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NEURODIVERSE SEX THERAPY

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Are you autistic or an ADHD'er?
 

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Sexual intimacy is an important part of a couple’s relationship yet can feel like an unsurmountable challenge for neurodiverse couples to overcome. To make matters worse, sex often becomes so emotionally loaded that the couple will make an unspoken agreement that the topic is off limits for discussion.

 

So it should not be surprising that one study showed that 50% of neurodiverse couples had no sexual activity. Fortunately, with outside help, there is hope!

 

Addressing the barriers to a healthy sex life with an understanding and acceptance of neurodiversity can set a couple on path to revive their sex life or to start one that has never existed. 

Our work with couples usually covers the areas listed below. Please know that these topics are NOT listed in order of importance as issues impact each couple in very different ways. We work with the couple so that they define their own issues and set the priority for our focus in therapy.


Desire Imbalance

A sexual challenge for all couples, both neurotypical and neurodiverse, can be a mismatched libido but the struggle is especially pronounced for neurodiverse couples. This problem occurs when one person has a higher sex drive than his or her partner. This libido difference can stay relatively steady throughout a relationship or can vary depending on the changes in each partner's body and what is happening in their lives . 


The libido imbalance can be viewed similarly to other differences that a couple may have. Examples include different levels of desire for travel, reading, exercise, and other life activities. However, the negotiation around mismatched libidos may be more difficult to resolve because it often gets played out through non-verbal cues which may be difficult for the NT partner to pick up on.

This unresolved libido imbalance can lead to tension and confusion about how often a couple will have sex. And not having this worked out can make the high desire partner feel sexually unwanted while the low desire partner feels pressured and overwhelmed. Because one’s sexuality can say so much about a person’s identity and the health of their relationship, working through these issues in the safety of therapy is often needed to break the sexual and communication logjam.

 

The solutions that may be explored in therapy to address the couple's libido differences depend on the couple's unique situation but may include:

  • clarification of sexual and non-sexual touch,

  • scheduling sex (but not to the complete exclusion of spontaneous sex),

  • experimenting with different frequencies or rhythms for sexual encounters,

  • discussing how to initiate sex and taking turns doing so,

  • practicing how to say “no” to sex without rejecting one’s partner,

  • not pressuring one’s partner when receiving a “no,” and

  • a commitment to rescheduling if a scheduled time doesn’t work out.

Sensory Issues

Studies show that 80% of AS partners are hyper or hypo sensitive to sensations of sound, taste, sight, touch, smell or pressure. This will surely impact physical intimacy as couples approach each other for sexual contact. Many AS partners may become overwhelmed when they are being overstimulated.

 

These sensations can create extreme levels of distress. In this state, the AS partner may lose the ability to explain what is happening, resulting in a meltdown and/or shut down. Thus, it is critical to talk about these issues when the couple is not in a stressful moment, such as in therapy.

 

Also, a partner may feel shame in discussing these topics, like he or she is flawed and not worthy of being in a relationship. Accordingly, in therapy we are careful to approach the subject in a non-blaming or shaming way. By viewing the sensory challenges in the context of neurodiversity and by exploring workarounds together, a couple can begin to experiment with ways to create sensations that feel pleasurable for both partners. 

Communication

While communication in day-to-day situations can be a mix of verbal and nonverbal communication, when it comes to sexual activity, the non-verbal component increases exponentially. When non-verbal communication is lacking, sex can be experienced as mechanical, unfulfilling, frustrating and/or disconnected.

 

We have found that AS and NT partners can bridge the non-verbal communication gap by slowing down the communication and being intentional about their needs and desires before, during, and after sex. In therapy we introduce take-home exercises that increase eye contact and make it OK to ask about body language if it is not understood.

Additionally, the couple is invited to verbalize what may otherwise be spoken non-verbally. In other words, the couple is invited to substitute clear and direct communication for non-verbal language. Further, “code words” or “safety words” are established in therapy and can be used during sexual encounters to avoid painful triggers or boundary violations. Many couples feel greatly relieved by the addition of concrete language to their sex lives as it usually results in the ultimate satisfaction of long-neglected sexual wants and desires. 

Experience levels

Many AS partners have had difficulty connecting sexually with others in their lives before meeting their current partner. Delayed hormonal development during puberty may have been a contributing factor. Also, challenges in building friendships, a time-consuming special interest, or a fear around meeting new people may have limited the AS partner’s prior sexual experiences. Even worse, the AS partner may have had negative sexual experiences that caused deep emotional wounds.

 

As a result, the AS partner may have a distorted view of the expectations of a romantic relationship, one that is based on movies and books rather than real-life experiences. Of course, all of the challenges could be equally true for the NT partner. In therapy, we may suggest individual sessions to explore a partner’s sexual history to begin healing wounds that may have occurred in the past. And when the couple is ready, these issues can be addressed in couples therapy where the couple heals together and jointly creates clear and realistic sexual expectations based on a deeper understanding of each other.

Define Sex

We also work with couples to consider how narrow or broad their view of sex is. For example, the AS partner may focus exclusively on sexual intercourse while the NT partner has a more expansive view of sexual connection; whereby sex may include a touch on the shoulder after dinner, flirting during the day, a provocative text, foreplay, and spending time in the bed talking after sexual intercourse. Furthermore, neurodiversity may impact gender identification and sexual preferences in nuanced ways that should be discussed with great care. Exploring each partner's view of sex within the safe confines of therapy can help the couple understand each other in new ways, reset expectations, and create an openness to new ways to sexually connect.


Enthusiastic Consent

Sexual enjoyment will rapidly decrease if one partner does not want to be there. An AS partner, especially a AS female, may struggle with saying “no” to sex if she feels overwhelmed by the sensory input of the sexual experience. Furthermore, an AS partner may view sex as a “task to be performed” and not appreciate the bonding opportunity or not understand why the reluctant partner is saying "no." In therapy, we work hard to make room for both partners to express what they are experiencing and to create an atmosphere where sex only takes place when both partners enthusiastically consent. 


You vs. Me

Because it may not be natural for the AS partner to put him or herself in his partner’s shoes, it may be easy for him to focus on his own needs and neglect his partner’s needs. However, if this issue is brought to the forefront without criticism, the AS partner may be willing to go to great lengths to please his partner. In therapy, we will create opportunities to shift focus from self to the partner and do so in a loving way.

Emotional intimacy

A relationship struggling with misunderstanding, frustration, anger, and disappointment in non-sexual areas will often find sex unfulfilling. Usually, one’s body will involuntarily shut down if there is little or no emotional connection. For this reason, in therapy, we work first to reestablish emotional safety before exploring sexual reconnection. 

Your Body 

It is important to understand that there are two categories of issues that arise in sex therapy:
 

  • Sexualized Issue: This is a non-sex related issue that shows up in the bedroom. Most of the issues listed above are good examples of a problem that is rooted in emotions or thinking that is impacting sex.
     

  • Physical Sex issue: We will talk to you about physical issues such as vulvodynia or impotence due to radiation for prostate cancer. We will then recommend that you seek out a medical specialist for a full evaluation.

    Then we will work in tandem with the medical specialist to find ways to have the best sex life possible given the medical condition. Doing so, helps reduce the shame and blame that usually accompany having a medical issue that impacts one's sexual relationship.

Practical Steps

Here are some of the practical steps that are introduced in therapy that may help neurodiverse couples:
 

  • Agree on what non-sexual touch is and is not, and be clear about what communication is needed to go beyond non-sexual touch.
     

  • Practice phrases to express sexual likes and dislikes.
     

  • Practice asking your partner what he or she likes.
     

  • Practice using a 1 to 10 scale to communicate the level of sensations and how much you like something.
     

  • Negotiate a schedule for sex with a beginning and end time. 
     

  • Learn how your partner likes to be approached for sex.
     

  • Practice how to say “no” when approached for sex.
     

  • Agree that the sex does not end immediately after intercourse.
     

  • Discuss what each person would like to have happen during sex. Break it down step by step. Talk about what happens when someone wants to explore something new or different.
     

  • Discuss boundaries and what is off-limits.
     

  • Find code or safety words if either partner feels a boundary is crossed, sensations are being over-stimulated, if a partner is feeling overwhelmed, or if consent is being withdrawn. Practice using the code words.
     

  • Have all of the discussions listed above when not engaged sexually and when both partners are focused on the conversation with little or no distracting sensory input.

Helpful Research:

SEX ED. FOR SELF-ADVOCATES

This guide is a sexuality and sex education resource written specifically for people on the autism spectrum age 15 and up. 

https://researchautism.org/sex-ed-guide/

Gender and Sexuality in Autism

https://www.spectrumnews.org/news/gender-and-sexuality-in-autism-explained/

Aston, M. C., & Attwood, T. (2014). The other half of Asperger syndrome (autism spectrum disorder): A guide to living in an intimate relationship with a partner who is on the autism spectrum. London, UK: Jessica Kingsley.

Carew, A. (2020). Playing a part: Neurodiversity and Self-discovery in “Sex and Death.” Metro, (205), 64–67.  doi:329840875839108

Ekblad, L. (2018, August 16). Gender identity in autism and neurodiversity. https://doi.org/10.31234/osf.io/np9h8

Mackenzie, R. & Watts, J. (2013, April). Sexual health, neurodiversity and capacity to consent to sex. Tizard Learning Disability Review.  10.1108/13595471311315119

Myhill, G., & Jekel, D. (2015, March). Neurology Matters: Recognizing, understanding, and treating neurodiverse couples in therapy. FOCUS, NASW Massachusetts Chapter.

Schöttle, D., Briken, P., Tüscher, O., & Turner, D. (2017). Sexuality in autism: hypersexual and paraphilic behavior in women and men with high-functioning autism spectrum disorder. Dialogues in clinical neuroscience, 19(4), 381–393. https://doi.org/10.31887/DCNS.2017.19.4/dschoettle

Tavassoli, T., Miller, L. J., Schoen, S. A., Nielsen, D. M., & Baron-Cohen, S. (2013). Sensory over-responsivity in adults with autism spectrum conditions. Autism, 18(4), 428-432. doi:10.1177/1362361313477246

Desire Imbalance
Sensory Issues
Communication
Experience
What is Sex?
Consent
You vs. Me
Emotions
Your Body
Practical Steps

What is a "Screening" Test?

Autism Screeners

ADHD Screeners

What is a Screening Test?

Curious clients often start by taking one or more of the on-line screening tests listed below (not definitive tests).

Screening tests are initial assessments designed to identify individuals who might be autism or an ADHD'er. These tests are typically brief and aim to quickly determine whether a more comprehensive evaluation is necessary. Screening tests are not diagnostic tools but rather serve to flag potential developmental issues or ASD characteristics.

Screener says "low" or "no"

If the results of the screening tests below indicate no or a very low indication of autism or ADHD as compared to the average for the population, you may decide that an in-depth evaluation is not warranted.

Screener says "possible"

However, if the screening tests indicate that ASD and/or ADHD is possible, you should strongly consider an in-depth evaluation.  The first step is to fill out our contact form so you can book a free consult with us.

 

Warning

Please be aware that these screening tests:
 

  • are limited in depth and scope,
     

  • may limit the amount that you learn about yourself,
     

  • are insufficient for a in-depth assessment, and
     

  • are not a replacement for the clinical judgment based thorough assessment by a caring and well-trained clinician.

ASD SCREENING

  • TOP 4 RECOMMENDED AUTISM SCREENERS
     
  • 1. Autism Spectrum Quotient (AQ) Test 
    • The most common screener for Autism. Based on 50 questions. Score is based on the number of Autistic traits.  

      • Created for autistic adults without co-occurring intellectual disabilities. 

      • Less effective at screening those with highly developed masking skills and autistic individuals who are extroverted and/or imaginative.

      • Scoring:

        • a result of 26 or higher (50 points total) indicates the possibility of Asperger’s

        • 80% of autistic people score 32 or higher

        • Most non-autistic males score 17 on average

        • Most non-autistic females score 15 on average
           

  • 2. Ritvo Autism & Asperger Diagnostic Scale (RAADS-14)
    • Higher emphasis on internal experiences than outward behaviors. Effective for distinguishing Autism from other conditions which may be confused for autism (Bipolar, PTSD, Social Anxiety).

      • Scoring:

        • 14 and above out of possible 42 are indicative of possible Autism

  • 3. Modified Girls Questionnaire for Autism Spectrum Condition (GQ-ASC) - Scale for Adult Women
    • This screening questionnaire is designed to identify behaviors and abilities in women that are associated with autism.

    • A total score of greater than 56 indicates a high level of autistic traits; sensitive to 80% of cases.

  • 4. Camouflaging Autistic Traits Questionnaire (CAT-Q)
    • The CAT-Q measures the level of Autistic camouflaging (masking, social compensation, and assimilation). 

    • Identifies Autistic individuals who do not meet diagnostic criteria for autism on other tests due to masking autistic traits. 

    • Risk: Factors other than Autism may cause a person to have a high masking score; therefore, CAT-Q may have a higher rate of false positives. 

    • Administration: Click on this link and self administer. After testing, you will receive an email. Please forward that email to your assigned Assessment Professional.

       

ADDITIONAL AUTISM SCREENERS
 

  • Autism Spectrum Screening Questionnaire (ASSQ) 

    • The original ASSQ consists of 27 items for a maximum score of 54 points. 

    • The higher the point total, the greater the likelihood that you show signs of autism spectrum disorder.

    • Score of 51 or higher on the ASSQ indicates possibility of ASD and further assessment is recommended.
       

  • Online Autism Test For Adults (Autism 360)

    • Scoring:

      • 0 to 320 - no autism;

      • 321 to 885 - less than 20% chance of autism symptoms;

      • 886 to 1470 - moderate probability of autism symptoms,

      • 1471 to 1865 - high probability autism symptoms,

      • 1866 and above - 90+% chance of being formally diagnosed with Autism. 

    • Self-learning assessment tool (the test improves over time as more data is collected from previous test takers).​

    • Factors in "360 degree" symptoms that adults with Autism may have.

    • Questions focus on observation skills, social interactions, communication skills, behavioral patterns, sensory & motor skills, and personal interest level.

    • Nominal cost of $1.99.

 

  • Adult Repetitive Behaviors Questionnaire-2 (RBQ-2A)

    • Measures repetitive behavior and restricted interest (criteria B). Most screeners focus on criteria A. By focusing on criteria B, it is easier to distinguish autism from anxiety disorders.

    • Individuals with autism and ADHD may have lower scores.
      ​​​

  • Empathy Quotient (EQ) Test 
    • This 60-item questionnaire is designed to measure empathy in adults. 

      • a result of 30 or below indicates the possibility of Asperger’s

      • 81% of people previously designated Asperger syndrome score 30 or lower

      • Most non-autistic males score 42 on average

      • Most non-autistic females score 47 on average

  • Aspie Quiz

    • This screening test has not been independently validated in a clinical setting and is not recommended. 

ADHD SCREENING

RECOMMENDED ADHD SCREENERS

Adult ADHD Self-Report Scale (ASRSv1.1)​​

  • High sensitivity. Records high % of those with ADHD although may include conditions with similar symptoms (false positives)

  • 18 item questionnaire (straightforward and simple to take)

  • Scoring: If four or more marks appear in the darkly shaded boxes within Part A then highly consistent with ADHD in adults and further investigation is warranted. 

     

Copeland Symptom List for Adult ADD (link coming soon)
  • Targets Adult Attention Deficit Disorder (ADD), which is a term that has been traditionally used to describe a form of attention deficit hyperactivity disorder (ADHD) without the hyperactivity component. However, in the current diagnostic criteria, ADD is considered a subtype of ADHD known as ADHD, Predominantly Inattentive Presentation (ADHD-PI).

  • Designed for Self-Assessment: The list is intended for individuals to self-assess and reflect on their own behaviors and symptoms over a period of time. 

  • Wide Range of Symptoms: The Copeland Symptom List covers a broad spectrum of symptoms, including but not limited to difficulty concentrating, impulsiveness, trouble managing time, problems with organizing tasks, and emotional challenges such as mood swings.

The Structured Adult ADHD Self-Test (SAAST) (link coming soon)
  • Helps identify potential symptoms of Adult Attention Deficit Hyperactivity Disorder (ADHD) through self-assessment.

  • Covers a range of behaviors and symptoms commonly associated with ADHD in adults, including difficulty concentrating, impulsiveness, disorganization, and hyperactivity.

  • Includes 22 statements and duration is between 5 and 10 minutes.

  • Participants are asked to rate these based on the frequency or intensity of the symptoms over a specified period.

  • Scores over 24 together with the absence of mitigating factors (mental illness, other medical conditions, etc) are generally consistent with ADHD, but they do not confirm a diagnosis.

     

ADDITIONAL ADHD SCREENERS

ADHD in Women Symptom Test

  • ​If you score 54-72, that means you answered "Often" or "Very Often" to most of the questions and should pursue a formal diagnosis as there is a possibility that you may be experiencing symptoms of ADHD. 
     

ADD Symptom Test for Adults

  • Focus on Inattentive ADHD (not hyperactivity)​

  • ​If you score 45-60, that means you answered "Often" or "Very Often" to most of the questions and should pursue a formal diagnosis as there is a possibility that you may be experiencing symptoms of Inattentive ADHD. 

Wender Utah ADHD Rating Scale (WURS)

  • Full self-report questionnaire consists of 61-items.

  • Link above includes 25 of which are highly relevant for ADHD Measures ADHD traits present in childhood. 

  • Focuses on childhood traits (presence of ADHD in childhood is required for diagnosis).

  • Focus is on behaviors and may not capture clients who extensively mask ADHD and those with ADHD-inattentive type.

  • Scoring explained here

Weiss Functional Impairment Rating Scale (WFIRS-S) - Self Report

  • ADHD symptoms and actual impairment overlap but are distinct concepts. Test focuses on items that are most often targets of treatment. 

  • Can be used to measure progress of treatment. 

  • Consists of 61-items, 25 of which are highly relevant items for ADHD (thus used in the scale for ADHD)

  • Must be manually scored. Scoring explained on this PDF

The Barratt Impulsiveness Scale (BIS-11

  • Measures different forms of impulsivity often present in ADHD-hyperactive and ADHD-combined types.

  • Not a full ADHD screener. 

  • Segments impulsivity into three different areas (motor, self-control, and non-planning).

Vanderbilt ADHD Diagnostic Rating Scale

  • This is a parent report screener for CHILDREN ages 6-12.

  • It is NOT for adults.

  • Includes six different subscales:

    • ADHD-inattentive type

    • ADHD hyperactive/impulsive type

    • ADHD-combined type

    • Oppositional defiant disorder (ODD)

    • Conduct disorder

    • Anxiety/depression

  • Screens for oppositional defiant disorder and conduct disorder. Such diagnoses can be misleading. Neurodivergent kids may be mislabeled.
     

PsychCentral On-line assessment

  • 0-20     ADHD unlikely

  • 20-39   Attention Deficit Disorder Possible

  • 40+       Attention Deficit Disorder Likely

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