Autism Spectrum in Sexual Diversity

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In psychoanalysis, it can always be said to be "so many individuals, so many sexualities".  The concept of autism spectrum would further expand the recent diversity of sexuality.
 
Psychiatry and sexuality
“Sexual diversity” has become a heated topic globally in relation to social, cultural and political concerns, since human rights for lesbian, gay, bisexual, and transgender (LGBT) individuals were internationally secured through the Declaration of Sexual Rights in 1999 and the Declaration of Montreal in 2006. These rights may be perceived as the realization of freedom from suppression. The recent changes have influenced psychoanalytic practice in various ways. Previously, psychiatry considered LGBT a psychopathology. Homosexuality was excluded from the list of mental disorders by the DSM (Diagnostic and Statistical Manual of Mental Disorders) -II (sixth printing, 1974) and ICD (International Classification of Diseases) -10 (1990) and currently it is not considered a psychopathology. The notion of “gender identity disorder” was replaced by the concept of “gender dysphoria” in the DSM-5 (2013), by “gender incongruence” in the ICD-11 (2018) and it no longer is believed to be a disorder. Thus, sexual orientation and sexual identity have shifted from individual psychopathologies to socio-cultural diversity. These recent changes necessarily expanded the scope of  “healthy sexuality.”  However, if the changes mean simply replacing physio-psychological problems with socio-cultural problems, the essence of the issues might be distorted.
 
Paraphilic disorders, which were considered sexual perversions, are now listed in the DSM-5 and ICD-11 as mental disorders or psychopathologies. If individuals with these disorders did not violate laws with respect to these psychopathologies, the individuals would be less likely to seek psychiatric treatment. Furthermore, patients with eating disorders or personality disorders often have potential sexual pathologies and dynamics associated with sexual orientation and ego identity (Okada, 2016b). The recent expansion of the notion of sexual diversity might have reduced the psychopathology surrounding sexuality in psychiatry. Nevertheless, various dynamics would still be suppressed in psychiatry. 
 
Psychoanalysis and sexuality
Historically, psychoanalysis has discussed the development and pathology of human sexuality. According to the theory of psycho-sexual development (Freud, 1905), humans are directed toward genital primacy during the genital phase of adolescence by shifting the object of drive cathexis from bodily sites of oneself to self and ego and to other persons. The genital character (Reich, 1949) that acquires the status of genital primacy is still sometimes an ideal form of sexuality. According to the theory of psychosocial development (Erikson, 1956), identity issues during adolescence and problems with intimacy and generativity during adulthood can be understood as a developmental task regarding sexuality. Freud (1905) argued that infantile sexuality is a type of perversion and that neurosis is a negative form of perversion.

Human sexuality potentially involves perversion and thus it is conflictual and compromised; it often is pathological and creative as well. The psychodynamics of sexuality are believed to be on a spectrum ranging from unconscious-covert to conscious-overt behaviours, or from normal psychology to abnormal psychology. Understanding the psychodynamics of the sexuality spectrum is quite useful in psychoanalysis, which is based on the principle of the continuum of normality and abnormality. Further, the contemporary manifestations of sexual diversitymust be understood as expressed throughbio-psycho-socio-cultural dynamics. To this end, it is important to point out the socio-cultural climate of my country, where I practice psychoanalysis and psychotherapy. Arguably, introducing a socio-cultural climate for sexuality to modern Japan would further expand the global diversity of sexuality.
 
Modern Japan and sexuality
Historically, Japan has been characterized as a male chauvinistic society. However, since the beginning of the twenty-first century, measures have been taken by the nation based on the philosophy of gender equality, and gender diversity has been promoted in many areas. Along these lines, to protect their safety and security, women-only cars were introduced in trains in urban areas and, in clinical medicine, women-only outpatient services that provide medical care by women staff have become a prominent part of hospitals in light of gender-specific medicine. These changes stress gender difference and gender equality, although some people might interpret them as ways to exclude men. The confusions between the meanings of “sexuality” and “gender,” “distinction” and “discrimination,” and “fairness” and “equality” add complexity to our current ideas about sexual diversity. 
 
In Japan in the twenty-first century, newly coined and trendy terms have been created, such as “herbivore boys,” who have little desire for love and sex, and “carnivore girls,” who have a lot of desire for them. Unisex fashion became a youth culture. Herbivore boys can be understood as asexual in the sense that they have little sexual desire, and “unisex” can be understood as meaning “neuter” in the sense that it is somewhere between the masculine and the feminine. In reality, however, males or females could be herbivores or carnivores, and they could be bipolar and multipolar as a group. 
 
Since the 1980s, Japanese subculture has had men referred to as otaku,[1]who are fans of anime and computer gaming. This phenomenon has drawn attention, and some of these men are sexually attracted to and worship female pop idols. Since the 1990s, women referred to as fujyoshi[2]who fantasize about men’s homosexual relationships also have drawn attention. These phenomena are just one socio-cultural observation in modern Japan and they cannot all be considered psychopathological. However, if we try to psychodynamically understand their described worldview on sexuality, they seem not to have had genuine genital loveexperiences, and their sexuality can be assessed as immature and perverted. 
 
Fragments of clinical cases
Psychoanalysts are neither sociologists nor psychopathologists. Their perspective is always based on analytical interactions with their clinical cases. The summaries of some relevant clinical cases are described below.

Ms. A was in her early 40s and presented with indefinite complaints. Through the process of free association as an enactment of the object relation of seeing, being seen, showing and hiding something, I reconceptualized dynamics of the phallic phase as the phallic/vaginal phase (Okada, 2014).

However, over the course of long-term psychoanalytic treatment, Ms. A had difficulty actually experiencing emotional intercourse with the analyst during transference because of fairly strong resistance, and she had always indulged in sexual fantasies with ideal men in her inner world. It was suspected that autism spectrum was the bedrock of her hysteria.
 
Mr. B was a high school boy with an excellent academic record. He was apprehended by the police after he masturbated and ejaculated on a high school girl’s skirt at a used bookstore. Although he had the moral understanding to know right from wrong, he could not suppress his sexual urge to act. However, he had no masturbatory fantasy and ejaculation was just a physical action for him. It was believed that autism spectrum was behind his sexual perversion.
 
Ms. C was a female transsexual student in her mid-20s. She had felt uncomfortable about being a woman since high school and she began thinking about sex reassignment surgery during her college years; simultaneously, she was diagnosed with an autism spectrum disorder. Support for her transsexuality and autism spectrum disorder was not integrated. Although she approached older women who were receptive to her, she had no objects of love and sex in either her internal or external world.  
 
Ms. D was a woman in her late 20s who was weakly adaptive to environmental change and relatively unlikely to gain weight. She had little interest in food, sleep, or sexual relations, and she tended to present with psychosomatic symptoms, such as alexithymia and alexisomia. Several years after initiating psychoanalytic therapy, she married an older man she met at her workplace. She and her husband had been in a sexless relationship from the beginning of married life. They always slept in separate bedrooms and she felt absolutely no discomfort regarding that relationship. Her sexual inactivity was believed to derive from autism spectrum. 
 
Ms. E was a female student who planned a “welcome sushi party” for foreign students at her college. As the sushi was made by hand, all hands had to be kept clean. Notably, the antiseptic solution must be washed away with water to prevent the antiseptic solution from entering the mouth through the sushi. However, she had difficulty understanding why flushing the antiseptic solution off her hands was necessary after cleaning her hands.She stated that she had a boyfriend during high school, but she only promised an e-mail relationship, and they had no emotional or physical sexual relationship. She still sleeps in the same bedroom as her parents and four brothers[3]and she is comfortable with her everyday lifestyle. Her sexuality was immature, and it was believed that autism spectrum was the foundation of her behaviour. 
 
Autism spectrum behind diverse sexuality in modern Japan
None of the psychopathology of the patients we encounter in psychoanalytic treatment is the same. In this sense, human sexuality is always diverse. Although the clinical cases presented above exhibit various sexual dynamics and pathologies, they demonstrate little conflict and defensiveness and, thus, were understood as autism spectrum stemming from ego defects or autistic parts of the individuals’ personalities.  Understanding the sexualities of these cases presented as the dynamics of perversion, is probably inadequate. The perspective of autism spectrum could further expand the clinical understanding of sexuality that has hitherto been understood as a defense or perversion.
 
The notion of “autism spectrum” in current psychiatry will present a biological ego defect model. Many people with autism spectrum are not medically diagnosed with autism spectrum disorder. In current psychoanalysis, the human ego essentially consists of autistic and non-autistic parts.
 
I became a medical doctor in 1991 and a psychoanalyst in 2010 (Okada, 2016a) and over the past decade, I feel anincreasing number of problems are associated with the autism spectrum in Japan. The recent psychiatric and socio-cultural changes surrounding sexuality must surely expand the diversity of “healthy sexuality.”  Just as the concept of the autism spectrum expands the understanding of human diversity, it will expand the understanding of human sexual diversity too.
 
References
Erikson, E.H. (1956), The problem of ego identity. J Am Psychoanal Assoc. 4(1):56-121.
Freud, S. (1905), Three Essays on the Theory of Sexuality, S.E. 7.
Okada, A. (2014), Hysteria, resistance and free association, Japanese Contributions to Psychoanalysis, 4, 66-80.
-- (2016a), On becoming a psychoanalyst in Japan, Psychoanalytic Inquiry, 36(2): 155-161.
-- (2016b), The real among the fake: on the process of psychoanalysis of bulimia patient. Japanese Contributions to Psychoanalysis, 5, 75-90.
Reich, W. (1949), Character-analysis (3rd ed.). Oxford, England: Orgone Institute Press.