Received: 28 December 2020 Accepted: 25 August 2021

DOI: 10.1002/aur.2604

RESEARCH ARTICLE

The sexual health, orientation, and activity of autistic adolescents

and adults

Elizabeth Weir | Carrie Allison | Simon Baron-Cohen

Autism Research Centre, Department of Abstract

Psychiatry, University of Cambridge,
Cambridge, UK
Small studies suggest significant differences between autistic and nonautistic
individuals regarding sexual orientation and behavior. We administered an
Correspondence anonymized, online survey to n = 2386 adults (n = 1183 autistic) aged 16–
Elizabeth Weir, Autism Research Centre, 90 years to describe sexual activity, risk of sexually transmitted infections
Department of Psychiatry, University of
Cambridge, Cambridge, UK.
(STIs), and sexual orientation. Autistic individuals are less likely to report sexu-
Email: [email protected] ally activity or heterosexuality compared to nonautistic individuals, but more
likely to self-report asexuality or an ‘other’ sexuality. Overall, autistic, and non-
Funding information autistic groups did not differ in age of sexual activity onset or contraction of
Applied Health Research and Care (ARC-EoE); STIs. When evaluating sex differences, autistic males are uniquely more likely to
Autism Research Trust, Grant/Award Number:
G72423; Cambridge and Peterborough NHS be bisexual (compared to nonautistic males); conversely, autistic females are
Foundation Trust, Grant/Award Number: uniquely more likely to be homosexual (compared to nonautistic females). Thus,
G102307; Corbin Charitable Trust; Innovative both autistic males and females may express a wider range of sexual orientations
Medicines Initiative 2 Joint Undertaking (JU),
Grant/Award Number: 777394; Medical in different sex-specific patterns than general population peers. When comparing
Research Council; National Institute of Health autistic males and females directly, females are more likely to have diverse sex-
Research (NIHR); Rosetrees Trust, Grant/ ual orientations (except for homosexuality) and engage in sexual activity, are
Award Numbers: G102199, G102307,
RG72423; Templeton World Charity less likely to identify as heterosexual, and have a lower mean age at which they
Foundation; Wellcome Trust, Grant/Award first begin engaging in sexual activity. This is the largest study of sexual orienta-
Number: 214322\Z\18\Z; University of tion of autistic adults. Sexual education and sexual health screenings of all chil-
Cambridge; Department of Health; Health
Research; National Institute for Health dren, adolescents, and adults (including autistic individuals) must remain
Research; Biomedical Research Centre; priorities; healthcare professionals should use language that affirms a diversity
AUTISM SPEAKS; Horizon 2020; European of sexual orientations and supports autistic individuals who may have increased
Union; Innovative Medicines Initiative;
Wellcome Trust risks (affecting mental health, physical health, and healthcare quality) due to
stress and discrimination from this intersectionality.

KEYWORDS
adults, adolescents, sexual health, sexual orientation, sexual activity

INTRODUCTION Association, 2013). Historically autism was classified as a

rare condition; however, prevalence estimates have
Autism spectrum conditions (henceforth autism) are a set increased in recent years and now approximately 1%–2%
of lifelong, neurodevelopmental conditions characterized of the population are diagnosed as autistic (likely due to
by social and communication differences, restricted inter- changes in diagnostic criteria and improved recognition
ests, and repetitive behaviors. In addition, autistic indi- of the condition due to increased awareness) (Maenner
viduals may also have differences in cognitive profile, et al., 2020). There also appears to be a sex-bias in
including atypical sensory perception, information autism: Males are diagnosed approximately three to four
processing, and motor abilities; critically, the autistic times more frequently than females (Loomes et al., 2017;
population is heterogeneous and may exist along the full Maenner et al., 2020). As autism diagnoses become more
spectrum of intellectual ability (American Psychiatry frequent, greater numbers of adolescents and adults are

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2021 The Authors. Autism Research published by International Society for Autism Research and Wiley Periodicals LLC.

2342 wileyonlinelibrary.com/journal/aur Autism Research. 2021;14:2342–2354.

 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WEIR ET AL. 2343

being recognized as autistic than ever before; however, healthcare needs) and minority stress (George &
there is still relatively little large-scale research on the Stokes, 2018b; Hall et al., 2020; Pecora, Hancock,
experience of these groups, particularly in regard to their et al., 2020; Warrier et al., 2020).
sexual activity and orientation. Autistic individuals are also particularly vulnerable
Traditionally, it was incorrectly thought that autistic to sexual victimization and increased risk of inappropri-
individuals were largely uninterested in sexual or roman- ate offending (Pecora et al., 2019; Pecora, Hancock,
tic relationships; however, research and clinical practice et al., 2020). Autistic females report higher rates of
has demonstrated that most autistic individuals are inter- unwanted sexual experiences than both nonautistic
ested in sexual and/or romantic relationships (with most individuals and autistic males (Brown-Lavoie
research in the area focusing on autistic individuals with- et al., 2014; Pecora, Hooley, et al., 2020), and this may
out co-occurring intellectual disability) (Dewinter be differentially affected by sexuality (Pecora, Hooley,
et al., 2013; Sala et al., 2020). Recent research in several, et al., 2020). Likelihood of sexual victimization may be
relatively small samples has established significant differ- partially mediated by sexual knowledge (Brown-Lavoie
ences between autistic and nonautistic individuals in the et al., 2014); yet, studies suggest that autistic individ-
areas of sexual activity and sexual orientation, which uals may have reduced access to and/or inadequate sex-
may vary based on sex. Autistic individuals, and particu- ual education (Dewinter et al., 2013; Pecora, Hancock,
larly autistic females, are more likely to report greater et al., 2020), as well as less perceived and actual sexual
sexuality diversity, including less sexual desire/libido knowledge (Brown-Lavoie et al., 2014). Taken collec-
(Bejerot & Erikson, 2014; Bush, 2019; Bush et al., 2020; tively, these results suggest a pattern of unique vulnera-
Pecora et al., 2019), higher rates of asexuality bility among autistic individuals, and particularly
(Bush, 2019; Bush et al., 2020; George & Stokes, 2018a), among autistic females, likely due to additive effects of
higher rates of hypersexual behavior/ fantasies (Schöttle marginalization based on sex, sexual orientation, lim-
et al., 2017), lower rates of heterosexuality (Dewinter ited sexual education/knowledge, and perpetrators tak-
et al., 2017; George & Stokes, 2018a; Pecora, Hancock, ing advantage of certain common features of autism
et al., 2020), and higher rates of nonheterosexuality (e.g., social naïveté, misunderstanding friend-
(including homosexuality and bisexuality specifically) ships, etc.).
(Bejerot & Erikson, 2014; Dewinter et al., 2017; In addition to consequences regarding sexual vic-
George & Stokes, 2018a; Pecora, Hancock, et al., 2020). timization, lack of appropriate sexual education and/ or
One very large study (n = 47,000+ individuals) found sexual knowledge may increase the likelihood of con-
that individuals with self-reported high autistic traits were tracting sexually transmitted infections (STIs), which
1.73 times (95% CI: 1.01–2.90) as likely to identify as continue to be a primary public health concern due to
bisexual and 3.05 times (95% CI: 2.56–3.63) as likely to their capacity to pose long-term physical health prob-
identify with a sexuality that could not be described as lems. A few studies have shown reduced risk of STIs
hetero-, homo-, nor bisexual (Rudolph et al., 2018). A among individuals with autism, intellectual disability,
recent study of autistic females found that they were 2.33 and other developmental disabilities (Fortuna
times (95% CI: 1.33–4.09) as likely to identify as bisexual et al., 2016; Schmidt et al., 2019). However, crucially,
and 2.39 times (95% CI: 1.26–4.52) as likely to identify as the authors are not aware of any studies on the relative
homosexual (Pecora, Hooley, et al., 2020); and in the risk of STIs that exclude individuals who have not
general population, several studies suggest that females engaged in any sexual activity. Considering evidence of
may be more likely to identify as bisexual and that males diminished sexual contact/ libido among autistic indi-
may be more likely to identify as homosexual (Copen, viduals, current studies may not be measuring relative
Chandra, & Febo-Vazquez, 2016; Wang et al., 2019). risk of STIs between autistic and nonautistic individuals
However, the authors are not aware of any similar stud- but instead are capturing relatively lower risk of engag-
ies that use adjusted regression analyses (controlling for ing in sexual activity in general; thus, future studies
demographic differences) to estimate the relative odds of must work to estimate whether the prevalence of STIs
identifying with particular sexual orientations across all differs among autistic and nonautistic individuals who
autistic individuals, or any studies that attempt to quan- have been sexually active.
tify sex differences. Even though current research into sexual health and
The sexuality and experiences of autistic individuals sexual orientation of autistic adolescents and adults is
may have significant implications for healthcare, as stud- limited in size and scope, it is clear that differences in
ies suggest that intersectionality of autism and being Les- these areas may leave autistic individuals vulnerable to
bian, Gay, Bisexual, Trans, Queer, Asexual, and other wide-ranging negative consequences with regards to both
identities not listed here (LGBTQA+) may result in mental and physical health. The current study aims to
worse mental health symptoms, worse overall health, and address these gaps and establish a comparison of experi-
lack of adequate healthcare (even including being refused ences regarding sexuality and sexual activity between
healthcare) likely due to institutionalized sources of mar- autistic and nonautistic individuals from adolescence to
ginalization (e.g., inadequate insurance coverage for old age.
 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2344 WEIR ET AL.

METHODS aimed to recruit an international cohort. Our use of

social media enabled us to advertise the study to individ-
The survey uals around the globe and participants from 62 different
countries were included in this study.
Using an anonymous, self-report survey, participants The survey first opened in February 2018 and data
completed demographic information, a short version of collection ended in August 2019; however, there were
the Autism Spectrum Quotient (a measure of autistic two periods in which survey collection was paused, in
traits, AQ-10) (Allison et al., 2012; Greenberg order to consider different means of advertising the sur-
et al., 2018), questions about lifestyle-related factors vey. We performed a sensitivity analysis for all analyses
(including exercise, diet, sleep, disability, and social/ and used z-tests to determine if these pauses affected our
sexual history), personal medical history, and family results for all binomial regression analyses; we found no
medical history, as part of the Autism and Physical statistically significant differences. Full results from the
Health Survey (APHS). Thus, the present study uses a sensitivity analysis are provided in Table S1.
sample from the APHS dataset to investigate the sexual
health, orientation, and activity patterns of autistic and
nonautistic adolescents and adults. All questions related The cohort
to sexual and social history were developed using publicly
available information from the National Health Service N = 3657 individuals accessed the survey. Any con-
(NHS), National Institute for Health and Care Excel- senting individual of at least 16 years of age was eligible
lence, National Institutes of Health (NIH), and the to participate. 1102 individuals were excluded due to
World Health Organization (WHO). All questions ‘incomplete’ response, meaning that they exited the sur-
related to social and sexual history were optional, as they vey before completing required questions in the lifestyle
may be sensitive in nature for some participants. The spe- section (which includes information on substance use and
cific phrasing of all questions is provided in sexual health). 83% of excluded individuals (n = 914) did
Figures S1—S5. not even complete the demographics section of the sur-
vey, making their responses unusable. Due to their poten-
tially sensitive nature, questions related to sexual health
Recruitment were optional; and participants were not excluded due to
nonresponse on any optional questions. We developed an
This study used a cross-sectional, anonymized online sur- algorithm to exclude potential duplicate responses (as we
vey to identify the patterns of sexual activity and sexual did not collect any personally identifiable data). We
orientation among autistic and nonautistic adults. It used excluded all responses (n = 112) that matched any previ-
a convenience sampling framework and recruited partici- ous response on 11 criteria (autism diagnosis [yes/no],
pants via the Cambridge Autism Research Database specific autism diagnosis, type of diagnosing practitioner,
(CARD), Autistica’s Discover Network, autism support year of autism diagnosis, country of residence, sex
groups and charities (including the Autism Research assigned at birth, current gender identity, education-level,
Trust), and social media (specifically Twitter and age, maternal age at birth, and paternal age at birth). In
Facebook). As the study was advertised to some groups addition, we excluded one intersex individual, as our
and forums related to autism, the control population analysis strategy covaries for sex assigned at birth.
may be biased toward those with an interest in autism or The autistic cohort included all eligible individuals
those with undiagnosed autism. To limit this bias, we also who self-reported an autism diagnosis made by a quali-
publicized the study via Facebook in an advertisement fied health practitioner. As the survey was anonymous,
that did not mention autism but instead asked individuals we did not ask participants to provide evidence of their
to provide further information about their physical health diagnosis; however, we asked participants to disclose
to researchers. In addition, we intentionally advertised additional information (type of practitioner who diag-
the study to any individuals over the age of 16 from an nosed them, the year of their diagnosis, their specific
international population (and did not target individuals diagnosis, and whether they have a syndromic form of
based on interests or group participation in any way)—as autism) in order to verify their diagnosis. The control
this provided the best opportunity for a general popula- group included all eligible individuals without a diagno-
tion sample. After clicking onto the survey, the consent sis of autism. As we followed a case–control design, we
form and information sheet did specify that the study was excluded any individual from both the autistic and con-
related to understanding differences between autistic and trol groups for whom we could not verify their autism
nonautistic adults; as such, the study recruitment was status (n = 56); this included individuals who self-
likely still subject to some selection bias even if this strat- diagnosed as autistic, suspected autism, or were
egy attempted to mitigate it. All advertisements were awaiting autism assessment. The final sample was com-
advertised to both nonautistic and autistic individuals. posed of n = 2386 individuals, including 1183 autistic
Although the survey was only available in English, we individuals.
 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WEIR ET AL. 2345

Covariates sex assigned at birth, age, ethnicity, education-level, and

country of residence, respectively) to compare all patterns
We controlled for age, sex assigned at birth, education- of sexual activity, orientation, and health between autistic
level, ethnicity, and country of residence. We defined males and females directly.
education-level as the highest qualification held with the To consider the effect of age, we stratified our sample
following options: “No formal qualifications”, “Second- into two age groups: (1) Younger adults aged 16–40 years
ary School/High School level qualifications”, “Further and (2) Older adults aged 41–90 years. We ran binomial
vocational qualifications”, “University Undergraduate logistic regression models (controlling for sex, age, eth-
level qualifications (BA, BSc, etc.)”, and “University nicity, education-level, and country of residence) to test
Postgraduate level qualifications (MA, MSc, PhD, Cer- differences between autistic and nonautistic groups for
tificate, etc.)”. It was coded as a categorical variable and sexual orientation, activity, and health in the younger
used as a proxy measure of socio-economic status. Due and older samples separately.
to low response rates from each non-White ethnic back- Missingness for the covariates of age, education-level,
ground, we used a binary representation of ethnicity ethnicity, and country of residence was addressed using
(white vs. non-White) in our analyses. Finally, as we rec- predictive mean matching for five imputations using the
ruited a diverse, international population, we derived a ‘MICE’ package (Azur et al., 2011). For continuous
categorical variable of country of residence based on the measurements of age of sexual activity onset, only one
most frequent countries listed with the following options: imputation was used due to the incompatibility of R
“United Kingdom,” “United States of America,” packages. Table 2 provides further information on miss-
“Germany,” “Australia,” and “Other.” Full information ing data among covariates. Finally, to minimize Type I
on the distribution of participants’ ethnicity are available errors from multiple testing, we utilized the False Discov-
in Table 1. ery Rate correction and used a p threshold of 0.05 across
all analyses (Benjamini & Hochberg, 1995).

Statistical analysis
RESULTS
We used R Version 3.6.2 to conduct all analyses. Across
nearly all analyses regarding sexual history, we utilized The sample predominantly comprised females, White
an unadjusted and adjusted model, employing Fisher’s individuals, UK residents, and those without intellectual
exact tests (using the ‘CrossTable’ function from the disability. There were significant group differences, and
‘gmodels’ package) and Binomial Logistic Regression this was expected based on the methodology and recruit-
(using the ‘glm’ function from the ‘stats’ package) con- ment strategies employed. A summary of demographic
trolling for sex assigned at birth, age, ethnicity, information for both the autistic and nonautistic cohorts
education-level, and country of residence, respectively. has been provided in Table 1 below.
The only exception is regarding age of sexual activity Overall, we found few quantitative differences in sex-
onset; for this analysis, we used the Wilcoxon Signed- ual activity between autistic and nonautistic participants.
Rank test for the unadjusted model and multiple linear Confirming previous findings in smaller samples, autistic
regression for the adjusted model (again controlling for males (compared to nonautistic males) and autistic
sex assigned at birth, age, ethnicity, education-level, and females (compared to nonautistic females) were both less
country of residence), as the outcome of interest was likely to report ever having engaged in sexual activity—
continuous. though autistic males are particularly less likely to have
We also assessed sex and age differences across all engaged in sexual activity; however, a majority of all
analyses. Autistic individuals may be more likely to expe- groups (autistic females, autistic males, nonautistic
rience a wider range of gender identities than others;17 as females, and nonautistic males) all report having been
such, our designation of individuals as ‘females’ and sexually active. Interestingly, as shown in Table 2 below,
‘males’ speaks only to their sex assigned at birth and not our results suggest that there are no differences between
of their gender identity. To consider sex effects, we first risk of contracting an STI between autistic and non-
conducted additional binomial logistic regression models autistic adolescents and adults (Adjusted Model 1), even
accounting for the interaction of sex and diagnosis before accounting for differences in lifetime engagement
(as well as controlling for sex assigned at birth, age, eth- with sexual activity. Further, these results do not change
nicity, education-level, and country of residence). For all after asexuality is included in the analyses as a covariate
analyses, which showed a significant effect, we estimated (Adjusted Model 2). There was also no statistically signif-
sex-specific values by using the ‘glht’ function of the icant difference in the mean age of sexual activity onset
‘multcomp’ package and reported sex-specific values in between autistic (mean: 18.51; SD: 4.44) and nonautistic
lieu of our overall model. Second, we employed both (mean: 18.25; SD: 3.70) adolescents and adults who
unadjusted and adjusted models (using Fisher’s exact reported ever engaging in sexual activity in our analyses
tests and Binomial Logistic Regression controlling for using an unadjusted model (FDR p value: 0.412), Model
 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2346 WEIR ET AL.

TABLE 1 Participant demographics

Characteristics Autism (n = 1183) Controls (n = 1203) p values (sig. Level)

Age (years), mean (SD) 41.04 (14.41) 41.86 (15.59) 0.344

Age (years), categories, N (%)
16–29 303 (25.61) 311 (25.85)
30–39 250 (21.13) 240 (19.95)
40–49 252 (21.30) 252 (20.95)
50–59 214 (18.09) 206 (17.12)
60–69 113 (9.55) 127 (10.56)
70+ 25 (2.11) 52 (4.32)
Missing 26 (2.20) 15 (1.25)
Sex assigned at birth, N (%) 0.005 (**)
Female 746 (63.06) 825 (68.58)
Male 437 (36.94) 378 (31.42)
Gender identity, N (%) <0.001 (***)
Cisgender 1031 (87.15) 1178 (97.92)
Transgender 149 (12.60) 24 (2.00)
Missing 3 (0.25) 1 (0.08)
Ethnicity, N (%) 0.007 (**)
White 1045 (88.33) 1020 (84.78)
Non-White 135 (11.42) 183 (15.21)
Mixed race 77 (6.51) 73 (6.07)
Asian 18 (1.52) 43 (3.57)
Latin American/Hispanic 7 (0.59) 23 (1.91)
Arab/Middle Eastern 0 17 (1.41)
Jewish 16 (1.35) 17 (1.41)
African/Black/Caribbean 6 (0.51) 9 (0.75)
Other 11 (0.93) 1(0.08)
Missing 3 (0.25) 0
Education, N (%) <0.001 (***)
No formal qualifications 57 (4.82) 14 (1.16)
Further vocational qualifications 215 (18.17) 138 (11.47)
Secondary school/High school 211 (17.84) 171 (14.21)
University undergraduate 354 (29.92) 354 (29.43)
University postgraduate 344 (29.08) 523 (43.47)
Missing 2 (0.17) 3 (0.25)
Country of residence <0.001 (***)
United Kingdom 842 (71.17) 759 (63.09)
United States of America 120 (10.14) 174 (14.46)
Germany 31 (2.62) 33 (2.74)
Australia 33 (2.79) 20 (1.66)
Other 156 (13.19) 214 (17.79)
Missing 1 (0.08) 3 (0.25)
Intellectual disability, N (%) <0.001 (***)
Self-identified 21 (1.78) 4 (0.33)
Abbreviation: SD, standard deviation.
Note: Significance Level: ***(p < 0.001), **(p < 0.01), *(p < 0.05), Δ (p < 0.10). p values were from Pearson’s Chi Square test (categorical) or from a Mann–Whitney U
test (means). These are demographic data before imputation. The results remain highly similar after imputation.
 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WEIR ET AL. 2347

1 (FDR p value: 0.066), or Model 2 (FDR p value:

0.274
0.002
0.002

0.993
FDR
0.142). However, Figure 1 below provides a visual repre-
sentation of these patterns, which supports a relatively
wider age range for autistic compared to nonautistic
0.482 (0.303, 0.768)c
0.239 (0.124, 0.458)c
0.844 (0.648, 1.100)
1.003 (0.723, 1.391)
Adjusted model 2b

individuals.
As we did not define the term “STI” specifically in the
OR (95% CI)

survey text and other infections (including urinary tract

infections, yeast infections, etc.) can easily be mis-
classified as STIs, we also performed a sensitivity analysis

Exact p value was too small to be precisely determined; for the purposes of the FDR calculations, we estimated this p value as equal to 0.0009, in order to provide the most conservative analysis.
using data from the specific STI question. For the pur-
0.146
0.002
0.002

0.713

poses of the sensitivity analysis, among those who

FDR

reported any data related to STIs, individuals were coded

as having an STI only if they reported contracting one of
0.384 (0.248, 0.593)c
c

0.805 (0.620, 1.045)

0.222 (0.118, 0.417)

0.929 (0.711, 1.213)

the following: chancroid, chlamydia, crabs, gonorrhea,

Adjusted model 1a

hepatitis, herpes, HIV/AIDS, HPV/Warts, molluscum

OR (95% CI)

contagiosum, scabies, syphilis, trichomoniasis, or pelvic

inflammatory disease; all others were coded as having no
confirmed STI. We also asked individuals to endorse
whether they had a yeast infection, vaginosis, or yeast in
men—as these are commonly mistaken for STIs; individ-
0.103
<0.001
<0.001

0.603

uals who only reported one of those three infections were

FDR

coded as having no STI. Even using this stricter defini-

tion of STI, the results did not change in either the
0.786 (0.701, 0.881)
0.401 (0.301, 0.532)
0.293 (0.194, 0.435)

0.914 (0.698, 1.194)

unadjusted (OR: 0.847; 95% CI: 0.639–1.121; p value:

Unadjusted model

0.244) or adjusted models (OR: 0.858; 95% CI: 0.649–

OR (95% CI)

1.135; p value: 0.284).

Our results replicate previous findings regarding sex-
ual orientation among autistic adolescents and adults,
showing far greater likelihood of identifying as asexual or
‘other’ sexual orientation compared to nonautistic indi-
12.84
88.77
88.95

14.45

Binomial Logistic Regression adjusting for age, sex, ethnicity, education, country of residence, and asexuality.

viduals. We also found that autistic individuals were less

%

likely to identify as heterosexual than others. There were

Sexual activity of autistic individuals compared with nonautistic individuals

Total (n)

significant interactions of sex and diagnosis for bisexual-

Binomial logistic Regression adjusting for age, sex, ethnicity, education, and country of residence.
1199
1066
819
371

ity and homosexuality (and sex-specific values have been

Abbreviations: FDR, false discovery rate; 95% CI, 95% confidence interval; OR, odds ratio.

reported below). These results indicate that autistic males

Nonautistic

are uniquely more likely to identify as bisexual compared

Yes (n)

to nonautistic males (whereas there was no significant dif-

154
727
330

154

ference between female groups); conversely, autistic

females are uniquely more likely to identify as homosex-
10.38
76.02
70.18

13.36

All individuals who reported never being sexually active were excluded.

ual compared to sex-matched peers (whereas there was

%

no significant difference between male groups). Full

results are provided below in Table 3.
Total (n)

Our results regarding sex differences were of particu-

738
436
1175
868

lar interest, as they suggest a different and more complex

pattern than was previously reported. When comparing
Autistic
Yes (n)

autistic females and males directly, our results largely

122
561
306

116

support previous findings. Autistic females report greater

sexual diversity than autistic males (George &
Ever sexually active (females)

Stokes, 2018a)—except for homosexuality (for which

Ever Sexually Active (males)

there were no significant differences). They are more

d
Ever contracted an STI
Ever contracted an STI

likely to report ever having engaged in sexual activity

compared to autistic males (Bush, 2019). Our study pro-
vides the first evidence that autistic females (mean: 18.02;
SD: 4.00) who report ever engaging in sexual activity
TABLE 2

may begin initial sexual contact at a younger age than

autistic males who report ever engaging in sexual activity
(mean: 19.44; SD: 5.06) using unadjusted (FDR p value:
b

d
a

c
 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2348 WEIR ET AL.

<0.001) and adjusted models (FDR p value: <0.001). Full between younger autistic vs. nonautistic adults (aged 16–
results are presented in Table 4 below. Additionally, 40 years) and older autistic vs. nonautistic adults (aged
Figure 2 shows the distribution of age of first sexual 41–90 years). Overall, we found similar patterns of sexual
activity between autistic males and females separately. orientation, activity, and health among younger and
As a note, autistic female and male groups did differ on older adult groups. However, we also found that older
demographic variables of age, education-level, and coun- autistic adults were particularly likely to identify as bisex-
try of residence; however, these factors were controlled ual compared to nonautistic older adults (likely driving
for in our adjusted model to limit biases resulting from this effect overall); in contrast, there were larger differ-
these differences. ences between younger groups than older groups in
Finally, we performed analyses stratified into two age regard to the likelihood of identifying as homosexual
groups to determine if there were different patterns (with younger autistic adults being particularly likely to

F I G U R E 1 Age at which autistic

and nonautistic individuals first
engaged in sexual activity

TABLE 3 Sexual orientation of autistic individuals compared to nonautistic individuals

Autistic Nonautistic Unadjusted model Adjusted modela

Yes Total Yes Total
(n) (n) % (n) (n) % OR (95% CI) FDR OR (95% CI) FDR Sig.

Asexual 118 1174 10.05 18 1194 1.51 7.295 (4.385, 12.825) <0.001 8.107 (4.860, 13.525) <0.001 ***
Bisexual (females) 119 738 16.13 109 820 13.29 1.254 (0.937, 1.679) 0.166 1.259 (0.826, 1.917) 0.816
Bisexual (males) 41 436 9.40 13 374 3.48 2.879 (1.483, 5.955) 0.001 3.459 (1.342, 8.919) 0.005 **
b
Heterosexual 740 1174 63.03 992 1194 83.08 0.347 (0.285, 0.423) <0.001 0.309 (0.252, 0.379) 0.002 **
Homosexual (females) 56 738 7.59 20 820 2.44 3.282 (1.916, 5.835) <0.001 3.105 (1.445, 6.670)b 0.002 **
Homosexual (males) 33 436 7.57 32 374 8.56 0.875 (0.510, 1.504) 0.658 0.791 (0.364, 1.718) 0.993
Other 67 1174 5.71 10 1194 0.84 7.161 (3.639, 15.687) <0.001 7.612 (3.860, 15.013) <0.001 ***
Abbreviations: FDR, false discovery rate; 95% CI, 95% confidence interval; OR, odds ratio.
Note: Significance level: ***(p < 0.001), **(p < 0.01), *(p < 0.05), Δ(p < 0.10).
a
Binomial logistic regression adjusting for age, sex, ethnicity, education, and country of residence.
b
Exact p value was too small to be precisely determined; for the purposes of the FDR calculations, we estimated this p value as equal to 0.0009, in order to provide the
most conservative analysis.
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WEIR ET AL. 2349

TABLE 4 Different patterns of sexual orientation, activity, and health between autistic males and females

Females Males Unadjusted model Adjusted modela

Yes Total Yes Total
(n) (n) % (n) (n) % OR (95% CI) ‡ FDR OR (95% CI)b FDR Sig.

Asexual 96 738 13.01 22 436 5.05 2.812 (1.722, 4.774) <0.001 2.644 (1.619, 4.318) <0.001 ***
Bisexual 119 738 16.13 41 436 9.40 1.851 (1.257, 2.771) 0.003 1.558 (1.055, 2.300) 0.039 *
Heterosexual 415 738 56.23 325 436 74.54 0.439 (0.335, 0.573) <0.001 0.485 (0.370, 0.637) <0.001 ***
Homosexual 56 738 7.59 33 436 7.57 1.003 (0.629, 1.621) 1.00 0.934 (0.585, 1.493) 0.777
Other 52 738 7.05 15 436 3.44 2.126 (1.161, 4.120) 0.017 2.220 (1.217, 4.049) 0.017 *
Ever sexually active 561 738 76.02 306 436 70.18 1.346 (1.022, 1.771) 0.050 1.652 (1.225, 2.227) 0.002 **
Ever contracted an STI 83 741 11.20 39 434 8.99 1.277 (0.844, 1.960) 0.304 1.417 (0.936, 2.147) 0.128
c
Ever contracted an STI 78 564 13.83 38 304 12.50 1.123 (0.730, 1.752) 0.678 1.202 (0.779, 1.854) 0.456
Abbreviations: FDR, false discovery rate; 95% CI, 95% confidence interval; OR, odds ratio.
Note: Significance level: ***(p < 0.001), **(p < 0.01), *(p < 0.05), Δ(p < 0.10).
a
Binomial logistic regression adjusting for age, sex, ethnicity, education, and country of residence.
b
Odds ratios and 95% confidence intervals use autistic males as the reference group.
c
All individuals who reported never being sexually active were excluded.

F I G U R E 2 Age at which
autistic males and females first
engaged in sexual activity

report this identity). Aligning with previous research on between autistic and nonautistic adolescents and adults.
this age group, we found that younger autistic individuals These findings may have important implications for the
were less likely to have ever contracted an STI compared healthcare of autistic individuals, and in particular
to younger nonautistic adults (Fortuna et al., 2016; regarding sexual health screenings and support for men-
Schmidt et al., 2019). Full results can be found in Table 5 tal health.
below. Our findings bolster previous evidence that autistic
individuals identify with a wider range of sexual orienta-
tions than others (Bush, 2019; Bush et al., 2020; Dewinter
DISCUSSION et al., 2017; George & Stokes, 2018a; Pecora, Hancock,
et al., 2020; Pecora, Hooley, et al., 2020; Rudolph
Autistic adolescents and adults may be less likely to et al., 2018). Our results clarify that autistic males are
engage in sexual activity than nonautistic individuals but uniquely more likely to identify as bisexual than other
may be more likely to have diverse sexual orientations; males and autistic females are uniquely more likely to
further, sex-specific patterns of sexual orientation and identify as homosexual than other females—suggesting
activity may be different between autistic and nonautistic that autistic adults do not conform to the same sex-
adults. Overall, our results do not suggest differences in specific patterns of sexual orientation observed in the
lifetime risk of STIs or age of sexual activity onset general population. Autistic individuals are 8.1 and 7.6
 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2350 WEIR ET AL.

TABLE 5 Different patterns of sexual orientation, activity, and health between autistic and nonautistic adults stratified by age group

Younger adults adjusted modela Older adults adjusted modela

OR (95% CI) FDR Sig. OR (95% CI) FDR Sig.

Asexual 7.548 (3.838, 14.841) <0.001 *** 10.277 (4.564, 23.142) <0.001 ***
Bisexual 1.391 (1.008, 1.919) 0.059 Δ 1.914 (1.167, 3.140) 0.016 *
Heterosexual 0.327 (0.250, 0.428) <0.001 *** 0.267 (0.190, 0.374) <0.001 ***
Homosexual 1.925 (1.204, 3.077) 0.011 * 1.456 (0.782, 2.709) 0.290
Other 7.740 (2.929, 20.453) <0.001 *** 6.684 (2.528, 17.676) <0.001 ***
Ever sexually active 0.262 (0.188, 0.366) <0.001 *** 0.242 (0.150, 0.392) <0.001 ***
Ever contracted an STI 0.623 (0.410, 0.947) 0.039 * 0.839 (0.593, 1.185) 0.349
Ever contracted an STIb 0.805 (0.521, 1.243) 0.349 0.907 (0.637, 1.292) 0.588
Abbreviations: FDR, false discovery rate; 95% CI, 95% confidence interval; OR, odds ratio.
Note: Significance level: ***(p < 0.001), **(p < 0.01), *(p < 0.05), Δ(p < 0.10).
a
Binomial logistic regression adjusting for age, sex, ethnicity, education, and country of residence.
b
All individuals who reported never being sexually active were excluded.

times more likely to self-report identifying as asexual or adults (Fortuna et al., 2016) and the second study only con-
‘other’ sexual orientation than nonautistic individuals, sidered STI risk among individuals with any intellectual or
respectively. These odds ratios are far higher than those developmental disability, grouping together a highly het-
previously reported in a large sample of individuals with erogeneous sample of individuals with autism, cerebral
high autistic traits (ORs: 1.7–3.1) (Rudolph et al., 2018), palsy, down syndrome, spina bifida, intellectual disability,
and in a smaller sample of autistic females (ORs: 2.3–2.4) as well as those with fragile X, prader willi, and fetal alco-
(Pecora, Hooley, et al., 2020). These results align with hol syndrome (Schmidt et al., 2019). Thus, it is likely that
previous findings in the field to confirm relatively greater previous studies have not accurately captured the sexual
likelihood of identifying as a nonheterosexual sexual ori- activity and behavior of sexually active autistic individuals
entation and relatively lower likelihood of identifying as specifically.
heterosexual; however, future research should focus on The results from our main analyses also support that
replicating these findings in population-based samples of risk of STIs may be partially mediated by high rates of
both autistic females and males to confirm actual odds of asexuality and lack of ever engaging in sexual activity
identifying with each sexual orientation and the sex dif- among autistic adults overall, as significance and odds
ferences therein. ratios attenuated after accounting for these factors sepa-
Further, when comparing autistic females and males rately and additively. Although our study does not directly
directly, our results suggest that autistic females tend to inquire about interest in sexual activity, our results con-
identify with a wider range of sexual orientations (except firm that asexuality may play a key role in reducing sexual
for homosexuality), are more likely to engage in sexual activity among autistic individuals—and particularly
activity, and are more likely to do so initially at a relatively among autistic females. The results from Adjusted Model
younger age. Further, our results confirm previous findings 1 suggest that autistic females were 38% and autistic males
showing that the majority of both autistic males and were 22% as likely to report ever having engaged in sexual
females endorsed engaging in sexual activity (Bush, 2019; activity compared to sex-matched peers; however, the
Dewinter et al., 2013; Sala et al., 2020), even if the relative group differences decreased to autistic females being 48%
proportion of individuals was smaller than nonautistic and autistic males being 24% as likely to report ever hav-
males and females (Bush, 2019; George & Stokes, 2018a). ing engaged in sexual activity compared to sex-matched
Our results refute previous findings suggesting that peers in Adjusted Model 2, after accounting for self-
autistic individuals have reduced risk of STIs compared to reported asexuality among the participants. Interestingly,
others (Fortuna et al., 2016; Schmidt et al., 2019), instead asexuality does not account for all of the variance between
supporting that there is no significant difference in relative autistic and nonautistic females and males (respectively)
lifetime risk of STIs. While our age-stratified results suggest regarding sexual activity. It is possible that this difference
that younger autistic adults (aged 16–40 years) may be less could be accounted for by reduced libido previously
likely to engage in sexual activity than younger nonautistic reported among autistic individuals (Bejerot &
adults, this effect was eliminated after removing individuals Erikson, 2014; Bush, 2019; Pecora et al., 2019), or that
who have not ever engaged in sexual activity from the anal- autistic adults’ actual sexual activity may not meet their
ysis. It is also possible that our results differ from the two desire for it, due to differences with social communication,
previous studies in this area for practical reasons: The first sensory sensitivities, or mental health conditions such as
study only included a sample of 255 autistic adults which is anxiety, which can often co-occur with autism (Croen
unlikely to be demographically representative of all autistic et al., 2015; Hand et al., 2019). Taking into account
 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WEIR ET AL. 2351

reports of limited sexual knowledge/ education, low speakers, as the survey was only distributed in English;
healthcare satisfaction, and high odds of unmet healthcare this is reflected in the demographics of our sample, as the
needs (Dewinter et al., 2013; Mason et al., 2019; vast majority of participants reported countries of resi-
Nicolaidis et al., 2013; Pecora, Hancock, et al., 2020), exis- dence with English as the native language (over 80% of
ting research may have underestimated true rates of STIs the population resided in the United Kingdom,
among autistic adults. Future research should focus on United States, or Australia). Further, white individuals,
clarifying true lifetime prevalence rates of STIs among UK residents, and females were overrepresented in our
autistic and nonautistic adults comparatively. sample; as such, our results may not be representative of
Our age-stratified results also suggest that older autis- all individuals. In particular, as attitudes toward sexual
tic adults may be uniquely likely to identify as bisexual, orientation and sexual activity may depend on norms
whereas younger autistic adults may be uniquely likely to within different languages, religions, and cultures, differ-
identify as homosexual compared to peers of similar age ences between our findings and past work in the area
ranges (respectively). These findings provide some evi- may simply reflect sampling biases (e.g., our study over-
dence that social norms (which change across time) may sampled individuals from the UK and US whereas previ-
have affected individuals’ acceptance of their specific sex- ous studies may have oversampled individuals from
ual orientation; yet, our results support overall that autis- Europe and Australia). Additionally, our recruitment
tic individuals of both age groups are more likely than methods may have also biased our control group toward
others to identify with diverse sexual orientations and less individuals with an interest in autism, including those
likely to identify as heterosexual—which may be affected who may have undiagnosed autism—underestimating
by social norms, biological differences, other factors, or a true group differences between autistic and nonautistic
combination of these. Our findings do not support a dif- adults; to minimize this risk, we excluded all individuals
ference in the mean age at which autistic and nonautistic who suspect autism, are awaiting autism assessment,
adults report first engaging in sexual activity; however, and/or self-diagnosed as autistic from both the autistic
Figure 1 above shows a relatively wider distribution and nonautistic control groups.
among autistic adults, with a greater number of outliers There are also several other limitations of the study
on both sides. This is particularly concerning regarding that should be considered. First, it is possible that the
sexual activity prior to the age of 13 years, which may odds of identifying as a nonheterosexual orientation are
relate to child sexual victimization; however, as our study greater among actually autistic individuals compared to
did not define sexual activity specifically or ask about those with high autistic traits; however, it is also possible
child sexual abuse, no definitive conclusions can be that our study is underpowered to provide true effect size
drawn from these findings at this time. differences, and that the odds ratios represented here are
Our online, self-report, and cross-sectional methodol- artificially inflated due to “winner’s curse” (a statistical
ogy enabled recruitment of a large cohort of autistic ado- phenomenon common to epidemiology and genetics
lescents and adults (aged 16–90 years; mean age where the effect size reported first is greater than the effect
approximately 41 years), providing the unique opportunity sizes reported in later studies of the same group)
to describe the sexual health and orientation across the (Ioannidis, 2008). Second, our survey did not specifically
lifespan. This is the largest study of sexual orientation of define the terms “sexual activity”, “STIs”, or “sexual ori-
autistic adolescents and adults and the first to consider entation”; however, our results largely align with several
asexuality and likelihood of ever engaging in sexual activ- previous studies in these areas (Bush, 2019; Bush
ity in measures of sexual health. This is also the first study et al., 2020; Dewinter et al., 2017; George &
that quantifies the odds of identifying with a particular Stokes, 2018a; Pecora, Hancock, et al., 2020; Pecora,
sexual orientation, as well as the relative sex differences of Hooley, et al., 2020; Rudolph et al., 2018), and our results
those patterns while controlling for key demographic con- did not change when more strictly defining “STIs” in a
founders, such as age, sex (where appropriate), ethnicity, sensitivity analysis. Third, sexual health and sexual activ-
education-level, and country of residence. ity are complex and attitudes toward them may change
over time; this study cannot accurately describe all aspects
of these multifaceted experiences. Fourth, the study relied
Limitations on a self-report methodology on topics that may have
been taboo or sensitive for some participants. For this
Despite recruiting a large number of autistic individuals reason, we explicitly told participants that the survey was
(particular older and female autistic individuals), the anonymous and that all questions regarding sexual health
results presented are unlikely to represent the experiences were optional; however, we maintained high response
of all autistic individuals. Our survey design and recruit- rates even through this section (>99% for all questions
ment methods inherently exclude individuals without related to sexual orientation and health). Still, it is possi-
access to a computer and/or the internet, as well as those ble that autistic individuals may have been more candid
who are not physically or intellectually able to fill in a about their experiences than others due to differences in
self-report survey. They also exclude non-English communication style and/or lessened concerns about
 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2352 WEIR ET AL.

adherence to social norms. Fifth, as we do not yet under- these identities, particularly when discussing sexual educa-
stand the factors that contribute to an individual’s sexual tion, sexual health, and consent. Psychiatrists should also
orientation, the group differences observed regarding sex- be aware of possible intersectionality between gender, sex-
ual orientation may correspond to these factors or to dif- ual orientation, and/or disability, as their autistic patients
ferences in acceptance of one’s own sexuality (again, may be particularly likely to experience mental or physical
possibly due to differences in communication style/ health problems due to discrimination and minority stress
lessened adherence to social norms typical of autism). (George & Stokes, 2018b; Hall et al., 2020). Healthcare
providers should work cooperatively with autistic and non-
autistic individuals alike to communicate effectively and
Clinical implications make plans to ensure that sexual relationships and sexual
contact remain affirming, safe, and fulfilling.
Currently, autistic individuals overall report lower satis-
faction and self-efficacy within healthcare, as well as A C K N O W L E D G M EN T S
higher odds of unmet healthcare needs than others We are grateful to Paula Smith and Rosemary Holt for
(Mason et al., 2019; Nicolaidis et al., 2013); and assistance with advertisement, as well as Sarah Hampton
LGBTQA+ autistic individuals may be particularly vul- for helpful conversations about use of language when dis-
nerable to worse mental and physical health, as well as cussing sensitive topics. Thanks also to all our partici-
inadequate healthcare (George & Stokes, 2018b; Hall pants, as well as the Cambridge Autism Research
et al., 2020; Pecora, Hooley, et al., 2020). Previous Database, Autistica’s Discover Network, and various
research that suggests that current sexual education of autism support groups and charities for assisting our
autistic individuals remains inadequate (Dewinter recruitment. Funding for this project was generously pro-
et al., 2013; Pecora, Hancock, et al., 2020), and that vided by the Autism Research Trust (Grant Number:
autistic females have self-reported lower rates of cervical RG72423), the Rosetrees Trust (Grant Number:
cancer screenings (Nicolaidis et al., 2013). Our results G102199), and the Cambridge and Peterborough NHS
also suggest that autistic adults are just as likely to con- Foundation Trust (Grant Number: G102307). EW is
tract STIs as others; further, other studies suggest that supported by funding from the Corbin Charitable Trust.
autistic females may be more likely to have gynecological SBC received funding from the Wellcome Trust 214322\Z
and/or hormone-associated conditions (including poly- \18\Z. For the purpose of Open Access, the author has
cystic ovarian syndrome) (Cherskov et al., 2018; Ruta applied a CC BY public copyright license to any Author
et al., 2011), which can increase risk of diabetes, cardio- Accepted Manuscript version arising from this submis-
vascular conditions, and cancers (Bhupathy et al., 2010; sion. Further to this SBC received funding from Innova-
Brand et al., 2011; Cherskov et al., 2018; Mantovani & tive Medicines Initiative 2 Joint Undertaking (JU) under
Fucic, 2014). Thus, improving sexual education and grant agreement No 777394. The JU receives support
ensuring regular gynecological/ sexual health appoint- from the European Union’s Horizon 2020 research and
ments for autistic adolescents and adults across the spec- innovation programme and EFPIA and AUTISM
trum should remain a priority. SPEAKS, Autistica, SFARI. SBC and CA also received
Healthcare professionals should be aware of increased funding from the Autism Research Trust, Autistica, the
risk of sexual victimization and abuse among autistic indi- MRC and the NIHR Cambridge Biomedical Research
viduals across the lifespan (Brown-Lavoie et al., 2014; Centre. The research was supported by the National
Pecora et al., 2019), and should take extra time and care to Institute for Health Research (NIHR) Collaboration for
communicate effectively with autistic people when dis- Leadership in Applied Health Research and Care East of
cussing relationships, sexual contact, and sexual health to England at Cambridgeshire and Peterborough NHS
ensure appropriate safeguarding; these risks may be partic- Foundation Trust. The views expressed are those of the
ularly acute for autistic females and those with diverse sex- author(s) and not necessarily those of the NHS, NIHR or
ual orientations (Pecora et al., 2019; Pecora, Hooley, Department of Health and Social Care.
et al., 2020). As challenges with social communication are
a core feature of autism, practitioners providing these well- ETHICS ST ATE ME NT
ness checks (including sexual health screenings, as well as This study received ethical approval (HBREC.2017.28)
screenings for abuse during pediatric visits) may need extra from the University of Cambridge Human Biology
time with autistic individuals and should focus on asking Research Ethics committee. All participants included in
specific, rather than open-ended questions; further, practi- this sample provided informed consent.
tioners should allow individuals to communicate in the
way they feel most comfortable, including via written com- OR CID
munication (Nicolaidis et al., 2015). Providers should also Elizabeth Weir https://orcid.org/0000-0001-5434-9193
be aware that autistic individuals may be more likely to Carrie Allison https://orcid.org/0000-0003-2272-2090
identify with a wider spectrum of genders and sexualities, Simon Baron-Cohen https://orcid.org/0000-0001-9217-
and their language should be affirming and inclusive of all 2544
 19393806, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/aur.2604 by Cochrane France, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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