Transgender Youth Executive Functioning: Relationships with Anxiety Symptoms, Autism Spectrum Disorder, and Gender-Affirming Medical Treatment Status

Time is of the essence: Age at autism diagnosis, sex assigned at birth, and psychopathology

LAY ABSTRACT

Previous research has shown that girls/women are diagnosed later than boys/men with autism. Individuals who are diagnosed later in life, especially girls/women, have greater anxious and depressive symptoms. Previous research has been limited due to narrow inclusionary criteria for enrollment in studies. The present study uses two samples-one clinic-based, large "real-world" sample and another research-based sample with strict criteria for autism diagnosis-to understand the relationships between diagnostic age, sex assigned at birth, and symptoms of anxiety/depression. In both samples, those who were diagnosed later had greater anxious/depressive symptoms, and anxiety was not predicted by sex. In the clinic-based but not research-based sample, those assigned female at birth were diagnosed later than those assigned male at birth. In the clinic-based sample only, individuals assigned female at birth and who were later diagnosed experienced greater symptoms of anxiety/depression compared to those assigned male who benefited from earlier diagnostic timing. Within the research-based sample, those assigned female at birth had greater depressive symptoms than those assigned male. These findings highlight the importance of timely identification of autism, especially for girls/women who are often diagnosed later. Community-based samples are needed to better understand real-world sex-based and diagnostic age-based disparities in mental health.

Research methods at the intersection of gender diversity and autism: A scoping review

LAY ABSTRACT

Research has increasingly focused on the intersection between gender diversity and autism. To better understand this literature, this scoping review systematically searched five databases for peer-reviewed literature on gender diversity and autism published between 2018 and 2023. Included studies (N = 84) were of English language, featured original qualitative or quantitative findings, and examined a psychosocial connection between autism and gender spectra variables. Most studies focused on measuring prevalence of autism among gender-diverse individuals. While the overall study rigor was acceptable, weaknesses in measurement, sample selection, and definition of key terms were noted. Promisingly, studies in this area appear to be shifting away from a pathologizing lens and towards research methods that engage in meaningful collaboration with the autistic, gender-diverse community to investigate how to best enhance the quality of life and wellbeing of this population.

Diagnostic assessment of autism spectrum disorder in transgender and gender diverse youth

Objective: Higher prevalence of autism spectrum disorder (ASD) diagnosis and associated traits has been observed among transgender and gender diverse (TGD) youth, and the number of TGD youth requesting evaluation for autism is growing. This study explored the demographic and clinical profiles of TGD youth evaluated in a specialty autism clinic. Method: Retrospective autism evaluation results for 41 TGD youth aged 5-18 years and 67 cisgender-matched controls were included in the study. Results: Approximately, half of TGD youth were diagnosed with autism (TGDASD+; n = 19 vs. TGDASD-; n = 22). There were no group differences in sex assigned at birth, gender identity, FSIQ, race, or ethnicity. Compared to TGDASD- (allistic) youth, TGD autistics had significantly lower adaptive functioning and were more likely to have an IEP eligibility of ASD. Anxiety and mood disorders were more common in TGD youth, whereas language disorders were more prevalent in cisgender controls. Attention-Deficit/Hyperactivity Disorder (ADHD) was more common among TGDASD- youth (72%) than TGDASD+ youth (47%), though not significantly. Conclusions: TGD youth with school-based IEP eligibilities of ASD and lower adaptive functioning are more likely to be diagnosed with ASD upon medical evaluation. The combination of identifying as TGD and having ADHD may heighten suspicion for ASD. Asking about gender identity during autism evaluations for children middle school-aged and older is recommended.

Gender diversity is correlated with dimensional neurodivergent traits but not categorical neurodevelopmental diagnoses in children

BACKGROUND

Gender clinic and single-item questionnaire-based data report increased co-occurrence of gender diversity and neurodevelopmental conditions. The nuances of these associations are under-studied. We used a transdiagnostic approach, combining categorical and dimensional characterization of neurodiversity, to further the understanding of its associations with gender diversity in identity and expression in children.

METHODS

Data from 291 children (Autism N = 104, ADHD N = 104, Autism + ADHD N = 17, neurotypical N = 66) aged 4-12 years enrolled in the Province of Ontario Neurodevelopmental Network were analyzed. Gender diversity was measured multi-dimensionally using a well-validated parent-report instrument, the Gender Identity Questionnaire for Children (GIQC). We used gamma regression models to determine the significant correlates of gender diversity among age, puberty, sex-assigned-at-birth, categorical neurodevelopmental diagnoses, and dimensional neurodivergent traits (using the Social Communication Questionnaire and the Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Rating Scales). Internalizing and externalizing problems were included as covariates.

RESULTS

Neither a categorical diagnosis of autism nor ADHD significantly correlated with current GIQC-derived scores. Instead, higher early-childhood dimensional autistic social-communication traits correlated with higher current overall gender incongruence (as defined by GIQC-14 score). This correlation was potentially moderated by sex-assigned-at-birth: greater early-childhood autistic social-communication traits were associated with higher current overall gender incongruence in assigned-males-at-birth, but not assigned-females-at-birth. For fine-grained gender diversity domains, greater autistic restricted-repetitive behavior traits were associated with greater diversity in gender identity across sexes-assigned-at-birth; greater autistic social-communication traits were associated with lower stereotypical male expression across sexes-assigned-at-birth.

CONCLUSIONS

Dimensional autistic traits, rather than ADHD traits or categorical neurodevelopmental diagnoses, were associated with gender diversity domains across neurodivergent and neurotypical children. The association between early-childhood autistic social-communication traits and overall current gender diversity was most evident in assigned-males-at-birth. Nuanced interrelationships between neurodivergence and gender diversity should be better understood to clarify developmental links and to offer tailored support for neurodivergent and gender-diverse populations.

Supporting the health and wellbeing of trans autistic school-aged youth: a systematic literature review

Introduction : This systematic literature review (SLR) aims to synthesize available research which examines the supports required for trans autistic school-aged youth to improve their mental health, wellbeing, and quality of life. Current literature highlights the need to support this specific school-aged population, but the research that synthesizes the existing limited research is lacking. This SLR brings together existing literature and highlights recommended inclusive interventions, programs, support mechanisms, and protective factors needed to support and promote optimal mental health and wellbeing.

Methods

This review followed the 2020 PRISMA Guidelines and included JBI quality appraisal tools of included studies. Three electronic databases were used, with literature search conducted on 18 July 2023. Literature, including book chapters, were assessed against predetermined inclusion and exclusion criteria, with included studies written in English, online full-text availability, peer-reviewed, and reported data relevant to research question. Abstract, full-text review, and quality appraisal were conducted by three independent reviewers to ensure rigor. Findings from included studies were synthesized using thematic analysis.

Results

Twenty studies were included for final synthesis with five using qualitative methodologies, two case reports, and 13 cross-sectional studies. The final synthesis comprised five themes, indicating therapy should focus on mental health, particularly internalized feelings and emotions that may lead to suicidal ideation without support, whereas interventions should support executive functioning, communication, and socialization. Clinicians should make adaptions to their clinics and practices to support the neurodivergent-related needs of their clients. Schools should work toward having well-articulated and embedded policies supporting gender affirmation and preventing bullying and ostracization to ensure trans autistic youth develop positive health and wellbeing, and overall good quality of life.

Conclusions

In many cases support measures discussed were limited. The complexities of supporting the needs of school-aged trans autistic youth requires further research, specifically focusing on the voices of trans autistic youth.

Executive functions in adolescents with gender dysphoria

Aim: Aim of this study is evaluating EF by performing neurocognitive tests, and to identify gender-related differences in EF between adolescents with and without GD.Methods: 8 Female-to-Male transgender adolescents (FtMs), and 14 Male-to-Female transsexual adolescents (MtFs) (Gender Dysphoria Group, GDG) and 29 boys, 21 girls (Control Group, CG), were tested in a cross-sectional study, using the Wisconsin Card Sorting Test (WCST), Controlled Oral Word Association Test (COWAT), and Stroop Color and Word Test (SCWT). The psychiatric diagnoses were established by using the KD-SADS.Results: Among GDG 72.7%, had at least one psychopathology. There weren't any significant differences in, estimated IQ scores, or WCST subtest scores between the 2 groups. COWAT total word count and SCWT-5 total duration test scores were better in the CG.Conclusion: CG had better performance on verbal fluency and response inhibition whereas no differences found on set shifting abilities. In consideration of the existence of EF-related impairment in adolescents with GD, appropriate support and interventions are expected to improve their adaptation skills and comorbid psychopathologies. These results should be interprete cautiously and additional larger scale studies are needed to obtain more comprehensive data related to gender differences in EF of adolescents with GD.

The lived experience of gender dysphoria in autistic young people: a phenomenological study with young people and their parents

Gender dysphoria is distress in relation to incongruence between an individual's gender and sex assigned at birth. Gender clinics offer support for gender dysphoria, and there is a higher prevalence of autism in young people attending such clinics than in the general population. We aimed to investigate the lived experiences of autistic young people who have experienced gender dysphoria, and their parents, using a multi-perspectival IPA design. Young autistic people aged 13-17 years (n = 15), and their parents (n = 16), completed in-depth interviews about the young person's experience of gender dysphoria. We analysed each individual transcript to generate individual themes, and for each of the dyads, developed themes which acknowledged the similarities and differences in parent-child perspectives. The first superordinate theme was coping with distress which had two subordinate themes; understanding difficult feelings and focus on alleviating distress with external support. This theme described how young people were overwhelmed by negative feelings which they came to understand as being about gender incongruence and looked to alleviate these feelings through a gender transition. The second superordinate theme was working out who I am which had two subordinate themes: the centrality of different identities and needs and thinking about gender. This theme described how young people and their parents focused on different needs; while young people more often focused on their gender-related needs, parents focused on autism-related needs. We conclude that young people and parents may have different perspectives and priorities when it comes to meeting the needs of autistic young people who experience gender dysphoria.

Reproductive and Fertility Knowledge and Attitudes Among Transgender and Gender-Expansive Youth: A Replication and Extension

Purpose

This study sought to replicate and expand a previous pilot investigation of reproductive knowledge, attitudes toward fertility and parenthood, and sources of information on these topics among transgender and gender-expansive (TGE) youth.

Methods

The Yale Pediatric Gender Program (YPGP) Reproductive Knowledge and Experiences Survey (YPGP-RKES) was administered to 70 TGE adolescents receiving care at an interdisciplinary clinic providing gender-affirming health care at an academic medical center. Data gathered included sources of information on reproduction and fertility, concerns about future parenthood and reproduction, and interest in different types of parenthood.

Results

Over a third (39.1%) of participants reported it was important to them to have a child one day, while only a small proportion (23.2%) reported an interest in biological parenthood. A plurality of participants (37.3%) reported at least one concern about future fertility. The number of reproductive concerns did not differ by age or treatment (puberty blockers or gender-affirming hormones vs. no treatment) status. With respect to needs for more information and sources of information, most (56.5%) participants received information about fertility issues before this study, with the most cited source of information being online research.

Conclusions

The current study replicated and extended previous findings on the reproductive attitudes and knowledge of TGE adolescents. Understanding the informational needs and priorities of adolescent TGE patients presenting for medical treatment will allow providers to give more robust patient education. This will, in turn, facilitate patients' ability to provide fully informed consent for treatment that aligns with their fertility and reproductive priorities and goals.

Brief Report: An Exploration of Alexithymia in Autistic and Nonautistic Transgender Adults

Background

Research has shown that many autistic people have alexithymia, a psychological trait characterized by difficulties in identifying and describing emotions. It is also now clear that there is a high rate of autism among transgender people, but we know little about the intersection of autism and gender diversity or about the clinical features of autistic transgender individuals.

Methods

Seventy-eight nonautistic transgender, 56 autistic transgender, 106 nonautistic cisgender, and 107 autistic cisgender adults completed the Toronto Alexithymia Scale-20 and the Autism-spectrum Quotient as part of an online study. We also used the General Alexithymia Factor Score-8 as an additional alexithymia score.

Results

We found that nonautistic transgender participants reported significantly higher mean levels of alexithymia than nonautistic cisgender participants, and that there was a significant overrepresentation of individuals in this group who met the clinical cutoff for alexithymia. The difference in alexithymia between autistic cisgender and autistic transgender participants was nonsignificant, with >50% of each group scoring above the clinical cutoff point. Of note, when we used the General Alexithymia Factor Score-8, the difference between autistic transgender participants and autistic cisgender participants was significant, with autistic transgender participants reporting higher mean levels of alexithymia.

Conclusion

Results suggest that nonautistic transgender individuals might be more prone to experience alexithymia (including at clinically significant levels) than nonautistic cisgender people. When autism occurs in transgender people, the average level and clinical rate of alexithymia is higher than among nonautistic transgender people and potentially higher than among autistic cisgender people. Our findings are in keeping with evidence of a subgroup of transgender people with "subclinical autism" and inconsistent with the notion that autism among transgender and gender diverse people is a "phenomimic" of autism. Lastly, our study highlights the potential importance of screening autistic and nonautistic transgender people for alexithymia.

Health Care Disparities Among Autistic LGBTQ+ People

Background

Lesbian, gay, bisexual, transgender, or queer (LGBTQ+) people and disabled people experience disparities in access to health care compared with others. However, we have yet to understand how health care disparities may be further exacerbated at the intersection of disability and LGBTQ+ identity, particularly among autistic people.

Objectives

The primary goals of this study were to (1) examine differences in unmet health care needs and health status between LGBTQ+ autistic people and straight/cisgender autistic people and (2) explore how state policies and demographics predict the unmet health care needs of the autistic LGBTQ+ people.

Methods

We conducted a cross-sectional analysis using data from the 2019 National Survey on Health and Disability that included a subsample of autistic participants, with 62 LGBTQ+ adults and 58 straight/cisgender adults. To address our first study goal, we used an independent samples t-test, and to address our second study goal, we used Poisson regression.

Results

The LGBTQ+ group reported significantly more days of poor physical and mental health, more co-occurring diagnoses, and more unmet health care needs than the straight/cisgender group. For LGBTQ+ people, protective state health care laws and a lower income resulted in significantly more health care needs being met.

Conclusions

Findings from this study suggest that the intersection of an LGBTQ+ identity and autism is associated with greater disparities in physical and mental health as well as unmet health care needs; however, state policies prohibiting discrimination of LGBTQ+ people may act as a protective factor and result in fewer unmet health care needs. Future research should examine additional structural factors that may mitigate health inequities for autistic LGBTQ+ people.

The autism spectrum among transgender youth: default mode functional connectivity

The common intersection of autism and transgender identities has been described in clinical and community contexts. This study investigates autism-related neurophenotypes among transgender youth. Forty-five transgender youth, evenly balanced across non-autistic, slightly subclinically autistic, and full-criteria autistic subgroupings, completed resting-state functional magnetic resonance imaging to examine functional connectivity. Results confirmed hypothesized default mode network (DMN) hub hyperconnectivity with visual and motor networks in autism, partially replicating previous studies comparing cisgender autistic and non-autistic adolescents. The slightly subclinically autistic group differed from both non-autistic and full-criteria autistic groups in DMN hub connectivity to ventral attention and sensorimotor networks, falling between non-autistic and full-criteria autistic groups. Autism traits showed a similar pattern to autism-related group analytics, and also related to hyperconnectivity between DMN hub and dorsal attention network. Internalizing, gender dysphoria, and gender minority-related stigma did not show connectivity differences. Connectivity differences within DMN followed previously reported patterns by designated sex at birth (i.e. female birth designation showing greater within-DMN connectivity). Overall, findings suggest behavioral diagnostics and autism traits in transgender youth correspond to observable differences in DMN hub connectivity. Further, this study reveals novel neurophenotypic characteristics associated with slightly subthreshold autism, highlighting the importance of research attention to this group.

Transidentities and autism spectrum disorder: A systematic review

Transidentity and autism frequently co-occur. Previous reviews have focused mainly on frequencies. Here, we conducted a systematic review to condense all the studies and themes on this co-occurrence and to offer a global view. We followed the PRISMA method and selected 77 articles (including 59 clinical studies) in April 2022. We found 5 main themes (sex ratio, theories, sexual orientation, clinical and social consequences, and care implications) in addition to frequencies. Many theories have been proposed to explain the co-occurrence. One posits that social difficulties related to autism would lead to less identification with gender norms and less pressure to conform to these norms, allowing for greater gender diversity in people with autism. Given their difficulties with social interactions and communication, the announcement of one's transidentity to one's social group is often discredited, increasing the risk of suffering and delayed care. Many reports reaffirm the importance of providing specialised care for transgender people with autism. Autism is not a contraindication for gender-affirming treatment. However, some cognitive specificities can affect the planning of care, and transgender people with autism are at high risk of discrimination and harassment. We conclude that there is a need to raise awareness about gender and autism.

Healthcare clinician perspectives on the intersection of autism and gender dysphoria

LAY ABSTRACT

Autistic people are more likely to have a gender identity which does not match their sex assigned at birth. Some people experience distress about their sex and gender not matching, which is called gender dysphoria. Such individuals may wish to attend a gender clinic to access healthcare support for gender dysphoria. Currently, there is limited evidence to help clinicians best support autistic people who need healthcare for gender dysphoria. We wanted to find out what healthcare clinicians think about working with autistic patients with gender dysphoria. We interviewed 16 clinicians who work in healthcare services with adults and young people who are autistic and experience gender dysphoria. We recorded the interviews and carefully analysed the content to find key themes. We found that clinicians worked with patients to try and better understand their experiences of gender dysphoria. Clinicians identified features of autism that they believed were related to gender identity and dysphoria including different thinking styles, social differences, and sensory sensitivities. Clinicians noticed that autistic people spoke about their gender in different ways to non-autistic people. Clinicians tried to adapt their practice to better meet the needs of their autistic patients. These adaptations tended to focus on differences in the assessment process, for example, offering longer or shorter appointments and changing their communication style. We conclude that clinicians were offering an individualised approach to autistic patients experiencing gender dysphoria. However, these clinicians were particularly interested in working with autistic people, and so may not be representative of the wider clinician population. Clinicians working in this area should receive training on autism adaptations and the intersection of autism and gender dysphoria.

Self-Perception of Transgender Adolescents after Gender-Affirming Treatment: A Follow-Up Study into Young Adulthood

Purpose: Early medical treatment for transgender adolescents should contribute to healthy psychological development, including the development of positive self-perception. However, at present, there are no longitudinal studies that have examined whether current treatment approaches meet this expectation. Therefore, the aim of this single-arm retrospective study was to examine transgender adolescents' self-perception changes over the course of irreversible medical gender-affirming treatment. Method: The total study sample consisted of 70 adolescents (49 trans men and 21 trans women). Self-perception was assessed before the start of gender-affirming hormone treatment (mean age = 14.65, standard deviation (SD) = 2.08) and at least 6 months after gender-affirming surgeries (mean age = 20.70, SD = 1.49) by Self-Perception Profile for Adolescents (SPPA). The SPPA is a self-report measure that examines self-perception on seven different domains: Scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, close friendship, and global self-worth. Multilevel modeling (random intercepts model) was conducted to determine the effect of time for all domains of self-perception. Results: It was found that the domains of physical appearance and global self-worth improved significantly over the course of treatment. No domain worsened significantly over the course of treatment. The domains of scholastic competence, social acceptance, athletic competence, and close friendship remained stable over time. Conclusion: This study provides the first suggestive evidence that irreversible gender-affirming treatment for adolescents could contribute to the development of a more positive self-perception.