Asexuality is commonly regarded as lack of sexual attraction. Research in asexuality grew progressively in the past two decades. However, asexuals’ patterns of sexual behavior and psychological processes were not yet systematized. This review searched for articles that could potentially help establishing these patterns. Articles published in English until December 31st 2019 were retrieved from Medline, Embase, Cochrane, EBSCO, PubMed, Scopus, and PsycARTICLES. A systematic search was conducted using an exhaustive list of key terms regarding asexuality and sexual behavior following PRISMA guidelines. Of the 195 initially retrieved, only 23 were considered for this review. Of the 23 articles, 16 were quantitative studies, 5 were qualitative studies, and 2 comprised quantitative and qualitative studies. Overall, current findings suggest that asexuals present great heterogeneity of sexual behaviors and psychological processes regarding sexuality, including different aspects and types of interpersonal and romantic relationships, sexual attitudes or fantasies. Conversely, data did not find support for the claim that asexuals present impaired sexual functioning. The little geographic and cultural diversity of the samples is a major limitation in these studies, preventing the properly representation of asexuals. Furthermore, asexuals may benefit from evidence on the biopsychosocial factors shaping sexual, emotional, and relationship well-being, as far as such evidence is built upon asexuals’ lenses, rather than on heteronormativity criteria.
Asexuality is currently accepted by many researchers as a lifelong lack of sexual attraction (e.g., [1, 2]) unique sexual orientation (e.g., [3, 4]), and sexual identity (e.g., [5,6,7]) which all align with the definition of asexuality by AVEN, the Asexual Visibility and Education Network . As a whole, asexuals are believed to represent 1% of the general population [9, 10], and were marginalized in many ways as a sexual minority.
From an historical perspective, asexuals seem to be first labeled in 1948 by Kinsey as “Category X”, i.e., individuals who had no sexual response to sexual stimuli [9, 11]. No further research on asexuality took place for many decades. In 2001, the activist David Jay founded AVEN (www.asexuality.org), which become the world’s largest online community of asexuals. AVEN’s efforts at building public recognition of the asexual or “Ace” community resulted in the reborn of asexuality in science, after Kinsey's work. There is still ongoing debate on whether to characterize asexuality as a sexual dysfunction, more specifically a severe case of low sexual desire. Nonetheless, research has not confirmed this assumption [12, 13], and the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders established asexuality as an exclusion criterion for female sexual interest/arousal disorder and male hypoactive sexual desire disorder . In a nutshell, the fact that asexuals do not report personal distress stemming from their sexuality, as reported in research (e.g., [2, 12]) is enough to dismiss a potential diagnosis of disturbance. When asexuals do feel distress, this is more likely to stem from social stigma , and/or from the pressure from partners to have sex .
Asexuals are an heterogeneous population [4, 17, 18], and some may engage in solitary and/or partnered sexual activity, while others do not (e.g., [19, 20]). That is, some asexuals have or want to have romantic partners, i.e., have a romantic orientation; on the other hand, some asexuals do not have and do not want to have romantic partners, i.e., are aromantic (e.g., [13, 21]). In addition, the Ace spectrum may include other identities, namely demisexuals (who experience sexual attraction only in the context of a romantic attraction), Gray-A (who fall in the perceived gray area between sexual and asexual), and A-fluid (who apply the term to a general fluidity to sexuality as a whole) ; and diverse sexual orientations (see ).
Knowledge on asexuality is growing but is still scattered. At this stage, it seems important to clarify the potential patterns of asexual behavior found in research. Adding evidence on these patterns will hopefully help deconstruct stigma around asexuality, highlight diversity, and adjust the services provided to this population fitting their characteristics and identities.
Despite the expected diversity of sexual behaviors within asexuality, asexuals’ behaviors and psychological processes, including the cognitive and emotional variables underpinning sexuality, have not been systematized. Yet, evidence on asexuals’ specificities in sexual behaviors and psychological processes could positively impact the quality of health services, as well-informed professionals may better fit asexuals’ psychological, medical, and social needs. Accordingly, the current systematic review aimed to acknowledge and systematize asexuals’ patterns of sexual behavior and psychological processes regarding sexuality (i.e., cognitions and emotions), including sexual functioning, relationship dynamics, and asexuals’ sense of identity.
An extensive search of Medline, Embase, and Scopus databases was conducted to retrieve English-language articles published up to 31 Dec 2019 (PROSPERO registration). We used an exhaustive list of key terms combining “asexuality” or “asexual” or “self-labeled asexuals” with “sexual dysfunction” or “sexual functioning” or “sexual desire” or “sexual arousal”. Additional searches were conducted using “asexuality” or “asexual” or “self-labeled asexuals” and “paraphilia” or “sexual behavior” or “intimacy” or “sexual attraction”. Full search strategy is shown in the Supplementary material and the protocol was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement . Retrieved studies had to include the asexuality theme, regardless its measurement approach. Retrospective studies, prospective clinical studies, or comparative, were included in the qualitative analysis. Congress meetings, editorial comments, and review papers were excluded. Further exclusion criteria were full texts not available in English.
Two reviewers (G.I.R. and A.U.) independently assessed the eligibility of the identified papers and any disagreements were discussed with a third reviewer (S.S.). The primary end point of this systematic review was to identify sexual behaviors and psychological processes in asexuals.
Literature search results—A flow chart with steps for final study selection can be found in Fig. 1. A total of 195 studies were retrieved, of which only 177 remained after removing duplicates. These titles and abstracts were screened in order to remove 151 references that did not meet this review’s criteria. Based on full-text reviews of 26 remaining studies, 9 articles were excluded due to results being unconnected to our research question. This review also identified six additional titles among the references of the original articles. These were deemed relevant to our purpose and therefore included. A total of 23 studies were considered for this review. A summary of details and results can be found on Table 1. Of 23 articles, 16 were quantitative studies, 5 were qualitative studies, and 2 comprised quantitative and qualitative studies [2, 13]. The large majority of the studies gathered data from western countries, with one exception which used participants from China . More than half studies used samples recruited from AVEN’s website. Five studies used national probabilistic samples [5, 10, 25,26,27]. One study conducted laboratorial research with a sample of women. Findings on the patterns of asexual behavior and psychological processes may be organized in several themes: identity (gender and sexual identity); cognitive (meanings, beliefs, attitudes, and fantasies concerning sex); psychophysiological (sexual arousal); behavioral (solitary and partnered sexual activity); and, interpersonal (romantic relationships).
Results and discussion
Gender and sexual identity of asexuals
Research identified that asexuals are more likely to be women, (e.g., [2, 5, 10]) less likely to be cisgender , and more likely to be LGBTQ [lesbian, gay, bisexual, transgender, and queer] . However, these assertions are speculative and require careful interpretations. Bogaert  speculated that women are more likely than men to be asexual, as women are less likely to be conditioned towards sexual orientation, such as masturbation and sexual fantasy. Alternatively, the higher percentage of asexual women in studies might relate with gender roles and the conservative belief that women do not have sexual feelings (discussed further in the “beliefs” section). On the other hand, it might be paradoxical to describe asexuals as being LGB (lesbian, gay, bisexual) considering these represent sexual orientations and refer to same-sex or bisexual sexual attraction, and asexuality refers to lack thereof.
Sexual cognitions of asexuals
In a qualitative study, asexuals seemed to interpret fewer behaviors as sexual comparing to non-asexuals (those who do not self-identify as asexuals or who experience sexual attraction), including perceiving masturbation as nonsexual . The same study noted asexuals did not seem averse or afraid of sex, they were simply uninterested or bored by it, taking no pleasure from sexual acts. The findings of a qualitative research by Scherrer  on the meanings of some sexual behaviors for asexuals suggested the same, where some participants considered masturbation a bodily activity that was unconnected with sex. On the other hand, other asexuals considered masturbation a sexual act and were not interested in pursuing it. Scherrer  reflects that the lack of pleasure may partially explain why some asexuals view some sexual behaviors as nonsexual, but highlights that asexuality may in fact challenge the binary boundaries of sexual/non-sexual.
Dysfunctional sexual beliefs are erroneous beliefs about sexuality that may predispose or maintain sexual difficulties . A study focused on the psychological features and dysfunctional sexual beliefs of asexuals  verified that asexual women reported more conservative beliefs (i.e., viewing sex as procreative/coitus), more beliefs about sexual desire as sin (i.e., considering sex a male activity, and that women must control their sexual urges), more age-related beliefs (i.e., believing sexuality is negatively affected by age), and more denying affection primacy beliefs (i.e., believing sex should occur in the context of love and affection) than non-asexual women. Likewise, asexual men reported more conservative beliefs, more female sexual power beliefs (e.g., believing women may use sex as a means to subjugate men), and more women’s satisfaction beliefs (i.e., beliefs related to the idea that erectile performance is central to women’s satisfaction) than non-asexual men. These sexual beliefs could be related to the religious status of participants . Previous studies have found dysfunctional sexual beliefs to be associated with sexual desire and arousal problems in both women (e.g., ) and men (e.g., ). The role of sexual dysfunctional beliefs in asexuality remains unclear. However, considering asexuals do not experience distress stemming from low desire (e.g., [2, 12]) it is possible asexuals have no need in changing dysfunctional sexual beliefs, as these are likely coherent with themselves and consist in no dysfunction. As recognized by the authors, beliefs are “dysfunctional” in the sense they constitute some vulnerability to sexual problems; when they do not, such beliefs are a legitimate part of how one appraises sexuality .
Attitudes refer to one’s evaluations of a wide variety of objects, issues, and people, including the self, and may implicate behavioral, cognitive, and/or emotional reactions (cf. ). Explicit attitudes may diverge from more automatic or implicit attitudes , particularly when it comes to sexuality which is sensitive to social desirability issues or lack of introspective access. A qualitative study by Carrigan  exploring asexuals’ discourses detected that asexuals positioned themselves as sex-positive (endorse sex as positive and healthy without experimenting sexual desire), sex-neutral (have no interest in sex), sex-averse (the idea of having sex is problematic), or anti-sex (the idea of other people having sex is problematic), denoting an evaluative component about sex (positive, negative, neutral). In a study assessing explicit and implicit attitudes toward sex, asexuals exhibited more negative explicit and implicit attitudes as compared with controls . In contrast, another study with non-asexual men and women found that positive implicit and explicit sexual attitudes were associated with higher sexual desire . These somehow intuitive data on sexual attitudes are consistent with asexuals’ sexual behavior.
Research has shown that asexuals are more likely to report never having had a sexual fantasy [12, 19, 20]. According to Yule et al. , asexuals reporting sexual fantasies consider such fantasies less sexually arousing than non-asexuals. The same study found a large overlap on sexual fantasy content between the two groups, namely concerning BDSM (Bondage and Discipline), S/M (Sadism and Masochism), fetishes, and fantasies of nonconsent. Yet, asexuals were less likely to fantasize about topics such as group sex, public sex, and having an affair. Furthermore, among asexuals who have sexual fantasies, they are more likely to report fantasies about sexual activities that do not involve themselves [19, 20]. This is consistent with the case reports from Bogaert , where he noticed asexuals’ sexual fantasies often did not involve themselves or other people, or involved unknown or fictional characters. It seems as if someone who may not experience sexual attraction, may nonetheless engage in sexual fantasy, possibly to facilitate physiological sexual arousal and masturbation .
Sexual desire and arousal
Asexuals were shown to have significantly lower sexual desire than non-asexuals, including those with sexual interest/desire dysfunction; however, they revealed no distress unlike those presenting with sexual dysfunction [2, 12]. Interestingly, for asexual women who engaged in sexual activity, there was a significant positive correlation between sexual distress and desire, in such the asexual women experienced higher levels of distress with increasing levels of sexual desire . This apparent paradox pairing distress and higher desire was described in some gay and heterosexual men who experience increased sexual desire under negative mood states [37, 38]. The male sample studied by Bancroft et al. might have been using sex to manage negative mood states, which was pointed as a mechanism involved in hypersexuality (cf. [39, 40]). However, in asexuals, increased sexual desire is likely the cause of distress rather than a consequence, as high desire might be perceived incoherent with their identity.
Moreover, there are differences observed in asexuals’ dyadic sexual desire and solitary sexual desire. Dyadic sexual desire refers to other or partner-oriented sexual desire, while solitary sexual desire refers to individual oriented sexual desire (cf. ). Some studies identified a negative relationship between asexuality and dyadic sexual desire [13, 24, 42], but no relationship with solitary sexual desire [13, 42, 43], or a slightly lower relationship with solitary sexual desire . Spector, Carey  proposed that dyadic sexual desire and solitary sexual desire might serve different needs; specifically, solitary sexual desire may serve the purpose of tension release, while dyadic sexual desire may serve the purpose to feel emotional and physical intimacy with another. It was suggested that asexuals might masturbate for tension release , as well as a means to procrastinate or manage boredom , which is consistent with Spector’s proposal .
Asexuals also present distinct subjective and psychophysiological sexual arousal when compared to non-asexuals. While subjective sexual arousal is measured by self-report means, capturing individuals’ experience of sexual arousal, psychophysiological sexual arousal refers to the genital component, usually measured by (photo)plethysmography. These indexes are not always concordant . Asexuals presented significantly lower subjective sexual arousal compared to non-asexuals . However, in a laboratory study using psychophysiological sexual arousal in response to an erotic film, no significant differences were found between asexual and non-asexual women . The same study found no increase in negative or positive affect in response to the erotic film in asexual women (i.e., the film was perceived as neutral and non-sexual). However, in this study, asexual women had higher genital-subjective sexual arousal concordance compared to non-asexual women . Research has consistently shown women report low concordance on genital-subjective sexual arousal  but the findings of Brotto and Yule  dispute this, as low concordance do not seem to apply to asexual women. Similarly to men, asexual women may have higher interoceptive awareness of genital sensations than non-asexual women . The authors hypothesize that asexuals may be highly attuned with their genital arousal due their lack of sexual activity.
Sexual behaviors of asexuals
Asexuals may report lack of sexual attraction for others and still engage in some sexual activities. In the early study of Bogaert , asexuals reported having fewer sexual partners, later onset of sexual activity (if it occurred), and less frequent sexual activity with current partner (when existing) comparing to non-asexuals. Research has shown that asexuals are less likely to engage in sexual intercourse [2, 12, 24, 25, 27], kissing or petting , and to engage in masturbation [19, 24] as compared with non-asexuals. Nevertheless, this does not mean sexual activity among asexuals is necessarily infrequent, particularly masturbation. A study identified that approximately half of asexual participants were having sexual activities in the past year  while another study showed that the majority of asexuals engaged in masturbation . Moreover, in this study, asexual men seem to present similar frequency of masturbation than non-asexuals. On the contrary, in a qualitative study of the diaries of asexuals, it was found asexual women were significantly less likely to masturbate than non-asexual women, non-asexual men, and asexual men . Yet, the same study found both asexual men and asexual women were less likely to masturbate for sexual pleasure as one would expect with a sample of non-asexuals. The differences in masturbatory behavior may result from the different sampling strategies used in these studies. Also, these results indicate heterogeneity in sexual behavior among asexuals as mentioned elsewhere [4, 17].
On a different note, a study with a sample from the Adult Baby/Diaper Lover (ABDL) community Zamboni and Madero  found most asexuals did not report sexual activity in their ABDL practices, and those who did, reported only solitary sexual behavior. Compared to non-asexuals, asexuals reported wearing diapers more frequently and having greater enjoyment of ABDL role-play. The authors argue that similarly to BDSM, ABDL practices allow asexuals to create a safe space where they can express affection without feeling sexual attraction.
Interpersonal or romantic relationships of asexuals
Asexuals may consider themselves either aromantic or romantic , and some may separate love from sex . Aromantic asexuals experience no “romance drive”, and no desire to find a partner, while romantic asexuals are relationship oriented and may establish dyadic partnerships . In a qualitative study exploring asexuals’ views on ideal relationships, aromantic asexuals described their ideal relationships as instances of friendship with lack of physical contact, and romantic asexuals described their ideal relationships as dyadic relationships, primarily monogamous, with physical contact . The views of aromantic asexuals are consistent with the findings of a study from Carvalho et al.  where asexuals presented lower levels of extraversion, and with the findings of a study from Brotto et al. , where asexuals presented more social withdrawal and inhibition.
Commonly, several asexuals have a current romantic relationship or have had romantic relationships in the past [2, 18, 25]. One study did not find significant differences in being in intimate relationships between asexuals and LGBTQ non-asexuals identified individuals’ . Previous studies have shown minority stress negatively affects romantic pursuits in LGB when compared with heterosexuals, but these pursuits are equally meaningful in both groups . Accordingly, just like other sexual minorities, asexuals may face similar micro and macro challenges when pursuing romantic relationships.
When asexuals are partnered with other asexuals, sex does not require negotiation whilst when partnered with non-asexuals this may eventually occur. In a qualitative study, partnered asexuals have described being able to be naked and physically close to their partners without the pressure or expectation of sexual intercourse; however, for asexuals partnered with non-asexuals, sexual activity was negotiated [2, 48]. This included the sexual activities they were willing to take part in, the frequency, and the boundaries around the relationship in the event that the asexual did not engage in any sexual activity with his/her sexual partner . In some instances, engaging in sexual behavior for romantic asexuals seems related with the willingness to comply with partner wishes , as many asexuals are in relationships with non-asexuals . In a study with heterosexuals in dating relationships, more than one third reported consenting to undesired sexual activity to satisfy a partner’s needs, to promote intimacy, and to avoid relationship tension, with positive emotional outcomes . While asexuals engaging in intercourse despite lack of sexual attraction may be within normal experience , many asexual women described these sexual experiences to be extremely distressing .
The outcomes of this review strengthen the idea that asexuals are a heterogeneous group. However, research used mainly samples of self-labeled asexuals from AVEN and may not be capturing the true diversity of asexuality in the general population. Possibly, heterogeneity among asexuals is even broader than detected by research. This is particularly relevant when discussing gender and sexual identity of asexuals. Research suggested there are more women and LGBTQ individuals among asexuals (e.g., [2, 5, 10, 28]). however, due to sample homogeneity, may be risky to make such assumptions.
One important aspect of asexuality seems to be the lack of distress stemming from low desire (e.g., [2, 12]). As previously discussed, when asexuals feel distress stemming from sex, this is likely to relate with stigma or relationship difficulties caused by discrepancies in sexual desire [15, 16]. We cannot highlight enough, distress does not stem from low desire itself, but rather from social stigma or relationship consequences. Meanwhile, we should not assume engaging in sexual activity is necessarily distressing for asexual individuals. Research has shown many asexuals engage in masturbation and intercourse as part of normal experience (e.g., [2, 26]). When involving a non-asexual partner, sexual activity is often negotiated [18, 48] to secure partner wishes . For some asexuals, namely the ones who find sex uninteresting or boring (neutral), engaging in partnered sexual activity may not have negative outcomes. In fact, sex may even have positive outcomes. Contrarily, for asexuals who are sex averse or anti-sex, it is worth studying if partnered sexual activity results in negative emotional outcomes of abusive dynamics.
Taken together, the results of this review indicate some asexuals may differ from non-asexuals in the way they interpret sexual cues, as they showed no changes in affect when viewing erotic clips , but revealed increased negative affect when experiencing sexual desire in the context of sexual activity . Perhaps one of the most puzzling findings on research concerns the fact asexuals seem to interpret less behaviors as being sexual [13, 28, 43]. Yet, asexual women showed higher concordance between subjective and genital sexual arousal , differing substantially from non-asexual women. Brotto and Yule  speculate their participants may have higher interoceptive awareness of genital arousal compared to non-asexuals, but this requires further exploration.
Asexuals present beliefs that would be dysfunctional for many non-asexual people (see ); however, this sort of cognitive processing may actually be adaptive because sexual beliefs seem to be coherent with the desire of not having sex.
A final note on heterogeneity: although asexuals differ from non-asexuals in some aspects, they may also share some features. For example, they seem to share some views on romance and monogamy , and content of sexual fantasy and masturbation . As highlighted elsewhere, generalizations about “asexuals” as a group are problematic . Despite the fact we are able to identify some hallmarks of the sexual behavior of asexuals, it seems as complex to assume a pattern for asexuals as it would be for the general population. Further research on asexuality will hopefully continue to deconstruct stigma around asexuality, informing health care specialists and the public in general.
Limitations and future directions
Some methodological difficulties of studying asexuality should be highlighted. A major limitation in the study of asexuality concerns how asexuality is defined by participants, who may or may not self-identify as asexuals. Most samples were recruited from AVEN, and these participants are likely to use the definitions and discourses around asexuality found on that site . In addition, researchers frequently use samples which are not geographically nor culturally diverse, and therefore data may not represent asexuals from the general community. To the best of our knowledge, there is only one study using psychophysiological measures, which limits the interpretation of findings.
In order to mitigate these flaws in future research, it would be important to expand sampling methods to absorb participants outside the Ace community, and also to use measures such as the Asexuality Identification Scale , which is gender-neutral and does not require individuals to self-identify as asexuals. Moreover, when recruiting participants from the Ace community, it seems more appropriate to refer to romantic orientation categories, namely heteroromantic, homoromantic, biromantic or panromantic, as endorsed in asexuals’ discourses . However, when dealing with asexuals in the larger community, sexual orientation categories might suffice.
What clearly emerges of paramount importance from current knowledge on asexuality is that research on asexuality should aim at non-pathologizing. Studying asexuality with sexual function/dysfunction emphasis and using surveys underlying sexual norms may not favor asexuals nor enrich the study of human sexuality as a whole . At this stage it seems relevant to investigate the factors involved in sexual and emotional well-being, as well as the factors involved in relationship satisfaction of asexuals. Further understanding on the relationship dynamics of asexuals might be particularly useful for those who keep romantic relationships with non-asexuals, as it might help preventing abuse, empowering asexuals. As far as we are aware, no studies on violence and victimization of asexuals have taken place.
This systematic review supports the existence of great heterogeneity among asexuals. Research found that asexuals give different meanings to sexual acts, have more negative attitudes toward sex, and are more likely to have no sexual fantasies, or fantasies not involving themselves or others. Findings outline that asexuals present lower levels of subjective sexual arousal but no differences in psychophysiological sexual arousal as compared with non-asexuals. Furthermore, studies indicate asexuals may engage in some sexual activities, although they are less likely to engage in sexual intercourse or masturbation, and these seem greatly influenced by partner characteristics. In addition, some asexuals are romantic while others are aromantic. Self-labeled romantic asexuals seem more likely to have relationships with same-sex partners comparing with non-asexuals. Finally, this review did not find support for the claim asexuals present impaired sexual functioning. Even so, we are clearly lacking research on key aspects such as sexual functioning, sexual satisfaction or well-being, built upon asexuals’ lenses rather than centered on heteronormativity criteria.
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de Oliveira, L., Carvalho, J., Sarikaya, S. et al. Patterns of sexual behavior and psychological processes in asexual persons: a systematic review. Int J Impot Res 33, 641–651 (2021). https://doi.org/10.1038/s41443-020-0336-3