Toward a Gender-Sensitive Approach of Psychiatric Rehabilitation in Autism Spectrum Disorder (ASD): A Systematic Review of Women Needs in the Domains of Romantic Relationships and Reproductive Health

Abstract

Later age of diagnosis, better expressive behaviors, increased use of camouflage strategies but also increased psychiatric symptoms, more unmet needs, and a general lower quality of life are characteristics often associated with female gender in autism spectrum disorder (ASD). Psychiatric rehabilitation has shown small to moderate effectiveness in improving patients' outcomes in ASD. Few gender differences have been found in the response to psychiatric rehabilitation. This might be related to the predominance of males in research samples, but also to the lack of programs directly addressing women's unmet needs. The objectives of the present paper were: (i) to review the needs for care of autistic women in romantic relationships and reproductive health; (ii) to review the existing psychosocial treatments in these domains; and (iii) to evaluate the strengths and limitations of the current body of evidence to guide future research. A systematic electronic database search (PubMed and PsycINFO), following PRISMA guidelines, was conducted on autistic women's needs for care relating to psychiatric rehabilitation in romantic relationships and reproductive health. Out of 27 articles, 22 reported on romantic relationships and 16 used a quantitative design. Most studies were cross-sectional (n = 21) and conducted in North America or Europe. Eight studies reported on interventions addressing romantic relationships; no published study reported on interventions on reproductive health or parenting. Most interventions did not include gender-sensitive content (i.e., gender variance and gender-related social norms, roles, and expectations). Autistic women and autistic gender-diverse individuals may face unique challenges in the domains of romantic relationships and reproductive health (high levels of stigma, high risk of sexual abuse, increased psychiatric symptoms, and more unmet needs). We discussed the potential implications for improving women's access to psychiatric and psychosocial treatment, for designing gender-sensitive recovery-oriented interventions, and for future research.

Gender differences in psychosocial function and self-reported health status in late-diagnosed autistic adults: results from the FACE-ASD national cohort

“…This further supports the need to improve autistic women's access to diagnosis, to adequate treatment and more generally to service provision that could address their unique challenges and needs for care (e.g. provider training to the female autism phenotype or extra support in the domains of romantic relationships and reproductive health; Dubreucq & Dubreucq, 2021;Hull et al, 2020;Strang et al, 2020). Second, co-occurring physical health conditions are common and are associated with poorer adult outcomes, but remain often under-detected and under-treated (Rydzewska et al, 2021;Weir et al, 2021).…”

“…increased risk for sexual or domestic abuse; Bargiela et al, 2016; Pecora et al, 2019; peripartum depression, feelings of social isolation in the postnatal period, or communication difficulties with perinatal health providers; Pohl, Crockford, Blakemore, Allison, & Baron-Cohen, 2020). Third, compared with autistic men, autistic women often report more unmet needs related to their mental health concerns, to vocational services and to reproductive health issues; Brugha et al, 2016; Dubreucq & Dubreucq, 2021; Taylor & DaWalt, 2020; Tint & Weiss, 2018). Aligning with this, autistic women are more likely to be undiagnosed or misdiagnosed than autistic men even in epidemiological studies (Brugha et al, 2016; Loomes, Hull, & Mandy, 2017).…”

“…According to the ‘female autism phenotype’ (i.e. a behavioral expression of autism that could be more common in women; Hull et al, 2020), while autistic women have similar core autistic symptoms compared with men, they also tend to report poorer mental and physical health and a reduced quality of life (Brugha et al, 2016; Dubreucq & Dubreucq, 2021; Hull et al, 2020; Taylor & DaWalt, 2020; Tint et al, 2018). Given autistic women tend to report more often than men to be involved in a relationship or to be a parent (Power et al, 2013; Schöttle, Briken, Tüscher, & Turner, 2017), this could be related to the impact of gendered social, norms, roles, pressures and expectations on a person's wellbeing and sense of identity (Dubreucq & Dubreucq, 2021; Kanfiszer, Davies, & Collins, 2017).…”

“…who may have been confronted to challenges in early adulthood but received less support from providers; Bishop-Fitzpatrick et al, 2016; McCauley et al, 2020a). We also hypothesized that general functioning would be negatively associated with impairment in social communication. According to the literature reviewed above (Brugha et al, 2016; Dubreucq & Dubreucq, 2021; Hull et al, 2020; Taylor & DaWalt, 2020; Tint et al, 2018), we hypothesized that there would be gender differences in aspects of adult outcome related to health status (i.e. comparable objective outcomes but poorer mental and physical health and poorer self-reported health status in autistic women). While associations between verbal ability or female gender and co-occurring health conditions can vary according to sample characteristics (e.g.…”

“…According to the literature reviewed above (Brugha et al, 2016; Dubreucq & Dubreucq, 2021; Hull et al, 2020; Taylor & DaWalt, 2020; Tint et al, 2018), we hypothesized that there would be gender differences in aspects of adult outcome related to health status (i.e. comparable objective outcomes but poorer mental and physical health and poorer self-reported health status in autistic women).…”