The Intersection of Autism and Transgender and Nonbinary Identities:Community and Academic Dialogue on Research and Advocacy

Many transgender people are autistic. Community expressions of the autism transgender intersection abound. Some commentators have questioned the proportional overrepresentation of autism among gender-diverse people, suggesting these individuals may not be truly autistic or truly transgender. However, increasing evidence challenges assertions that deny the authenticity of co-occurring autistic and transgender identities. Specifically, research by authors of this article indicates autistic transgender people show neurophenotypes generally consistent with cisgender autistic people and implicit gender phenotypes consistent with nonautistic transgender people. This article features a dialogue between eight leading experts in the field of intersectional autism and gender diversity, including clinicians, researchers, community advocates, and experts who are themselves autistic transgender. Key topics of discussion included: how research findings on autism and gender diversity inform respectful and supportive responses to autistic transgender people; the benefits and harms of increased societal attention toward the autism transgender intersection; and research and advocacy priorities. The expert panel concluded the following: (1) it is important to respect transgender autistic people’s wellness and resilience, while also acknowledging the pathologization and stigmatization they face; (2) autistic gender-diverse people are experts of their own identity and should be involved in all aspects of research and clinical care; (3) research is needed to understand the disparities autistic transgender people face; (4) attempts to restrict autistic transgender people’s access to gender care are unsupported by existing research; (5) adult gender care may benefit from incorporating universal design principles and neurodiversity-affirming strategies to reduce barriers to care and improve clinician–client communication in treatment delivery and the informed consent process; (6) cross-cultural and cross-societal research will improve best care practices in diverse contexts; (7) research and advocacy must be inclusive across ethnoracial identities, including in leadership and perspectives represented; and (8) a life span developmental framework is needed for adult research in this field.</p

The Toronto Adolescent and Youth Cohort Study:Study Design and Early Data Related to Psychosis Spectrum Symptoms, Functioning, and Suicidality

BACKGROUND: Psychosis spectrum symptoms (PSSs) occur in a sizable percentage of youth and are associated with poorer cognitive performance, poorer functioning, and suicidality (i.e., suicidal thoughts and behaviors). PSSs may occur more frequently in youths already experiencing another mental illness, but the antecedents are not well known. The Toronto Adolescent and Youth (TAY) Cohort Study aims to characterize developmental trajectories in youths with mental illness and understand associations with PSSs, functioning, and suicidality.METHODS: The TAY Cohort Study is a longitudinal cohort study that aims to assess 1500 youths (age 11-24 years) presenting to tertiary care. In this article, we describe the extensive diagnostic and clinical characterization of psychopathology, substance use, functioning, suicidality, and health service utilization in these youths, with follow-up every 6 months over 5 years, including early baseline data.RESULTS: A total of 417 participants were enrolled between May 4, 2021, and February 2, 2023. Participants met diagnostic criteria for an average of 3.5 psychiatric diagnoses, most frequently anxiety and depressive disorders. Forty-nine percent of participants met a pre-established threshold for PSSs and exhibited higher rates of functional impairment, internalizing and externalizing symptoms, and suicidality than participants without PSSs.CONCLUSIONS: Initial findings from the TAY Cohort Study demonstrate the feasibility of extensive clinical phenotyping in youths who are seeking help for mental health problems. PSS prevalence is much higher than in community-based studies. Our early data support the critical need to better understand longitudinal trajectories of clinical youth cohorts in relation to psychosis risk, functioning, and suicidality.</p

Behavioral and Emotional Problems in Gender-Nonconforming Children: A Canadian Community-Based Study

Objective: To examine childhood gender nonconformity (GNC) and psychological well-being in a community-based sample using measures that bridge clinical and nonclinical literature. Method: Caregivers reported on the GNC (Gender Identity Questionnaire for Children [GIQC]) and behavioral and emotional problems (Child Behavior Checklist [CBCL]) of their children aged 6 to 12 years (N = 1719, 48.8% boys). The GIQC was compared to the commonly used single-item proxy, CBCL Item 110 (“wishes to be of the opposite sex”). Results: Using the GIQC, 2.3% of boys and 2.8% of girls showed GNC levels comparable to those of children referred clinically for gender dysphoria (GD). Item 110 was endorsed for 1.7% of boys and 1.8% of girls. These measures corresponded, but Item 110 endorsement was biased toward more extreme GNC. Among boys, increased GNC on the GIQC, but not Item 110, corresponded with increased clinical-range CBCL problems. Among girls, Item 110 endorsement was associated with increased clinical-range Externalizing problems, whereas the GIQC indicated that intermediate gender expression was associated with fewer externalizing problems. Overall, rates of clinical-range CBCL problems among GNC children were consistent with those reported for GD-referred children. Conclusion: The scope of mental health risk among community children who exhibit GNC is likely considerably greater than previously recognized. A substantial minority of community children show GNC and mental health risk levels comparable to those seen among GD-referred children. Also, compared to the GIQC, a more comprehensive GNC measure, CBCL Item 110 is likely useful only for detecting extreme manifestations of GNC, which may affect associations with mental health

An examination of the biodevelopment of gender expression in children ages 6- to 12-years

Previous clinical research on children who experience gender dysphoria has demonstrated links between marked childhood gender variant behaviour and several variables thought to provide a window on biological processes affecting brain sexual differentiation during the pre-/perinatal period. These variables include handedness, birth order, and birth weight. The present study investigated, via parent-report, whether these factors were associated with inter-individual variation in childhood gender expression in a large community sample (n ¼ 2377, 51.4% boys). Consistent with previous studies, elevated gender variance was associated with non-right-handedness in boys and girls, and later fraternal birth order in boys. In contrast to prior clinical studies, there were no associations between gender expression and birth order in girls, and no interactions of birth weight and birth order in predicting gender variance in boys. Thus, handedness in both genders and late fraternal birth order in boys appear to apply widely as predictors of inter-individual variation in childhood gender expression, whereas the other factors examined here may only predict more marked levels of gender variance as examined in previous clinical research of children who experience gender dysphoria

Prevalence of the Wish to be of the Opposite Gender in Adolescents and Adults with Autism Spectrum Disorder

Several studies have suggested an overrepresentation of (symptoms of) autism spectrum disorder (ASD) among individuals with gender dysphoria. Three studies have taken the inverse approach in children with ASD and showed increased parent report of the wish to be of the opposite gender in this group. This study compared the self-reported wish to be of the opposite gender (one item of the Youth Self-Report [YSR] and the Adult Self-Report [ASR]) of 573 adolescents (469 assigned boys and 104 assigned girls) and 807 adults (616 assigned males and 191 assigned females) with ASD to 1016 adolescents and 846 adults from the general population. Emotional and behavioral problems were measured by the DSM-oriented scales of the YSR and ASR. In addition, the Children's Social Behavior Questionnaire and the Adult Social Behavior Questionnaire were used to measure specific subdomains of the ASD spectrum to test whether specific subdomains of ASD were particularly involved. Significantly more adolescents (6.5%) and adults (11.4%) with ASD endorsed this item as compared to the general population (3-5%). In adolescents, assigned girls endorsed this item more than assigned boys. No significant gender differences were found in the adults with ASD. In addition, on all DSM-oriented scales of both the YSR and ASR, adolescents and adults with ASD who endorsed the gender item had significantly higher scores compared to those without. There were no significant associations between endorsement of the gender item and any specific subdomain of ASD, providing no evidence for a sole role of one of the ASD subdomains and endorsement of the wish to be the opposite gender

Autistic Symptoms in Children and Adolescents with Gender Dysphoria

Studies have shown an increase of symptoms of autism spectrum disorder (ASD) in gender dysphoria (GD). Various hypotheses try to explain this possible co-occurrence (e.g., a role of resistance to change, stereotyped behaviors or prenatal testosterone exposure). This study examined ASD symptoms with the Children's Social Behavior Questionnaire (CSBQ) in 490 children with GD compared to 2507 typically developing (TD) and 196 children with ASD. CSBQ total scores of the GD sample were in between scores from the TD and ASD sample. The GD sample showed elevated levels of autistic symptomatology on all subdomains, not only on stereotyped and resistance to change. Further, no gender differences and interaction effects were found on the total CSBQ, making a sole role for prenatal testosterone unlikely

Separation anxiety and gender variance in a community sample of children

In clinical child and retrospective adult samples, childhood gender variance (GV; i.e., cross-gender behaviour) has been associated with separation anxiety (SA; i.e., distress related to separation from attachment figures) in males. This study examined GV and SA in a nonclinical sample of 892 boys and 933 girls aged 6–12 years via parent-reports. Parental factors (i.e., parenting style, parent–child relationship, willingness to serve as an attachment figure, attitudes towards gender stereotypes in children) were examined as potential moderators. GV predicted SA in boys, even when statistically controlling for general psychopathology and demographic variables. Authoritative parenting, closeness in the parent–child relationship, willingness to serve as an attachment figure, and liberal attitudes towards gender stereotypes in children moderated the association between GV and SA in both boys and girls. Thus, SA may be a unique internalizing problem related to GV in boys in nonclinical samples and influenced by a variety of parental factors

Gay, lesbian, and gender nonconforming individuals with autism

Historically, it has been assumed that autistic individuals were asexual or maladaptive in their sexual behavior. No distinction in this was made by gender. It is now clear that autistic men and autistic women express a desire for a level of sexuality similar to non-autistic individuals; have satisfying experiences like non-autistic individuals; and have some specific difficulties including communication with others, and for autistic women increased victimization. Compared to the general population sexual desire is similar for autistic men, but lower for autistic women, whereas, rates of sexual encounters and relationships are similar for autistic women, while lower for autistic men. Gender and sexual orientation are more diverse among autistic individuals, which intersect with autism to increase mental health risks. Forensically, victimization is higher among both male and female autistic individuals, but there is little evidence that autistic men are more likely to have sexually offended than others in the general population. Finally, there are some well-developed programs to support autistic individuals to explore, develop, and understand their own sexuality; however, much remains to be understood, particularly in the influence of older age, elder-status, and ID upon sexuality in either gender.<br/

Re-evaluation of the Dutch approach: are recently referred transgender youth different compared to earlier referrals?

The background of this article is to examine whether consecutively transgender clinic-referred adolescents between 2000 and 2016 differ over time in demographic, psychological, diagnostic, and treatment characteristics. The sample under study consisted of 1072 adolescents (404 assigned males, 668 assigned females, mean age 14.6 years, and range 10.1–18.1 years). The data regarding the demographic, diagnostic, and treatment characteristics were collected from the adolescents’ files. Psychological functioning was measured by the Child Behaviour Check List and the Youth Self-Report, intensity of gender dysphoria by the Utrecht Gender Dysphoria Scale. Time trend analyses were performed with 2016 as reference year. Apart from a shift in sex ratio in favour of assigned females, no time trends were observed in demographics and intensity of dysphoria. It was found, however, that the psychological functioning improved somewhat over time (CBCL β − 0.396, p < 0.001, 95% CI − 0.553 to − 0.240, YSR β − 0.278, p < 0.001, 95% CI − 0.434 to − 0.122). The percentage of referrals diagnosed with gender dysphoria (mean 84.6%, range 75–97.4%) remained the same. The percentage of diagnosed adolescents that started with affirmative medical treatment (puberty suppression and/or gender-affirming hormones) did not change over time (mean 77.7%; range 53.8–94.9%). These findings suggest that the recently observed exponential increase in referrals might reflect that seeking help for gender dysphoria has become more common rather than that adolescents are referred to gender identity services with lower intensities of gender dysphoria or more psychological difficulties

Gay, lesbian, and gender nonconforming individuals with autism

Historically, it has been assumed that autistic individuals were asexual or maladaptive in their sexual behavior. No distinction in this was made by gender. It is now clear that autistic men and autistic women express a desire for a level of sexuality similar to non-autistic individuals; have satisfying experiences like non-autistic individuals; and have some specific difficulties including communication with others, and for autistic women increased victimization. Compared to the general population sexual desire is similar for autistic men, but lower for autistic women, whereas, rates of sexual encounters and relationships are similar for autistic women, while lower for autistic men. Gender and sexual orientation are more diverse among autistic individuals, which intersect with autism to increase mental health risks. Forensically, victimization is higher among both male and female autistic individuals, but there is little evidence that autistic men are more likely to have sexually offended than others in the general population. Finally, there are some well-developed programs to support autistic individuals to explore, develop, and understand their own sexuality; however, much remains to be understood, particularly in the influence of older age, elder-status, and ID upon sexuality in either gender