Aston. M.C (2012) Asperger Syndrome in the Bedroom
‘Sexual and Relationship Therapy:
International Perspectives on Theory, Research and Practice’ 27(1) 73-79.
Imagine the following scenario: as a sex therapist you have seen Mark and Sarah for an initial assessment, you are now working with them together in a follow up session. The couple have been married for a year and have presented with a total lack of intimacy or sexual contact.
Sarah has refused to be physically intimate with Mark since their wedding night and although she is totally committed to Mark and wants the relationship to continue, states that she has found being physically touched by him both painful and repulsive. As you explore more and you discuss the couple's history it becomes apparent that Sarah has never had an orgasm and finds kissing Mark distasteful. She struggles to understand why it is such an issue for him and why he cannot be content with masturbation.
What would you conclude from this?
What strategies would you suggest that the couple try to resolve their issues? Would you feel comfortable applying sensate focus to this couple's therapy?
Would you at any point consider exploring the possibility that Sarah may be on the Autistic spectrum, in particular have Asperger syndrome (AS)?
If it was known Sarah was affected by Asperger syndrome would you know the best way to work in order to benefit the couple?
In my research (Aston, 2001) I found that fifty per cent of the heterosexual and homosexual couples that completed my questionnaires, reported that there was no sexual activity within their relationship; in fact, there was no affection or tactile expression whatsoever. That is quite high when one takes into account that some of the respondents had not been together for more than two years. It is not surprising though when one becomes aware that one partner in the relationship is affected by Asperger syndrome. Asperger syndrome is a pervasive developmental disorder that has been found to affect approximately 1 in 200 to 300 people (Ehlers and Gillberg 1993; Kadesjo, Gillberg and Hagberg 1999). Although it is thought that the numbers are much higher, especially considering the volume of undiagnosed AS. It affects more males than females, in a ration of 4 to 1 (Ehlers and Gillberg 1993).
Asperger syndrome will affect communication, both verbal and nonverbal, social interaction and empathic thought. It can also cause obsessive interests, need for structure and routine, motor clumsiness and, sensory sensitivity. Sensory sensitivity will be discussed in more detail later in this paper and concerns an area that can greatly affect sexual behaviour. Sensory sensitivity is one of the symptoms which is important for sex therapists to understand.
Communication, mind-reading, social interaction and empathy are major ingredients required for the formation and maintenance of a relationship. In a sexual relationship, a couple affected by AS will require a very different kind of intervention and support than would normally be offered in typical psychosexual therapy - regardless as to whether the couple are heterosexual, or same-sex. So what would a sex therapist need to be aware of, what would be the best support and strategy that would benefit the couple they are working with?
The first thing to understand is Asperger syndrome. How it will impact on each individual and on a couple's relationship? Sometimes I find that professionals can tend to look for or expect a specific personality type when they hear the word Asperger syndrome. The typical stereotype is often seen as an individual who rarely makes eye contact, talks in a monotone voice, is introvert and a loner; this is far from the reality. People with AS are as unique and different as the rest of the population. The clients I see all come with their individual characteristics, personalities and opinions.
This can make the recognition and diagnosis of AS very difficult; it can take years to really become familiar with what can appear as very subtle differences in how a person interacts in therapy. When working with a client with AS you may get the feeling that something is missing, that communication does not flow as it should. You may find yourself stating the obvious and having to explain a point that you thought was quite clear and apparent. For example, having to explain in detail the relevance and importance of flattery and or affection towards their partner, in the lead up to the sexual act. This may be a concept not easily understood by an AS partner, especially as to why it is so important to their non-AS partner.
A person with AS can be inclined to believe that the fact they have gone out to work, or completed a task in the house, is an adequate demonstration and evidence of their love. The partner with AS find it confusing that despite their efforts, their partner is still left feeling undervalued and that they are criticised for not meeting their partner's emotional needs or being emotionally supportive. It is this very lack of emotional support and empathetic understanding that will be raised repeatedly by the non-AS partner. A person's ability to emotionally reciprocate another's feelings is largely dependent upon having a developed theory of mind. However, theory of mind will be underdeveloped in a person with AS.
Theory of mind is the part of the brain that provides the ability to mind read, to instinctively know what it is another is feeling and what their needs are, whilst respecting and being aware that another's feelings and needs could be quite different to our own. Difficulty in reading their partner's body language is a precursor to a break down or misunderstanding in AS/non-AS relationships. It is important that a therapist has an adequate understanding of what this means.
By the time a child is three to four years old, they will usually be able to illustrate an ability to apply theory of mind. However, in children affected by AS, theory of mind does not begin to develop until between the ages of nine to fourteen (Happe and Frith, 1995). Consequently, theory of mind is not fully developed or wired correctly, which can be similar in nature to that of being affected by dyslexia. Having dyslexia does not mean a person cannot read, write or spell, it just means these tasks may be more difficult for them. Having AS does not mean someone cannot communicate, to socially interact or empathise, it just means it will be more difficult and making sense of social situations might be processed in the brain via a different route than used by a non-AS individual.
Research has found that when an AS adult is asked a question that requires theory of mind to work out the answer, it is not the part of the brain responsible for theory of mind that activates; instead it is the logical part of the brain (Carter, 1998). This means that someone with AS is trying to work out everything using the logical part of their brain. Now logic is great for logical things, however people are not always logical, especially when they are in a relationship and emotions are involved. This aspect of mind-reading is very difficult for someone with AS and unless their partner is willing to spell out and explain how they feel, it is likely it will either be totally missed or misunderstood.
Sex therapy on the whole follows a logical process and is behaviour focused. For many of my clients with AS they are more than willing to learn new behaviours to sexually arouse and satisfy their partners, especially if it involves actions as opposed to words. However the AS partner will struggle with the elements of intimate behaviour that require empathy and a developed theory of mind; such as getting the timing right; being sensitive to the others' feelings and respecting that the needs of their partner may be different from their own. For example, when a client stated, during a sex therapy session, that she had never had an orgasm in over twenty years of marriage, her partner reacted quite earnestly by saying: "That's ok dear, I have always had an orgasm!" He completely missed the relevance of what she was saying and how it made her feel as he was quite satisfied with their love making and could not understand why she found this an issue.
When there is an understanding of theory of mind, then it is easy to understand that his response was not a man who was behaving selfishly, and his remark was not callous, rather, in fact, was quite honest and innocent. This was the first time his partner had mentioned it and he was unaware that this had been making her unhappy.
You will need to be very clear and direct with your client wit AS while also teaching their partner to have the same directness. It is important never to make assumptions or take it for granted that the client with AS understands what it is that you want them to do. For example, one partner said that she was disappointed that her husband never said anything nice to her during lovemaking and she felt undesired and taken for granted. The therapist suggested that next time they made love he flatter her and say something nice to her. The therapist added this had to be something he meant and was sincere about.
On the couples next visit the therapist asked if he had managed to say something nice to his wife, he grunted back that it had not made any difference. When asked what he had said, his wife replied that he had told her that he thought she was an excellent cook! Fortunately in retrospect, having an understanding of AS, allowed both his wife and therapist to see the funny side of the situation. This situation was solved by working together to provide him with a fool proof checklist on things he could say that would make her feel good. He of course decided on the aspects of his wife that he found desirable and he was given help on how he might express them in a romantic way.
Romance is often the very thing that can be lacking from the sexual side of the relationship and this can, in time, have a detrimental effect upon the quality, or willingness of either partner to participate in making love. Often it is not realised by the AS partner that sexual acts may need to be precipitated by emotional closeness and that a lack of this can result in their partner's reluctance to make love. Consequently, love making becomes non-existent.
In my Asperger Couples workbook (Aston, 2009) I discuss using a 'wooing list'. This can be a fool proof list that can be used by the AS partner as a guide to help them to know what to say and do. The list is something that is put together by the couple and will offer the AS partner the security of knowing they're unlikely to get it wrong.
I am sometimes presented with couples where there is no sexual activity at all and it is often the male client with AS who has withdrawn totally from the physical side of the relationship. Sometimes this will be due to him feeling he is constantly being criticised by his partner and as a result he loses his desire for her/him. In some circumstances, the AS partner may have misunderstood the intentions of their partner leading them to feel like they have failed them sexually. For example, taking a suggestion to try a new sexual position as personal criticism of their current technique. It is possible to avoid this sensitive reaction in therapy if the messages are delivered by the therapist rather than the non-AS partner, as this will allow the information to be received on a far less personal basis.
Making love can be very important for some of the male clients with AS, as they feel it is the one way they can truly express their love and affection for their partner. Making love is more about doing than talking and they will go to great lengths to get it right. For some they will read up on techniques and strategies to please their partner, leading to a point where one partner may say that it was the best sex they have ever experienced. This is great at the time and the couple may find themselves in sexual bliss. However, the non-AS partner may find from this point onwards that the love making process does not change and the same pattern is repeated over and over again, until eventually non-AS partners will say they would like to try something different. In response to this they may find themselves being accused of being critical and their initial honesty questioned. It is very important that routines are not established in love making in a AS/non-AS relationship and that the non-AS partner is able to suggest variations and change in the love making to avoid assumptions and routines taking over.
A strategy I have found to overcome this and refresh the lovemaking between a couple, is an exercise where each will say exactly what they want their partner to do during love making. This would involve the couple finding a safe and undisturbed place to make love. Starting fully clothed, each would take turns to say what they would like from the other. Some of the requests made often come as quite a surprise to the other partner. For example, one person always assumed that their partner with AS liked to be touched on the breasts and it came as quite a surprise when the partner with AS did not make this request, which leads us to another very important area that a sex therapist needs to be aware of, when working with a couple in which one or both partners are affected by AS.
Sensory sensitivity was first highlighted by Hans Asperger in 1944 (Asperger, 1944, 1991) and is being increasingly recognised as an area that can be very problematic for an AS individual. Sensory sensitivity can cause an over- or under-reaction to stimuli affecting any of the five senses, which include hearing, touch, taste, smell and sight. The senses play a key role in the sexual act and are likely to be heightened during this time. The senses play a key role in arousal and orgasm, stimulating a partner by caressing and tactile expression, forms the basis of sensate focus in sex therapy. This is often a strategy employed by a therapist to allow the couple to get to know each other's bodies as well as their own, while taking the focus away from penetration.
Touch or a specific type of touch, such as soft tickling, can feel very unpleasant or indeed painful for someone with AS. This can affect any area of their body. For some it may be the arms, for others it could be the breasts, clitoris or penis. Some clients I have worked with find it very hard to tell their partner how being touched by them makes them feel and as a result will find ways to avoid being touched. This can cause misunderstandings as the non- AS partner will feel rejected or rebuffed, when their partner backs off from them or is reluctant to take their clothes off.
Sensory sensitivity, in this way, seems to affect more of the women I see than the men and it is often areas such as the nipples or clitoris that are most affected. They are often aware that these are the areas that their partner likes to touch and have been made to feel frigid or inadequate by their lack of arousal or refusal to be touched in these areas. One client with AS had been told in love making that she was a freak and was then accused of not being a 'real woman' because she had moved her partners hand away from her breasts. Such insensitive and cruel remarks can be very damaging and can leave someone with AS feeling inadequate and low in confidence. When I saw this client with her present partner, the sexual side of the relationship had become non-existent as she had felt unable to tell her partner how painful it felt to have her nipples touched during lovemaking. She was afraid that her partner would react or judge her as had been her previous experience.
For the partner to understand that this was due to AS and not because she did not desire or want to be with the partner, completely changed the relationship. Both were able to move forward and have a satisfactory sexual relationship that worked for both of them. As well as being oversensitive, there can also be an under-sensitivity and this can cause difficulty in orgasm for both men and women with AS. For some men this can be the penis and it may be that he finds penetration not tight or firm enough for him to reach an orgasm and his preference will become masturbation, which will allow him to add as much pressure as required.
One strategy I found helpful in males with AS and under-sensitivity of the penis, who have a female partner, is if the female partner places her hand or hands outside the entrance to her vagina. This is best achieved in the missionary position. The partner can clasp his penis by forming a circle with her fingers during penetration to give him the extra pressure he needs. Supporting couples for which sensory sensitivity is an issue, can be quite a challenge for the sex therapist but certainly not one, if the couple are willing to try, that cannot be worked through and overcome.
Other areas that the AS partner can react strongly is with taste and smell, two senses that are linked. I have found that women with AS in particular are often over sensitive in this area. This sensitivity can present itself in different forms, it might be an absolute repulsion to the taste of bodily fluids and this can include saliva. This type of repulsion can result in the refusal to participate in kissing and once again result in the non-AS partner feeling very rejected. It may be the smell of the other person's body, that results from lovemaking, that the AS partner finds unpleasant and only by exploring openly and safely will the reasons be discovered. These reactions will be difficult to change; they are very real for the person with AS, as it may feel abusive for them, to be coerced into having to experience the taste or smell of something that is repulsive to them. In an attempt to overcome their sensitivity and/or aversion to their partners smell or taste a person with AS may try to remedy this by ensuring their partner and/or themselves always washes before intimate contact. This need for their partner's cleanliness before intimate contact can become an obsession in the partner with AS.
One lady explained how she was questioned when she went to bed by her AS partner as to whether she had showered and cleaned her teeth. After they had made love she was requested to immediately get out of bed and wash. The whole love making experience became totally clinical and when her partner with AS came to bed wearing latex gloves to keep their hands clean she finally drew the line and insisted they sought psychosexual therapy together. She did not know at the time her partner had AS and they were fortunate enough to see a therapist that recognised the causes and recommended they look up Asperger syndrome to see if they recognised the effects of it. They did and have since sought an assessment for AS and are now working on their relationship.
For many couples finding out about Asperger syndrome can be the difference between staying together and separating. I receive more and more reports from couples who have been fortunate enough to have chosen a therapist who had an awareness and understanding of AS and was able to signpost the couple in the right direction. If a therapist suspects their client was depressed or affected by dyslexia they would hopefully signpost their client in the right direction, there is no reason why Asperger syndrome should be seen as any different. As therapists, we are there to benefit our clients and offer them the best possible chance they can have to make improvements to their relationships. The sexual side of a person is an aspect of 'who' they are. When Asperger syndrome is recognised and understood, they and their partner can really start to understand each other and grow in their intimacy together.
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