Gender identity and sexual orientation in autism spectrum disorder

Gender diversity among adolescents with obesity in a weight management programme

Gender dysphoria (GD) and obesity share commonalities, including associations with mental health comorbidities, disordered eating, body dissatisfaction and may intensify with physical and developmental changes during adolescence. While associations of obesity and gender diversity have been identified, rates of gender diversity among adolescents with obesity remain unclear. The aim was to examine gender diversity among adolescents with obesity in a weight management programme. A single-centre cross-sectional questionnaire study was conducted. Eligible adolescents received the Gender Identity/GD Questionnaire for Adolescents and Adults (GIDYQ-AA), a validated instrument measuring gender diversity and GD. Gender identities, sexual orientations, questionnaire scores, and frequency of GD (GIDYQ-AA score <3) were determined. The relationship of GIDYQ-AA scores and BMI Z-score (BMIz) was assessed. Of 72 consenting youth, 29 assigned females (AF) and 17 assigned males (AM) completed GIDYQ-AA and demographic questions. Seventeen (59%) AF reported non-heterosexual orientations, and 6 (21%) reported non-cisgender identities. One (6%) AM reported non-cisgender identity. Two (4%) AF individuals had GD based on GIDYQ-AA scores. GIDYQ-AA scores did not correlate with BMIz. In conclusion, adolescents with obesity, particularly AF with non-heterosexual orientation, reported high rates of non-cisgender identity and GD. Routine screening for gender-related concerns in weight management settings may be warranted.

A Systematic Review of Gender Dysphoria Measures in Autistic Samples

This systematic review investigated how studies have measured gender dysphoria (GD) in autistic samples and the impact of using different measures on study results. The literature search identified 339 relevant papers, with 12 of them meeting the inclusion criteria. Results showed that seven different measures of GD characteristics have been used with autistic samples and that the studies consistently reported a greater number of GD characteristics and a greater severity of GD in autistic compared to non-autistic samples. Methodological common practices were found in recruiting participants from clinical settings rather than the general population, having more autistic males than females in the samples, for studies being conducted in Europe, North America, and Oceania, and using single-item measures of GD for samples of autistic children. Issues were identified with study designs and measures of GD, suggesting a need for a more standardized multi-item self-report measure of GD for use in clinical and non-clinical samples across different ages and cultures.

Associations between Social Experiences and Psychological Health for Autistic Youth with Low IQ

PURPOSE

Social experiences are consistently associated with psychological health among autistic individuals. However, most extant studies on this topic exclude individuals with autism who have lower IQ or are otherwise unable to self-report. The current study addresses this gap by examining associations of negative peer experiences and social participation with psychological health among autistic youth with low IQ.

METHODS

An online survey was collected from 268 parents of autistic adolescents and adults ages 15-25. Negative peer experiences included measures of peer victimization and being ignored. Social participation was assessed by the amount of participation and parents' perceptions of whether their youth felt the amount of participation was meeting their needs. Psychological health was assessed by parents' report of their youth's psychological quality of life, as well as whether they felt their son/daughter was currently depressed.

RESULTS

Results suggested low rates of social participation in this sample, with relatively high rates of being ignored. Regression analysis found that lower rates of peer victimization and more activities in which parents perceived that the amount of time was meeting their youth's needs was associated with higher psychological quality of life and lower likelihood that parents felt their son/daughter was depressed.

CONCLUSION

Though youth with autism and low IQ are often excluded from interventions aimed at improving social experiences, these findings suggest that promoting positive social experiences and ameliorating negative ones might be an avenue to improving psychological health in this group.

Giftedness and atypical sexual differentiation: enhanced perceptual functioning through estrogen deficiency instead of androgen excess

Syndromic autism spectrum conditions (ASC), such as Klinefelter syndrome, also manifest hypogonadism. Compared to the popular Extreme Male Brain theory, the Enhanced Perceptual Functioning model explains the connection between ASC, savant traits, and giftedness more seamlessly, and their co-emergence with atypical sexual differentiation. Overexcitability of primary sensory inputs generates a relative enhancement of local to global processing of stimuli, hindering the abstraction of communication signals, in contrast to the extraordinary local information processing skills in some individuals. Weaker inhibitory function through gamma-aminobutyric acid type A (GABAA) receptors and the atypicality of synapse formation lead to this difference, and the formation of unique neural circuits that process external information. Additionally, deficiency in monitoring inner sensory information leads to alexithymia (inability to distinguish one's own emotions), which can be caused by hypoactivity of estrogen and oxytocin in the interoceptive neural circuits, comprising the anterior insular and cingulate gyri. These areas are also part of the Salience Network, which switches between the Central Executive Network for external tasks and the Default Mode Network for self-referential mind wandering. Exploring the possibility that estrogen deficiency since early development interrupts GABA shift, causing sensory processing atypicality, it helps to evaluate the co-occurrence of ASC with attention deficit hyperactivity disorder, dyslexia, and schizophrenia based on phenotypic and physiological bases. It also provides clues for understanding the common underpinnings of these neurodevelopmental disorders and gifted populations.

Neurological care for LGBT+ people

Sexual and gender minority (LGBT+) people face unique health disparities that must be considered by health-care providers to ensure equitable and inclusive care. Although traditionally LGBT+ health has not been integrated into neurology training, sexual orientation and gender identity have direct relevance to neurological health, driven by both systemic and interpersonal factors. In this Review, we summarize the evidence for associations between sexual orientation and gender identity with the prevalence and outcomes of various neurological conditions, including neurodegenerative diseases, epilepsy, stroke and neurodevelopmental disorders, among others. We describe important clinical considerations pertaining to LGBT+ people and recommend language and practices to promote inclusive care, as well as highlight gaps in need of further research and possible strategies to minimize these, including systematic collection of sexual orientation and gender identity and use of inclusive language.

Autistic Women's Experience of Motherhood: A Qualitative Analysis of Reddit

Autistic mothers remain under-represented in parental and autism research despite the associated physical and psychosocial challenges that accompany the transition to motherhood. Extant literature suggests autistic mothers experience sensory difficulties, communication challenges, stigma, and comorbidities as difficulties, but these studies have focused on autistic women in the perinatal period. The aim of this study was to examine reflections on motherhood from a Reddit community for autistic parents. Identified themes were Autistic Mothering is Different, Autistic Mothers Need Autistic Mothers, Autistic Mothers Experience Stigma, and Learnings from Lockdown. Findings extend existing research by offering insight into the ways autism impacts mothers beyond the perinatal period and have important implications for the future design and delivery of support services for autistic mothers.

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.

Autistic Traits, Gender Minority Stress, and Mental Health in Transgender and Non-Binary Adults

The present study investigated the relation between autistic traits and gender minority stress and the relative importance of autistic traits and gender minority stress in predicting mental health outcomes in gender minority adults. An online survey was completed by 90 transgender women, 72 transgender men, 48 non-binary individuals assigned male at birth (AMAB), and 98 non-binary individuals assigned female at birth (AFAB). Autistic traits positively correlated with internalised transphobia in the non-binary groups. In general, higher autistic traits and gender minority stress correlated with poorer mental health outcomes. After controlling for gender minority stress, autistic traits accounted for additional variance of suicidality across gender minority groups, anxiety symptoms in the non-binary groups, and all mental health outcomes in non-binary AFAB.

Contrasting Views of Autism Spectrum Traits in Adults, Especially in Self-Reports vs. Informant-Reports for Women High in Autism Spectrum Traits

There is uncertainty among researchers and clinicians about how to best measure autism spectrum dimensional traits in adults. In a sample of adults with high levels of autism spectrum traits and without intellectual disability (probands, n = 103) and their family members (n = 96), we sought to compare self vs. informant reports of autism spectrum-related traits and possible effects of sex on discrepancies. Using correlational analysis, we found poor agreement between self- and informant-report measures for probands, yet moderate agreement for family members. We found reporting discrepancy was greatest for female probands, often self-reporting more autism-related behaviors. Our findings suggest that autism spectrum traits are often underrecognized by informants, making self-report data important to collect in clinical and research settings.

Short report: Recommendations for education, clinical practice, research, and policy on promoting well-being in autistic youth and adults through a positive focus on sexuality and gender diversity

LAY ABSTRACT

In this article, we propose recommendations on what we can do to promote that autistic people can enjoy their sexuality and gender identity, because that contributes to overall well-being.First, we briefly summarize the existing research on sexuality and gender diversity in autistic individuals.Next, we propose recommendations for how to promote sexual and gender diversity-related health and well-being. Based on what is known about sexuality, gender diversity, and relationships in autistic adolescents and adults, we convened an international group of autistic and non-autistic researchers, advocates, parents, and professionals to develop recommendations to promote sexual and gender health in autistic people.The resulting recommendations were checked through an online survey distributed to autistic people across the world. The online participants endorsed the importance of eight final recommendations related to:1. Providing education and information on sexuality, relationships, and gender diversity to autistic individuals and their families;2. Improving expertise in and accessibility to healthcare for sexuality, relationships, and gender-related questions, with specific attention to prevention of and support after sexual victimization; and3. Meaningfully including the autism community in future research that addresses well-being relating to sexuality, relationships, and gender diversity.These community-driven recommendations aim to promote sexual health and well-being in autistic individuals internationally.

"Maybe No One Knows We Need Help": Understanding the Experiences of Autistic Working Mothers in Australia

Background

Although there are no known studies investigating autistic working mothers, research has demonstrated that managing employment and motherhood in non-autistic populations has specific challenges, as does employment in autistic populations. This autistic-led study aimed at investigating the experience of autistic working mothers to identify benefits, challenges, and support needs.

Methods

We utilized a subjectivist epistemological perspective to learn about the experiences of autistic working mothers. We recruited 10 autistic working mothers (aged 34-50 years) via social media advertisements, who participated in a 45- to 60-minute semi-structured interview where we asked questions developed in consultation with a community reference group. We transcribed interviews and then analyzed them using inductive reflexive thematic analysis.

Results

We identified three key themes. The first theme, "Wellbeing: Work gives me purpose," discusses how employment supports mental well-being. The second theme, "Challenges: It's hard being an autistic working mother," includes the challenges of balancing work and caregiving, guilt related to being a working mother, and issues with part-time work. The third theme, "The invisible disability: Everyone thinks I look okay," discusses the lack of understanding of participants' challenges, with assumptions they are coping, and the lack of supports that led to some participants no longer seeking assistance.

Conclusions

The responses of the autistic women who took part support a view that autistic working mothers may experience some similar challenges to non-autistic working mothers, including stress in juggling caring and work roles. They identified additional challenges related to their gender and their autistic identity, including a lack of understanding of the female (or "internalized") presentation of autism. These findings will help autistic working mothers by promoting a better understanding of their experiences and challenges when they speak with health professionals, government, and employers seeking support and accommodations.

Exploring Identity Importance for Autistic Adults and Associations with Disclosure Experiences: A Brief Report

Background

A strong autistic identity can help to support mental well-being, reduce anxiety and depression, increase self-esteem, and strengthen a shared community for autistic people. Autistic people are regularly faced with a decision to disclose their autistic identity to others and report a range of experiences after disclosure. The purpose of this brief report was to examine the association between identity and disclosure decisions in a sample of autistic adults to gather preliminary evidence justifying future research. Specifically, we were interested in learning more about how autistic identity is associated with one's approach to disclosure, while also exploring associations with other identities such as ethnic, gender, sexual, and religious identity.

Methods

Participants (N = 111) completed an online questionnaire about their intersecting identities and their approach to disclosure. The research team that conducted this study was composed of both autistic and nonautistic researchers.

Results

Results demonstrated that participants who felt their autistic identity and sexual identity were highly important also reported frequent disclosure of being autistic. Religious, gender, and ethnic identity were not associated with one's disclosure decisions or their disclosure outcomes.

Conclusion

Overall, the results of this study emphasize the link between autistic and sexual identities and autism disclosure, but more research in this space is needed to better support the wider autism community.

Psychological Testing in a Complex Case: Psychosis in Co-occurring PTSD, Gender Dysphoria, and Bipolar Disorder

This case report investigates the concurrent presence of post-traumatic stress disorder (PTSD) and bipolar disorder (BD) in the transgender population. We present a case involving a 21-year-old female-to-male transgender individual (preferred pronouns - they/them). The patient had a history of psychosis, trauma, gender dysphoria (GD), inconsistent hormone (testosterone) treatments, and a self-attributed diagnosis of "associative identity disorder" with 21 distinct "identities." They had two emergency admissions in quick succession, both characterized by analogous symptoms. Contributing factors included a recent discontinuation of antipsychotic medications and a history of cannabis use. Their family history included BD in the patient's mother and schizophrenia in their paternal grandfather. The differential diagnoses considered were brief psychosis, BD, PTSD, and substance-induced mania/psychosis. A notable improvement in the patient's clinical presentation was observed during their hospital stay. Their therapeutic regimen comprised olanzapine, hydroxyzine, topiramate, trazodone, and lithium carbonate extended-release. Additionally, the patient underwent psychological testing. This progress solidified the primary diagnosis as PTSD coexisting with BD, manifesting episodes of mania and psychosis. This report highlights the critical role of psychological evaluations in assessing symptoms in patients with multiple psychiatric co-morbidities. Our findings emphasize the importance of a comprehensive, multidisciplinary approach for accurate diagnosis and efficacious treatment of such intricate cases.

Sexually Transmitted Infection Among Adolescents and Young Adults with Autism Spectrum Disorder: A Nationwide Longitudinal Study

The association between autism spectrum disorder (ASD) and subsequent sexually transmitted infections (STIs) and the potential effects of medications on STI risk remain unknown. In all, 5076 adolescents and young adults with ASD and 57,060 age-/sex-matched individuals without ASD were enrolled between 2001 and 2009 and followed-up to the end of 2011 for identification of subsequent STIs. The results revealed that patients with ASD were prone to acquiring an STI [hazard ratio (HR) 3.36] compared with the comparison group. Long-term use of atypical antipsychotics was associated with a lower risk of acquiring an STI later in life compared with nonuse (HR 0.34). We recommend that clinicians closely monitor risky sexual behaviors and STI risk in patients with ASD.

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.

Predictors of Sexual Victimization Among Autistic and Non-Autistic College Students

PURPOSE

This study examined predictors of sexual victimization among autistic and non-autistic college students. Specifically, we aimed to determine whether autistic students are more likely than non-autistic students to experience unwanted sexual contact and sexual assault, controlling for co-occurring diagnoses. We also aimed to determine whether students with other disabilities, specifically ADHD, learning disability (LD), and psychological disorders, are more likely than students without these disabilities to experience unwanted sexual contact and sexual assault.

METHODS

Autistic students (n=270) and non-autistic students (n=270) who had participated in a nationwide survey were matched on demographic characteristics and co-occurring diagnoses. Logistic regression analyses were conducted to address the research questions and evaluate predictors of unwanted sexual contact and sexual assault.

RESULTS

Autistic students were as likely as non-autistic students to have experienced unwanted sexual contact and sexual assault, controlling for co-occurring diagnoses. Regardless of autism diagnostic status, students with ADHD were more likely than students without ADHD to have experienced unwanted sexual contact and sexual assault.

CONCLUSIONS

Although autism diagnostic status was not a significant predictor of unwanted sexual contact or sexual assault, other factors associated with increased risk of sexual victimization, such as co-occurring ADHD, are likely to be found in autistic populations. This study highlights the importance of educational, social, and institutional supports to decrease sexual victimization among college students with neurodevelopmental disabilities.

Exploring health behaviors and the role of pet dogs in households with autistic children: the DANE study

Introduction

Autism spectrum disorder (ASD) often presents a unique set of risk factors that impact healthy eating and physical activity. Animal-assisted interventions (AAI) are a promising approach for autistic children. There is growing evidence for the positive impact of AAIs on self-regulation, which is necessary for initiating and maintaining behavioral changes. Pet dogs offer several potential advantages as a vehicle for an AAI focused on health behaviors. However, little is known about the experiences of autistic children and their families with respect to dog ownership and the mechanisms through which such an AAI might operate.

Methods

We conducted interviews with ten parent-child dyads to explore the role of pet dogs in the lives and lifestyle habits of families with an autistic child. Interview guides were designed to explore the relationship between the autistic child and the pet dog and the role of the dog in family life; attitudes and practices related to physical activity and nutrition; and thoughts about intervention strategies. We used a directed qualitative content analysis approach for analysis.

Results

Themes indicate a strong bond between the child and the dog, the child's enjoyment in caring for their dog, and successful integration of dogs within family routines. In contrast, minor themes emerged around the challenges that owning a pet dog posed for families with an autistic child. In terms of nutrition and physical activity, a major theme among children was that healthy eating and exercise were important for both them and their dogs. However, minor themes suggest challenges with healthy eating and exercise and room for improvement for these behaviors. Parents held favorable views toward an intervention that would incorporate the family dog to teach children about nutrition and physical activity, although they expressed some concerns about feasibility.

Discussion

This exploratory work suggests that AAIs to improve nutrition and physical activity could build on the strong bond that children have with their pet dogs, but should consider the specific needs of each family, including the needs of the pet dog.

"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.

Gender Diverse Autistic Young Adults: A Mental Health Perspective

Gender diverse autistic young adults often face mental health challenges which can increase the challenge of obtaining gender-affirming care. Social and communication differences associated with autism compounds the already complex process of navigating a path toward gender affirmation for individuals with these intersecting identities. In this case series of four gender diverse autistic adults, we demonstrate that success in management of their mental health crises was achieved through enlisting family and social support, obtaining effective mental health treatment, and accessing gender-affirming healthcare. These cases selected from two neuropsychiatric outpatient tertiary referral clinics demonstrate that effective mental health treatment supports ultimate success for these individuals in their journeys toward living as the gender with which they identify. We conclude that healthcare practices and treatment recommendations which incorporate internationally recognized standards of care guidelines for gender diverse individuals improve patient outcomes.

The Autism Spectrum: Behavioral, Psychiatric and Genetic Associations

Autism spectrum disorder (ASD) consists of a group of heterogeneous genetic neurobehavioral disorders associated with developmental impairments in social communication skills and stereotypic, rigid or repetitive behaviors. We review common behavioral, psychiatric and genetic associations related to ASD. Autism affects about 2% of children with 4:1 male-to-female ratio and a heritability estimate between 70 and 90%. The etiology of ASD involves a complex interplay between inheritance and environmental factors influenced by epigenetics. Over 800 genes and dozens of genetic syndromes are associated with ASD. Novel gene–protein interactions with pathway and molecular function analyses have identified at least three functional pathways including chromatin modeling, Wnt, Notch and other signaling pathways and metabolic disturbances involving neuronal growth and dendritic spine profiles. An estimated 50% of individuals with ASD are diagnosed with chromosome deletions or duplications (e.g., 15q11.2, BP1-BP2, 16p11.2 and 15q13.3), identified syndromes (e.g., Williams, Phelan-McDermid and Shprintzen velocardiofacial) or single gene disorders. Behavioral and psychiatric conditions in autism impacted by genetics influence clinical evaluations, counseling, diagnoses, therapeutic interventions and treatment approaches. Pharmacogenetics testing is now possible to help guide the selection of psychotropic medications to treat challenging behaviors or co-occurring psychiatric conditions commonly seen in ASD. In this review of the autism spectrum disorder, behavioral, psychiatric and genetic observations and associations relevant to the evaluation and treatment of individuals with ASD are discussed.

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.

Topics and timing of sexuality and relationship education for autistic and non-autistic adults in the United States

INTRODUCTION

Sexuality and relationship education is a learning area that historically has been overlooked, especially for autistic individuals. To inform future programming, we are in need of evidence-based reasoning to guide program design, such as what to cover and when. In particular, the social aspects of sexuality and relationship education, which are less commonly addressed, need further scrutiny.

OBJECTIVE

To identify sexuality and relationship education priorities and timelines based on feedback from autistic and non-autistic adults.

METHODS

An online anonymous survey of adults in the United States posed questions about sexuality and relationship education, sexual and relationship experiences, and autistic traits.

RESULTS

Comparisons by diagnostic group (autistic and non-autistic) revealed no significant differences in the timing of sexual experiences. Autistic individuals were significantly more likely to indicate that they wanted to learn more about gender identity, sexual orientation, consent, and assertiveness than non-autistic peers. However, the majority of all participants across diagnostic groups wanted more information across all surveyed topics.

CONCLUSIONS

Lack of differences in timing of sexuality-related experiences highlights the importance of beginning sexuality and relationship education early for all learners. Important diagnostic group differences highlight critical areas of development for sexuality and relationship education programming. The importance of incorporating needs of autistic learners into program design is highlighted for future work. Overall findings support the idea that more sexuality and relationship education across the lifespan would best meet the learning needs of all people.

Sexual and reproductive health services for autistic young people in the United States: A conceptual model of utilization

BACKGROUND

Sexual and reproductive health services promote the ability of people to have safe, satisfying, non-coercive sexual experiences and make informed decisions about pregnancy. Stakeholder input is needed to understand barriers or facilitators to service access for autistic people, who report unmet needs.

METHODS

We recruited 18 autistic people, 15 parents, and 15 service providers in the United States to participate in an interview and two surveys. Using their input, we created a conceptual model of sexual and reproductive health service needs, access barriers, and facilitators.

RESULTS

Stakeholders rated a variety of sexual and reproductive health services as important for autistic people, including those with intellectual disability or minimal verbal language. Stakeholders identified barriers to sexual and reproductive health service utilization including lack of service availability, lack of service providers with autism or neurodiversity training, lack of accurate information about autism and sexuality, verbal and communication differences that are not accommodated by service providers, and socio-cultural attitudes about sexuality. Stakeholders identified facilitators to service access including person-centered, trauma-informed care, service accommodations such as clear and detailed expectations, and long-enough appointments. We created a conceptual model based on the social ecological model of health to organize these utilization factors and support future research, provider, and policy action. Stakeholders provided feedback and responded favorably on the model's accuracy, utility for spurring research, practice, and policy improvements, and application to diverse groups of autistic people.

CONCLUSIONS

The model shows the many feasible ways to support equitable access to services for autistic people.

Sex-specific mechanisms for eating disorder risk in men and women with autistic traits: the role of alexithymia

BACKGROUND

A poorly understood relationship exists between eating disorders (ED) and autism spectrum conditions (ASC: henceforth 'autism'). ED are more prevalent in autistic people and people with high autistic traits, and autistic features are prognostic of longer illness. Aiming to understand what increases the risk of ED in relation to autism and autistic traits, previous research has implicated alexithymia as a causal mechanism in this relationship. These studies could not, however, disentangle whether alexithymia explains the relationship between ED pathology and autistic traits directly or through its impact on anxious/depressive symptoms, which in turn result in higher ED symptomatology. Moreover, despite evidence for sex differences in the aetiology of ED, little research has examined the impact of sex on these relationships.

METHODS

Focusing on the association between autistic traits and ED psychopathology, we examined independent mediating effects of alexithymia and anxious/depressive symptoms, as well as sequential mediation effects where alexithymia affects ED psychopathology via its impact on anxious/depressive symptoms. Participants were 198 men and 265 women with formally diagnosed and suspected ED, who completed an online survey of standardised scales.

RESULTS

In men, higher autistic traits were associated with ED psychopathology sequentially via greater alexithymia and through that, greater depressive/anxious symptoms. In women, alexithymia mediated the relationship between autistic traits and ED psychopathology both directly and sequentially through its impact on anxious/depressive symptoms. Interestingly, depressive/anxious symptoms also mediated that relationship independently from alexithymia.

CONCLUSIONS

While cross-sectional, these findings suggest that the relationship between autistic traits and ED symptomatology is mediated by other variables. In support of its proposed role in the aetiology of ED, alexithymia was directly associated with ED symptoms in women. It also affected ED symptoms indirectly, in all participants, via its effect on depressive/anxious symptoms. Interventions focusing on alexithymia may facilitate recovery not only via their effect on ED, but via their effect on other forms of state psychopathology which contribute to the maintenance and development of ED. Sex differences, however, reflect that alternative therapeutic targets for men and women may be beneficial.

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.

Gendered play behaviours in autistic and non-autistic children: A population-based cohort study

LAY ABSTRACT

Non-autistic children tend to show gendered patterns of play behaviours - boys are more likely to play with 'masculine' toys, and girls are more likely to play with 'feminine' toys. However, little is known about whether autistic children follow these patterns as well. We looked at the masculinity and femininity of autistic and non-autistic children's play behaviours at multiple time points. Parents reported their children's play behaviours at ages 30, 42 and 57 months, and children reported their own play behaviours at 8 years old. We found no difference between autistic and non-autistic girls, who both showed more feminine play behaviours as they got older. Autistic boys' play behaviours were reported as less masculine than non-autistic boys at 42 and 57 months, and at 8 years old. We also found that non-autistic boys' play tended to become more masculine as they got older, but this was not the case for autistic boys. Our findings suggest that differences in autistic and non-autistic boys' play behaviours may develop at around 42 months old.

Barriers to healthcare and their relationship to well-being and social support for autistic adults during COVID-19

AIM

The present study aimed to investigate barriers to healthcare and their relationships to social and emotional well-being and intersectional inequalities for autistic adults during COVID-19 restrictions in the UK.

BACKGROUND

Autistic adults experience severe health inequalities and report more barriers to accessing health services compared to other both disabled and non-disabled populations. The COVID-19 pandemic has impacted many areas of society that may have increased vulnerability of autistic people to social and health inequalities, including delivery of healthcare from in-person to remote methods.

METHOD

One hundred twenty-eight autistic adults who lived in the UK took part in an online survey. Measures included the Barriers to Healthcare Checklist (Short Form) and PROMIS outcome measure bank to assess emotional well-being and social support. Participants rated their agreement with items, retrospectively considering three different points of the trajectory of COVID-19 restrictions: before COVID-19, during the first lockdown in spring 2020, and in the month prior to taking the survey during autumn 2020. They completed a follow-up survey six months later to continue to assess change as restrictions in the UK were eased.

FINDINGS

The average number of barriers to healthcare showed no significant change between all four time points. However, the nature of barriers to healthcare changed at the point of lockdown and persisted beyond the easing of COVID-19 restrictions. Barriers to healthcare were associated with some social and emotional well-being variables and demographic groups including gender, education and presence of additional disabilities. The findings may help to identify areas to target to improve access to both remote and in-person health systems for autistic people as modes of delivery continue to change over time.

Omar ZT, Segun E, Evbayekha EO, Abolurin A, Egberuare EO, Ezegbe HC, Adegbosin A, Adedeji AG, Angaye EG, Izundu IC, Oyelade BO. Impact of Adverse Childhood Experiences on Resilience and School Success in Individuals With Autism Spectrum Disorder and Attention-Deficit Hyperactivity Disorder

Adolescents with emotional and behavioral disorders face known academic challenges and poor life outcomes. It was imperative to explore and find if the new diagnostic criterion for diagnosing autism profoundly affects educational outcomes and resilience in individuals diagnosed with co-occurring autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD). The literature is robust on the impact of adverse childhood experiences (ACEs) on educational outcomes and resilience in adolescents with no history of disability. Still, there remains a dearth of literature explaining, with no ambiguity, the complex relationships between ACEs and resilience, school engagement, and success in individuals with co-occurring ASD and ADHD. This study reviews the existing scholarships on the topic. The significance of this review is that it informs healthcare providers, rehabilitation counselors, and educators about the need for early identification of individuals with ASD and ADHD with a background in ACEs. This will enable interventions early enough to ensure they are more resilient and can obtain improved success in school-related and outside-school activities and eventually improved quality of life.

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.

A capabilities approach to understanding and supporting autistic adulthood

There is little comprehensive research into autistic adulthood, and even less into the services and supports that are most likely to foster flourishing adult autistic lives. This limited research is partly because autism is largely conceived as a condition of childhood, but this focus of research has also resulted from the orthodox scientific approach to autism, which conceptualizes autistic experience almost entirely as a series of biologically derived functional deficits. Approaching autism in this way severely limits what is known about this neurodevelopmental difference, how research is conducted and the services and supports available. In this Review, we adopt an alternative research strategy: we apply Martha Nussbaum’s capabilities approach, which focuses on ten core elements of a thriving human life, to research on autistic adulthood. In doing so, we identify areas where autistic adults thrive and where they often struggle, and highlight issues to which researchers, clinicians and policymakers should respond. The resulting picture is far more complex than conventional accounts of autism imply. It also reveals the importance of engaging autistic adults directly in the research process to make progress towards genuinely knowing autism and supporting flourishing autistic lives.

The focus on functional deficits in conventional autism research constrains understanding of autistic lives. In this Review, Pellicano et al. appraise research on autistic adulthood through a capabilities lens to identify areas where autistic adults thrive, and where more research and services are needed to enhance their quality of life.

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.

Increased perceived stress is negatively associated with activities of daily living and subjective quality of life in younger, middle, and older autistic adults

Few studies have examined self‐reported perceived stress in autistic adults. Existing studies have included relatively small, predominantly male samples and have not included older autistic adults. Using a large autistic sample (N = 713), enriched for individuals designated female at birth (59.3%), and spanning younger, middle, and older adulthood, we examined perceived stress and its associations with independence in activities of daily living and subjective quality of life (QoL). Perceived stress for autistic adults designated male or female at birth was compared to their same birth‐sex counterparts in a general population sample. In addition, within the autistic sample, effects of sex designated at birth, age, and their interaction were examined. Regression modeling examined associations between perceived stress and independence in activities of daily living and domains of subjective QoL in autistic adults, after controlling for age, sex designated at birth, and household income. Autistic adults reported significantly greater perceived stress than a general population comparison sample. Relative to autistic adults designated male at birth, those designated female at birth demonstrated significantly elevated perceived stress. Perceived stress contributed significantly to all regression models, with greater perceived stress associated with less independence in activities of daily living, and poorer subjective QoL across all domains—Physical, Psychological, Social, Environment, and Autism‐related QoL. Findings are contextualized within the literature documenting that autistic individuals experience elevated underemployment and unemployment, heightened rates of adverse life events, and increased exposure to minority stress.

The Operationalisation of Sex and Gender in Quantitative Health-Related Research: A Scoping Review

Current trends in quantitative health research have highlighted the inadequacy of the usual operationalisation of sex and gender, resulting in a growing demand for more nuanced options. This scoping review provides an overview of recent instruments for the operationalisation of sex and gender in health-related research beyond a concept of mutually exclusive binary categories as male or masculine vs. female or feminine. Our search in three databases (Medline, Scopus and Web of Science) returned 9935 matches, of which 170 were included. From these, we identified 77 different instruments. The number and variety of instruments measuring sex and/or gender in quantitative health-related research increased over time. Most of these instruments were developed with a US-American student population. The majority of instruments focused on the assessment of gender based on a binary understanding, while sex or combinations of sex and gender were less frequently measured. Different populations may require the application of different instruments, and various research questions may ask for different dimensions of sex and gender to be studied. Despite the clear interest in the development of novel sex and/or gender instruments, future research needs to focus on new ways of operationalisation that account for their variability and multiple dimensions.

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.

Loving Objects: Can Autism Explain Objectophilia?

Objectophilia (also known as objectum-sexuality) involves romantic and sexual attraction to specific objects. Objectophiles often develop deep and enduring emotional, romantic, and sexual relations with specific inanimate (concrete or abstract) objects such as trains, bridges, cars, or words. The determinants of objectophilia are poorly understood. The aim of this paper is to examine the determining factors of objectophilia. We examine four hypotheses about the determinants of objectophilia (pertaining to fetishism, synesthesia, cross-modal mental imagery, and autism) and argue that the most likely determining factors of objectophilia are the social and non-social features of autism. Future studies on the determinants of objectophilia could enhance our understanding and potentially lessen the marginalization experienced by objectophiles.

Autistic Traits, Empathizing-Systemizing, and Gender Diversity

Previous research indicates a link between autism and transgender and gender-diverse identities, though the association is not yet fully understood. The current study examined autistic traits (Autism Spectrum Quotient [AQ]), empathizing (Empathizing Quotient-Short [EQ-S]), and systemizing (Systemizing Quotient-Short [SQ-S]) in a sample of 89 adults and aimed to test whether gender-diverse individuals exhibit cognitive profiles consistent with predictions derived from the Extreme Male Brain (EMB) theory. As most research has considered only cisgender people, we recruited a more diverse sample by contacting > 200 UK LGBTQ+ organizations and posting on social media. A range of non-cisgender identities (e.g., transgender male, transgender female, non-binary, genderqueer, transmasculine) and non-heterosexual orientations (e.g., bisexual) were represented, and participants were categorized into one of four groups: (1) assigned female at birth but does not identify as female (transgender AFAB) (n = 32), (2) cisgender female (n = 21), (3) assigned male at birth but does not identify as male (transgender AMAB) (n = 18), and (4) cisgender male (n = 18). After controlling for age and autism diagnostic status, transgender AFAB participants had marginally higher AQ scores, and significantly higher SQ-S and systemizing-relative-to-empathizing (D) scores, compared with the cisgender female group. No such differences were detected between the transgender AMAB and cisgender male groups. Our findings are broadly in line with predictions derived from the EMB theory, though as no transgender AFAB participants reported being heterosexual, it was not possible to determine whether these effects relate specifically to gender identity, to sexual orientation, or to both.

Are Autism Spectrum Disorder and Asexuality Connected?

Asexuality is a lack of sexual attraction to any gender. There is some evidence to suggest that many self-identified asexuals have a formal diagnosis of autism spectrum disorder which is characterized by deficits in social interaction and communication, as well as by restricted and repetitive interests and behaviors. Additionally, the literature shows that asexuality and lack of sexual attraction or low sexual interest is overrepresented in people with autism spectrum disorder compared with neurotypical samples. Nevertheless, no studies have been conducted to investigate the relationship between autism and asexuality in depth. We conducted a systematic review of the literature to examine whether asexuality and autism spectrum disorder are connected. We conclude that asexuality and autism share various aspects, such as a possible role of prenatal factors, reference to romantic dimensions of sexual attraction and sexual orientation, and non-partner-oriented sexual desire, but future research should explore and clarify this link.

A conceptual model of risk and protective factors for autistic burnout

Early qualitative research indicates that autistic burnout is commonly experienced by autistic people and is associated with significant, negative consequences for their mental health, wellbeing, and quality of life, including suicidality. Findings to date suggest that factors associated with being autistic and the widespread lack of autism awareness and acceptance within society contribute to the onset and recurrence of autistic burnout. Based on autistic adults' descriptions of their lived experiences, a Conceptual Model of Autistic Burnout (CMAB) is proposed, which describes a series of hypothesized relationships between identified risk and protective factors that may contribute to, or buffer against, autistic burnout. The theoretical framework for the CMAB is based on the Social-Relational model of disability and neurodiversity paradigm, and the Job Demands-Resources model of burnout, and Conservation of Resources theory. The CMAB offers a holistic perspective for understanding individual, social, and environmental factors that can influence autistic burnout via various direct and indirect pathways. Autistic burnout research is in its infancy and the CMAB provides a foundation for future investigations about this condition. LAY SUMMARY: Although many autistic people describe experiencing autistic burnout, there has been little research on this topic. Based on descriptions of autistic peoples' lived experiences, we developed a conceptual model to explore how various risk and protective factors may interact to contribute to, or prevent, autistic burnout.

Care of Transgender Patients: A General Practice Quality Improvement Approach

Primary care must ensure high quality lifelong care is offered to trans and gender minority patients who are known to have poor health and adverse healthcare experiences. This quality improvement project aimed to interrogate and audit the data of trans and gender minority patients in one primary care population in England. A new data collection instrument was created examining pathways of care, assessments and interventions undertaken, monitoring, and complications. General practitioners identified a sample from the patient population and then performed an audit to examine against an established standard of care. No appropriate primary care audit standard was found. There was inconsistency between multiple UK gender identity clinics’ (GIC) individual recommended schedules of care and between specialty guidelines. Using an international, secondary care, evidence-informed guideline, it appeared that up to two-thirds of patients did not receive all recommended monitoring standards, largely due to inconsistencies between GIC and international guidance. It is imperative that an evidence-based primary care guideline is devised alongside measurable standards. Given the findings of long waits, high rates of medical complexity, and some undesired treatment outcomes (including a fifth of patients stopping hormones of whom more than half cited regret or detransition experiences), this small but population-based quality improvement approach should be replicated and expanded upon at scale.

"No Way Out Except From External Intervention": First-Hand Accounts of Autistic Inertia

This study, called for by autistic people and led by an autistic researcher, is the first to explore ‘autistic inertia,’ a widespread and often debilitating difficulty acting on their intentions. Previous research has considered initiation only in the context of social interaction or experimental conditions. This study is unique in considering difficulty initiating tasks of any type in real life settings, and by gathering qualitative data directly from autistic people. Four face-to-face and 2 online (text) focus groups were conducted with 32 autistic adults (19 female, 8 male, and 5 other), aged 23–64 who were able to express their internal experiences in words. They articulate in detail the actions they have difficulty with, what makes it easier or harder to act, and the impact on their lives. Thematic analysis of the transcripts found four overarching themes: descriptions of inertia, scaffolding to support action, the influence of wellbeing, and the impact on day-to-day activities. Participants described difficulty starting, stopping and changing activities that was not within their conscious control. While difficulty with planning was common, a subset of participants described a profound impairment in initiating even simple actions more suggestive of a movement disorder. Prompting and compatible activity in the environment promoted action, while mental health difficulties and stress exacerbated difficulties. Inertia had pervasive effects on participants’ day-to-day activities and wellbeing. This overdue research opens the door to many areas of further investigation to better understand autistic inertia and effective support strategies.

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.

Sexual and Gender Minority Health in Neurology: A Scoping Review

Importance

Little is known about the neurologic health needs of sexual and gender minority (SGM) individuals, and existing research indicates health care disparities for this group.

Objective

To describe the current state of science in SGM neurology and highlight areas of knowledge and gaps to guide future research.

Evidence Review

All articles published before April 12, 2020, in PubMed, Embase, Web of Science, PsycInfo, CINAHL, and BIOSIS Previews were searched using a search string encompassing SGM descriptors and neurologic disorders. A total of 8359 items were found and entered into EndNote, and 2921 duplicates were removed. A blind title and abstract review was performed followed by full-text review in duplicate, with conflicts settled through consensus, to identify 348 articles eligible for data abstraction. Articles presenting primary data about an identified adult SGM population addressing a clinical neurology topic were included. Descriptive statistics were used for abstracted variables.

Findings

Of 348 studies, 205 (58.9%) were case reports or series, 252 (72.4%) included sexual minority cisgender men, and 247 (70.9%) focused on HIV. An association was found between autism spectrum disorder and gender dysphoria in 9 of 16 studies (56.3%), and a higher risk of ischemic stroke in transgender women was shown in other studies. Literature in neuroinfectious disease, the most common topic, largely focused on HIV (173 of 200 studies [86.5%]). Findings in other neurologic topics were limited by lack of data.

Conclusions and Relevance

In this rigorous compendium of SGM neurology literature, several deficiencies were found: most studies focused on a limited breadth of neurologic pathology, included only a portion of the overall SGM community, and did not assess other aspects of sociodemographic diversity that may contribute to disparities in health care access and outcomes among SGM individuals. Expanding neurologic research to include broader representation of SGM individuals and incorporating sociodemographic factors, like race/ethnicity and socioeconomic status, are essential steps toward providing equitable neurologic care for this community.

Testing a Model of Sexual Minority Orientation in Individuals with Typical Development, the Broad Autism Phenotype, and Autism Spectrum Disorder

Individuals with Autism Spectrum Disorder (ASD) and the Broad Autism Phenotype (BAP) are more likely than individuals with typical development (TD) to report a sexual minority orientation (e.g., Bejerot and Eriksson, PLoS ONE 9:1-9, 2014; DeWinter et al., Journal of Autism and Developmental Disorders 47:2927-2934, 2017; Qualls et al., Journal of Autism and Developmental Disorders 48:3974-3983, 2018). This study operationalized and tested the fit of an existing model of sexual orientation to examine which factors are associated with increased sexual minority orientation (Worthington et al., The Counseling Psychologist 30:496-531, 2002) in individuals with TD, BAP, and ASD. The model was found to have adequate fit, χ² (130) = 374.04, p < 0.001; RMSEA = 0.07; CFI = 0.95; SRMR = 0.08. Heterosexism was found to be the only predictor of sexual minority orientation and a significant predictor in the BAP and ASD groups, with increased daily heterosexist experiences predicting greater sexual minority orientation in these groups.

Brief Report: Links Between Nonconformity to Gender Norms, Autistic Features, and Internalizing Symptoms in a Non-clinical College Sample

Research shows elevated gender variance among autistic people and more autistic traits among gender diverse people, each of which is related to mental health concerns. Little work has explored broad features of these presentations in a non-clinical sample. College students (n = 174) ages 18-22 years completed questionnaires assessing the broader autism phenotype (BAP), autistic features, nonconformity to gender norms, and internalizing symptoms. Those with more BAP features or autistic communication reported more nonconformity to gender norms. Higher levels of internalizing symptoms were related to more gender nonconformity, BAP, and autistic features. Gender nonconformity marginally moderated the effect of BAP on depression but not anxiety. The BAP, autistic features, and gender nonconformity are important in understanding mental well-being.

Exploring Three Core Psychological Elements When Treating Adolescents on the Autism Spectrum: Self-Awareness, Gender Identity, and Sexuality

For those growing up on the autism spectrum, adolescence is associated with unique challenges. This narrative review explores three core psychological elements for clinicians to consider when treating adolescents on the autism spectrum: self-awareness, gender identity, and sexuality. Developmental tasks of adolescence include adaptation to a maturing mind and body, increased expectations for independence, and the ability to establish satisfying interpersonal relationships. What are welcome opportunities for non-autistic peers can become nearly insurmountable hurdles for autistic teens, which, in turn, could lead to crisis, particularly if skills needed for success in managing these tasks have not yet been acquired.

The presentation, recognition and diagnosis of autism in women and girls

Purpose

Autistic women and girls have received comparatively less attention within clinical practice and research. Research suggests women tend to be diagnosed later than men, and are more likely to experience misdiagnosis.

Design/methodology/approach

This paper aims to report a narrative literature review that examines research on the presentation, recognition, and diagnosis of autistic women and girls.

Findings

Findings suggest that autistic females present differently to males and highlight low recognition of the female presentation of autism among the general public, in social spheres, educational, clinical and forensic settings. This lack of recognition appears to affect the likelihood of females being referred for diagnosis, the reliability of diagnostic assessments and subsequent access to support.

Originality/value

Recommendations for clinical practice focus on initiatives to increase awareness of the female presentation of autism, improving the diagnostic process for females, increasing female representation within autism training and for future research to support these goals.

Sexuality and Gender Issues in Individuals with Autism Spectrum Disorder

This article reviews relevant literature on sexuality in individuals with autism spectrum disorder (ASD). Findings reveal a growing awareness of desire for sexual and intimate relationships in individuals with ASD. However, core impairments of ASD lead to difficulties establishing requisite knowledge and skills necessary to attain a healthy sexuality and facilitate relationships. Consequently, individuals with ASD present with increased risk of engaging in inappropriate sexual behaviors and sexual victimization than their typically developing peers. The literature asserts the need to implement effective sexual education programs to assist in development of healthy sexual identity and relationships that meet each individual's needs.