al
k
n
o
w
le
d
g
e
H
ig
h
er
ra
te
s
o
f
se
x
u
al
v
ic
ti
m
is
at
io
n
S
o
u
rc
es
o
f
se
x
u
al
k
n
o
w
le
d
g
e
(d
=
-
.4
6
)
S
ex
u
al
k
n
o
w
le
d
g
e
(d
=
-
1
.0
4
)
O
v
er
al
l
st
u
d
y
ef
fe
ct
si
ze
(d
=
-
0
.6
7
)
S
el
ec
ti
o
n
b
ia
s:
u
se
d
co
n
v
en
ie
n
ce
sa
m
p
li
n
g
S
tu
d
y
n
o
t
ex
cl
u
d
ed
:
ex
am
in
ed
v
ia
m
et
a-
an
al
y
si
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
B
y
er
s
et
al
.
(2
0
1
3
a,
b
)
U
S
A
(4
7
%
),
A
u
st
/N
Z
(1
6
%
),
U
K
(1
4
%
),
E
u
ro
p
e
(1
3
%
),
C
an
ad
a
(9
%
)
n
=
1
2
9
H
F
A
/A
S
(n
=
1
2
9
)
6
1
m
,
6
8
f
(M
=
3
5
.3
y
ea
rs
)
P
ar
ti
ci
p
an
ts
h
ad
so
m
e
(l
im
it
ed
)
re
la
ti
o
n
sh
ip
ex
p
er
ie
n
ce
P
ro
fe
ss
io
n
al
d
ia
g
n
o
si
s
(m
en
ta
l
h
ea
lt
h
o
r
m
ed
ic
al
p
ra
ct
it
io
n
er
;
6
1
%
)
A
Q
u
se
d
to
co
n
fi
rm
d
ia
g
n
o
si
s
in
st
u
d
y
(A
Q
[
3
2
)
S
ex
u
a
l
K
n
o
w
le
d
g
e
Q
u
es
ti
o
n
n
a
ir
e
M
o
d
ifi
ed
v
er
si
o
n
o
f
S
ex
u
a
l
A
ro
u
sa
b
il
it
y
a
n
d
S
ex
u
a
l
A
n
xi
et
y
In
ve
n
to
ry
S
ex
u
a
l
D
es
ir
e
In
ve
n
to
ry
S
ex
u
a
l
A
ct
iv
it
y
Q
u
es
ti
o
n
n
a
ir
e
S
ex
u
a
l
F
u
n
ct
io
n
in
g
Q
u
es
ti
o
n
n
a
ir
e
S
ex
u
a
l
C
o
g
n
it
io
n
s
C
h
ec
kl
is
t
O
n
li
n
e
S
ex
u
a
l
E
xp
er
ie
n
ce
Q
u
es
ti
o
n
n
a
ir
e
S
ex
u
al
k
n
o
w
le
d
g
e
S
ex
u
al
an
x
ie
ty
S
ex
u
al
ar
o
u
sa
b
il
it
y
D
es
ir
e
fo
r
so
li
ta
ry
se
x
u
al
ac
ti
v
it
y
D
y
ad
ic
d
es
ir
e
S
o
li
ta
ry
g
en
it
al
fr
eq
u
en
cy
S
ex
u
al
p
ro
b
le
m
s
S
ex
u
al
co
g
n
it
io
n
s
L
es
s
d
es
ir
e
fo
r
an
d
en
g
ag
em
en
t
in
se
x
u
al
ac
ti
v
it
ie
s
w
it
h
a
p
ar
tn
er
m
re
p
o
rt
ed
b
et
te
r
se
x
u
al
fu
n
ct
io
n
in
g
f
re
p
o
rt
ed
lo
w
er
d
es
ir
e
fo
r
so
li
ta
ry
se
x
u
al
ac
ti
v
it
y
,
lo
w
er
se
x
u
al
ar
o
u
sa
l
le
v
el
s,
an
d
le
ss
fr
eq
u
en
t
se
x
u
al
th
o
u
g
h
ts
f
re
p
o
rt
ed
g
re
at
er
le
v
el
s
o
f
se
x
u
al
an
x
ie
ty
an
d
re
la
te
d
p
ro
b
le
m
s
S
ex
u
al
k
n
o
w
le
d
g
e
(d
=
0
.3
5
)
S
ex
u
al
an
x
ie
ty
(d
=
–
0
.4
1
)
S
ex
u
al
ar
o
u
sa
b
il
it
y
(d
=
1
.1
9
)
D
es
ir
e
fo
r
so
li
ta
ry
se
x
u
al
ac
ti
v
it
y
(d
=
0
.7
4
)
D
y
ad
ic
d
es
ir
e
(d
=
1
.1
5
)
S
o
li
ta
ry
g
en
it
al
fr
eq
u
en
cy
(d
=
1
.1
0
)
S
ex
u
al
p
ro
b
le
m
s
(d
=
-
0
.5
1
)
S
ex
u
al
co
g
n
it
io
n
s
(d
=
1
.0
0
)
O
v
er
al
l
st
u
d
y
ef
fe
ct
si
ze
(d
=
0
.9
1
)
S
el
ec
ti
o
n
b
ia
s:
3
9
%
o
f
in
cl
u
d
ed
p
ar
ti
ci
p
an
ts
h
ad
n
o
t
re
ce
iv
ed
a
fo
rm
al
A
S
D
d
ia
g
n
o
si
s
P
er
fo
rm
an
ce
b
ia
s:
co
n
ta
in
ed
o
v
er
la
p
p
in
g
sa
m
p
le
fr
o
m
B
y
er
s
et
al
.’
s
(2
0
1
3
a)
st
u
d
y
L
im
it
ed
g
en
er
al
is
ab
il
it
y
:
M
aj
o
ri
ty
o
f
p
ar
ti
ci
p
an
ts
w
er
e
f,
h
ig
h
ly
ed
u
ca
te
d
d
es
p
it
e
th
e
cu
rr
en
t
M
:
F
A
S
D
ra
ti
o
in
th
e
g
en
er
al
p
o
p
u
la
ti
o
n
S
tu
d
y
n
o
t
ex
cl
u
d
ed
:
ex
am
in
ed
v
ia
m
et
a-
an
al
y
si
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
B
y
er
s
et
al
.
(2
0
1
3
a)
U
S
A
(5
7
%
),
A
u
st
/N
Z
(2
3
%
),
E
u
ro
p
e
(9
%
),
U
K
(7
%
),
C
an
ad
a
(4
%
)
n
=
1
4
1
H
F
A
/A
S
(n
=
1
4
1
)
5
6
m
,
8
5
f
(M
=
3
9
.6
y
ea
rs
)
P
ar
ti
ci
p
an
ts
w
er
e
in
a
d
y
ad
ic
re
la
ti
o
n
sh
ip
P
ro
fe
ss
io
n
al
d
ia
g
n
o
si
s
(m
en
ta
l
h
ea
lt
h
o
r
m
ed
ic
al
p
ra
ct
it
io
n
er
)
A
Q
u
se
d
to
co
n
fi
rm
d
ia
g
n
o
si
s
in
st
u
d
y
(A
Q
[
2
6
)
G
lo
b
a
l
M
ea
su
re
o
f
S
ex
u
a
l
S
a
ti
sf
a
ct
io
n
S
el
f-
E
st
ee
m
S
u
b
sc
a
le
o
f
S
ex
u
a
li
ty
S
ca
le
H
u
rl
b
er
t
In
d
ex
o
f
S
ex
u
a
l
A
ss
er
ti
ve
n
es
s
M
o
d
ifi
ed
v
er
si
o
n
o
f
S
A
I
a
n
d
S
ex
u
a
l
A
n
xi
et
y
In
ve
n
to
ry
S
ex
u
a
l
D
es
ir
e
In
ve
n
to
ry
S
ex
u
a
l
A
ct
iv
it
y
Q
u
es
ti
o
n
n
a
ir
e
S
ex
u
a
l
F
u
n
ct
io
n
in
g
Q
u
es
ti
o
n
n
a
ir
e
S
ex
u
a
l
K
n
o
w
le
d
g
e
Q
u
es
ti
o
n
n
a
ir
e
S
ex
u
a
l
C
o
g
n
it
io
n
s
C
h
ec
kl
is
t
S
ex
u
al
k
n
o
w
le
d
g
e
S
ex
u
al
an
x
ie
ty
S
ex
u
al
ar
o
u
sa
b
il
it
y
D
es
ir
ab
il
it
y
fo
r
so
li
ta
ry
se
x
u
al
ac
ti
v
it
y
D
y
ad
ic
d
es
ir
e
F
re
q
u
en
cy
o
f
so
li
ta
ry
se
x
u
al
ac
ti
v
it
y
S
ex
u
al
p
ro
b
le
m
s
P
o
si
ti
v
e
se
x
u
al
co
g
n
it
io
n
s
N
eg
at
iv
e
as
so
ci
at
io
n
b
et
w
ee
n
d
eg
re
e
o
f
sy
m
p
to
m
im
p
ai
rm
en
t
an
d
se
x
u
al
sa
ti
sf
ac
ti
o
n
,
d
es
ir
e
an
d
ar
o
u
sa
b
il
it
y
P
o
si
ti
v
e
as
so
ci
at
io
n
b
et
w
ee
n
d
eg
re
e
o
f
sy
m
p
to
m
im
p
ai
rm
en
t,
se
x
u
al
an
x
ie
ty
,
an
d
se
x
u
al
p
ro
b
le
m
s
m
re
p
o
rt
ed
b
et
te
r
se
x
u
al
fu
n
ct
io
n
in
g
,
h
ig
h
er
le
v
el
s
o
f
se
x
u
al
w
el
lb
ei
n
g
an
d
sa
ti
sf
ac
ti
o
n
,
m
o
re
fr
eq
u
en
t
p
o
si
ti
v
e
se
x
-
re
la
te
d
th
o
u
g
h
ts
an
d
fe
w
er
se
x
u
al
p
ro
b
le
m
s
f
h
ad
g
re
at
er
le
v
el
s
o
f
se
x
u
al
k
n
o
w
le
d
g
e
S
ex
u
al
k
n
o
w
le
d
g
e
(d
=
-
0
.7
4
)
S
ex
u
al
an
x
ie
ty
(d
=
–
1
.1
6
)
S
ex
u
al
ar
o
u
sa
b
il
it
y
(d
=
3
.0
)
D
es
ir
ab
il
it
y
fo
r
so
li
ta
ry
se
x
u
al
ac
ti
v
it
y
(d
=
0
.8
8
)
D
y
ad
ic
d
es
ir
e
(d
=
2
.3
5
)
L
ev
el
o
f
so
li
ta
ry
g
en
it
al
fr
eq
u
en
cy
(d
=
1
.8
0
)
S
ex
u
al
p
ro
b
le
m
s
(d
=
-
0
.9
1
)
P
o
si
ti
v
e
se
x
u
al
co
g
n
it
io
n
s
(d
=
2
.5
0
)
O
v
er
al
l
st
u
d
y
ef
fe
ct
si
ze
(d
=
1
.4
7
)
S
el
ec
ti
o
n
b
ia
s:
In
cl
u
d
ed
p
ar
tici
p
an
ts
th
at
h
ad
n
o
t
re
ce
iv
ed
a
fo
rm
al
A
S
D
d
ia
g
n
o
si
s
L
im
it
ed
g
en
er
al
is
ab
il
it
y
:
m
aj
o
ri
ty
o
f
p
ar
ti
ci
p
an
ts
w
er
e
f,
h
ig
h
ly
ed
u
ca
te
d
.
S
am
p
le
n
o
t
re
p
re
se
n
ta
ti
v
e
o
f
M
:
F
A
S
D
ra
ti
o
in
th
e
g
en
er
al
p
o
p
u
la
ti
o
n
A
tt
ri
ti
o
n
b
ia
s:
2
6
%
o
f
p
ar
ti
ci
p
an
ts
d
id
n
o
t
co
m
p
le
te
su
rv
ey
S
tu
d
y
n
o
t
ex
cl
u
d
ed
:
ex
am
in
ed
v
ia
m
et
a-
an
al
y
si
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
B
y
er
s
an
d
N
ic
h
o
ls
(2
0
1
4
)
U
S
A
(5
6
%
),
A
u
st
ra
li
a
N
Z
(2
6
%
),
U
K
(1
0
%
),
E
u
ro
p
e
(7
%
),
C
an
ad
a
(5
%
)
n
=
2
0
5
7
7
m
,
1
2
8
f
(M
=
3
8
.6
y
ea
rs
,
S
D
=
9
.9
)
D
ia
g
n
o
st
ic
cr
it
er
ia
u
se
d
fo
r
in
it
ia
l
d
ia
g
n
o
si
s
n
o
t
sp
ec
ifi
ed
A
u
ti
sm
S
p
ec
tr
u
m
Q
u
o
ti
en
t
(A
Q
)
u
se
d
to
co
n
fi
rm
d
ia
g
n
o
si
s
in
st
u
d
y
(A
Q
[
2
6
)
In
te
rp
er
so
n
a
l
E
xc
h
a
n
g
e
M
o
d
el
o
f
S
ex
u
a
l
S
a
ti
sf
a
ct
io
n
G
lo
b
a
l
M
ea
su
re
o
f
S
ex
u
a
l
S
a
ti
sf
a
ct
io
n
S
ex
u
a
l
R
ew
a
rd
s/
C
o
st
s
C
h
ec
kl
is
t-
R
ev
is
ed
R
el
at
io
n
sh
ip
sa
ti
sf
ac
ti
o
n
S
ex
u
al
sa
ti
sf
ac
ti
o
n
S
ex
u
al
re
w
ar
d
s
an
d
co
st
s
P
o
o
re
r
se
x
u
al
sa
ti
sf
ac
ti
o
n
P
o
o
re
r
re
la
ti
o
n
sh
ip
sa
ti
sf
ac
ti
o
n
in
m
th
an
f
O
v
er
al
l
st
u
d
y
ef
fe
ct
si
ze
:
d
=
0
.3
6
S
el
ec
ti
o
n
b
ia
s:
in
cl
u
d
ed
p
ar
ti
ci
p
an
ts
th
at
h
ad
n
o
t
re
ce
iv
ed
a
fo
rm
al
A
S
D
d
ia
g
n
o
si
s
P
er
fo
rm
an
ce
b
ia
s:
co
n
ta
in
ed
o
v
er
la
p
p
in
g
sa
m
p
le
fr
o
m
B
y
er
s
et
al
.
(2
0
1
3
a,
b
)
L
im
it
ed
g
en
er
al
is
ab
il
it
y
:
M
aj
o
ri
ty
o
f
p
ar
ti
ci
p
an
ts
w
er
e
f,
h
ig
h
ly
ed
u
ca
te
d
,
d
es
p
it
e
th
e
cu
rr
en
t
M
:F
A
S
D
ra
ti
o
in
th
e
g
en
er
al
p
o
p
u
la
ti
o
n
b
ei
n
g
2
–
3
:1
V
ar
ia
b
le
s
in
cl
u
d
ed
in
st
u
d
y
w
er
e
n
o
t
co
m
p
ar
ab
le
fo
r
m
et
a-
an
al
y
si
s
w
it
h
o
th
er
in
cl
u
d
ed
st
u
d
ie
s
C
h
an
an
d
Jo
h
n
(2
0
1
2
)
S
tu
d
ie
s
fr
o
m
A
u
st
ra
li
a,
B
el
g
iu
m
,
N
o
rt
h
er
n
G
re
ec
e,
U
S
A
T
o
ta
l
re
le
v
an
t
st
u
d
ie
s
(n
=
4
)
T
o
ta
l
re
le
v
an
t
su
b
je
ct
s
(n
=
9
2
)
A
Q
([
2
6
–
3
2
)
D
S
M
-I
V
-T
R
R
ev
ie
w
ar
ti
cl
e.
D
id
n
o
t
m
ea
su
re
n
ew
em
p
ir
ic
al
d
at
a
S
ex
u
al
k
n
o
w
le
d
g
e/
se
x
ed
u
ca
ti
o
n
In
te
re
st
in
se
x
u
al
it
y
/
d
es
ir
e
fo
r
re
la
ti
o
n
sh
ip
s
In
ap
p
ro
p
ri
at
e
an
d
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
(i
n
cl
u
d
in
g
m
as
tu
rb
at
io
n
)
S
ex
u
al
d
ev
el
o
p
m
en
t
A
w
ar
en
es
s
o
f
p
ri
v
ac
y
re
la
te
d
is
su
es
S
o
u
rc
es
o
f
se
x
u
al
k
n
o
w
le
d
g
e
P
ar
en
ta
l
co
n
ce
rn
L
es
s
so
ci
al
so
u
rc
es
o
f
ro
m
an
ti
c
k
n
o
w
le
d
g
e,
k
n
o
w
le
d
g
e
o
f
p
ri
v
ac
y
is
su
es
,
se
x
ed
u
ca
ti
o
n
th
an
T
D
D
es
ir
e
fo
r
in
ti
m
at
e
re
la
ti
o
n
sh
ip
s
co
m
b
in
ed
w
it
h
lo
w
le
v
el
s
o
f
ro
m
an
ti
c
fu
n
ct
io
n
in
g
le
ad
s
to
in
ap
p
ro
p
ri
at
e
se
x
u
al
an
d
co
u
rt
in
g
b
eh
av
io
u
rs
G
re
at
er
le
v
el
s
o
f
p
ar
en
ta
l
co
n
ce
rn
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
P
u
b
li
ca
ti
o
n
b
ia
s:
M
aj
o
ri
ty
o
f
st
u
d
ie
s
in
cl
u
d
ed
re
p
o
rt
ed
si
g
n
ifi
ca
n
t
re
su
lt
s
o
n
ly
N
ar
ra
ti
v
e
li
te
ra
tu
re
ar
ti
cl
e.
D
id
n
o
t
p
ro
d
u
ce
n
ew
em
p
ir
ic
al
d
at
a
R
ev
ie
w
ed
st
u
d
ie
s
th
at
re
p
o
rt
d
at
a
o
n
A
S
D
,
u
n
ab
le
to
ex
tr
ac
t
d
at
a
o
n
H
F
A
o
n
ly
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
D
ew
in
te
r
et
al
.
(2
0
1
3
b
)
S
tu
d
ie
s
fr
o
m
A
u
st
ra
li
a,
D
en
m
ar
k
,
B
el
g
iu
m
,
N
et
h
er
la
n
d
s,
U
S
A
T
o
ta
l
re
le
v
an
t
st
u
d
ie
s
(n
=
1
7
)
T
o
ta
l
re
le
v
an
t
su
b
je
ct
s
(n
=
5
9
3
)
3
9
1
m
,
2
0
2
f
N
o
t
S
p
ec
ifi
ed
R
ev
ie
w
ar
ti
cl
e.
D
id
n
o
t
m
ea
su
re
n
ew
em
p
ir
ic
al
d
at
a
S
o
li
ta
ry
se
x
u
al
b
eh
av
io
u
r
S
ex
u
al
in
te
ra
ct
io
n
an
d
re
la
ti
o
n
sh
ip
s
S
ex
u
al
k
n
o
w
le
d
g
e
S
ex
u
al
in
te
re
st
an
d
o
ri
en
ta
ti
o
n
G
en
d
er
id
en
ti
ty
S
ex
u
al
so
ci
al
is
at
io
n
/s
o
u
rc
es
o
f
se
x
u
al
k
n
o
w
le
d
g
e
S
ex
ed
u
ca
ti
o
n
S
ex
u
al
v
ic
ti
m
is
at
io
n
M
aj
o
ri
ty
ex
p
re
ss
in
te
re
st
in
se
x
u
al
it
y
*
5
0
%
re
p
o
rt
d
es
ir
e
fo
r
a
re
la
ti
o
n
sh
ip
In
co
n
si
st
en
t
re
su
lt
s
in
le
v
el
o
f
se
x
u
al
k
n
o
w
le
d
g
e
an
d
se
x
ed
u
ca
ti
o
n
w
h
er
e
av
er
ag
e
le
v
el
s
(O
u
sl
ey
an
d
M
es
ib
o
v
1
9
9
1
,
B
y
er
s
et
al
.
2
0
1
3
a)
an
d
lo
w
er
le
v
el
s
(H
én
au
lt
an
d
A
tt
w
o
o
d
2
0
0
6
;
K
o
n
st
an
ta
re
as
an
d
L
u
n
sk
y
1
9
9
7
;
M
eh
za
b
in
an
d
S
to
k
es
2
0
1
1
)
re
p
o
rt
ed
f
re
p
o
rt
h
ig
h
er
le
v
el
s
o
f
se
x
u
al
k
n
o
w
le
d
g
e
[
5
0
%
en
g
ag
e
in
se
x
u
al
b
eh
av
io
u
rs
to
w
ar
d
s
o
th
er
s
in
cl
u
d
in
g
se
x
G
re
at
er
in
te
re
st
in
se
x
u
al
re
la
ti
o
n
sh
ip
th
an
ex
p
er
ie
n
ce
o
f
a
re
la
ti
o
n
sh
ip
4
0
–
7
7
.8
%
m
v
er
su
s
2
0
–
5
4
.5
%
f
en
g
ag
e
in
m
as
tu
rb
at
io
n
N
o
sy
st
em
at
ic
re
se
ar
ch
g
en
d
er
id
en
ti
ty
,
o
u
tc
o
m
es
o
f
se
x
ed
u
ca
ti
o
n
,
an
d
in
te
rv
en
ti
o
n
s
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
P
u
b
li
ca
ti
o
n
b
ia
s:
M
aj
o
ri
ty
o
f
st
u
d
ie
s
in
cl
u
d
ed
re
p
o
rt
ed
si
g
n
ifi
ca
n
t
re
su
lt
s
o
n
ly
N
ar
ra
ti
v
e
li
te
ra
tu
re
re
v
ie
w
.
D
id
n
o
t
p
ro
d
u
ce
n
ew
em
p
ir
ic
al
d
at
a
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
in
ca
se
s
o
f
se
x
u
al
p
ro
b
le
m
s
in
H
F
A
T
h
e
d
ev
el
o
p
m
en
t
o
f
se
x
u
al
it
y
is
u
n
d
er
st
u
d
ie
d
in
H
F
A
D
ew
in
te
r
et
al
.
(2
0
1
3
a)
N
et
h
er
la
n
d
s
n
=
8
H
F
A
(n
=
8
)
8
m
(M
=
1
7
.9
y
ea
rs
)
D
S
M
-I
V
A
u
ti
sm
D
ia
g
n
o
st
ic
O
b
se
rv
at
io
n
S
ch
ed
u
le
(A
D
O
S
)
u
se
d
to
co
n
fi
rm
d
ia
g
n
o
si
s
S
em
i-
st
ru
ct
u
re
d
in
te
rv
ie
w
:
an
al
y
se
d
in
to
th
em
es
u
si
n
g
in
te
rp
re
ti
v
e
p
h
en
o
m
en
o
lo
g
ic
al
an
al
y
si
s
F
al
li
n
g
in
lo
v
e
H
av
in
g
a
re
la
ti
o
n
sh
ip
B
o
d
il
y
ch
an
g
es
M
as
tu
rb
at
io
n
P
ar
tn
er
ed
se
x
u
al
ex
p
er
ie
n
ce
s
S
ex
ed
u
ca
ti
o
n
P
o
rn
o
g
ra
p
h
y
C
o
m
m
o
n
,
ag
e-
ap
p
ro
p
ri
at
e
ex
p
re
ss
ed
in
te
re
st
in
se
x
u
al
it
y
,
en
g
ag
em
en
t
in
se
x
u
al
b
eh
av
io
u
rs
an
d
re
la
ti
o
n
sh
ip
s
D
efi
ci
ts
in
h
er
en
t
to
A
S
D
(s
en
so
ry
an
d
in
fo
rm
at
io
n
p
ro
ce
ss
in
g
is
su
es
)
le
d
to
d
if
fi
cu
lt
ie
s
in
u
n
d
er
st
an
d
in
g
an
d
n
eg
at
iv
e
ex
p
er
ie
n
ce
s
o
f
se
x
d
ev
el
o
p
m
en
t
an
d
se
x
u
al
it
y
P
re
d
o
m
in
an
t
sou
rc
es
o
f
se
x
ed
u
ca
ti
o
n
w
er
e
n
o
n
-s
o
ci
al
(i
n
te
rn
et
,
p
o
rn
o
g
ra
p
h
y
,
et
c.
)
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
L
im
it
ed
g
en
er
al
is
ab
il
it
y
:
sm
al
l,
al
l
m
al
e
sa
m
p
le
Q
u
al
it
at
iv
e
ar
ti
cl
e.
D
id
n
o
t
in
cl
u
d
e
em
p
ir
ic
al
d
at
a
N
o
co
m
p
ar
is
o
n
g
ro
u
p
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
G
il
m
o
u
r
et
al
.
(2
0
1
2
)
C
an
ad
a
n
=
3
6
4
H
F
A
(n
=
8
2
)
2
7
m
,
5
5
f
(M
=
2
8
.9
y
ea
rs
,
S
D
=
9
.3
)
T
D
(n
=
2
8
2
)
1
0
2
m
,
1
8
0
f
(M
=
2
3
.2
y
ea
rs
,
S
D
=
7
.3
)
D
ia
g
n
o
st
ic
cr
it
er
ia
u
se
d
fo
r
in
it
ia
l
d
ia
g
n
o
si
s
n
o
t
sp
ec
ifi
ed
A
Q
u
se
d
to
co
n
fi
rm
d
ia
g
n
o
si
s
in
st
u
d
y
(A
Q
[
3
2
)
S
ex
u
a
l
E
xp
er
ie
n
ce
Q
u
es
ti
o
n
n
a
ir
e
S
ex
u
a
l
V
o
ca
b
u
la
ry
T
es
t
S
el
l
S
ca
le
o
f
S
ex
u
a
l
O
ri
en
ta
ti
o
n
S
ex
u
al
k
n
o
w
le
d
g
e
S
ex
u
al
at
ti
tu
d
es
S
ex
u
al
b
eh
av
io
u
rs
/e
x
p
er
ie
n
ce
s
S
ex
u
al
o
ri
en
ta
ti
o
n
C
o
m
m
o
n
in
te
re
st
in
se
x
u
al
it
y
an
d
en
g
ag
em
en
t
in
se
x
u
al
b
eh
av
io
u
rs
L
o
w
er
sc
o
re
s
o
n
h
et
er
o
se
x
u
al
it
y
th
an
T
D
H
ig
h
er
sc
o
re
s
h
o
m
o
se
x
u
al
it
y
b
is
ex
u
al
it
y
,
an
d
as
ex
u
al
it
y
th
an
T
D
L
o
w
er
sc
o
re
s
o
n
h
et
er
o
se
x
u
al
it
y
in
H
F
A
f
th
an
H
F
A
m
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
O
v
er
re
p
re
se
n
ta
ti
o
n
o
f
H
F
A
f
(n
=
5
5
)
co
m
p
ar
ed
to
H
F
A
m
(n
=
2
7
)
G
en
d
er
ra
ti
o
n
o
t
re
p
re
se
n
ta
ti
v
e
o
f
w
h
at
is
se
en
in
w
id
er
H
F
A
p
o
p
u
la
ti
o
n
O
v
er
re
p
re
se
n
ta
ti
o
n
o
f
T
D
(n
=
3
6
4
)
co
m
p
ar
ed
to
H
F
A
(n
=
1
2
0
)
V
ar
ia
b
le
s
in
cl
u
d
ed
in
st
u
d
y
(s
ex
u
al
id
en
ti
ty
,
se
x
u
al
o
ri
en
ta
ti
o
n
)
n
o
t
co
m
p
ar
ab
le
fo
r
m
et
a-
an
al
y
si
s
w
it
h
o
th
er
in
cl
u
d
ed
st
u
d
ie
s
G
in
ev
ra
et
al
.
(2
0
1
5
)
It
al
y
n
=
2
0
4
C
o
m
p
le
te
d
b
y
p
ar
en
ts
H
F
A
/A
S
(n
=
1
7
)
1
2
m
,
5
f
D
S
(n
=
9
3
)
4
1
m
,
5
2
f
T
D
(n
=
9
4
)
5
0
m
,
4
4
f
(M
=
1
4
.4
y
ea
rs
)
P
ro
fe
ss
io
n
al
D
ia
g
n
o
si
s
(t
h
ro
u
g
h
ch
il
d
n
eu
ro
p
sy
ch
ia
tr
ic
se
rv
ic
es
)
S
ex
u
a
l
B
eh
a
vi
o
u
r
S
ca
le
(S
B
S
;
S
to
k
es
an
d
K
au
r
2
0
0
5
)
S
o
ci
al
b
eh
av
io
u
r
P
ri
v
ac
y
aw
ar
en
es
s
S
ex
ed
u
ca
ti
o
n
S
ex
u
al
B
eh
av
io
u
r
P
ar
en
ta
l
C
o
n
ce
rn
s
P
o
o
re
r
so
ci
al
b
eh
av
io
u
rs
th
an
D
S
an
d
T
D
ad
o
le
sc
en
ts
L
es
s
en
g
ag
em
en
t
in
p
ri
v
ac
y
re
la
te
d
b
eh
av
io
u
rs
th
an
D
S
an
d
T
D
ad
o
le
sc
en
ts
L
es
s
se
x
ed
u
ca
ti
o
n
th
an
D
S
an
d
T
D
ad
o
le
sc
en
ts
M
o
re
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
th
an
D
S
an
d
T
D
ad
o
le
sc
en
ts
G
re
at
er
p
ar
en
ta
l
co
n
ce
rn
th
an
p
ar
en
ts
o
f
D
S
an
d
T
D
ad
o
le
sc
en
ts
L
ev
el
s
o
f
en
g
ag
em
en
t
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
in
cr
ea
se
d
o
v
er
ti
m
e
S
o
ci
al
b
eh
av
io
u
rs
(d
=
-
0
.1
9
)
P
ri
v
ac
y
se
ek
in
g
b
eh
av
io
u
rs
(d
=
-
1
.3
)
S
ex
ed
u
ca
ti
o
n
(d
=
–
0
.2
6
)
In
ap
p
ro
p
ri
at
e
se
x
u
al
is
ed
b
eh
av
io
u
rs
(d
=
0
.2
0
)
P
ar
en
ta
l
co
n
ce
rn
(d
=
0
.0
9
)
M
ea
su
re
m
en
t
b
ia
s:
se
x
u
al
b
eh
av
io
u
r
an
d
p
ri
v
ac
y
su
b
sc
al
es
o
f
S
B
S
h
av
e
m
o
d
er
at
e
C
ro
n
b
ac
h
’s
al
p
h
as
an
d
re
q
u
ir
e
fu
rt
h
er
d
ev
el
o
p
m
en
t
M
ea
su
re
m
en
t
b
ia
s:
p
ar
en
ta
l-
re
p
o
rt
st
u
d
y
,
re
su
lt
s
m
ay
b
e
u
n
d
er
es
ti
m
at
io
n
s
o
f
le
v
el
s
o
f
so
ci
al
co
n
ta
ct
,
in
si
g
h
t
an
d
en
g
ag
em
en
t
in
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
d
u
e
to
la
ck
o
f
k
n
o
w
le
d
g
e
o
f
ch
il
d
’s
b
eh
av
io
u
r
w
h
en
th
ey
ar
e
n
o
t
p
re
se
n
t
S
tu
d
y
n
o
t
ex
cl
u
d
ed
:
ex
am
in
ed
v
ia
m
et
a-
an
al
y
si
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
N
o
si
g
n
ifi
ca
n
t
im
p
ro
v
em
en
ts
in
en
g
ag
em
en
t
in
so
ci
al
b
eh
av
io
u
rs
,
p
ri
v
ac
y
re
la
te
d
b
eh
av
io
u
rs
,
le
v
el
s
o
f
se
x
ed
u
ca
ti
o
n
,
an
d
p
ar
en
ta
l
co
n
ce
rn
s
o
v
er
ti
m
e
G
li
d
d
en
et
al
.
(2
0
1
5
)
U
n
it
ed
K
in
g
d
o
m
T
o
ta
l
re
le
v
an
t
st
u
d
ie
s
(n
=
7
)
T
o
ta
l
re
le
v
an
t
su
b
je
ct
s
(n
=
1
6
7
)
D
S
M
-I
V
/5
o
r
IC
D
-
1
0
d
ia
g
n
o
si
s
o
f
A
S
D
M
ic
h
ig
a
n
G
en
d
er
Id
en
ti
ty
T
es
t
(M
IG
IT
;
D
u
ll
et
al
.
1
9
7
5
)
G
en
d
er
d
y
sp
h
o
ri
a
H
ig
h
co
-o
cc
u
rr
en
ce
o
f
A
S
D
an
d
g
en
d
er
d
y
sp
h
o
ri
a
in
ch
il
d
an
d
ad
u
lt
sa
m
p
le
s
w
h
en
co
m
p
ar
ed
to
T
D
p
o
p
u
la
ti
o
n
In
cr
ea
se
d
A
S
D
sc
o
re
s
in
ad
u
lt
s
at
te
n
d
in
g
g
en
d
er
d
y
sp
h
o
ri
a
se
rv
ic
es
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
P
u
b
li
ca
ti
o
n
b
ia
s:
M
aj
o
ri
ty
o
f
st
u
d
ie
s
in
cl
u
d
ed
re
p
o
rt
ed
si
g
n
ifi
ca
n
t
re
su
lt
s
o
n
ly
R
ev
ie
w
ar
ti
cl
e
su
m
m
ar
is
in
g
ex
is
ti
n
g
d
at
a.
D
id
n
o
t
p
ro
d
u
ce
n
ew
,
ra
w
d
at
a
E
m
pi
ri
ca
l
da
ta
ba
se
d
on
en
ti
re
A
S
D
po
pu
la
ti
on
,
di
d
no
t
re
po
rt
ex
tr
ac
ta
bl
e
d
at
a
fo
r
H
F
A
G
o
ld
sw
o
rt
h
y
(2
0
1
0
)
A
u
st
ra
li
a
n
=
9
4
H
F
A
(n
=
1
7
)
2
1
m
,
7
3
f
7
6
p
ar
tn
er
s
o
f
in
d
iv
id
u
al
s
w
it
h
H
F
A
(M
o
f
to
ta
l
sa
m
p
le
=
4
2
.5
2
y
ea
rs
,
S
D
=
1
4
.5
7
)
N
o
t
sp
ec
ifi
ed
S
el
f-
re
p
o
rt
w
ri
tt
en
q
u
es
ti
o
n
n
ai
re
w
h
ic
h
in
cl
u
d
ed
a
m
o
d
ifi
ed
v
er
si
o
n
o
f
R
ea
so
n
s
fo
r
H
a
vi
n
g
S
ex
Q
u
es
ti
o
n
n
a
ir
e
R
el
at
io
n
sh
ip
ch
ar
ac
te
ri
st
ic
s
S
ex
u
al
A
tt
ra
ct
io
n
S
ex
u
al
in
te
re
st
S
ex
u
al
b
eh
av
io
u
r
S
am
e
se
x
u
al
in
te
re
st
s
as
T
D
.
H
F
A
m
or
e
li
ke
ly
to
ra
te
ch
ar
ac
te
ri
st
ic
s
th
at
as
si
st
in
m
ee
ti
ng
th
ei
r
so
ci
al
n
ee
d
s
as
an
im
p
o
rt
an
t
fa
ct
o
r
as
so
ci
at
ed
w
it
h
in
it
ia
l
at
tr
ac
ti
on
th
an
T
D
H
F
A
f
m
o
re
li
k
el
y
to
es
ta
b
li
sh
a
re
la
ti
o
n
sh
ip
to
fu
lfi
l
so
ci
al
n
ee
d
s
th
an
T
D
f
H
F
A
m
m
o
re
li
k
el
y
to
ra
te
m
ee
ti
n
g
co
g
n
it
iv
e
n
ee
d
s
an
d
th
e
ab
il
it
y
to
m
ak
e
d
ec
is
io
n
s
O
v
er
al
l
st
u
d
y
ef
fe
ct
si
ze
:
d
=
1
.0
0
U
n
ev
en
sa
m
p
le
:
o
v
er
re
p
re
se
n
ta
ti
o
n
o
f
H
F
A
fe
m
al
es
V
ar
ia
b
le
s
in
cl
u
d
ed
in
st
u
d
y
(a
tt
ra
ct
io
n
,
re
la
ti
o
n
sh
ip
ch
ar
ac
te
ri
st
ic
s)
n
o
t
co
m
p
ar
ab
le
fo
r
m
et
a-
an
al
y
si
s
w
it
h
o
th
er
in
cl
u
d
ed
st
u
d
ie
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
ea
si
ly
as
a
ch
ar
ac
te
ri
st
ic
o
f
in
it
ia
l
at
tr
ac
ti
o
n
th
an
T
D
m
G
o
u
g
eo
n
(2
0
1
0
)
S
tu
d
ie
s
fro
m
A
u
st
ra
li
a,
B
el
g
iu
m
,
C
an
ad
a,
N
o
rt
h
er
n
G
re
ec
e,
U
K
,
U
S
A
T
o
ta
l
re
le
v
an
t
st
u
d
ie
s
(n
=
6
)
T
o
ta
l
re
le
v
an
t
su
b
je
ct
s
(n
=
1
0
5
)
7
0
m
,
3
5
f
N
o
t
sp
ec
ifi
ed
R
ev
ie
w
ar
ti
cl
e.
D
id
n
o
t
m
ea
su
re
n
ew
em
p
ir
ic
al
d
at
a
In
ap
p
ro
p
ri
at
e
an
d
ap
p
ro
p
ri
at
e
so
ci
al
b
eh
av
io
u
rs
S
ex
u
al
k
n
o
w
le
d
g
e
S
ex
u
al
in
te
re
st
s
S
ex
u
al
ex
p
er
ie
n
ce
s
S
ex
u
al
b
eh
av
io
u
rs
(i
n
cl
u
d
in
g
se
lf
-d
ir
ec
te
d
an
d
p
re
se
n
ce
o
f
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
)
E
n
g
ag
em
en
t
in
p
ri
v
ac
y
re
la
te
d
b
eh
av
io
u
rs
S
o
u
rc
es
o
f
se
x
u
al
k
n
o
w
le
d
g
e
L
ev
el
o
f
p
ar
en
ta
l
co
n
ce
rn
D
ev
el
o
p
m
en
ta
l
ti
m
e
tr
en
d
s
o
f
se
x
u
al
d
ev
el
o
p
m
en
t
A
S
D
m
re
p
o
rt
ed
g
re
at
er
le
v
el
s
o
f
in
te
re
st
in
se
x
u
al
it
y
an
d
d
at
in
g
th
an
A
S
D
f
L
o
w
er
le
v
el
s
o
f
so
ci
al
is
at
io
n
,
se
x
u
al
b
eh
av
io
u
rs
,
aw
ar
en
es
s
o
f
an
d
en
g
ag
em
en
t
in
p
ri
v
ac
y
re
la
te
d
b
eh
av
io
u
rs
th
an
T
D
L
o
w
er
le
v
el
s
o
f
so
ci
al
an
d
ro
m
an
ti
c
fu
n
ct
io
n
in
g
,
m
o
re
at
y
p
ic
al
se
x
u
al
b
eh
av
io
u
rs
(s
ta
lk
in
g
,
se
ek
in
g
in
ap
p
ro
p
ri
at
e
ro
m
an
ti
c
ta
rg
et
s)
th
an
T
D
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
P
u
b
li
ca
ti
o
n
b
ia
s:
M
aj
o
ri
ty
o
f
st
u
d
ie
s
in
cl
u
d
ed
re
p
o
rt
ed
si
g
n
ifi
ca
n
t
re
su
lt
s
o
n
ly
N
ar
ra
ti
v
e
sy
st
em
at
ic
re
v
ie
w
.
D
id
n
o
t
p
ro
d
u
ce
n
ew
em
p
ir
ic
al
d
at
a
E
m
p
ir
ic
al
d
at
a
b
as
ed
o
n
en
ti
re
A
S
D
p
o
p
u
la
ti
o
n
,
d
id
n
o
t
re
p
o
rt
ex
tr
ac
ta
b
le
d
at
a
fo
r
H
F
A
H
ar
ac
o
p
o
s
an
d
P
ed
er
so
n
(1
9
9
2
)
D
en
m
ar
k
n
=
8
1
C
o
m
p
le
te
d
b
y
ca
re
g
iv
er
s
in
g
ro
u
p
h
o
m
es
(n
=
2
0
)
H
F
A
(n
=
2
2
)
L
F
A
(n
=
5
9
)
5
7
m
,
2
4
f
(M
=
2
5
.8
y
ea
rs
)
D
S
M
-I
II
S
el
f-
re
p
o
rt
w
ri
tt
en
q
u
es
ti
o
n
n
ai
re
co
m
p
le
te
d
b
y
ca
re
rs
d
ev
el
o
p
ed
fo
r
st
u
d
y
p
u
rp
o
se
s.
In
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
(l
ev
el
an
d
fr
eq
u
en
cy
)
A
p
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
(l
ev
el
an
d
fr
eq
u
en
cy
)
M
as
tu
rb
at
io
n
S
ex
u
al
co
n
ta
ct
S
ex
u
al
o
ri
en
ta
ti
o
n
R
ep
o
rt
ed
d
es
ir
e
fo
r
an
in
ti
m
at
e
d
y
ad
ic
re
la
ti
o
n
sh
ip
R
ep
o
rt
ed
d
if
fi
cu
lt
ie
s
es
ta
b
li
sh
re
ci
p
ro
ca
l
in
ti
m
at
e
su
ch
re
la
ti
o
n
sh
ip
s
2
0
%
m
,
1
%
f
en
g
ag
e
in
m
as
tu
rb
at
io
n
2
ca
se
s
o
f
H
F
A
f
b
ei
n
g
m
is
u
se
to
sa
ti
sf
y
se
x
u
al
n
ee
d
s
o
f
T
D
m
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
M
ea
su
re
m
en
t
b
ia
s:
R
es
u
lt
s
b
as
ed
o
n
ca
re
rs
’
se
lf
-r
ep
o
rt
s
an
d
m
ay
n
o
t
b
e
an
ac
cu
ra
te
re
p
re
se
n
ta
ti
o
n
o
f
tr
u
e
m
ea
su
re
an
d
fr
eq
u
en
cy
o
f
ce
rt
ai
n
se
x
u
al
b
eh
av
io
u
rs
E
m
p
ir
ic
al
d
at
a
b
as
ed
o
n
en
ti
re
A
S
D
p
o
p
u
la
ti
o
n
,
d
id
n
o
t
re
p
o
rt
ex
tr
ac
ta
b
le
d
at
a
fo
r
H
F
A
N
o
co
m
p
ar
is
o
n
g
ro
u
p
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
H
ay
w
ar
d
an
d
S
au
n
d
er
s
(2
0
1
0
)
A
u
st
ra
li
a
N
o
t
ap
p
li
ca
b
le
N
o
t
sp
ec
ifi
ed
N
o
t
ap
p
li
ca
b
le
S
ex
u
al
d
ev
el
o
p
m
en
t
S
ex
u
al
in
te
re
st
S
ex
u
al
d
es
ir
e
S
ex
u
al
ex
p
er
ie
n
ce
s
R
o
m
an
ti
c
fu
n
ct
io
n
in
g
S
ex
ed
u
ca
ti
o
n
P
h
y
si
ca
ll
y
an
d
se
x
u
al
d
ev
el
o
p
m
en
t
ac
co
rd
in
g
to
n
o
rm
al
d
ev
el
o
p
m
en
ta
l
st
ag
es
S
am
e
le
v
el
o
f
se
x
u
al
d
es
ir
e
as
T
D
in
d
iv
id
u
al
s
P
o
o
r
so
ci
al
an
d
em
o
ti
o
n
al
in
si
g
h
t,
d
el
ay
ed
aw
ar
en
es
s
o
f
so
ci
al
ly
ac
ce
p
ta
b
le
n
o
rm
s
in
re
la
ti
o
n
to
se
x
u
al
it
y
.
T
h
is
le
ad
s
to
in
ab
il
it
y
to
as
se
ss
w
h
et
h
er
to
p
er
fo
rm
se
x
u
al
ac
ts
in
p
u
b
li
c
o
r
p
ri
v
at
e
B
3
0
%
o
f
ad
o
le
sc
en
ts
ex
p
er
ie
n
ce
an
in
cr
ea
se
in
b
eh
av
io
u
rs
o
f
co
n
ce
rn
R
eq
u
ir
em
en
t
fo
r
se
x
ed
u
ca
ti
o
n
ta
il
o
re
d
to
en
h
an
ci
n
g
so
ci
al
sk
il
ls
an
d
ed
u
ca
ti
o
n
ar
o
u
n
d
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
S
el
ec
ti
o
n
b
ia
s:
R
ev
ie
w
ar
ti
cl
e
th
at
in
cl
u
d
ed
fi
n
d
in
g
s
fr
o
m
a
sm
al
l
se
le
ct
io
n
o
f
st
u
d
ie
s.
R
es
u
lt
s
m
ay
n
o
t
b
e
co
m
p
ar
ab
le
to
st
u
d
ie
s
as
se
ss
in
g
in
d
iv
id
u
al
s
w
it
h
h
ig
h
er
le
v
el
s
o
f
fu
n
ct
io
n
in
g
,
o
r
th
o
se
d
ia
g
n
o
se
d
w
it
h
d
if
fe
re
n
t
d
ia
g
n
o
st
ic
cr
it
er
ia
G
o
v
er
n
m
en
t
re
p
o
rt
(s
u
m
m
ar
y
p
ap
er
).
D
id
n
o
t
p
ro
d
u
ce
n
ew
d
at
a
F
in
d
in
g
s
b
as
ed
o
n
en
ti
re
A
S
D
p
o
p
u
la
ti
o
n
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
se
x
u
al
it
y
an
d
se
x
u
al
h
ea
lt
h
H
el
le
m
an
s
et
al
.
(2
0
0
7
)
B
el
g
iu
m
n
=
4
1
C
o
m
p
le
te
d
b
y
p
ro
fe
ss
io
n
al
ca
re
g
iv
er
s
(n
=
1
7
)
H
ig
h
-f
u
n
ct
io
n
in
g
in
st
it
u
ti
o
n
al
iz
ed
m
(n
=
2
4
)
A
D
(n
=
1
4
),
A
S
(n
=
6
),
P
D
D
-N
O
S
(n
=
4
)
(M
=
1
7
y
ea
rs
)
D
S
M
-I
V
-T
R
In
te
rv
ie
w
a
b
o
u
t
S
ex
u
a
li
ty
in
A
u
ti
sm
T
h
eo
re
ti
ca
l
k
n
o
w
le
d
g
e
S
o
ci
o
-s
ex
u
al
sk
il
ls
S
ex
u
al
b
eh
av
io
u
r
S
ex
u
al
p
ro
b
le
m
s
(p
re
se
n
ce
o
f)
T
y
p
ic
al
ag
e-
ap
p
ro
p
ri
at
e
se
x
u
al
in
te
re
st
s
an
d
b
eh
av
io
u
r
re
p
o
rt
ed
in
th
e
m
aj
o
ri
ty
o
f
su
b
je
ct
s
9
6
%
re
p
o
rt
ed
in
te
re
st
in
se
x
u
al
it
y
4
2
%
o
f
re
p
o
rt
ed
a
d
es
ir
e
to
es
ta
b
li
sh
an
in
ti
m
at
e
o
r
se
x
u
al
re
la
ti
o
n
sh
ip
1
3
%
m
as
tu
rb
at
ed
in
p
re
se
n
ce
o
f
o
th
er
s
4
2
%
fa
il
ed
to
d
is
ti
n
g
u
is
h
b
et
w
ee
n
d
es
ir
ed
an
d
u
n
d
es
ir
ed
le
v
el
s
o
f
co
n
ta
ct
7
%
re
p
o
rt
ed
d
if
fi
cu
lt
ie
s
in
se
x
u
al
fu
n
ct
io
n
in
g
E
x
p
er
ie
n
ce
s
o
f
an
x
ie
ty
an
d
d
is
tr
es
s
fr
o
m
ch
an
g
es
in
se
co
n
d
ar
y
se
x
u
al
ch
ar
ac
te
ri
st
ic
s
as
so
ci
at
ed
w
it
h
p
u
b
er
ty
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
S
el
ec
ti
o
n
b
ia
s:
L
im
it
ed
g
en
er
al
is
ab
il
it
y
:
in
st
it
u
ti
o
n
al
is
ed
,
al
l
m
al
e
sa
m
p
le
M
ea
su
re
m
en
t
b
ia
s:
se
lf
-r
ep
o
rt
st
u
d
y
,
le
ss
li
k
el
y
to
re
su
lt
in
u
n
d
er
es
ti
m
at
ed
fr
eq
u
en
cy
o
f
se
x
u
al
b
eh
av
io
u
rs
N
o
co
m
p
ar
is
o
n
g
ro
u
p
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
H
én
au
lt
an
d
A
tt
w
o
o
d
(2
0
0
6
)
C
an
ad
a
(n
=
1
4
),
A
u
st
ra
li
a
(n
=
9
),
U
S
A
(n
=
3
),
F
ra
n
ce
(n
=
2
)
n
=
7
8
H
F
A
/A
S
(n
=
2
8
)
1
9
m
,
9
f
(M
=
3
4
y
ea
rs
)
T
D
(n
=
5
0
)
DS
M
-I
V
(A
P
A
1
9
9
4
)
A
Q
(B
ar
o
n
-C
o
h
en
et
al
.
2
0
1
4
)
u
se
d
to
co
n
fi
rm
d
ia
g
n
o
si
s
in
st
u
d
y
(A
Q
[
3
2
)
D
er
o
a
g
ti
s
S
ex
u
a
l
F
u
n
ct
io
n
in
g
In
ve
n
to
ry
(D
S
F
I)
S
ex
u
al
k
n
o
w
le
d
g
e
S
ex
u
al
ex
p
er
ie
n
ce
s
S
ex
u
al
d
es
ir
e
G
en
er
al
sa
ti
sf
ac
ti
o
n
S
ex
u
al
sa
ti
sf
ac
ti
o
n
L
es
s
se
x
u
al
k
n
o
w
le
d
g
e
F
ew
er
se
x
u
al
ex
p
er
ie
n
ce
s
th
an
T
D
L
ev
el
s
o
f
se
x
u
al
d
es
ir
e
S
ex
u
al
fa
n
ta
si
es
co
m
p
ar
ab
le
to
T
D
m
h
ad
le
ss
se
x
u
al
k
n
o
w
le
d
g
e,
an
d
re
p
o
rt
ed
fe
w
er
se
x
u
al
ex
p
er
ie
n
ce
s
m
h
ad
h
ig
h
er
le
v
el
s
o
f
d
y
ad
ic
se
x
u
al
d
es
ir
e
th
an
f
M
o
f
d
ev
el
o
p
in
g
an
in
te
re
st
in
se
x
u
al
it
y
1
4
y
ea
rs
M
o
f
fi
rs
t
se
x
u
al
in
te
rc
o
u
rs
e
2
2
y
ea
rs
R
ep
o
rt
ed
an
x
ie
ty
,
d
ep
re
ss
ed
m
o
o
d
,
lo
n
el
in
es
s,
an
d
v
ar
y
in
g
le
v
el
s
o
f
d
is
tr
es
s
S
ex
u
al
k
n
o
w
le
d
g
e
(H
F
A
m
v
s
H
F
A
f;
d
=
-
0
.2
8
)
S
ex
u
al
ex
p
er
ie
n
ce
(H
F
A
m
v
s
H
F
A
f;
d
=
-
0
.3
4
)
S
ex
u
al
d
es
ir
e
(H
F
A
m
v
s
H
F
A
f;
d
=
0
.2
7
)
G
en
er
al
sa
ti
sf
ac
ti
o
n
(H
F
A
m
v
s
H
F
A
f;
d
=
0
.8
3
)
S
ex
u
al
sa
ti
sf
ac
ti
o
n
(H
F
A
m
v
s
H
F
A
f;
d
=
0
.2
9
)
S
el
ec
ti
o
n
b
ia
s:
d
id
n
o
t
re
cr
u
it
T
D
p
ar
ti
ci
p
an
ts
,
in
cl
u
d
ed
an
av
er
ag
e
M
o
n
al
l
m
ea
su
re
s
o
f
se
x
u
al
it
y
(M
=
5
0
)
to
co
m
p
ar
e
to
H
F
A
.
S
co
re
s
fo
r
T
D
m
ay
n
o
t
ac
cu
ra
te
ly
re
p
re
se
n
t
th
o
se
in
th
e
g
en
er
al
p
o
p
u
la
ti
o
n
S
tu
d
y
n
o
t
ex
cl
u
d
ed
:
ex
am
in
ed
v
ia
m
et
a-
an
al
y
si
s
K
al
y
v
a
(2
0
1
0
)
N
o
rt
h
er
n
G
re
ec
e
n
=
5
6
C
o
m
p
le
te
d
b
y
te
ac
h
er
s
(n
=
5
6
).
H
F
A
/A
S
(n
=
2
0
)
1
6
m
,
4
f
(M
=
1
0
y
ea
rs
)
L
F
A
(n
=
5
6
)
3
8
m
,
1
8
f
(M
=
1
0
y
ea
rs
)
D
S
M
-I
V
P
ro
fe
ss
io
n
al
d
ia
g
n
o
si
s
v
ia
a
m
u
lt
id
is
ci
p
li
n
ar
y
te
am
o
f
a
p
sy
ch
o
lo
g
is
t,
p
sy
ch
ia
tr
is
t,
so
ci
al
w
o
rk
er
an
d
sp
ee
ch
th
er
ap
is
t
M
o
d
ifi
ed
v
er
si
o
n
o
f
S
ex
u
a
l
B
eh
a
vi
o
u
r
S
ca
le
(S
B
S
)
S
o
ci
al
co
n
ta
ct
S
o
ci
al
in
si
g
h
t
S
ex
u
al
b
eh
av
io
u
r
P
ri
v
ac
y
re
la
te
d
b
eh
av
io
u
rs
P
ar
en
ta
l
co
n
ce
rn
G
re
at
er
le
v
el
o
f
se
x
u
al
aw
ar
en
es
s
an
d
en
g
ag
em
en
t
in
so
ci
al
ly
ac
ce
p
ta
b
le
se
x
u
al
b
eh
av
io
u
rs
in
H
F
A
v
er
su
s
L
F
A
G
re
at
er
re
p
o
rt
ed
co
n
ce
rn
fo
r
H
F
A
/
A
S
th
an
L
F
A
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
S
el
ec
ti
o
n
b
ia
s:
u
n
ev
en
sa
m
p
le
si
ze
:
m
o
re
ch
il
d
re
n
w
it
h
L
F
A
th
an
H
F
A
/A
S
In
el
ig
ib
le
co
m
p
ar
is
o
n
g
ro
u
p
.
C
o
u
ld
n
o
t
ex
tr
ac
t
d
at
a
o
n
H
F
A
o
n
ly
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
K
au
r
(2
0
0
9
)
A
u
st
ra
li
a,
In
d
ia
,
S
in
g
ap
o
re
n
=
2
7
5
C
o
m
p
le
te
d
b
y
p
ar
en
ts
.
H
F
A
/A
S
(n
=
6
6
)
D
S
=
(n
=
5
6
)
T
D
(n
=
1
5
3
)
(M
=
1
5
y
ea
rs
)
D
S
M
-I
V
-T
R
S
ex
u
a
l
B
eh
a
vi
o
u
r
S
ca
le
,
2
n
d
ed
it
io
n
,
(S
B
S
-I
I)
d
ev
el
o
p
ed
fo
r
st
u
d
y
p
u
rp
o
se
s
S
o
ci
al
co
n
ta
ct
S
o
ci
al
in
si
g
h
t
S
ex
u
al
b
eh
av
io
u
r
P
ri
v
ac
y
re
la
te
d
b
eh
av
io
u
rs
P
ar
en
ta
l
co
n
ce
rn
L
es
s
so
ci
al
co
n
ta
ct
ac
ro
ss
co
u
n
tr
ie
s
L
es
s
so
ci
al
in
si
g
h
t
ac
ro
ss
co
u
n
tr
ie
s
G
re
at
er
p
ar
en
ta
l
co
n
ce
rn
M
o
re
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
D
if
fe
re
n
ce
s
in
d
ev
el
o
p
m
en
ta
l
tr
en
d
s
in
H
F
A
an
d
T
D
,
so
ci
al
co
n
ta
ct
an
d
so
ci
al
in
si
g
h
t
im
p
ro
v
ed
w
it
h
ag
e
in
H
F
A
,
y
et
re
m
ai
n
ed
at
a
si
m
il
ar
le
v
el
in
T
D
L
ev
el
s
o
f
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
w
er
e
d
if
fe
re
n
t
in
H
F
A
an
d
T
D
at
ag
e
1
0
,
b
o
th
d
ec
re
as
ed
o
v
er
ti
m
e,
w
h
er
e
th
ey
w
er
e
at
si
m
il
ar
le
v
el
s
at
ag
e
1
9
L
ev
el
s
o
f
p
ar
en
ta
l
co
n
ce
rn
in
cr
ea
se
d
o
v
er
ti
m
e
in
p
ar
en
ts
o
f
H
F
A
,
d
ec
re
as
ed
o
v
er
ti
m
e
in
p
ar
en
ts
o
f
T
D
S
o
ci
al
co
n
ta
ct
(d
=
–
0
.5
5
)
In
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
(d
=
0
.4
1
)
P
ar
en
ta
l
co
n
ce
rn
(d
=
0
.6
7
)
D
ev
el
o
p
m
en
ta
l
tr
en
d
s:
S
o
ci
al
co
n
ta
ct
(d
=
0
.2
0
)
In
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
(d
=
0
.2
0
)
P
ar
en
ta
l
co
n
ce
rn
(d
=
0
.2
0
)
O
v
er
al
l
st
u
d
y
ef
fe
ct
si
ze
(d
=
-
0
.4
6
)
M
ea
su
re
m
en
t
b
ia
s:
se
x
u
al
b
eh
av
io
u
r
su
b
sc
al
e
o
f
S
B
S
-I
I
h
as
m
o
d
er
at
e
C
ro
n
b
ac
h
’s
al
p
h
as
an
d
re
q
u
ir
es
fu
rt
h
er
d
ev
el
o
p
m
en
t
M
ea
su
re
m
en
t
b
ia
s:
p
ar
en
ta
l-
re
p
o
rt
st
u
d
y
,
re
su
lt
s
m
ay
b
e
u
n
d
er
es
ti
m
at
io
n
s
o
f
le
v
el
s
o
f
so
ci
al
co
n
ta
ct
,
in
si
g
h
t
an
d
en
g
ag
em
en
t
in
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
d
u
e
to
la
ck
o
f
k
n
o
w
le
d
g
e
o
f
ch
il
d
’s
b
eh
av
io
u
r
w
h
en
th
ey
ar
e
n
o
t
p
re
se
n
t
S
tu
d
y
n
o
t
ex
cl
u
d
ed
:
ex
am
in
ed
v
ia
m
et
a-
an
al
y
si
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
M
eh
za
b
in
an
d
S
to
k
es
(2
0
1
1
)
A
u
st
ra
li
a
n
=
6
0
H
F
A
(n
=
2
1
)
1
2
m
(M
=
2
5
.3
y
ea
rs
,
S
D
=
3
.6
)
9
f
(M
=
2
3
.4
y
ea
rs
,
S
D
=
1
.9
)
T
D
(n
=
3
9
)
1
5
m
(M
=
2
3
.7
y
ea
rs
,
S
D
=
3
.1
)
2
4
f
(M
=
2
2
.6
y
ea
rs
,
S
D
=
2
.1
)
N
o
t
sp
ec
ifi
ed
D
S
M
-I
V
?
(p
er
so
n
al
co
m
m
u
n
ic
at
io
n
S
to
k
es
,
2
0
1
4
)
A
d
ap
te
d
v
er
si
o
n
o
f
S
B
S
S
o
ci
al
co
n
ta
ct
S
o
ci
al
in
si
g
h
t
S
ex
u
al
B
eh
av
io
u
r
P
ri
v
ac
y
re
la
te
d
b
eh
av
io
u
rs
P
ar
en
ta
l
C
o
n
ce
rn
S
ex
E
d
u
ca
ti
o
n
F
ew
er
so
ci
al
b
eh
av
io
u
rs
F
ew
er
se
x
u
al
b
eh
av
io
u
rs
F
ew
er
se
x
u
al
ex
p
er
ie
n
ce
s
L
es
s
se
x
ed
u
ca
ti
o
n
G
re
at
er
le
v
el
s
o
f
co
n
ce
rn
fo
r
fu
tu
re
se
x
u
al
in
te
ra
ct
io
n
s
N
o
si
g
n
ifi
ca
n
t
d
if
fe
re
n
ce
s
b
et
w
ee
n
H
F
A
an
d
T
D
o
n
p
ri
v
ac
y
se
ek
in
g
b
eh
av
io
u
r
an
d
aw
ar
en
es
s
o
f
p
ri
v
ac
y
ru
le
s
S
o
ci
al
b
eh
av
io
u
rs
(d
=
-
1
.8
1
)
P
ri
v
ac
y
se
ek
in
g
b
eh
av
io
u
rs
(d
=
0
.3
5
)
S
ex
ed
u
ca
ti
o
n
(d
=
–
1
.2
8
)
S
ex
u
al
is
ed
b
eh
av
io
u
rs
(d
=
-
1
.2
8
)
O
v
er
al
l
st
u
d
y
ef
fe
ct
si
ze
(d
=
1
.1
0
)
U
n
ev
en
sa
m
p
le
si
ze
:
2
1
p
ar
ti
ci
p
an
ts
w
it
h
H
F
A
,
3
9
T
D
p
ar
ti
ci
p
an
ts
S
tu
d
y
n
o
t
ex
cl
u
d
ed
:
ex
am
in
ed
v
ia
m
et
a-
an
al
y
si
s
N
ic
h
o
ls
(2
0
0
9
)
U
S
A
N
o
t
ap
p
li
ca
b
le
N
o
t
sp
ec
ifi
ed
S
u
m
m
ar
is
ed
ex
is
ti
n
g
re
se
ar
ch
.
D
id
n
o
t
ad
m
in
is
te
r
te
st
in
st
ru
m
en
ts
/
in
te
rv
en
ti
o
n
s.
F
em
al
es
w
it
h
H
F
A
P
u
b
er
ty
an
d
se
x
u
al
it
y
fo
r
fe
m
al
es
w
it
h
H
F
A
P
sy
ch
o
lo
g
ic
al
is
su
es
as
so
ci
at
ed
w
it
h
ad
o
le
sc
en
ce
in
fe
m
al
es
w
it
h
H
F
A
H
F
A
f
d
is
p
la
y
co
n
ce
rn
fo
r
so
ci
al
st
at
u
s
at
th
e
sa
m
e
d
ev
el
o
p
m
en
ta
l
p
er
io
d
as
T
D
f
C
h
al
le
n
g
es
as
so
ci
at
ed
w
it
h
H
F
A
f
an
d
se
x
u
al
it
y
incl
u
d
e:
d
if
fi
cu
lt
ie
s
in
em
o
ti
o
n
al
re
co
g
n
it
io
n
an
d
re
ci
p
ro
ci
ty
,
p
o
o
r
af
fe
ct
d
u
e
to
aw
ar
en
es
s
o
f
b
ei
n
g
d
if
fe
re
n
t
to
T
D
f,
an
d
m
is
in
te
rp
re
ta
ti
o
n
o
f
ro
m
an
ti
c
ad
v
an
ce
s
o
r
d
is
in
te
re
st
fr
o
m
ta
rg
et
p
ar
tn
er
s
F
ew
er
so
u
rc
es
o
f
so
ci
al
co
n
ta
ct
an
d
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
L
im
it
ed
g
en
er
al
is
ab
il
iy
:
b
o
o
k
th
at
in
cl
u
d
ed
fi
n
d
in
g
s
fr
o
m
a
sm
al
l
se
le
ct
io
n
o
f
st
u
d
ie
s.
R
es
u
lt
s
m
ay
n
o
t
b
e
co
m
p
ar
ab
le
to
st
u
d
ie
s
as
se
ss
in
g
in
d
iv
id
u
al
s
w
it
h
in
th
e
w
id
er
H
F
A
p
o
p
u
la
ti
o
n
F
in
d
in
g
s
ab
o
u
t
H
F
A
f
w
er
e
al
so
ap
p
li
ca
b
le
to
H
F
A
m
B
o
o
k
su
m
m
ar
is
in
g
ex
is
ti
n
g
re
se
ar
ch
.
D
id
n
o
t
in
cl
u
d
e
n
ew
,
ra
w
d
at
a
th
at
co
u
ld
b
e
an
al
y
se
d
v
ia
m
et
a-
an
al
y
si
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
th
u
s
le
ss
so
u
rc
es
fo
r
le
ar
n
in
g
,
an
d
in
st
ea
d
le
ar
n
ab
o
u
t
se
x
u
al
it
y
th
ro
u
g
h
n
o
n
-s
o
ci
al
so
u
rc
es
R
eq
u
ir
em
en
t
fo
r
S
ex
u
al
it
y
ed
u
ca
ti
o
n
ta
il
o
re
d
sp
ec
ifi
ca
ll
y
to
w
ar
d
fe
m
al
es
w
it
h
H
F
A
is
es
se
n
ti
al
in
re
d
u
ci
n
g
th
e
ri
sk
o
f
p
h
y
si
ca
l
o
r
se
x
u
al
ab
u
se
an
d
ex
p
lo
it
at
io
n
in
f
O
u
sl
ey
an
d
M
es
ib
o
v
(1
9
9
1
)
U
S
A
n
=
4
1
H
F
A
(n
=
2
1
)
1
1
m
(M
=
2
7
y
ea
rs
,
S
D
=
5
.4
),
1
0
f
(M
=
2
7
y
ea
rs
,
S
D
=
5
.9
)
ID
(n
=
2
0
)
1
0
m
(M
=
2
7
y
ea
rs
,
S
D
=
5
.9
),
1
0
f
(M
=
2
7
y
ea
rs
,
S
D
=
7
.9
)
P
ro
fe
ss
io
n
al
d
ia
g
n
o
si
s
(P
sy
ch
o
lo
g
is
t)
C
h
il
d
h
o
o
d
A
u
ti
sm
R
at
in
g
S
ca
le
(C
A
R
S
)
u
se
d
to
co
n
fi
rm
d
ia
g
n
o
si
s
in
st
u
d
y
S
el
f-
re
p
o
rt
w
ri
tt
en
m
u
lt
ip
le
-c
h
o
ic
e
q
u
es
ti
o
n
n
ai
re
as
m
ea
su
re
o
f
at
ti
tu
d
es
an
d
ex
p
er
ie
n
ce
s
o
f
se
x
u
al
it
y
an
d
d
at
in
g
S
tr
u
ct
u
re
d
In
te
rv
ie
w
o
ra
ll
y
ad
m
in
is
te
re
d
b
y
ex
am
in
er
to
as
se
ss
k
n
o
w
le
d
g
e
an
d
u
n
d
er
st
an
d
in
g
o
f
a
ra
n
g
e
o
f
se
x
u
al
it
y
-
re
la
te
d
te
rm
s
an
d
co
n
ce
p
ts
S
ex
u
al
at
ti
tu
d
es
S
ex
u
al
k
n
o
w
le
d
g
e
S
ex
u
al
ex
p
er
ie
n
ce
s
S
ex
u
al
ac
ti
v
it
y
R
ep
o
rt
ed
in
te
re
st
in
d
at
in
g
se
x
u
al
it
y
le
ss
th
an
se
x
u
al
k
n
o
w
le
d
g
e
an
d
ex
p
er
ie
n
ce
L
es
s
se
x
u
al
ex
p
er
ie
n
ce
th
an
ID
L
es
s
in
te
re
st
in
se
x
u
al
it
y
th
an
ID
G
re
at
er
in
te
re
st
in
se
x
u
al
it
y
an
d
d
at
in
g
in
m
H
ig
h
er
le
v
el
s
o
f
se
x
u
al
fr
u
st
ra
ti
o
n
an
d
m
as
tu
rb
at
io
n
in
m
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
M
ea
su
re
m
en
t
b
ia
s:
st
ru
ct
u
re
d
(s
el
f-
re
p
o
rt
)
in
te
rv
ie
w
,
le
ss
li
k
el
y
to
re
su
lt
in
u
n
d
er
es
ti
m
at
ed
o
r
in
ac
cu
ra
te
m
ea
su
re
o
f
se
x
u
al
ex
p
er
ie
n
ce
s,
k
n
o
w
le
d
g
e
an
d
b
eh
av
io
u
rs
)
S
tu
d
y
co
m
p
ar
es
ID
an
d
H
F
A
.
D
at
a
fo
r
H
F
A
al
o
n
e
n
o
t
ex
tr
ac
ta
b
le
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
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e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
S
ev
le
v
er
et
al
.
(2
0
1
3
)
U
S
A
N
o
t
sp
ec
ifi
ed
N
o
t
sp
ec
ifi
ed
R
ev
ie
w
ar
ti
cl
e.
D
id
n
o
t
m
ea
su
re
n
ew
em
p
ir
ic
al
d
at
a
S
ex
u
al
ab
u
se
S
ex
u
al
o
ff
en
d
in
g
S
ex
u
al
it
y
ed
u
ca
ti
o
n
G
re
at
er
ri
sk
o
f
se
x
u
al
ab
u
se
,
ex
p
lo
it
at
io
n
an
d
se
x
u
al
o
ff
en
d
in
g
P
re
li
m
in
ar
y
ev
id
en
ce
o
f
an
o
v
er
re
p
re
se
n
ta
ti
o
n
o
f
A
S
D
in
fo
re
n
si
c
se
tt
in
g
s
O
b
se
ss
io
n
al
in
te
re
st
s
m
ay
le
ad
to
d
an
g
er
o
u
s
b
eh
av
io
u
rs
if
in
te
re
st
s
d
ev
el
o
p
ed
ar
o
u
n
d
se
x
u
al
it
y
H
ig
h
er
ra
te
s
o
f
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
(i
n
ap
p
ro
p
ri
at
el
y
to
u
ch
in
g
,
co
n
ti
n
u
in
g
to
p
u
rs
u
e
o
r
st
al
k
ro
m
an
ti
c
in
te
re
st
s
d
es
p
it
e
la
ck
o
f
re
ci
p
ro
ci
ty
)
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eq
u
ir
em
en
t
fo
r
ed
u
ca
ti
o
n
p
ro
g
ra
m
sp
ec
ifi
ca
ll
y
ta
il
o
re
d
to
th
e
n
ee
d
s
o
f
H
F
A
S
tu
d
y
re
ta
in
ed
fo
r
q
u
al
it
at
iv
e
sy
n
th
es
is
o
n
ly
L
im
it
ed
g
en
er
al
is
ab
il
iy
:
re
v
ie
w
ar
ti
cl
e
th
at
in
cl
u
d
ed
fi
n
d
in
g
s
fr
o
m
a
sm
al
l
se
le
ct
io
n
o
f
st
u
d
ie
s
R
ev
ie
w
ar
ti
cl
e
su
m
m
ar
is
in
g
ex
is
ti
n
g
d
at
a.
D
id
n
o
t
p
ro
d
u
ce
n
ew
,
ra
w
d
at
a
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu
d
y
an
d
co
u
n
tr
y
S
am
p
le
p
ar
ti
ci
p
an
t
d
et
ai
ls
In
te
rv
en
ti
o
n
/
in
st
ru
m
en
ts
u
se
d
O
u
tc
o
m
e
m
ea
su
re
s/
v
ar
ia
b
le
s
ex
am
in
ed
O
u
tc
o
m
es
/fi
n
d
in
g
s
E
ff
ec
t
si
ze
R
is
k
o
f
b
ia
s
R
ea
so
n
fo
r
ex
cl
u
si
o
n
fr
o
m
q
u
an
ti
ta
ti
v
e
sy
n
th
es
is
(q
u
al
it
at
iv
e
st
u
d
ie
s
o
n
ly
)
S
am
p
le
si
ze
d
es
cr
ip
ti
o
n
D
ia
g
n
o
st
ic
cr
it
er
ia
S
to
k
es
an
d
K
au
r
(2
0
0
5
)
A
u
st
ra
li
a
n
=
7
3
C
o
m
p
le
te
d
b
y
p
ar
en
ts
H
F
A
/A
S
(n
=
2
3
)
1
7
m
(M
=
1
2
.6
y
ea
rs
,
S
D
=
1
.9
)
6
f
(M
=
1
3
.0
y
ea
rs
,
S
D
=
0
.6
)
T
D
(n
=
5
0
)
3
3
m
(M
=
1
3
.5
y
ea
rs
,
S
D
=
1
.4
)
1
7
f
(M
=
1
3
.1
y
ea
rs
,
S
D
=
1
.5
)
N
o
t
sp
ec
ifi
ed
D
S
M
-I
V
?
(p
er
so
n
al
co
m
m
u
n
ic
at
io
n
S
to
k
es
,
2
0
1
4
)
S
B
S
d
ev
el
o
p
ed
fo
r
st
u
d
y
p
u
rp
o
se
s.
S
o
ci
al
co
n
ta
ct
S
o
ci
al
in
si
g
h
t
S
ex
u
al
B
eh
av
io
u
r
P
ri
v
ac
y
re
la
te
d
b
eh
av
io
u
rs
P
ar
en
ta
l
C
o
n
ce
rn
D
ev
el
o
p
m
en
ta
l
ti
m
e
p
at
te
rn
s
F
ew
er
so
ci
al
b
eh
av
io
u
rs
L
es
s
se
x
-r
el
at
ed
k
n
o
w
le
d
g
e
L
es
s
p
ri
v
ac
y
-r
el
at
ed
sk
il
ls
M
o
re
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
L
ev
el
s
o
f
p
ri
v
ac
y
-
re
la
te
d
b
eh
av
io
u
r,
se
x
ed
u
ca
ti
o
n
an
d
se
x
u
al
b
eh
av
io
u
r
in
cr
ea
se
d
w
it
h
ag
e
in
H
F
A
,
y
et
n
o
t
T
D
G
re
at
er
p
ar
en
ta
l
co
n
ce
rn
,
in
cr
ea
se
d
o
v
er
ti
m
e
in
H
F
A
d
ec
re
as
ed
in
T
D
S
o
ci
al
b
eh
av
io
u
rs
(d
=
-
1
.9
3
)
P
ri
v
ac
y
se
ek
in
g
b
eh
av
io
u
rs
(d
=
-
0
.5
9
)
S
ex
ed
u
ca
ti
o
n
(d
=
–
1
.2
2
)
In
ap
p
ro
p
ri
at
e
se
x
u
al
is
ed
b
eh
av
io
u
rs
(d
=
1
.1
9
)
P
ar
en
ta
l
co
n
ce
rn
(d
=
1
.7
0
)
D
ev
el
o
p
m
en
ta
l
ti
m
e
p
at
te
rn
s:
so
ci
al
co
n
ta
ct
(d
=
0
.2
0
)
D
ev
el
o
p
m
en
ta
l
ti
m
e
p
at
te
rn
s:
se
x
u
al
is
ed
b
eh
av
io
u
rs
(d
=
0
.5
0
)
D
ev
el
o
p
m
en
ta
l
ti
m
e
p
at
te
rn
s:
p
ar
en
ta
l
co
n
ce
rn
(d
=
0
.6
7
)
M
ea
su
re
m
en
t
b
ia
s:
se
x
u
al
b
eh
av
io
u
r
an
d
p
ri
v
ac
y
su
b
sc
al
es
o
f
S
B
S
h
av
e
m
o
d
er
at
e
C
ro
n
b
ac
h
’s
al
p
h
as
an
d
re
q
u
ir
e
fu
rt
h
er
d
ev
el
o
p
m
en
t
P
ar
en
ta
l-
re
p
o
rt
st
u
d
y
,
re
su
lt
s
m
ay
b
e
u
n
d
er
es
ti
m
at
io
n
s
o
f
le
v
el
s
o
f
so
ci
al
co
n
ta
ct
,
in
si
g
h
t
an
d
en
g
ag
em
en
t
in
in
ap
p
ro
p
ri
at
e
se
x
u
al
b
eh
av
io
u
rs
d
u
e
to
la
ck
o
f
k
n
o
w
le
d
g
e
o
f
ch
il
d
’s
b
eh
av
io
u
r
w
h
en
th
ey
ar
e
n
o
t
p
re
se
n
t
S
tu
d
y
n
o
t
ex
cl
u
d
ed
:
ex
am
in
ed
v
ia
m
et
a-
an
al
y
si
s
J Autism Dev Disord
123
T
a
b
le
1
co
n
ti
n
u
ed
S
tu