Apparent autistic traits in transgender people: a prospective study of the impact of gender-affirming hormonal treatment

Changes in affect variability after starting gender-affirming hormone therapy

Negative affect variability is determined by how often and how strongly negative affect changes over time. Cisgender women report greater variability in affect than cisgender men. It has been suggested that sex hormone changes may influence affect variability. Transgender people frequently opt to use sex hormones in the form of gender-affirming hormone therapy (GAHT), but the extent to which GAHT can change negative affect variability is not yet clear. Therefore, this study aims to study changes in negative affect variability after starting GAHT. We have included data from 92 participants from the RESTED study: 47 persons starting masculinizing hormones (MH), i.e. testosterone, and 45 persons starting feminizing hormones (FH), i.e., estrogens and anti-androgens. Participants completed up to 7 consecutive daily diaries at each of three time points: before starting GAHT, and after 3 and 12 months of GAHT. The daily diaries collected participants' reports on symptoms related to negative affect: experienced low mood, less interest, tense feelings and restless feelings. We have used linear mixed models to compare negative affect variability during one week, corrected for mean negative affect, between groups (MH versus FH) and measurement time points. Results show that in the MH group, variability in tense feelings and restless feelings decreased after 3 and 12 months of GAHT, respectively. In the FH group, variability in low mood increased after 3 months and 12 months of GAHT, as did variability in restless feelings after 12 months of GAHT. Group comparisons indicate significant group differences in changes in variability in low mood and restless feelings, with stronger increases in variability of negative affect in the FH group compared to MH group after 3 and 12 months of GAHT. Our findings indicate that variability patterns in negative affect in transgender persons change after starting GAHT, with participants who start masculinizing hormones moving to a profile which more closely resembles that of cisgender men and participants who start feminizing hormones moving to a profile which more closely resembles that of cisgender women. Future studies should focus on measuring both negative and positive affect variability during GAHT, preferably through multiple measurements per day, taking into account diverse social and daily contextual factors during GAHT.

Is it still autism? The increasing broadening of the autism spectrum

Clinical significance of a broad autism phenotype (BAP) seems to be increasingly supported by growing reports of high prevalence of subthreshold autism spectrum disorder (sASD) or autistic traits (AT) in various demographic samples, particularly in individuals with psychiatric conditions. We question this increasing extension of the autism spectrum and its potential negative consequences for clinical services, research, cultural attitudes, and resource allocation, as well as alternative explanations of what is currently attributed to sASD and AT. In modern psychiatry the diagnostic threshold is paramount and associated with a significant impairment of functioning, implying that symptom specificity is more relevant than sensitivity. Within a syndrome, symptoms have to be present together, with the parts related to and interconnected with the whole. Single autism symptomatic dimensions have low syndromic specificity and can be observed in many different mental disorders. For instance, communication problems may present in communication disorders, social-cognitive difficulties can be found in schizophrenia, and rigid and/or repetitive behaviors can be found in obsessive compulsive disorder. One alternative interpretation of AT and/or sASD relates to personality traits. For example, within the Big 5 Model, low openness is associated with a dislike of change and a narrow range of interests, low extraversion with social withdrawal and coldness, and low agreeableness with disinterest in others and disregard for their feelings. These risks of overreliance on non-specific aspects of autism are particularly likely to occur with screening checklists, self-assessment, or assessment by a lay interviewer with only limited expertise in clinical assessment.

Autistic Characteristics in a Nationally Representative Clinical Sample of Adolescents Seeking Medical Gender-Affirming Treatment in Norway

PURPOSE

Several studies have reported on the intersection of autism and gender incongruence (GI) in clinical populations. This study aims to investigate autistic characteristics and registered autism spectrum diagnoses (ASD) in a clinical cohort of 83 adolescents referred to the National Gender Team for Children and Adolescents in Norway during 2020.

METHODS

Parents completed the Social Responsiveness Scale (SRS). Background information and registered psychiatric diagnoses were extracted from patient files.

RESULTS

The results showed that 25% of the participants scored within the clinical range on the SRS: 27.4% of adolescents who were assigned female at birth (AFAB) and 19.0% of adolescents who were assigned male at birth (AMAB). AFAB had significantly higher scores on SRS Total Scale and the Social Motivation and Autistic Mannerisms subscales compared to the female norm group. AMAB had higher scores on the Social Motivation subscale and lower scores on the Social Awareness subscale, compared to the male norm population. Information from patient files revealed that 67.5% had one or more registered psychiatric diagnosis. 9.6% had received an ASD diagnosis, all AFAB. 18.1% had received an attention deficit hyperactivity disorder (ADHD) diagnosis. The most common psychiatric diagnoses were depression (25.3%) and anxiety disorders (18.1%). Further, 44.6% had a history of self-harm, and 15.7% had a history of a suicide attempt.

CONCLUSION

The results showed an overrepresentation of ASD diagnoses and autistic characteristics measured by SRS for AFAB. There was an overrepresentation of psychiatric diagnoses for both the AFAB and the AMAB group in this study sample. Implications for treatment and future research are discussed.

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.

Engaging the AQ10 to Predict Professional Burnout or Poor Work-Related Psychological Wellbeing Among Anglican Clergy in Wales

The ten-item Autism Spectrum Quotient (AQ10) is a self-report instrument originally designed to identify referrals for professional diagnosis for Autism Spectrum Disorders (ASD). Recent studies suggest that this instrument may also be tapping more generalised affective disorders. Working with this interpretation, this study examines the predictive power of the AQ10 to account for additional variance, after personal and personality factors have been taken into account, on the two scales of the Francis Burnout Inventory. Data provided by 220 Anglican clergy serving in Wales demonstrated that 8.6% of the participants recorded six or more red flags on the AQ10 (and so qualified for referral for specialist diagnostic assessment) and that higher scores on the AQ10 are associated with significantly lower levels of satisfaction in ministry and with significantly higher levels of emotional exhaustion in ministry. These data suggest that screening with the AQ10 may be helpful in identifying clergy vulnerable to professional burnout and to poor work-related psychological wellbeing, in addition to its primary purpose of screening for ASD.

The influence of sex steroid treatment on insular connectivity in gender dysphoria

BACKGROUND

Sex-specific differences in brain connectivity were found in various neuroimaging studies, though little is known about sex steroid effects on insular functioning. Based on well-characterized sex differences in emotion regulation, interoception and higher-level cognition, gender-dysphoric individuals receiving gender-affirming hormone therapy represent an interesting cohort to investigate how sex hormones might influence insular connectivity and related brain functions.

METHODS

To analyze the potential effect of sex steroids on insular connectivity at rest, 11 transgender women, 14 transgender men, 20 cisgender women, and 11 cisgender men were recruited. All participants underwent two magnetic resonance imaging sessions involving resting-state acquisitions separated by a median time period of 4.5 months and also completed the Bermond-Vorst alexithymia questionnaire at the initial and final examination. Between scans, transgender subjects received gender-affirming hormone therapy.

RESULTS

A seed based functional connectivity analysis revealed a significant 2-way interaction effect of group-by-time between right insula, cingulum, left middle frontal gyrus and left angular gyrus. Post-hoc tests demonstrated an increase in connectivity for transgender women when compared to cisgender men. Furthermore, spectral dynamic causal modelling showed reduced effective connectivity from the posterior cingulum and left angular gyrus to the left middle frontal gyrus as well as from the right insula to the left middle frontal gyrus. Alexithymia changes were found after gender-affirming hormone therapy for transgender women in both fantasizing and identifying.

CONCLUSION

These findings suggest a considerable influence of estrogen administration and androgen suppression on brain networks implicated in interoception, own-body perception and higher-level cognition.

A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people

This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.

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.