Brief Report: Gender Identity Differences in Autistic Adults: Associations with Perceptual and Socio-cognitive Profiles

Revisiting the Link: A qualitative analysis of the diverse experiences of gender dysphoria as a subset of pervasive social dysphoria co-occurring with autism in Japan

LAY ABSTRACT

Studies have suggested that autistic people are more likely to experience gender dysphoria, which refers to the gender-related distress emerging from personal factors and gender norms that some transgender people experience. Transgender people are diverse; some experience gender incongruence (i.e. an incompatibility between a person's gender identity and that expected of them based on their birth-assigned gender), whereas others do not. Therefore, the association of autistic transgender people's gender dysphoria with gender incongruence varies, and the literature has overlooked such diversity. Interviews with 15 Japanese autistic transgender adults revealed diverse gender dysphoria experiences independent of gender incongruence, such as resistance to the societal gender norms themselves, physical dysphoria caused by the imposition of gender, sensory disgust related to autistic sensory sensitivities, uncertainty about the gender norms of the social majority, and the autistic burden of living in a gendered society. Moreover, we found that most participants had not only accumulated distress over gender norms (i.e. gender dysphoria) but also over pervasive social norms, termed Pervasive Social Dysphoria. Our findings suggests that future co-occurrence research and practice must affirm these internal perspectives more, such as by providing support for both gender dysphoria and Pervasive Social Dysphoria, as autistic transgender people may experience gender dysphoria as a subset of Pervasive Social Dysphoria.

fNIRS Studies of Individuals with Speech and Language Impairment Underreport Sociodemographics: A Systematic Review

Functional near-infrared spectroscopy (fNIRS) is a promising tool for scientific discovery and clinical application. However, its utility depends upon replicable reporting. We evaluate reporting of sociodemographics in fNIRS studies of speech and language impairment and asked the following: (1) Do refereed fNIRS publications report participant sociodemographics? (2) For what reasons are participants excluded from analysis? This systematic review was preregistered with PROSPERO (CRD42022342959) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Searches in August 2022 included the terms: (a) fNIRS or functional near-infrared spectroscopy or NIRS or near-infrared spectroscopy, (b) speech or language, and (c) disorder or impairment or delay. Searches yielded 38 qualifying studies from 1997 to present. Eight studies (5%) reported at least partial information on race or ethnicity. Few studies reported SES (26%) or language background (47%). Most studies reported geographic location (100%) and gender/sex (89%). Underreporting of sociodemographics in fNIRS studies of speech and language impairment hinders the generalizability of findings. Replicable reporting is imperative for advancing the utility of fNIRS.

Inextricably tied: Nonbinary autistic individuals' views on how their gender identity and autism are connected

LAY ABSTRACT

This study explores the experiences and identities of nonbinary autistic people. The relationship between autistic and nonbinary identities has not been researched in detail. Few studies focus specifically on nonbinary autistic adults. We interviewed 44 nonbinary individuals for this study. Participants had thought-out opinions on gender identity and emphasized identifying with fluidity rather than traditional gender roles. Participants discussed the connection of their autistic and nonbinary identities and how it affected how people saw them and how they saw themselves. We have recommendations for programming, policy, and research from these findings.

Comparative Analysis of Gender-Based Differences in Behavioral Mastery, Goals, and Characteristics in Autistic Individuals: An Applied Behavior Analysis Study

Introduction  It is widely recognized that the prevalence and diagnosis of autism spectrum disorder (ASD) are more common in males than in females. Despite this, there is a significant gap in the body of autism research that investigates gender differences for treatment effects of applied behavior analysis (ABA) across a variety of measured variables. This research aims to comprehensively evaluate gender distinctions concerning target behavioral objectives, goals, and deficit variables. Materials and methods This study analyzed retrospective data from 100 participants, including 89 juveniles and four adults, with seven cases lacking age documentation, who underwent a three-month ABA program from March 19 to June 11, 2023. The ABA program included various methodologies such as functional analysis, discrete trial training, mass trials, and naturalistic training. Data on outcome measures, including target behavioral proficiency, age, average trials to proficiency, average teaching days to proficiency, open behavioral objectives, and target trends, were collected using the "Catalyst" software (Catalyst Software Corporation, New York, NY). Participant demographics were summarized using statistical analyses for categorical (gender and race/ethnicity) and continuous variables (percentage of mastered behavioral objectives, age, average trials, average teaching days, open objectives, percentage of failed objectives during maintenance, percentage of objectives with upward, downward, and flat trends). These statistics included mean, standard deviation, median, and range and were analyzed inferentially using nine separate two-sample independent t-tests and corresponding effect sizes using Cohen's d. Results There were no statistically significant disparities based on gender (p > 0.05) across all nine variables examined: Percentage of Targets Mastered, Age, Average Trials to Mastery, Average Teaching Days to Mastery, Open Targets, Percentage of Targets Failed in Maintenance, Percentage of Targets Trending Up, Percentage of Targets Trending Down, and Percentage of Targets Trending Flat, and wide confidence intervals were detected. Conclusions  Non-significant gender differences in response to ABA treatments regarding these nine behavioral goals, mastery, and deficit variables may be relevant. They suggest that ABA treatments could be equally beneficial for both male and female autistic individuals. These results should be interpreted cautiously. The general pattern observed, characterized by broad confidence intervals, carries a degree of statistical uncertainty, which may suggest substantial gender differences. These results might question the prevailing beliefs about the variation in treatment response based on gender. This could profoundly impact clinical practices, implying that healthcare professionals should not favor one gender over another when suggesting ABA therapies. Instead, the treatment advice should be tailored to each child's unique requirements and traits, regardless of gender. The investigators expect these results to encourage additional research in this field. Comprehending the elements that affect treatment response is vital for improving treatment results and customizing care.

Adverse Childhood Experiences and Health Outcomes Among Transition-Age Autistic Youth

BACKGROUND

Adverse childhood experiences (ACEs) have been associated with poor health outcomes in the general population. However, their impact on autistic youth remains unclear.

OBJECTIVE

The primary objective was to understand how childhood adversity is related to the general health, mental health, and physical health of transition-age autistic youth.

PARTICIPANTS AND SETTING

Using data from the 2018-2021 National Survey of Children's Health, this cross-sectional study involved 2056 autistic youth aged 12-17.

METHODS

Logistic regression was employed to test the association between three measures of ACEs - individual ACEs, cumulative ACEs, and grouped ACEs based on contexts, and health outcomes of autistic youth.

RESULTS

Our study observed a high prevalence of ACEs among autistic youth, with a substantially higher proportion experiencing multiple ACEs than their neurotypical peers. Individual ACEs were significantly associated with specific health issues. Cumulative ACEs demonstrated a clear dose-response relationship with health outcomes, with higher ACE counts increasing the likelihood of experiencing poor general health, mental health conditions, and physical health issues. Moreover, grouped ACEs associated with health differently, with community-based ACEs being particularly linked to general health status, mental health conditions, and physical health conditions, while family-based ACEs correlated more with more severe mental health conditions and being overweight.

CONCLUSION

These findings collectively emphasize the importance of addressing ACEs as a public health concern among transition-age autistic youth, highlighting the need for targeted interventions, prevention strategies, and support services to mitigate the negative impact of ACEs on the overall well-being of this growing community.

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.

Exploring Online Communication in Self-Identified Autistic Adolescents

PURPOSE

Social media sites provide autistic youth a familiar space to interact that is devoid of many of the challenges that accompany face-to-face interactions. As such, it is important to determine whether the linguistic profiles observed during online interactions are consistent with face-to-face interactions. This preliminary study took a step in this direction by examining gender differences observed in autistic adolescents in an online forum to determine whether they are consistent with the emerging body of research investigating linguistic gender differences in autistic adolescents.

METHOD

We analyzed the entries of self-identified autistic adolescents in an online forum to determine whether autistic girls (n = 99) and boys (n = 94) differ in their use of linguistic features as a proportion of total words produced. Transcriptions were coded across discourse, lexical, and semantic features and compared to previous research investigating linguistic gender differences in autistic people. Exploratory comparisons were also made to linguistic gender differences in neurotypical people.

RESULTS

Of the linguistic features we examined, three out of four of the gendered usage patterns observed in the online forum language samples were consistent with previous research on face-to-face communication for autistic adolescents. Only one feature out of 12 occurred in the same gender distribution as previous research on neurotypical communication.

CONCLUSIONS

Autistic girls and boys demonstrate largely consistent gender differences in their language use across in-person and online communication contexts. Interestingly, most of the significant gender differences previously reported in neurotypical communicators were not seen in this sample of autistic adolescents, suggesting that perhaps autistic individuals may linguistically express gender characteristics to a different extent or in a different manner than neurotypical individuals.

Perspectives of autistic adolescent girls and women on the determinants of their mental health and social and emotional well-being: A systematic review and thematic synthesis of lived experience

LAY ABSTRACT

Difficulties with mental health and low levels of well-being are more common among autistic girls and women than non-autistic people, but we do not fully understand why. Research does not focus enough on what autistic girls and women could tell us about this. This review aims to summarise the studies where autistic girls and women explain things that affect their mental health and well-being to help us understand how to prevent these difficulties from developing. Three research databases were searched to find possibly relevant studies. There were 877 studies found, which two researchers screened according to particular criteria. They found 52 studies that could be included in this review. One researcher evaluated the quality of these studies and extracted the key information from them. This review summarises the views of 973 autistic girls and women aged between 13 and 70+. The findings from the 52 studies were analysed, and we found many factors that affect the mental health and well-being of autistic girls and women. These factors fall into two categories: (1) difficulties living in a world not designed for autistic people and (2) the impact of stigma due to being autistic.

Cross-cultural variation in experiences of acceptance, camouflaging and mental health difficulties in autism: A registered report

Recent findings suggest that stigma and camouflaging contribute to mental health difficulties for autistic individuals, however, this evidence is largely based on UK samples. While studies have shown cross-cultural differences in levels of autism-related stigma, it is unclear whether camouflaging and mental health difficulties vary across cultures. Hence, the current study had two aims: (1) to determine whether significant relationships between autism acceptance, camouflaging, and mental health difficulties replicate in a cross-cultural sample of autistic adults, and (2) to compare these variables across cultures. To fulfil these aims, 306 autistic adults from eight countries (Australia, Belgium, Canada, Japan, New Zealand, South Africa, the United Kingdom, and the United States) completed a series of online questionnaires. We found that external acceptance and personal acceptance were associated with lower levels of depression but not camouflaging or stress. Higher camouflaging was associated with elevated levels of depression, anxiety, and stress. Significant differences were found across countries in external acceptance, personal acceptance, depression, anxiety, and stress, even after controlling for relevant covariates. Levels of camouflaging also differed across countries however this effect became non-significant after controlling for the covariates. These findings have significant implications, identifying priority regions for anti-stigma interventions, and highlighting countries where greater support for mental health difficulties is needed.

Effective digital support for autism: digital social stories

Social Stories™ is one of the most popular interventions for autistic children and has been researched extensively. However, effectiveness data has been gathered mainly through single-participant designs which generate outcomes which can lack generalizability and social validity. Stories Online For Autism (SOFA) is a digital application which supports the development and delivery of Social Stories in a real-world setting and has the potential to contribute toward furthering (1) Social Stories research and (2) research on digital applications for autism by gathering large data sets from multiple participants. Three data sets (N = 856) were gathered through the SOFA app and were analyzed to investigate three key variables: What predicted closeness-to-goal of the Social Stories (as rated by an adult/parent/guardian, n = 568); the child's comprehension of the Social Stories (assessed by story comprehension questions, n = 127); and the child's rating of the enjoyability of the Social Stories (n = 161). A merged data set then investigated correlations between these three key variables. Age range (≤15), gender, autism diagnosis, and the child's level of language understanding were the potential predictors for these three key variables. Regression analysis indicated that parental closeness-to-goal ratings for their children were highest for children who were younger and more verbal. Regression analysis also indicated that older children scored higher in comprehension assessment, and autistic children rated the Social Stories as more enjoyable. Closeness-to-goal, comprehension scores and enjoyment ratings did not significantly correlate with each other. This is the largest study of Social Stories effectiveness, which was enabled through the collection of data through a digital app from multiple participants. The results indicate that digital social stories are particularly effective for younger verbal children. While this was the case for all children, it was particularly true for autistic children and female (and gender-diverse) children. For the first time, the gathering of large digital data sets has highlighted that while digital Social Stories can be effective for autistic males, they can be more effective for autistic females and gender-diverse autistic individuals. Thus, the SOFA app can support the investigation of the factors which influence Social Stories outcomes that are generalizable and with high social validity.

Considerations for Expanding Research and Clinical Care for the Neurodivergent Gender Diverse Population

Little is currently known about the relationship between gender diversity and neurodiversity, although a growing body of researchers and clinicians are searching for more information to better serve this population. Gender-diverse individuals are three to six times more likely than cisgender individuals to identify as autistic or to report possible undiagnosed autism or autistic traits. Many gender-diverse individuals experience a shortage of gender-affirming medical care and are disproportionately impacted by barriers to mental health services. Similarly, autistic individuals report that the most common barrier to care is a lack of knowledgeable providers and/or resistance from providers to tailor care toward their specific needs. Two key areas in need of further research are 1) clinical approaches to gender-affirming medical and mental health care for neurodivergent patients and 2) the prevention and treatment of suicidality in gender-diverse neurodivergent individuals. Increasing collaborations amongst gender-diverse neurodivergent individuals, researchers, and clinicians are needed in order to further research and clinical practice to most directly and effectively improve physical and mental health care for the gender-diverse neurodivergent patient population.

Studies pertaining to language impairment in school-age autistic individuals underreport participant socio-demographics: A systematic review

LAY ABSTRACT

Although exclusion of racially and ethnically minoritized autistic individuals from research is a long-standing issue, we have yet to determine how exclusion impacts areas of autism research important for identifying language impairment. Diagnosis depends on the quality of the evidence (i.e. research) and is often the pathway to gaining access to services. As a first step, we examined how research studies related to language impairment in school-age autistic individuals report participant socio-demographics. We analyzed reports using age-referenced assessments in English (n = 60), which are commonly used by both practitioners and researchers to diagnose or identify language impairment. Findings showed only 28% of studies reported any information on race and ethnicity; in these studies, most (at least 77%) of the participants were white. In addition, only 56% of studies reported gender or sex and specified what they were reporting (gender, sex, or gender identity). Just 17% reported socio-economic status using multiple indicators. Altogether, findings indicate broad issues with underreporting and exclusion of racially and ethnically minoritized individuals, which might overlay with other aspects of identity including socio-economic status. It is impossible to determine the extent and precise nature of exclusion without intersectional reporting. To ensure that language in autism research is representative of the autistic population, future research must implement reporting guidelines and broaden inclusion of who participates in research studies.

Intersecting effects of sex/gender and autism on structural language: A scoping review

LAY ABSTRACT

Research about autism is mostly about boys and men, even though many autistic people are girls, women, and transgender/nonbinary. We wanted to learn more about how gender interacts with language skills in autistic people, so we reviewed existing research articles on this topic. We also wanted to know how this previous research talked about gender. Included articles had to measure language skills for autistic people of different genders. They also had to be published between 2000 and 2021. Twenty-four articles met these requirements. We found that autistic girls showed better language skills than autistic boys but worse skills than nonautistic girls. This may be one reason that autistic girls are underdiagnosed compared to autistic boys. If we compare autistic girls to nonautistic girls instead, we can see more language differences and possible areas to target in interventions. This study supports the need to create diagnostic and support measures for autism that take gender into account. Also, only one article mentioned autistic people who are transgender or nonbinary. Researchers who want to learn more about gender and autism need to understand gender diversity and recognize that many autistic people are transgender or nonbinary.

Common Intersection of Autism and Gender Diversity in Youth: Clinical Perspectives and Practices

Autism and gender diversity often intersect. Many transgender youth seeking gender-related medical interventions are autistic. Clinicians serving these youth lack an autism-specific evidence base to guide gender care decisions. At present, care decisions are based on extrapolation of care models from transgender youth samples, generally. At this point, there is no evidence to suggest that autistic youth are likely to experience shifts in gender or gender-related medical requests, although this has been insufficiently studied. In this article, cowritten by expert clinicians and autistic gender-diverse collaborators, an overview of clinical care considerations and the current evidence base is provided.

Autism-Related Language Preferences of French-Speaking Autistic Adults: An Online Survey

Background

In recent years, there have been increasing discussions surrounding the appropriate terminology to talk about autism. Initially, this debate revolved around the use of person-first language (e.g., person with autism) versus identity-first language (IFL; e.g., autistic person) but has recently expanded to other autism-related terms (e.g., deficits). However, to date, studies investigating autism-related language preferences have been limited to English-speaking countries, and little is known about preferences in other languages. This study addresses this gap by investigating the language preferences of French-speaking autistic adults.

Methods

Five hundred and forty-one French-speaking autistic adults (formal diagnosis and self-identified) completed an online survey where they selected terms they preferred to use to talk about: (1) the nomenclature of autism; (2) an autistic person; (3) someone's autistic identity; (4) autism more broadly; (5) the abilities of autistic people; and (6) people without a diagnosis of autism. Participants also revealed more about their language preferences via an open-text response.

Results

The most preferred terms were "Autisme," "Personne autiste," "Autiste," "Est Autiste," "Différence neurologique/cérébrale," "Différences," "Difficultés," "Personne neurotypique," "Neurotypique," and "Personne non-autiste." To better understand these preferences, participants' open comments were analyzed, revealing further support for IFL and the social model of disability, and a preference for simple, precise, and validated terms.

Conclusions

These results are consistent with autism terminology preferences in English-speaking countries and provide additional insight into the reasons underlying these preferences. Such work has implications for informing the language of researchers, clinicians, and other professionals in the field, as well as the general public.

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.

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.

The Predictive Relationship Between Sensory Reactivity and Depressive Symptoms in Young Autistic Children with Few to No Words

Depression and sensory reactivity are both common in autism. However, there is little understanding of the predictive relationship between these factors, or the nature of this relationship in autistic children who speak few to no words. This study set out to explore the longitudinal relationship between sensory reactivity and depressive symptoms in 33 young autistic children who speak few to no words. We found positive correlations between depressive symptoms and hyper-reactivity and sensory seeking at both timepoints, and across timepoints. We further found a bidirectional predictive relationship between depressive symptoms and sensory seeking. These results implicate sensory seeking in the development of depressive symptoms in young autistic children who use few to no words. Our findings have important implications for preventative mental health interventions, especially for those with a developmental language delay.

"My whole life has been a process of finding labels that fit": A Thematic Analysis of Autistic LGBTQIA+ Identity and Inclusion in the LGBTQIA+ Community

Background

Being nonheterosexual and noncisgender appears to be more common among autistic people. This intersection of identities is often stigmatized in research and society. However, we know that community involvement can protect against negative mental health outcomes associated with being a minority; researchers found this effect in separate studies examining participation in the autistic and Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexual plus other gender and sexual orientation-based identity (LGBTQIA+) communities. This study examined how autistic LGBTQIA+ individuals navigate their multiple marginalized identities and the LGBTQIA+ community.

Methods

Twelve autistic LGBTQIA+ people from the United Kingdom took part in semistructured interviews. Questions focused on identity and community. We analyzed the interviews using reflexive thematic analysis.

Results

We identified four overarching themes-Identity (Re)Development, Navigating Authenticity, Exclusion from Community Spaces, and Creating Change. Participants viewed accessing a community of similar others as a means of increasing understanding, self-knowledge, and self-acceptance. We identified several barriers to inclusion, including accessibility and gatekeeping. Participants discussed strategies to combat these obstacles, such as the creation of intersectional community spaces and activism and representation as a means of increasing autism understanding.

Conclusions

This study suggests that similar to other marginalized groups, autistic LGBTQIA+ individuals are motivated to engage in communities relevant to their identities. However, community spaces for autistic LGBTQIA+ are often inaccessible due to social, sensory, and identity-based barriers. Participants highlighted autism understanding as a barrier to coming out both in community and noncommunity settings. This suggests that improving autism acceptance and understanding is crucial to achieve accessible, intersectional, and inclusive community spaces.

Exploring the Experiences of Autistic Transgender and Non-Binary Adults in Seeking Gender Identity Health Care

Background

This study sought to obtain an in-depth understanding of autistic transgender and/or non-binary adults' experiences in accessing, or trying to access, gender identity health care (GIH). To our knowledge, no prior study researched this topic.

Methods

Through semi-structured interviews, we obtained the first-hand experiences of 17 participants. H.B. (cisgender, non-autistic) conducted a reflexive thematic analysis using an inductive approach, in collaboration with K.M., an autistic transgender disability community researcher, and under the supervision of S.K.K., a cisgender autistic autism researcher.

Results

Thematic analysis determined that poor knowledge of professionals, accessibility issues, and bureaucratic and economic barriers impacted participants' experiences when accessing GIH. Participants experienced a perceived lack of professional knowledge around autism and gender diverse health care needs, limited communication methods and accommodations, and misdiagnosis of mental health difficulties. Accessibility issues included unmet sensory needs, disruption to routine, and a lack of local provision. Further, participants shared that they struggled with unclear processes, standardization of care, long waiting lists, and confusing or inaccessible insurance coverage. Recommendations for improvements highlighted the need to listen to service users to positively impact their experiences in accessing GIH.

Conclusion

This study suggests that more training needs to be given to health care providers and professionals around autistic experience to help improve providers' competence in communication and providing person-centered accommodations. More training around gender diverse identities is needed, as well as increased knowledge on the co-occurrence of autism and transgender/non-binary identities, to positively impact patient experiences and help improve access to care.

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.

Oxytocin excites dorsal raphe serotonin neurons and bidirectionally gates their glutamate synapses

Oxytocin (OXT) modulates wide spectrum of social and emotional behaviors via modulation of numerous neurotransmitter systems, including serotonin (5-HT). However, how OXT controls the function of dorsal raphe nucleus (DRN) 5-HT neurons remains unknown. Here, we reveal that OXT excites and alters the firing pattern of 5-HT neurons via activation of postsynaptic OXT receptors (OXTRs). In addition, OXT induces cell-type-specific depression and potentiation of DRN glutamate synapses by two retrograde lipid messengers, 2-arachidonoylglycerol (2-AG) and arachidonic acid (AA), respectively. Neuronal mapping demonstrates that OXT preferentially potentiates glutamate synapses of 5-HT neurons projecting to medial prefrontal cortex (mPFC) and depresses glutamatergic inputs to 5-HT neurons projecting to lateral habenula (LHb) and central amygdala (CeA). Thus, by engaging distinct retrograde lipid messengers, OXT exerts a target-specific gating of glutamate synapses on the DRN. As such, our data uncovers the neuronal mechanisms by which OXT modulates the function of DRN 5-HT neurons.

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.

Centering the Inner Experience of Autism: Development of the Self-Assessment of Autistic Traits

Current tools for identifying autism are critiqued for their lack of specificity and sensitivity, especially in autistic people who are older, have higher verbal ability or significant compensatory skills, and are not cisgender boys. This may reflect the following: the historical focus of autism research on White (cisgender) male, upper and middle class children; limited interest in the inner, lived experience of autism; and the predominance of a deficit-based model of autism. We report here on the first attempt of which we are aware to develop a clinical self-report measure of autistic traits as described by autistic people. We believe this is an advance in methodology because prior work in the development of autistic trait/diagnostic measures has prioritized the perspectives of nonautistic clinicians and scientists. The measure was developed under the leadership of two autistic researchers and constructed by leveraging descriptions of autism by autistic people to generate items designed to encompass the range of the autistic experience, using strength-based, accessible language. The team utilized iterative feedback from a panel of autistic experts to refine and enhance the measure, called the Self Assessment of Autistic Traits (SAAT). It is intended for people 16 years or older and uses a format that is designed to increase its accessibility and acceptability for autistic respondents. Future work will report on the preliminary psychometrics of the SAAT, with a long-term goal of advancing our understanding of the inner autistic experience and enhancing the clinical and scientific assessment of autism.

In Addition to Stigma: Cognitive and Autism-Related Predictors of Mental Health in Transgender Adolescents

OBJECTIVE

Autism spectrum disorder (ASD) is significantly over-represented among transgender adolescents. Independently, ASD and gender diversity are associated with increased mental health risks. Yet, mental health in autistic-transgender adolescents is poorly understood. This study investigates mental health in the largest matched sample to date of autistic-transgender, non-autistic (allistic) transgender, and autistic-cisgender adolescents diagnosed using gold-standard ASD diagnostic procedures. In accordance with advancing understanding of sex/gender-related autism phenotypes, slightly subthreshold autistic diagnostic presentations (common in autistic girls/women) are modeled.

METHOD

This study includes 93 adolescents aged 13-21, evenly divided between autistic-transgender, autistic-cisgender, and allistic-transgender groups; 13 transgender adolescents were at the margin of ASD diagnosis and included within a larger "broad-ASD" grouping. Psychological and neuropsychological evaluation included assessment of mental health, IQ, LGBT stigma, ASD-related social symptoms, executive functioning (EF), and EF-related barriers to achieving gender-related needs.

RESULTS

Autistic-transgender adolescents experienced significantly greater internalizing symptoms compared to allistic-transgender and autistic-cisgender groups. In addition to stigma-related associations with mental health, ASD-related cognitive/neurodevelopmental factors (i.e., poorer EF and greater social symptoms) were associated with worse mental health: specifically, social symptoms and EF gender barriers with greater internalizing and EF problems and EF gender barriers with greater suicidality. Comparing across all ASD and gender-related groups, female gender identity was associated with greater suicidality.

CONCLUSIONS

Parsing the heterogeneity of mental health risks among transgender youth is critical for developing targeted assessments and interventions. This study identifies ASD diagnosis, ASD phenotypic characteristics, and EF-related gender barriers as potential risks for poorer mental health in transgender adolescents.

10 years of Bayesian theories of autism: A comprehensive review

Ten years ago, Pellicano and Burr published one of the most influential articles in the study of autism spectrum disorders, linking them to aberrant Bayesian inference processes in the brain. In particular, they proposed that autistic individuals are less influenced by their brains' prior beliefs about the environment. In this systematic review, we investigate if this theory is supported by the experimental evidence. To that end, we collect all studies which included comparisons across diagnostic groups or autistic traits and categorise them based on the investigated priors. Our results are highly mixed, with a slight majority of studies finding no difference in the integration of Bayesian priors. We find that priors developed during the experiments exhibited reduced influences more frequently than priors acquired previously, with various studies providing evidence for learning differences between participant groups. Finally, we focus on the methodological and computational aspects of the included studies, showing low statistical power and often inconsistent approaches. Based on our findings, we propose guidelines for future research.

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.

'Living in a world that's not about us': The impact of everyday life on the health and wellbeing of autistic women and gender diverse people

BACKGROUND

Autistic women and gender diverse people have specific needs related to their physical and mental health. They also experience more barriers to accessing services. While there are autobiographical accounts of the 'invisible' challenges that autistic women and gender diverse people face day-to-day, there has been limited research that explores how these experiences impact health and wellbeing.

OBJECTIVES

This study aimed to understand the everyday experiences of autistic women and gender diverse people, and their impact on health and wellbeing.

DESIGN

Qualitative methods were used to elicit rich information about the unique experiences of autistic women and gender diverse people.

METHODS

We conducted semi-structured interviews with 31 autistic adults. The data were analysed using reflexive thematic analysis.

RESULTS

We identified 3 themes and 10 subthemes. Our first theme described 'all the stuff that you have to do to get through life', including managing domestic tasks, parenting, unique health needs and co-occurring physical conditions. The second theme outlined the impact of 'living in a world that's not about us', describing how navigating the neurotypical world, managing gender role expectations and trying to fit impacts on mental health. Our third theme outlined the positive impacts of 'shedding all the layers and being myself', including the importance of formal identification, exploring autistic identity and community, and including autistic people in research to support them to 'have a good life on their own terms'.

CONCLUSION

This study emphasized the importance of shifting the responsibility of health and wellbeing from the individual, and the importance of interpersonal, community, cultural, policy and societal factors in ensuring positive health outcomes for autistic women and gender diverse people. It also highlighted areas that enable autistic women and gender diverse people to flourish, including autistic community connectedness, positive relationships and autistic-affirming support from health professionals.

Greater gender diversity among autistic children by self-report and parent-report

LAY ABSTRACT

Gender diversity broadly refers to the way in which an individual experiences (expressions and/or identities) their gender distinctly to that which would be expected based upon social norms for their gender assigned at birth. Recent research has shown a higher representation of gender diversity among autistic youth. Previous research in this area has relied on parent-report based on a single question from the Child Behavior Checklist Item-110, asking whether their child "Wishes to be the opposite sex." The Gender Diversity Screening Questionnaire Self-Report and Parent-Report were used to assess the experience of gender diversity in 244 children (140 autism spectrum disorder and 104 typically developing) between 10 and 13 years. The Item-110 was also collected. Results showed that autistic children endorsed much higher rates of Binary Gender Diversity (less identification with their designated sex and more with the other binary sex) and Nonbinary Gender Diversity (identification as neither male nor female) than typically developing children. Similarly, parents of autistic children reported significantly more gender-body incongruence experienced by their child than parents of typically developing children. Specifically, parents of autistic females-assigned-at-birth reported significantly more gender-body incongruence than autistic males-assigned-at-birth. Parent- and self-report measures were largely related. Moreover, statistical comparisons between and within the groups revealed associations between gender profiles and symptoms of anxiety, depression, and suicidality. Results extend previous reports showing increased rates of gender diversity in autistic children, now based on both self-report and parent-report, and highlight the need to better understand and support the unique and complex needs of autistic children who experience gender diversity.

Implicit and Explicit Gender-Related Cognition, Gender Dysphoria, Autistic-Like Traits, and Mentalizing: Differences Between Autistic and Non-Autistic Cisgender and Transgender Adults

Evidence indicates a link between autism spectrum disorder (ASD) and gender diversity, yet this intersection remains insufficiently understood. Here, we investigated whether (1) ASD affects gender-related cognition (i.e., mental processes of perceiving and interpreting one's own gender self-concept), (2) autistic people have increased gender dysphoria and recall limited gender-typed behavior from childhood, and (3) transgender individuals have increased ASD-like traits and difficulties in mentalizing. A total of 106 non-autistic cisgender (51 birth-assigned female), 107 autistic cisgender (57 birth-assigned female), 78 non-autistic transgender (41 birth-assigned female), and 56 autistic transgender adults (27 birth-assigned female) participated in the study. The mean age of participants was 31.01 years (range = 18 to 70). Using an explicit as well as an implicit measure, for the first time, we found that ASD affected gender-related cognition only in autistic cisgender people. Sex differences were also observed in this group. Whereas autistic cisgender birth-assigned males showed a stronger implicit gender-group identification than non-autistic cisgender birth-assigned males, autistic cisgender birth-assigned females showed a weaker gender-group identification than non-autistic cisgender birth-assigned females. Furthermore, autistic cisgender people reported significantly more gender dysphoric feelings and recalled significantly less gender-typed behavior from childhood than non-autistic cisgender individuals. No difference was observed between non-autistic and autistic transgender people. We also found that relative to non-autistic cisgender individuals, both non-autistic transgender and autistic transgender people reported significantly more ASD-like traits. However, mentalizing difficulties were observed only in the latter group. This research enhances our understanding of the link between ASD and gender diversity.

Theories on the Link Between Autism Spectrum Conditions and Trans Gender Modality: a Systematic Review

While research on the prevalence of co-occurring autism spectrum conditions (ASC) and trans gender modality (TGM) is available, less is known about the underlying mechanism of this association. Insight is needed to improve treatment of trans autistic people. This review provides an overview of theories on the ASC-TGM link and the available evidence for/against them published between January 2016 and October 2020. A systematic search was performed in PubMed, PsycINFO, Web of Science, and Scopus. This resulted in 36 studies, in which 15 theories were identified. Results indicate all theories lack substantial empirical support. Unlikely and promising theories were identified. The most promising theories were those on resistance to social norms and weakened sex differences. Future directions are provided.

Autism Spectrum Disorder and Gender Dysphoria/Incongruence. A systematic Literature Review and Meta-Analysis

The suggested overlap between autism spectrum disorder (ASD) and gender dysphoria/incongruence (GD/GI) has been much disputed. This review showed a relationship between ASD traits and GD feelings in the general population and a high prevalence of GD/GI in ASD. Our meta-analyses revealed that the pooled estimate of the prevalence of ASD diagnoses in GD/GI people was 11% (p < .001) and the overall effect size of the difference in ASD traits between GD/GI and control people was significant (g = 0.67, p < .001). Heterogeneity was high in both meta-analyses. We demonstrated that the chances that there is not a link between ASD and GD/GI are negligible, yet the size of it needs further investigation.

The lived experience of gender dysphoria in autistic adults: An interpretative phenomenological analysis

LAY ABSTRACT

Autistic people are more likely to be transgender, which means having a gender identity different to one's sex assigned at birth. Some transgender people experience distress about their gender and sex assigned at birth not matching which is called gender dysphoria. Research has focused on finding out why autistic people are more likely to have gender dysphoria, and less on what the experience of gender dysphoria is like for autistic people. We interviewed 21 autistic adults about their experience of incongruence between their gender identity and sex assigned at birth, and any associated distress. We carefully read the transcripts of the interviews, focusing on how participants understood their experiences. We found a range of themes from the interviews. Participants were distressed because their bodies did not match their gender identities. Participants told us they had to work hard to understand themselves and who they were, and to manage having multiple different needs such as mental health needs. It was upsetting for participants to experience discrimination because of being autistic and/or transgender. Some participants said it was more difficult to get transgender healthcare as an autistic person. Some participants thought being autistic had helped them understand their gender identity more than non-autistic people. Other participants found it was challenging to be both autistic and transgender. For example, most participants wanted to change their bodies to match their gender identity, but some participants were nervous about making changes to themselves and their routine due to being autistic. We conclude that autism can in some ways be helpful and other ways contribute to challenges for transgender autistic people.

Autism and chronic ill health: an observational study of symptoms and diagnoses of central sensitivity syndromes in autistic adults

BACKGROUND

Autistic adults, particularly women, are more likely to experience chronic ill health than the general population. Central sensitivity syndromes (CSS) are a group of related conditions that are thought to include an underlying sensitisation of the central nervous system; heightened sensory sensitivity is a common feature. Anecdotal evidence suggests autistic adults may be more prone to developing a CSS. This study aimed to investigate the occurrence of CSS diagnoses and symptoms in autistic adults, and to explore whether CSS symptoms were related to autistic traits, mental health, sensory sensitivity, or gender.

METHODS

The full sample of participants included 973 autistic adults (410 men, 563 women, mean age = 44.6) registered at the Netherlands Autism Register, who completed questionnaires assessing autistic traits, sensory sensitivity, CSS, physical and mental health symptoms. The reliability and validity of the Central Sensitization Inventory (CSI) in an autistic sample was established using exploratory and confirmatory factor analyses. Chi2 analyses, independent t-tests, hierarchical regression and path analysis were used to analyse relationships between CSS symptoms, autistic traits, measures of mental health and wellbeing, sensory sensitivity, age and gender.

RESULTS

21% of participants reported one or more CSS diagnosis, and 60% scored at or above the clinical cut-off for a CSS. Autistic women were more likely to report a CSS diagnosis and experienced more CSS symptoms than men. Sensory sensitivity, anxiety, age and gender were significant predictors of CSS symptoms, with sensory sensitivity and anxiety fully mediating the relationship between autistic traits and CSS symptoms.

LIMITATIONS

Although this study included a large sample of autistic adults, we did not have a control group or a CSS only group. We also could not include a non-binary group due to lack of statistical power.

CONCLUSIONS

CSS diagnoses and symptoms appear to be very common in the autistic population. Increased awareness of an association between autism and central sensitisation should inform clinicians and guide diagnostic practice, particularly for women where CSS are common and autism under recognised.

Transgender data collection in the electronic health record: Current concepts and issues

There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.

A Clinical Program for Transgender and Gender-Diverse Neurodiverse/Autistic Adolescents Developed through Community-Based Participatory Design

Objective: A series of studies report elevated rates of autism and autistic characteristics among gender-diverse youth seeking gender services. Although youth with the co-occurrence present with complex care needs, existing studies have focused on co-occurrence rates. Further, clinical commentaries have emphasized provider-centered interpretations of clinical needs rather than key stakeholder-driven clinical approaches. This study aimed to employ community-based participatory research methodologies to develop a key stakeholder-driven clinical group program.Method: Autistic/neurodiverse gender-diverse (A/ND-GD) youth (N = 31), parents of A/ND-GD youth (N = 46), A/ND-GD self-advocates (N = 10), and expert clinical providers (N = 10) participated in a multi-stage community-based participatory procedure. Needs assessment data were collected repeatedly over time from A/ND-GD youth and their parents as the youth interacted with one another through ongoing clinical groups, the curriculum of which was developed progressively through the iterative needs assessments.Results: Separate adolescent and parent needs assessments revealed key priorities for youth (e.g., the importance of connecting with other A/ND-GD youth and the benefit of experiencing a range of gender-diverse role models to make gender exploration and/or gender affirmation more concrete) and parents (e.g., the need for A/ND-related supports for their children as well as provision of an A/ND-friendly environment that fosters exploration of a range of gender expressions/options). Integration and translation of youth and parent priorities resulted in 11 novel clinical techniques for this population.Conclusions: With generally high acceptability ratings for each component of the group program, this study presents a community-driven clinical model to support broad care needs and preferences of A/ND-GD adolescents.

Anxiety, Insomnia, and Napping Predict Poorer Sleep Quality in an Autistic Adult Population

Autistic adults have a high prevalence of sleep problems and psychiatric conditions. In the general population sleep problems have been associated with a range of demographic and lifestyle factors. Whether the same factors contribute to different types of disturbed sleep experienced by autistic adults is unknown and served as the main aim of this study. An online survey was conducted with 493 autistic adults. Demographic information (e.g., age, gender), about lifestyle (e.g., napping), and information about comorbid conditions was collected. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality and the Epworth Sleepiness Scale (ESS) was used to assess daytime somnolence. Stepwise multiple regression analyses were used to examine predictors of each subscale score on the PSQI, as well as PSQI and ESS total scores. Results indicated that individuals who reported having a diagnosis of anxiety and insomnia were more likely to have poorer sleep quality outcomes overall. Furthermore, individuals who reported habitually napping had higher daytime dysfunction, increased sleep disturbances, and increased daytime sleepiness. These results provide novel insights into the demographic and lifestyle factors that influence sleep quality and daytime somnolence in autistic adults and can be used for targeted sleep interventions.

Mental health correlates and potential childhood predictors for the wish to be of the opposite sex in young autistic adults

LAY ABSTRACT

Autistic people/people with autism spectrum disorder are more likely to experience gender dysphoria. However, the possible longitudinal predictors and underlying mechanisms of this co-occurrence are unclear. To fill this knowledge gap, we assessed 88 people with autism spectrum disorder and 42 typically developing individuals at their average ages of 13.0 (baseline, childhood/adolescence) and 20.2 years old (follow-up, adulthood). At follow-up, their endorsement on the item "I wish I was the opposite sex" was used to evaluate gender dysphoric symptoms. We compared mental health symptoms between adults with and without this item endorsement at the follow-up assessment. We explored parent-reported family and autism characteristics-related predictors in childhood/adolescence to this item endorsement in adulthood. We found that more autistic adults reported the wish to be of the opposite sex than did typically developing individuals. Autistic adults who endorsed this item experienced more mental health challenges, more school bullying and cyberbullying, more suicidal ideation, and worse quality of life. Moreover, parent-reported lower family support and more stereotyped/repetitive behaviors during childhood/adolescence predicted the self-reported wish to be of the opposite sex in adulthood in autistic individuals. More attention and support should be provided to autistic people regarding gender development and related mental health and quality of life impact, especially during the transition period to young adulthood.

Sexual Knowledge, Desires, and Experience of Adolescents and Young Adults With an Autism Spectrum Disorder: An Exploratory Study

Although most persons with an Autism Spectrum Disorder (ASD) wish to have romantic and/or sexual relationships, little is known about self-report sexuality of adolescents/young adults with ASD. In this exploratory study, 172 male and female adolescents/young adults (68 with ASD and 104 without ASD) completed an online version of the Sexual Behavior Scale-Third edition. Although many more similarities than differences were observed between the groups for views and desires about romantic relationships (e.g., wishing to have a girlfriend/boyfriend), fewer participants with ASD (mostly boys) had experience with a variety of sexual/dyadic behaviors, and approximately half of girls with ASD reported negative sexual experiences. Significantly higher rates of participants with ASD felt their knowledge about sexuality was limited and found it difficult to understand sexual education compared with typically developing (TD) participants. Significantly lower rates of participants with ASD reported that they identify to their assigned gender compared with TD participants. Multiple regressions revealed that being older at first diagnosis and possessing better knowledge about sexuality were significant predictors of both positive and negative sexual experience. This study explores strengths and challenges related with the sexual health of adolescents/young adults with ASD and implications for clinical and educational practice are discussed.

Mental health difficulties among trans and gender diverse young people with an autism spectrum disorder (ASD): Findings from Trans Pathways

Recent research highlights an overlap of gender diversity and autism spectrum disorders (ASD); however, data on individuals who are trans and also on the autism spectrum are largely from clinical samples and may not be representative of individuals who are trans with ASD in the general population. In addition, there is scant literature on the mental health of these individuals and their experiences in accessing gender-affirming care. We investigated the prevalence of ASD in trans young people, their mental health (psychiatric diagnoses and self-harm and suicidal behaviors) and experiences in accessing gender-affirming care. This is an analysis of data collected in an Australian cross-sectional mixed methods survey (N = 859) of trans young people aged 14-25 years. Overall, 22.5% of participants had ever received a diagnosis of ASD from a health professional. This group was more likely to exhibit current psychopathology, have engaged in self-harming and suicidal behaviors, and was also more likely than the non-ASD diagnosed reference group to have received a psychiatric diagnosis. The ASD-diagnosed group were also more likely to experience barriers in accessing gender-affirming care. This is the first large population-based sample of trans individuals with ASD to report on mental health outcomes and experiences in accessing gender-affirming care. We highlight the necessity for clinicians working with either trans or ASD populations to have awareness of the co-occurrence, and to cultivate skills to work with individuals who are both trans and on the autism spectrum.

Sex Differences in Social Participation of High School Students with Autism Spectrum Disorder

There is lack of consensus in the literature regarding sex differences in social outcomes for individuals on the autism spectrum. Furthermore, little research has focused on the social experiences of high school students with autism spectrum disorder (ASD) during the school day. Using a large racially/ethnically diverse sample of high school students with ASD receiving special education services (n = 547; 76 females, 471 males), we examined sex differences in social interactions of youth both during and after school. We also tested for sex differences in background and phenotypic characteristics including autism severity, IQ, adaptive behavior, and mental health. Results indicated few statistically significant differences between males and females in social interactions and phenotypic characteristics (including raw scores of autism symptom severity). However, analysis of standardized scores of autism symptoms suggested that symptom scores for females with ASD diverged more from same-sex peers in the normed sample than scores of males with ASD. Lack of sex difference in social participation for youth with ASD in this study stands in contrast to patterns of sex differences in the general population. Findings suggest that few differences between males and females with ASD, both in social participation and autism symptom severity, might result in females with ASD being more dissimilar to their same-sex peers than males with ASD. Implications of findings for understanding sex differences in ASD across the life course are discussed. LAY SUMMARY: The present study examined sex differences in social participation in a large, diverse sample of high school students with autism spectrum disorder (ASD). Males and females were very similar in their social interactions both at school and outside of school, based on reports by teachers and parents. Level of autism symptoms was also similar for males and females. However, standardized scores of autism symptoms, which take into account age and sex specific norms, suggested that females with ASD may have behaviors that are more divergent from their same-sex peers than males with ASD.

"Masculine" Describes Gender Expressions, Not Neurobiologies: Response to Dutton and Madison (2020)

This letter is a response to "Gender Dysphoria and Transgender Identity Is Associated with Physiological and Psychological Masculinization: a Theoretical Integration of Findings, Supported by Systematic Reviews" by Dutton and Madison (2020), which relies on theorisations for which substantial counter-evidence exists, fails to engage with these or other criticisms of the theories upon which it seeks to build, and reaches conclusions that contradict existing evidence. Furthermore, the original theorisations contained in Dutton and Madison (2020), and the conclusions drawn from those theorisations, risk causing serious harm to already-marginalised groups.

Links Between Autistic Traits, Feelings of Gender Dysphoria, and Mentalising Ability: Replication and Extension of Previous Findings from the General Population

Gender nonconformity is substantially elevated in the autistic population, but the reasons for this are currently unclear. In a recent study, Kallitsounaki and Williams (Kallitsounaki and Williams, Journal of Autism and Developmental Disorders, 2020; authors 1 and 2 of the current paper) found significant relations between autistic traits and both gender dysphoric feelings and recalled cross-gender behaviour, and between mentalising ability and gender dysphoric feelings. The current study successfully replicated these findings (results were supplemented with Bayesian analyses), in sample of 126 adults. Furthermore, it extended the previous finding of the role of mentalising in the relation between autistic traits and gender dysphoric feelings, by showing that mentalising fully mediated this link. Results provide a potential partial explanation for the increased rate of gender nonconformity in the autistic population.

Autism trait prevalence in treatment seeking adolescents and adults attending specialist gender services

Background.

To assess the prevalence of autism traits in individuals accessing gender affirming treatments, we conducted a cross-sectional survey in the regional specialist gender services in Northern Ireland.

Methods.

One hundred and twenty-three individuals (38 adolescents and 69 adults) currently attending or who previously attended specialist gender services in Northern Ireland were recruited. Fifty-six individuals assigned male at birth (AMAB) and 66 individuals assigned female at birth (AFAB) took part in the study. Main outcome measures: Autism Quotient (AQ), Cambridge Behavior Scale (EQ), and RAADS-14.

Results.

Autism trait prevalence rates of 19.5% (AQ); 25.4% (RAADS-14); and 35.8% (poor empathy traits). A combined measure comprising all three provided a prevalence of 17.2%. There were no mean differences in the scores between AMAB (assigned male at birth) individuals and AFAB (assigned female at birth) individuals.

Conclusions.

Autism traits present additional challenges during the assessment and treatment of individuals with gender dysphoria. Autism screening tools can aid in the identification of individual with additional needs.

Feasibility and preliminary efficacy of a parent-mediated sexual education curriculum for youth with autism spectrum disorders

Youth with autism spectrum disorder can face social-communication challenges related to sexuality, dating, and friendships. The purpose of this study was to assess the feasibility, acceptability, and preliminary efficacy of the Supporting Teens with Autism on Relationships program. In total, 84 youth with autism spectrum disorder aged 9 to 18 and their parents participated in this study; two groups received the Supporting Teens with Autism on Relationships program (interventionist-led parent group vs parent self-guided), while an attentional control group received a substance abuse prevention program that included instruction in problem-solving and social skills. Feasibility and acceptability of the Supporting Teens with Autism on Relationships program was high overall. The Supporting Teens with Autism on Relationships program was effective in increasing parent and youth knowledge of sexuality, while the attentional control was not. There was preliminary support for improvement in parenting efficacy related to discussing sexuality with their children. Gains were seen among completers regardless of whether the parent received support from a facilitator. Implications and future directions are discussed.

Community-Based Participatory Design for Research that Impacts the Lives of Transgender and/or Gender-Diverse Autistic and/or Neurodiverse People

Objective

Research addressing the co-occurrence of autism (and/or neurodiversity) and gender-diversity (A/ND-GD) has been conducted largely without the perspectives and voices of the A/ND-GD community. Including A/ND-GD community advocates as research partners may be a critical next step for advancing research initiatives on the co-occurrence given the apparent complexity and alterity of the A/ND-GD experience.

Method

Consistent with the community-based participatory research (CBPR) model we propose herein, our authorship team includes a partnership between clinician researchers and diverse A/ND-GD community collaborators. Multiple facets of the A/ND-GD lived experience are examined, including through narratives provided by our A/ND-GD community partners.

Results

Based on our experience conducting A/ND-GD-related research and our lived experience as A/ND-GD self-advocates, we highlight challenges in this line of research, including risks of conducting studies without the involvement of the A/ND-GD community. And given that many A/ND-GD youth present with gender-related urgency during the teen years, we provide a developmental framework for how CBPR-informed methods may enrich our understanding of the care needs of these young people and provide context for the apparent heterogeneity in their gender needs and trajectories over time.

Conclusions

Integrating CBPR methodologies in A/ND-GD research initiatives has the potential to optimize the relevance of the research questions asked and the interpretation and contextualization of study findings.

A Review Update on Gender Dysphoria and ASD and Response to Corrections

Here we address the earlier published review by Øien et al. (J Autism Dev Disord, https://doi.org/10.1007/s10803-018-3686-7 , 2018) and the subsequent comments by Zucker and VanderLaan (J Autism Dev Disord, https://doi.org/10.1007/s10803-018-3748-x , 2018). The current commentary is a response to the corrections put forth by the latter authors where aspects related to diagnostic criteria of Gender Dysphoria and corrections to the existence of a control group were noted. Additionally, to highlight that research on Gender Dysphoria and ASD is becoming a very fast and growing field we also present an update of the original review which show a 13% increase of empirical studies published only in the past few months.