Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals

Prevalence and Correlates of Dating Violence Victimization Among a U.S.-Based Sample of Autistic Youth

Dating violence victimization is a pervasive public health problem that affects individuals of all age groups, but it holds particular significance during adolescence due to the potential long-term consequences on an individual's physical and psychological well-being, and potential influence on the health of adult relationships. Although there is now ample research on the topic of adolescent dating violence prevalence, risk factors, and consequences, to our knowledge, only four studies have assessed dating violence victimization among autistic youth. The current study was designed to investigate the prevalence of, and risk markers for, dating violence victimization among autistic youth. Specifically, the study had two aims: (a) to estimate the prevalence of dating violence victimization among autistic youth in a U.S.-based sample and (b) to identify correlates of dating violence for autistic youth, which include sociodemographic, mental health, and alcohol-related variables. We found that among participants who were in a romantic relationship in the past year, autistic participants were not any less likely to experience dating violence victimization compared to their non-autistic counterparts (40.7% for autistic youth vs. 38.0% for non-autistic youth). In addition, findings from the current study demonstrate the significant relationships between dating violence victimization and consequences of alcohol use, loneliness, and anxiety among autistic youth. Existing studies, in addition to the results of the current study, suggest the need for tailored dating violence prevention, support, and intervention to support the overall well-being of autistic youth.

Suicidal ideation and avoidant/restrictive food intake disorder: Findings from the ARFID-GEN study

This study examined the prevalence of suicidal ideation (SI) among adults with avoidant/restrictive food intake disorder (ARFID) across different demographic groups and explored associations between SI and specific ARFID dimensions. The sample included 3299 adults who screened positive for ARFID using two validated scales. SI over the past two weeks was assessed using item 9 from the Patient Health Questionnaire-9. The overall prevalence of SI was 22.9 %, with a higher prevalence among transgender and gender-diverse (TGD) individuals (34.7 %) compared to cisgender men (17.8 %) and cisgender women (16.8 %). Participants with SI (mean = 27.6 years, SD = 10.1) were younger than those without SI (mean = 32.3 years, SD = 13.4). The ARFID dimensions picky eating/sensory-based avoidance and low appetite/lack of interest in eating or food were positively associated with SI; however, these associations became non-significant after adjusting for age, gender, and depression. Interestingly, fear/concern about aversive consequences was significantly negatively associated with SI after adjusting for covariates. Our results suggest that the fear presentation of ARFID may be a distinct subtype with a lower risk of suicidality compared to other presentations, highlighting the importance of comprehensively evaluating ARFID dimensions and underlying depressive symptoms to better address the risk of suicidality.

Behavioral manifestations and neural mechanisms of empathic pain

Empathy is an important trait that allows individuals to comprehend and share the emotions and sentiments of others. It not only facilitates effective interpersonal communication, but also helps in establishing meaningful connections and fostering trust and understanding. Impaired empathy development can manifest as excessive self-centeredness, extreme egoism, and antisocial behaviors. Many psychiatric disorders, such as autism, narcissistic personality disorder, and schizophrenia, are often accompanied by empathy disorders. Pain empathy, which is a common behavioral paradigm of empathic behavior, is not only observed in humans but also in animals. By delving into the study of pain empathy, we can gain a deeper understanding of empathy itself. This understanding not only contributes to the advancement of scientific, clinical, and social fields, but also promotes the cultivation of emotional resonance and social harmony among humans, with profound significance and impact. This article provides a brief overview of the current understanding and mechanistic studies of pain empathy, as well as suggests future research directions.

Autistic perspectives on the moral and ethical considerations of genetic testing for autism

This study aimed to characterize the nuanced perspectives expressed by Autistic adults about genetic testing for autism. In this secondary analysis of an existing dataset, we used inductive content analysis of free-text responses that Autistic adults wrote in response to questions asking about perceptions of genetic testing for autism that had been included in a previous survey. Participants who completed the survey had been recruited online. Three-hundred eighty-nine participants wrote a total of 28,774 words in response to the questions of interest. While some respondents wrote about potential benefits of genetic testing (79/389), more (333/389) wrote about potential negative outcomes of genetic testing. Participants wrote about concerns of eugenics (281/389), described a lack of trust in how genetics information would be used (125/389), and raised concerns that genetic testing could increase discrimination (66/389). This is the largest study to date to conduct an in-depth analysis of Autistic adults' opinions on genetic testing for autism. Most respondents raised serious concerns. Additional work is needed to collect more Autistic opinions about genetic testing for autism.

Gender and family-role portrayals of autism in British newspapers: An intersectional corpus-based study

A recent large-scale study on the portrayal of autism in British newspapers revealed a deficit-based coverage, which concentrated on children and boys in particular, typically represented from the mothers' perspective. This follow-up study refines these representations, considering how they differ by gender and family role. We analysed 2998 text samples, which discussed autism in the context of four combinations of gender and family roles, namely, BOY, GIRL, FATHER and MOTHER. These samples included sources with different publication dates, reporting style and political orientation. Autism representations remained negative regardless of gender and family role. Over time, stories about autistic girls started to emerge, identifying them as a distinct group explicitly compared to autistic boys. Newspapers, especially broadsheets, associated girls with diagnostic difficulties, camouflaging and sometimes gender dysphoria - discussed particularly for those assigned female at birth. The child's autism was more often attributed to maternal than paternal behaviours or lifestyle. Autistic mothers were mentioned more often than fathers and were portrayed negatively. We conclude that newspapers portray female autism as less significant than male autism and, in addition, place mothers under more ethical scrutiny than fathers. These disparities reflect both historical biases in autism research and gender and family-role stereotypes.

Focusing on autism symptoms masks sex-specific needs of autistic children: An example from the Sydney Child Neurodevelopment Research Registry

Studies have shown that there are differences between the presentations of males and females diagnosed with autism. There remains a developing understanding about how the presentation of autism differs between boys (hereafter referred to as 'assigned males at birth') and girls (assigned females at birth). This study sought to investigate the presence of sex differences in autistic children. Participants (1.11-17.97 years) attended an assessment clinic and participated in measures of intelligence/development, social/communication skills and behaviour. Adaptive skills were evaluated using a range of standardised measures, and other clinical and demographic variables were collected (e.g. age, intelligence quotient, ratio of male to female). Assigned males at birth displayed more autism characteristics and greater symptom autism severity than assigned females at birth. No significant differences were found between assigned males at birth and assigned females at birth on any measure of intelligence. Children assigned males at birth received assessments 6 months earlier than children assigned females at birth on average. Externalising behaviour problems were more evident in assigned males at birth, but statistically significant differences in adaptive skills were not apparent between assigned males at birth and assigned females at birth. This study showed assigned females at birth and assigned males at birth differ in autism symptoms and severity and age at diagnosis based on a real-world sample. It highlights the importance of balancing assessments of symptoms with assessment of adaptive function.Lay abstractStudies have shown that there is a difference between biological sex at birth in autism spectrum disorder. There remains a lack of understanding about how the symptoms of autism differ between assigned males at birth and assigned females at birth. We looked at the presence of sex differences in a large group of autistic toddlers, children and adolescents, who were seen in a large diagnosis and assessment clinic. They participated in measures of intelligence/development, social/communication skills and behaviour. Their adaptive skills were evaluated and other clinical and information were collected. Assigned males at birth displayed more autism characteristics and greater symptom autism severity than assigned females at birth. There were no statistically significant differences between assigned males at birth and assigned females at birth on any measure of intellectual assessment. Assigned females at birth showed better nonverbal performance than assigned males at birth on formal developmental assessments. Children assigned males at birth received assessments 6 months earlier than children assigned females at birth. Externalising behaviour problems were more evident in assigned males at birth. This study provides evidence to show that autistic children assigned females at birth and assigned males at birth differ in terms of autism symptoms and severity and age at diagnosis based on a sample recruited in a real-world clinic. It highlights the importance of the growing debate between balancing assessments of symptoms with assessment of adaptive function.

Obsessive-compulsive symptoms in individuals with a history of eating disorders

BACKGROUND

OCD symptoms are well documented in anorexia nervosa (AN) and to a lesser extent in bulimia nervosa (BN), yet remain virtually unstudied in binge-eating disorder (BED).

METHODS

In this cross-sectional observational study, 5927 participants with lifetime eating disorders (EDs) (i.e., past or current) were categorized into five groups based on their diagnostic histories: AN only (n = 2330), BN only (n = 740), BED only (n = 665), AN and another ED diagnosis (AN Mixed) (n = 1293), and BN and BED (BN-BED) (n = 899). Obsessive-Compulsive Inventory-12 scores were compared across these groups and with OCD (n = 1040), anxiety-related disorders (ANX) (n = 423), and non-clinical community (NCC) (n = 1194) cohorts.

RESULTS

OCD symptoms were common among individuals with lifetime AN, BN, BED, and multiple EDs, with obsessing being the most prevalent dimension, followed by ordering, checking, and washing. The obsessing scale, which captures general intrusive thoughts rather than traditional OCD obsessions, was notably high. ED groups generally scored higher on the OCI-12 subscales than the ANX and NCC cohorts but lower than the OCD cohort, although ordering severity was higher in some ED groups. Positive correlations were found between ED symptoms and OCI-12 subscales, and gender-diverse individuals and men had greater OCD symptoms than women.

CONCLUSIONS

Clinicians should be vigilant for OCD symptoms in individuals with AN, BN, and BED. These findings call for research on the mechanisms linking EDs and OCD symptoms and support integrated treatment approaches for both conditions.

[Analyzing the Care Situation for Children and Adolescents with Gender Dysphoria from the Perspective of Clinical Experts]

Analyzing the Care Situation for Children and Adolescents with Gender Dysphoria from the Perspective of Clinical Experts Abstract: Abstract. Objective: The use of healthcare services by minors with gender dysphoria has steadily increased in recent years. Long waiting times indicate the difficulties in providing professional care for this vulnerable patient group. The study analyzed the medical care situation in the German-speaking countries according to medical and/or therapeutic experts primarily treating minors with gender dysphoria. Method: We conducted 41 guideline-based interviews with experts and prepared a subsequent content analysis. Results: We could confirm an increasing demand over the last 10 years. Patients nowadays have more specific ideas and seem to be better informed. The experts attribute changes in demand to increased public presence of gender diversity, increasing tolerance and acceptance, and easier access to information. They assessed the care situation as inadequate; particularly care capacity is insufficient, and previous experiences in healthcare are often negative. The young age of the patients, comorbidities, and research gaps pose challenges regarding the indication. Patient satisfaction with somatomedical measures is rated as rather high, and experiences with detransitions are rare. Conclusions: From the experts' view, the need for health care is high and requires more research in addition to further education for social/educational and medical/psychological/therapeutic professionals.

Disability barriers autistic girls face in secondary education: A systematic review

Autistic adolescent girls face complex and diverse challenges in the school setting, specifically mental health issues, unmet social and education needs, and social exclusion. This review provides an overview of research relating to the barriers autistic females face in school settings by reporting on their experiences as well as those of autistic women reflecting on their past. This literature review presents peer-reviewed journal articles published from January 2013 to March 2023. Based on the 17 identified articles, the barriers girls face in the compulsory education setting centred on 4 themes of societal barriers grounded in gender; the institutional or physical barriers of schools; social and communicative expectations; and stigmatization. These results underscore the need for future research to centre diverse autistic lived experiences and knowledge, and autistic inclusion at all levels of participation, from self-advocacy and peer support spaces to the co-development of training and policy.Lay abstractAutistic adolescent girls face complex and diverse challenges in the school setting, specifically mental health issues, unmet social and education needs, and social exclusion. The purpose of this review was to provide a general idea of research relating to the experiences of autistic females in secondary school settings by reporting on their experiences and the lived experiences of autistic women reflecting on their past. Based on the identified articles, the barriers girls face in the compulsory education setting centred on four themes of societal barriers grounded in gender; the institutional or physical barriers of schools; social and communicative expectations; and stigmatization. The study highlighted that there is a need to sensitize and educate widely on the topic of autism for teachers, to support staff, school psychologists and peers of autistic youth. The results call attention to the need for future research to focus on the different lived experiences and knowledge of autistic girls.

Longitudinal Relationships Between Depressive Attributional Style and Internalizing Symptoms in an Autism-Enriched Sample of Incoming College Students

Background

Anxiety and depression are among the most common psychiatric conditions reported in first-year college students. Autistic adults are estimated to face double the rate of anxiety and depression compared with non-autistic peers, influencing quality of life, social success, and academic performance. One potential avenue to understand and address internalizing symptoms in autistic adults beginning their college careers is depressive attributional style, a biased causal explanatory style in which negative life events are attributed to internal, stable, and global causes. The current study evaluates the relationship between depressive attributional style and symptoms of anxiety and depression across the first semester of college, as moderated by autistic traits. We also explore baseline depressive attributional style across additional marginalized aspects of identity based on race/ethnicity, gender, and sexual orientation, and examine potential interaction effects of autistic traits on these relationships.

Methods

Undergraduate students were recruited from four northeastern universities. Our sample (n = 144) includes 47 participants who self-identified or reported a formal autism diagnosis, and 97 non-autistic participants. Participants completed baseline and endpoint questionnaires, as well as a 2-minute biweekly survey, tracking changes in sadness, anhedonia, and anxiety throughout their first semester.

Results

Longitudinal analyses demonstrate that elevated depressive attributional style at baseline predicted biweekly anxiety, sadness, and anhedonia symptoms across the semester. This pattern extended across (was not moderated by) levels of autistic traits, however, participants who reported higher autistic traits endorsed a significantly greater depressive attributional style at baseline, and greater anxiety, sadness, and anhedonia throughout the semester. The relationship between autistic traits and depressive attributional style was strongest for participants with a nonheterosexual orientation.

Conclusion

This study underscores the autistic community-identified need for mental health research, with attention to intersecting identities, and suggests depressive attributional style for further investigation as a potential treatment target.

Abstract

In the first year of college, many students face challenges with anxiety and depression. Autistic students report even higher mental health concerns than non-autistic students. One way to understand why this happens is by looking at how college students explain negative events in their lives. Autistic students may have a more depressive attributional style, in which they see themselves as a cause of negative events and believe that bad things will persist. This outlook is known to contribute to anxiety and depression.

Abstract

We wanted to see how a depressive attributional style might relate to anxiety and depression over the first semester of college, and whether this is affected by autistic traits and stress. We also looked at how autistic traits influence the relationship between depressive attributional style and the marginalized aspects of identity based on race/ethnicity, gender, and sexual orientation.

Abstract

We gave surveys to college students about their attributional style and experiences with depression and anxiety. Participants completed several surveys both before and after their first semester at college. They also completed a brief survey two times per week during the semester.

Abstract

We found that a depressive attributional style at baseline (presemester) was related to depression and anxiety symptoms across the semester. Participants with higher levels of autistic traits reported a more depressive attributional style and greater depression and anxiety during the semester. Individuals with higher autistic traits who identify as LGBTQIA+ were more likely than heterosexual individuals with high autistic traits to have a more depressive attributional style.

Abstract

This study helps us understand that a depressive attributional style might be related to anxiety and depression in both autistic and non-autistic students. In addition, a depressive attributional style may be more common in autistic individuals. These findings could mean that helping people develop a more adaptive thinking about negative events could help prevent or treat anxiety and depression in college students.

Abstract

Because we wanted our study to be accessible for autistic students without a formal diagnosis, we were unable to look at how the social identity of being autistic related to anxiety and depression throughout the semester.

Abstract

These findings give us first evidence that a depressive attributional style appears to be related to anxiety and depression in autistic students. This suggests that interventions designed to address the depressive attributional style in non-autistic individuals could potentially benefit autistic individuals as well, which may support access to mental health treatment for the autistic community.

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

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

Gender and Autism Program: A novel clinical service model for gender-diverse/transgender autistic youth and young adults

Objective: Situated in Children's National Hospital (CNH)'s Neuropsychology Division, the Gender and Autism Program (GAP) is the first clinical service dedicated to the needs of autistic gender-diverse/transgender youth. This study describes GAP clinical assessment profiles and presents a multi-perspective programmatic review of GAP evaluation services. Method: Seventy-five consecutive gender- and neuropsychologically-informed GAP evaluations were analyzed, including demographics, gender and autism characterization, and primary domains evaluated. Three program-based Delphi studies were conducted and identify: clinician priorities and challenges in providing care, program administrator lessons learned and ongoing barriers, and considerations adapting this model for a rural academic medical center. Results: Nearly two-thirds of referrals were transfeminine. Most youth had existing autism diagnoses; of those undiagnosed, three-quarters were found to be autistic. Five goals of evaluations were identified: Mental health was always assessed, and most evaluations also assessed gender-related needs in the context of autism neurodiversity. Neuropsychological characterization of strengths and challenges informed personalized accommodations to support youth gender-related self-advocacy. Clinicians emphasized frequent youth safety concerns. Administrators emphasized the need for specialized training for working with families. Components for adaptation of the GAP in a rural academic medical center were identified. Conclusions: Since its founding, the GAP has proven a sustainable neuropsychology-based service with consistent referral flow and insurance authorizations. Capturing staff perspectives through rigorous Delphi methods, and addressing the GAP's feasibility and replicability, this study provides a road map for replicating this service. We also highlight GAP training of specialist clinicians, fundamental to addressing the desperate shortage of providers in this field.

The Fraternal Birth Order Effect in the Royal House of Nineveh

Based on evidence of the cuneiform documents and studies in prosopography of the Neo-Assyrian Empire of the seventh century BCE, it can be demonstrated that the last great king of the Sargonid dynasty, Assurbanipal (669-631 BCE), was the fourth son of his mother Ešarra-hammat. This information can be combined with later accounts in the Classical sources, in which the same Assyrian king, called Sardanapal(l)os in Greek, is depicted as effeminate and bisexual. The fact that the king Assurbanipal was the fourth son of his mother lends additional support to these later materials through the hypothesis that the fraternal birth order effect altered his gender identity and sexual orientation through maternal immune response. His father Esarhaddon was a sufferer of the autoimmune disease systemic lupus erythematosus, susceptibility to which is often connected to androgen deficiency, a condition that Assurbanipal may have inherited from his father. There are some indications that the effeminacy of king's character became the source of moral resentment among the political allies of Assyria and its native elites already during his lifetime.

Reconsidering "inclusive language:" Consequences for healthcare and equitableness of a growing linguistic movement to address gender identity with a path forward

Increasingly, the language of female reproduction is changing, so terms directly referencing people's sex are replaced with terms obscuring sex, a language form commonly called "inclusive language" but more accurately is "desexed language." Desexed language is promoted as assisting individuals experiencing an inner sense of themselves (a gender identity) in conflict with their sex, a state described as being transgender or gender-diverse. It seemingly assumes no harm to the general population. However, the scant existing research suggests it may not be well accepted or understood. There are a variety of types of desexed language, including globalizing language (e.g. replacing "women" with "people"), biology-based language (e.g. "lactating individuals," "menstruators"), neologisms ("chestfeeding"), appropriation of terms with other meanings ("sex assigned at birth"), and additive language (e.g. "women and birthing people"). Second- and third-person language (e.g. "if you are sexually active," "those who are pregnant") can be a type of desexed language depending on context. Desexed language is likely to have an adverse impact on people with low health literacy and language skills, risk alienation, and cause confusion, especially in non-Western countries and cultures. It may even cause harm to transgender and gender-diverse people who also need clear health communications as well as specialized healthcare. Widespread use of desexed language is contrary to the usual practice of implementing targeted tailored communications for those with specialized needs while using the most effective language for most people for general communications. Comprehensive research on the impact of desexed language is urgently needed.

Obsessional thinking and autistic traits are each uniquely associated with greater traits of gender dysphoria in clinical and nonclinical adult samples

BACKGROUND

Research has demonstrated a strong relationship between autism and gender dysphoria (GD) and that this relationship could be explained by obsessional interests which are characteristic of autism. However, these studies often measured obsessions using either single items which questions the reliability of the findings, or within autistic trait measures meaning the findings may simply index a more general relationship between autistic traits and GD. Therefore, the present study aimed to investigate the relationships between obsessional thoughts and traits of GD using a measure of obsessional thoughts alongside a measure of autistic traits, which was investigated in both non-clinical and clinical samples.

METHODS

A total of 145 non-clinical participants took part in Study 1 and all completed the Autism-Spectrum Quotient (AQ) as a measure of autistic traits, the Obsessive-Compulsive Inventory-Revised (OCI-R) obsessional thoughts subscale as a measure of obsessional thoughts, and the Gender-Identity/Gender-Dysphoria Questionnaire (GIDYQ) to measure traits of GD. For Study 2, a total of 226 participants took part in Study 2 and all completed the same measures as in Study 1. They included participants diagnosed with GD (N = 49), autism (N = 65), OCD (N = 46) and controls with no diagnosis (N = 66).

RESULTS

The hierarchical linear regression for Study 1 showed that both total AQ and OCI-R obsessional thoughts scores were uniquely associated with GIDYQ scores, with no interaction effect between the scores. The results for Study 2, from a hierarchical linear regression, once again found that obsessional thoughts and autistic traits were each uniquely associated with GIDYQ scores, but not their interaction. The GD and autistic groups both reported significantly greater traits of GD than the OCD and control groups, with the GD group reporting higher scores than the autistic group.

LIMITATIONS

Participants self-reported their diagnoses for Study 2, but diagnostic tests to verify these were not administered. Traits of GD were also measured at a single point in time, despite such traits being transient and continuous.

CONCLUSIONS

The results show both obsessional thoughts and autistic traits are uniquely associated with GD, and that autistic people experience greater traits of GD than other clinical groups.

Autistic Traits of People Who Engage in Pup Play: Occurrence, Characteristics and Social Connections

Pup play is a kink or BDSM activity and subculture that provides opportunities for social and sexual play and exploration. While growing scholarly attention has focused on the diverse dynamics of pup play cultures, and reasons for participation within them, no research has considered how pup play may be attractive for neurodivergent people. This study sample consisted of 413 pup play practitioners from an international internet survey to examine the occurrence of autistic traits and explore characteristics and social connections of people with autistic traits who engage in pup play. Autistic traits were assessed using the Autism-Spectrum Quotient-Short Form (AQ-S), with 1 in 2 participants reporting a score that is indicative of an autism diagnosis, substantially higher than the prevalence of autism in the general population (1 in 44). Using linear and multinomial regression analyses, we found that people with high autistic traits preferred non-flexible roles in pup play, had lower identity resilience, and more restricted sociosexuality. People with high autistic traits were also less likely to belong to pup play social communities or to closer-knit family/pack units despite wishing to and were also less likely to have a strong identification with pup play communities than people with low AQ-S scores. While these findings need to be treated as preliminary based on methodological and sample limitations, this research demonstrates the importance of considering intersections between autistic traits and sexual subcultures and provides evidence that sexuality research would be enhanced by a more inclusive approach to considering neurodivergence more broadly.

Voice pitch and gender in autism

Autistic adults are often perceived as having an atypical speech. The acoustic characteristics of these impressions prove surprisingly difficult to delineate, but one feature that does robustly emerge across different studies is higher pitch (F0 values) in autistic versus neurotypical individuals. However, there is no clear explanation why autistic individuals should have higher-pitched voices. We propose that the solution lies in the gender imbalance still prevalent in autism, which entails an overrepresentation of male participants in research on speech in autism. We analyse speech samples from a gender-balanced group of 40 autistic and 40 neurotypical adults, controlling for potential stress levels through electrodermal activity recordings. We find that autistic males tend to have higher pitch than neurotypical males, but that autistic females tend to have lower pitch than neurotypical females. The interpretation we put forth for our finding - that the autistic versus neurotypical group difference in pitch goes in opposite directions between males and females - is that autistic individuals tend to be less influenced by neurotypical gender stereotypes.Lay abstractIt is has often been observed that autistic individuals have higher-pitched voices than non-autistic ones, but no clear explanation for this difference has been put forth. However, autistic males are still dramatically over-represented in published research, including the acoustic studies that report higher pitch in autistic participants. In this study, we collected speech samples from a group of autistic and neurotypical adults that, unlike in most studies, was perfectly balanced between groups and genders. In this gender-balanced sample, pitch was significantly higher in autistic versus neurotypical men, but lower in autistic versus neurotypical women. Overall, women tend to have higher-pitched voices than men, but the magnitude of this difference is culture dependent and may be significantly influenced by the internalisation of normative expectations towards one's gender. We propose that higher pitch in autistic males and lower pitch in autistic females could be due, at least in part, to a lesser integration of sociolinguistic markers of gender. Our report shows that speech atypicality should not be operationalised in terms of systematic and unidirectional deviation from the neurotypical baseline.

Sexual Orientation and Gender Identity (SOGI): A Tutorial on Ethical Data Practices

In the U.S., approximately 13 million individuals identify as part of a sexual and gender minority (SGM). This broad spectrum includes sexual orientation identities such as gay, lesbian, bisexual, queer, pansexual, and same-gender-loving, as well as gender identities such as transgender, gender non-conforming, bigender, and two-spirit. As behavior analysts heed the call to engage in culturally competent practices that address diverse sexual orientation and gender identities (SOGI), they will likely consider collecting SOGI data as part of their practice. The benefits of SOGI data collection certainly exist. However, the historical oppression and increased vulnerability of SGM populations require a careful and thorough evaluation of ethical data collection practices to avoid harm and to ensure respectful and inclusive practices. The present tutorial aims to begin the discussion of ethical and effective SOGI data collection practices within behavior analysis by offering initial guidelines and considerations. We highlight methods that improve cultural sensitivity, and caution against traditional methods that could harm respondents or contribute to a non-inclusive environment.

"I Want More People Like Y'all to be Willing to Listen to People Like Us": A Qualitative Study Exploring Barriers and Facilitators to Care With Autistic Women and Caregivers

Recent surveillance data indicate an estimated 1 in 36 children are diagnosed with autism spectrum disorder (ASD). More males than females are diagnosed with ASD and children of color are less likely to be identified with ASD than White children. Given the rising prevalence estimates and persistent gender and racial/ethnic differences in diagnostic rates, it is time that we seek to better understand ASD as it relates to culture, care, and lived experience from the perspective of those we serve. Utilizing qualitative methods, the current research study sought to understand the lived experiences of three autistic women and three women caregivers of autistic children as it relates to the identification, diagnostic, and service delivery processes. In-depth focus group research revealed five major themes ranging from feelings associated with the diagnosis, dissatisfaction with services, the perspective of culture within autism and the family, and how culture should be considered by service providers in treatment planning and implementation. These results are discussed in the context of future research, and implications for autism service providers are provided.

Avoidant/restrictive food intake disorder (ARFID) symptoms in gender diverse adults and their relation to autistic traits, ADHD traits, and sensory sensitivities

BACKGROUND

There is emerging evidence to suggest gender diverse people are overrepresented in avoidant/restrictive food intake disorder (ARFID) samples. However, the mechanisms underlying elevated risk for ARFID in this group are currently unknown. Gender diversity and neurodivergence commonly co-occur, with elevated sensory sensitivities reported to be a shared experience common across autism, attention deficit hyperactivity disorder (ADHD), and ARFID. We aimed to examine the unique contribution of sensory sensitivities, including hypo- and hyper-sensitivity, in predicting ARFID symptoms in gender diverse adults, whilst controlling for autistic and ADHD traits.

METHODS

Gender diverse adults (N = 182; 142 assigned female at birth; M age = 28.6 years) in the UK participated in an online survey. We examined correlations between their self-reported ARFID symptoms, sensory sensitivities, autistic traits (not including sensory sensitivities), and ADHD traits whilst controlling for weight and shape concerns. We then used hierarchical multiple regression to investigate the unique contribution of sensory sensitivities to ARFID symptoms whilst controlling for the other neurodivergent traits.

RESULTS

In our gender diverse sample, higher levels of ARFID symptoms were associated with higher levels of sensory sensitivities, autistic traits, and ADHD traits, after controlling for weight and shape concerns. Furthermore, sensory sensitivities, specifically hyper-sensitivity, uniquely predicted levels of ARFID symptoms once we accounted for autistic and ADHD traits.

CONCLUSIONS

When considering neurodivergence, sensory hyper-sensitivities may be particularly relevant to ARFID symptomatology in gender diverse adults. Future research should explore associations between ARFID presentations and sensory sensitivities in large samples of gender diverse adults, to enable separate analyses by gender identity.

"What does 'often' even mean?" Revising and validating the Comprehensive Autistic Trait Inventory in partnership with autistic people

BACKGROUND

In this study, we revised the comprehensive autistic trait inventory (CATI)-a self-report inventory of autistic traits, in collaboration with autistic people and provided preliminary evidence for its validity as a self-report measure of autistic traits in the general population. An established strength of the CATI is its ability to capture female autistic traits. Our project aimed to extend this further, to increase the inventory's accessibility, and to minimise stigma induced by deficit-based representations of autistic experience.

METHODS

Together with 22 individuals from the autism and autistic communities, we created the Revised Comprehensive Autistic Trait Inventory (CATI-R). Revisions included rewording items to increase clarity or reduce stigma and expanding items to capture diverse autistic experiences. We also present a series of guidelines for developing self-report inventories of subclinical neurodivergent traits. We validated the CATI-R within a large sample (n = 1439), comprising people with a self-reported autism diagnosis (n = 331), people who self-identified as autistic (n = 44), and non-autistic participants (n = 1046).

RESULTS

We successfully validated a revision of the CATI. A confirmatory factor analysis supported the six-subscale structure (two-factor bifactors model: Chi-squared = 2705.73, p < .001, RMSEA = .04, SRMR = .03, CFI = .95, TLI = .94). Spearman's rank correlations showed positive relationships between all subscales (all rs >  .56, ps < .001). Convergent validity was demonstrated by significant correlations between the CATI-R and two contemporary inventories of autistic traits: the AQ (rho = .86, p < .01) and BAPQ (rho = .82, p < .01). Finally, a measurement invariance analysis indicated that total-scale scores can be compared across genders.

LIMITATIONS

Our study presents only initial evidence for the validity of the CATI-R that should be enriched with further analyses and types of data, including a larger number of participants who do not identify as male or female.

CONCLUSIONS

This project provides a revised trait inventory that resonates with actual autistic experience, along with guidelines for creating self-report measures that are sensitive, accessible, and non-stigmatising.

Health and Health Care Access of Autistic Transgender and Nonbinary People in Canada: A Cross-Sectional Study

Background

The existence and health care needs of individuals who are both autistic and transgender and nonbinary (TNB) are increasingly discussed publicly. While research demonstrating a greater prevalence of autism among TNB individuals continues to grow, little captures their experiences with primary, mental health, and gender-affirming care (GAC), particularly between self-identified and diagnosed autistic TNB individuals. This article explores this nexus.

Methods

We conducted a subgroup analysis of the Trans PULSE Canada 2019 national survey (n = 2873). We included both individuals who self-reported a diagnosis of autism (n = 230) and those who self-identify as autistic without one (n = 176). We compared participant demographics, health status, and health care experiences by autistic status (diagnosed, self-identified only, or allistic [non-autistic]) using weighted chi-square tests and logistic regression analyses.

Results

Of Trans PULSE participants, 14.3% were autistic (8.1% diagnosed, 6.2% self-identified). Compared with their allistic peers, autistic participants were younger, had lower levels of education, employment, and income, and were more likely to identify as asexual. They also reported worse overall general health, a higher rate of unmet health care needs, and significant mental health disparities. While few diagnosed (3.7%) or self-identified (1.1%) autistic participants reported being directly denied GAC due to autism, 25.5% of diagnosed and 36.1% of self-identified individuals preemptively avoided sharing information about it during GAC readiness assessments in the past year.

Conclusions

Our findings highlight the need for changes to treatment of autistic TNB people in primary and mental health care. Future research should explore both individual responses and systematic changes to these challenges.

Experiences of Gender-Diverse Youth Living With Chronic Pain

BACKGROUND

Although sex differences in pain are well documented, little is known regarding the relationship between gender and pain. Gender-diverse youth experience unique pain risk factors, including minority stress exposure, but are underrepresented in research.

OBJECTIVE

Elicit experiences of gender-diverse youth who live with chronic pain.

METHODS

Semistructured interviews were conducted with youth virtually using Zoom. Youth were recruited from a Canadian tertiary care pediatric hospital, community-based clinics, and the general population. Interviews were recorded, transcribed, and analyzed with a patient partner using reflexive thematic analysis, integrating relevant existing theoretical and empirical models for understanding gender and pain, identity development, minority stress, and intersectionality.

RESULTS

The final sample included 19 youth who represented a variety of gender identities and pain conditions and reported accessing a range of types and levels of care. Three themes were identified through qualitative analysis: (1) the fight to legitimize both their pain and gender, (2) the tension between affirming gender and managing pain and the role of gender euphoria as a buffer against pain, and (3) the role of intersecting (eg, neurodiversity and race) identities in understanding gender-diverse youths' pain experiences.

CONCLUSIONS

In a diverse sample of gender-diverse youth who live with chronic pain, experiences of invalidation and difficulty managing pain were experienced in the context of unique stressors and sources of joy in living as a gender-diverse individual. These results point to the need for more intersectional and affirming pain research and integration of findings into clinical practice.

Autistic and transgender/gender diverse people's experiences of health and healthcare

BACKGROUND

Autistic people and transgender/gender diverse people experience poorer healthcare experiences and greater risk of diagnosed, suspected, and assessment recommended health conditions, compared to non-autistic and cisgender individuals, respectively. Despite this, there is a paucity of studies on the healthcare experiences and health outcomes of transgender/gender diverse autistic individuals.

METHODS

We compared the healthcare experiences and health outcomes of cisgender autistic (n = 1094), transgender/gender diverse autistic (n = 174), and cisgender non-autistic adults (n = 1295) via an anonymous, self-report survey. All individuals whose sex assigned at birth did not match their current gender identity were categorized as transgender/gender diverse; this was possible to determine, as the survey asked about sex assigned at birth and gender in separate questions. Unfortunately, n = 57 transgender/gender diverse non-autistic participants were excluded from these analyses a priori, due to low power. Unadjusted and adjusted binomial logistic regression models with FDR correction were employed to assess healthcare experiences and rates of co-occurring mental and physical health conditions.

RESULTS

Both transgender/gender diverse and cisgender autistic adults had higher rates of all health conditions (including conditions that are formally diagnosed, suspected, or recommended for assessment), compared to cisgender non-autistic adults. Transgender/gender diverse autistic adults were 2.3 times more likely to report a physical health condition, 10.9 times more likely to report a mental health condition, and 5.8 times more likely to report self-harm than cisgender non-autistic adults. Both autistic groups also reported significantly poorer healthcare experiences across 50/51 items.

LIMITATIONS

These data were not originally collected to understand the experiences of transgender/gender diverse individuals. In addition, our recruitment strategies, use of a convenience sampling method, and the use of a self-report survey limit the generalizability of the study. As our sample was biased towards white individuals, UK residents, relatively highly educated individuals, those assigned female at birth, and those who currently identify as female, our findings may be less applicable to individuals of differing demographics. Finally, the present study does not include information on the experiences of transgender/gender diverse non-autistic people.

CONCLUSIONS

Autistic people have poorer self-reported health and healthcare; however, being gender diverse is associated with further risk for certain adverse experiences and outcomes. Future research on the health and healthcare experiences of transgender/gender diverse autistic people is urgently needed. In particular, forthcoming studies in this area should aim to recruit large-scale and representative studies and should compare the experiences of transgender/gender diverse autistic people to those of transgender/gender diverse non-autistic people. Greater recognition of challenges and reasonable adjustments are essential for people with marginalized, intersectional identities in clinical practice.

"Just Listen to Me. Help Me Explore it." An Interpretative Phenomenological Analysis Exploring Experiences of Gender Dysphoria, Identity And Resilience in Autistic Adolescents Assigned Female at Birth

Much of the current autism and gender literature has been based within a medical deficiency model; where both are seen as deficiencies rather than differences. However, there is currently minimal knowledge about the experiences of being an autistic adolescent who is both assigned female at birth and has gender dysphoria (GD), whilst even less is known about their experiences of social identity, self-concept and resilience. This study aims to explore experiences of GD with a particular focus on identity and resilience to promote parent and healthcare staff understanding; particularly around gender-affirming care, to foster positive mental health outcomes. Five assigned female at birth autistic adolescents, who identify as trans men/boys, took part in one-to-one semi-structured interviews, which were analysed using an Interpretative Phenomenological Approach. Five subordinate themes arose; "Having both autism and GD", "Finding where I belong", "Being more than labels", "Trying to cope" and "Making support successful". Our findings build on current literature and theory regarding the experience of concurrent autism and GD; highlighting its legitimacy, the ways in which autism impacts upon GD and how healthcare approaches and policy can increase accessibility and suitability of gender-affirming care.

Examining Diagnostic Trends and Gender Differences in the ADOS-II

Approximately 3-4 boys for every girl meet the clinical criteria for autism in studies of community diagnostic patterns and studies of autism using samples of convenience. However, girls with autism have been hypothesized to be underdiagnosed, possibly because they may present with differing symptom profiles as compared to boys. This secondary data analysis used the National Database of Autism Research (NDAR) to examine how gender and symptom profiles are associated with one another in a gold standard assessment of autism symptoms, the Autism Diagnostic Observation Schedule II (ADOS-II; Lord, C., Luyster, R., Guthrie, W., & Pickles A. (2012a). Patterns of developmental trajectories in toddlers with autism spectrum disorder. Journal of Consulting and Clinical Psychology, 80(3):477-489. https://doi.org/10.1037/a0027214 . Epub 2012 Apr 16. PMID: 22506796, PMCID: PMC3365612). ADOS-II scores from 6183 children ages 6-14 years from 78 different studies in the NDAR indicated that gender was a significant predictor of total algorithm, restrictive and repetitive behavioral, and social communicative difficulties composite severity scores. These findings suggest that gender differences in ADOS scores are common in many samples and may reflect on current diagnostic practices.

Executive functions in adolescents with gender dysphoria

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

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.

Exploring the role of sex hormones and gender diversity in multiple sclerosis

Sex and sex hormones are thought to influence multiple sclerosis (MS) through effects on inflammation, myelination and neurodegeneration, and exogenous hormones have been explored for their therapeutic potential. However, our understanding of how sex hormones influence MS disease processes and outcomes remains incomplete. Furthermore, our current knowledge is derived primarily from studies that focus exclusively on cisgender populations with exclusion of gender-diverse people. Gender-affirming hormone therapy comprising exogenous sex hormones or sex hormone blocking agents are commonly used by transgender and gender-diverse individuals, and it could influence MS risk and outcomes at various stages of disease. A better understanding of the impact and potential therapeutic effects of both endogenous and exogenous sex hormones in MS is needed to improve care and outcomes for cisgender individuals and, moreover, for gender-diverse populations wherein an evidence base does not exist. In this Perspective, we discuss the effects of endogenous and exogenous sex hormones in MS, including their potential therapeutic benefits, and examine both established sex-based dimorphisms and the potential for gender-diverse dimorphisms. We advocate for future research that includes gender-diverse people to enhance our knowledge of the interplay of sex and sex hormones in MS, leading to the development of more effective and inclusive treatment strategies and improvement of care for all individuals with MS.

Conducting ethical, co-produced research with autistic individuals with an eating disorder: best practice guidelines

There is a notable overlap between autism and eating disorders (EDs), and autistic individuals may experience poorer ED treatment outcomes than non-autistic peers. To make meaningful change in this field, it is imperative that we actively engage in co-production of research, however there are currently no guidelines to support co-production with autistic people with eating disorders. This paper reports on best practice guidelines that were co-produced across a series of workshops bringing together autistic people with EDs, researchers, clinicians, third-sector organisations, and parents/carers. The guidelines are intended to be used as a foundation for future co-produced autism and ED research. By creating a trusted, ethical co-production relationship, we hope to generate more clinically meaningful and translatable research.

Borderline Personality as a Factor in Late, Missed, and Mis-Diagnosis in Autistic Girls and Women: A Conceptual Analysis

Autism without intellectual disability is diagnosed later and with greater difficulty in girls/women relative to boys/men. For autistic girls and women, the journey to an autism diagnosis may include one or more misdiagnoses. Misdiagnosis with borderline personality disorder (BPD) or borderline traits may be particularly common, and characteristics often observed in autistic girls and women may contribute specifically to a risk of misdiagnosis with BPD. This review draws from a burgeoning literature on autism in girls and women to provide a detailed discussion of differential diagnosis of BPD and autism in cisgender girls/women, with a focus on phenotypic traits and/or their presentation that may be more common in autistic girls/women and that may be particularly prone to miscategorization as BPD. Distinctions between autism and BPD are identified, emphasizing the need for scrutiny of an individual's clinical presentation to tease apart differences between the autism and BPD phenotypes. We highlight instances in which similar phenotypic expressions may be driven by differing underlying factors. Implications for the distinction of autism and BPD/borderline traits in informing appropriate therapeutic intervention are discussed.

"I Don't Understand Their Sense of Belonging": Exploring How Nonbinary Autistic Adults Experience Gender

Background

The term "nonbinary" refers to all gender identities that are not exclusively male or female. Nonbinary identities are more common in autistic people than in nonautistic people. Yet research meaningfully exploring the unique intersection between autism and nonbinary identities is limited. Furthermore, little is known about how the experience of being nonbinary and autistic impacts access to autistic and queer communities; spaces that can protect against poor mental health outcomes.

Methods

We examined: (1) how nonbinary autistic people make sense of gender and (2) how they negotiate community. A participatory approach was adopted, involving a consulting group of 18 nonbinary autistic people at every stage of the research process. A separate group of five nonbinary autistic adults from the United Kingdom took part in semistructured interviews about autism, gender, and community. We analyzed interviews using Interpretative Phenomenological Analysis.

Results

Within an emergent framework (gender as two dimensional), we identified three themes: (1) Where do I belong? (2) (Re)framing difference. (3) Space to be (neuro)queer. Participants understood that being autistic and nonbinary problematized how they connected with "gender," a self-defined concept of high significance. Crucially, the queer community was felt to facilitate positive identity development, but participants emphasized a continued struggle with being misunderstood, largely by their nonautistic peers.

Conclusion

This study celebrates neuroqueer ways of being. We recommend that nonautistic people are given improved education on nonbinary autistic identities; supporting autistic people to understand their differences and facilitating positive identity development within queer spaces. Creating autistic-led community groups is furthermore key, due to the linguistic and embodied complexities of autistic gender identities.

Person-first and identity-first disability language: Informing client centred care

BACKGROUND

Addressing individuals with a disability can entail the use of person-first (person with a disability) or identity-first language (disabled person). However, there has been debate about use of these terms, yet there is a lack of evidence to inform preference across people with a broad range of health conditions, demographics, or health related factors.

METHODS

A 42-item survey measuring demographic and health condition factors, implicit and explicit preference for person-first and identity-first language use was open for completion by individuals with a self-reported health condition between July 7, 2021 and November 30, 2021. Recruitment was undertaken via posts on relevant social media sites and through community support and advocacy organisations.

RESULTS

Data analysis included responses from 875 valid surveys. Mean age of participants was 39.7 (SD: 13.7) years. There were 89 (10.2%) male, 637 female (72.8%) and 149 (17.0%) non-binary/other participants. When referring to themselves, participants most often reported use of identity first language (n = 335, 42.2%), followed by person-first language (n = 272, 34.1%), then both interchangeably (118, 23.7%). When referring to others, participants most often used person first language (n = 312, 39.4%), followed by both interchangeably (269, 34.0%), then identity-first language (n = 211, 26.6%). Disability language preference varied across health conditions, with participants with neurodevelopmental conditions most likely to use identity-first language and participants with digestive conditions most often preferencing person-first language. Participants who were younger and of non-binary gender preferred use of identity-first language. Appropriate use of identity-first language was rated significantly higher for people with a disability/health condition and family/friends than for third-party representatives, including healthcare professionals, educators, media and the general public.

CONCLUSION

Findings highlight the need to understand health condition and disability language preference in a more nuanced way to promote respectful language use when addressing people in the context of their disability/health condition.

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.

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

LAY ABSTRACT

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

The experiences of oppression among transgender and gender expansive young people in Australia: An interpretative phenomenological study

Background: Transgender and gender expansive (TGE) people experience poorer mental health outcomes compared to their cisgender counterparts. There is limited research on understanding the experiences of TGE school-aged young people from an Australian perspective. Since each country and state has different cultures, laws, and access to gender-affirming care research considering these differences is imperative.Methods: To address this gap, we used a qualitative design to explore the oppression of Australian TGE young people. Sixteen TGE participants (aged 14-17) completed individual semi-structured interviews. Data were analysed using interpretive phenomenological analysis.Results: Three superordinate themes were identified: (1) oppression within the education system; (2) oppression within the medical and allied health system; and (3) oppression within the family system. The findings highlight the various settings and contexts of oppression young people encounter. We identified what must change for a more equitable society and advocate for the implementation of gender-affirming change.Discussion and conclusion: This study contributes to the dearth of TGE adolescents's experiences and provides practical implications for society, especially in relation to the education, medical, and family systems. The implications include advocacy for more research in Australia and the inclusion of adolescents in policy reform. Limitations of this study and future directions are discussed.

Androgyny and atypical sensory sensitivity associated with savant ability: a comparison between Klinefelter syndrome and sexual minorities assigned male at birth

Introduction

The extreme male brain (EMB) theory, a major causal hypothesis of autism (ASD: autism spectrum disorder), attributes excess androgens during early development as one of the causes. While studies have generally followed the EMB theory in females at birth, the co-occurrence of ASD in males at birth has been observed in conditions that are assumed to be associated with reduced androgen action during early development, including Klinefelter syndrome (KS) and sexual minorities. ASD is also associated with atypical sensory sensitivity, synesthesia, and savant syndrome.

Methods

In the present study, we examined adult KS individuals (n = 22), sexual minorities assigned male at birth (n = 66), and control males matched for age and educational background to those with KS [Exploratory analysis (control 1st): n = 36; Reanalysis (control 2nd): n = 583]. Participants completed a self-report questionnaire assessing sensory hypersensitivity/hyposensitivity, savant tendency (developed for the present study), synesthesia, and sexual aspects, including gender identity and sexual orientation.

Results

The results of the exploratory analysis suggested that individuals with KS exhibited a higher tendency toward sensory hypersensitivity/hyposensitivity than the tendency exhibited by the controls. In the Reanalysis, sexual minorities were more likely to be synesthetes, and in both analyses sexual minorities exhibited a higher savant tendency and sensory hypersensitivity/hyposensitivity than the controls. Moreover, the gender dysphoric state was associated with phenotypes observed in individuals with ASD, such as synesthesia, savant tendency, and sensory hypersensitivity/hyposensitivity.

Discussion

These results suggest a common physiological background among gender dysphoria, synesthesia, savant tendency, and atypical sensory sensitivity. Thus, androgynous features (reduced effects of sex steroids during early development) in males at birth may be partially related to the phenotype commonly observed in individuals with ASD. Based on the present results, we propose that the reduction of sex steroids during early development may lead to atypical neurodevelopment and be involved in the atypicality of external and internal sensory perception, and thus in the atypicality of self-concept integration, through the disruption of oxytocin and the gamma-aminobutyric acid system modulating the neural excitation/inhibition balance.

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

LAY ABSTRACT

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

Gender, assigned sex at birth, and gender diversity: Windows into diagnostic timing disparities in autism

LAY ABSTRACT

Later autism diagnosis is associated with risk for mental health problems. Understanding factors related to later autism diagnosis may help reduce mental health risks for autistic people. One characteristic associated with later autism diagnosis is female sex. However, studies often do not distinguish sex assigned at birth and gender identity. Gender diversity may be more common in autistic relative to neurotypical people, and autism is more common in gender-diverse populations. We studied age at autism diagnosis by sex assigned at birth, gender identity, and gender diversity (gender-diverse vs cisgender) status, separately. We studied three separate autistic samples, each of which differed in how they were diagnosed and how they were recruited. The samples included 193 persons (8.0-18.0 years) from a research-recruited academic medical center sample; 1,550 people (1.3-25.4 years) from a clinic-based sample; and 244 people (18.2-30.0 years) from a community-enriched sample. We found significant differences in the clinic-based and community-enriched samples. People assigned female sex at birth were diagnosed with autism significantly later than people assigned male at birth. People of female gender were diagnosed significantly later than people of male gender. Gender-diverse people were diagnosed significantly later than cisgender people. Sex assigned at birth, gender identity, and gender diversity may each show unique relationships with age of autism diagnosis. Differences in how autistic people are diagnosed and recruited are important to consider in studies that examine sex assigned at birth or gender identity. More research into autism diagnosis in adulthood is needed.

Prevalence of autistic traits and their relationships with other psychopathological domains in young adults seeking psychiatric attention: a cluster analysis

BACKGROUND

Nearly two-thirds of individuals with a mental disorder start experiencing symptoms during adolescence or early adulthood, and the onset of a mental disorder during this critical life stage strongly predicts adverse socioeconomic and health outcomes. Subthreshold manifestations of autism spectrum disorders (ASDs), also called autistic traits (ATs), are known to be associated with a higher vulnerability to the development of other psychiatric disorders. This study aimed to assess the presence of ATs in a population of young adults seeking specialist assistance and to evaluate the study population across various psychopathological domains in order to determine their links with ATs.

METHODS

We recruited a sample of 263 adolescents and young adults referring to a specialized outpatient clinic, and we administered them several self-report questionnaires for the evaluation of various psychopathological domains. We conducted a cluster analysis based on the prevalence of ATs, empathy, and sensory sensitivity scores.

RESULTS

The cluster analysis identified three distinct groups in the sample: an AT cluster (22.43%), an intermediate cluster (45.25%), and a no-AT cluster (32.32%). Moreover, subjects with higher ATs exhibited greater symptomatology across multiple domains, including mood, anxiety, eating disorder severity, psychotic symptoms, and personality traits such as detachment and vulnerable narcissism.

CONCLUSIONS

This study highlights the importance of identifying ATs in young individuals struggling with mental health concerns. Additionally, our findings underscore the necessity of adopting a dimensional approach to psychopathology to better understand the complex interplay of symptoms and facilitate tailored interventions.

Autism or not? A case series of evaluation decision points in child and adolescent psychological assessment

Increase in the incidence of autism spectrum disorders (ASD) and increased attention to symptoms of ASD in social media have contributed to a significant rise in referrals for neuropsychological assessment of possible ASD. Many practitioners lack specific training in the assessment of ASD and may avoid addressing these concerns, despite the frequency of those referrals. This paper reviews potential contributors to the rise in referrals and several related conditions which share some overlap with features of ASD. That is followed by descriptions of four school-aged children and adolescents referred for comprehensive evaluation of suspected ASD. The authors describe decision points in the diagnostic process for those with or without proficiency in ASD-specific testing and close with a series of recommendations for the assessment of clients with complex presentations referred for suspected ASD.

Frailties of Memory: Implications for Therapists Treating Gender Dysphoric Youth

Therapists working with gender-questioning teens often encounter disparate narratives. Teens typically report memories consistent with their transgender identity, often recounting specific childhood events. Many parents, however, have different recollections of their teen's childhood. As sound, ethical care is predicated on reality, therapists face the difficult task of navigating these often-contradictory narratives. We present relevant scientific literature on memory and well documented cognitive mechanisms and reflect on past therapeutic controversies to help clinicians understand the complexity of memory and why it may be prudent for therapists to consider not only their patients' accounts of their pasts, but also that of their patient's parents.

Characterization of the literature informing health care of transgender and gender-diverse persons: A bibliometric analysis

BACKGROUND AND OBJECTIVE

Transgender and gender-diverse (TGD) persons experience health inequities compared to their cisgender peers, which is in part related to limited evidence informing their care. Thus, we aimed to describe the literature informing care provision of TGD individuals.

DATA SOURCE, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS

Literature cited by the World Professional Association of Transgender Health Standards of Care Version 8 was reviewed. Original research articles, excluding systematic reviews (n = 74), were assessed (n = 1809). Studies where the population of interest were only caregivers, providers, siblings, partners, or children of TGD individuals were excluded (n = 7). Results were synthesized in a descriptive manner.

RESULTS

Of 1809 citations, 696 studies met the inclusion criteria. TGD-only populations were represented in 65% of studies. White (38%) participants and young adults (18 to 29 years old, 64%) were the most well-represented study populations. Almost half of studies (45%) were cross-sectional, and approximately a third were longitudinal in nature (37%). Overall, the median number of TGD participants (median [IQR]: 104 [32, 356]) included in each study was approximately one third of included cisgender participants (271 [47, 15405]). In studies where both TGD and cisgender individuals were included (n = 74), the proportion of TGD to cisgender participants was 1:2 [1:20, 1:1]. Less than a third of studies stratified results by sex (32%) or gender (28%), and even fewer included sex (4%) or gender (3%) as a covariate in the analysis. The proportion of studies with populations including both TGD and cisgender participants increased between 1969 and 2023, while the proportion of studies with study populations of unspecified gender identity decreased over the same time period.

CONCLUSIONS

While TGD participant-only studies make up most of the literature informing care of this population, longitudinal studies including a diversity of TGD individuals across life stages are required to improve the quality of evidence.

The missing clinical guidance: a scoping review of care for autistic transgender and gender-diverse people

The co-occurrence of autism and gender diversity has been increasingly studied in the past decade. It is estimated that ∼11% of transgender and gender-diverse (TGD) individuals are diagnosed with autism. However, there is insufficient knowledge about appropriate gender-related clinical care for autistic TGD individuals. We performed a scoping review of current clinical guidance for the care of TGD individuals to identify what was said about autism. Clinical guidance documents were searched in PubMed, Web of Science, Google Scholar, Embase, Guidelines International Network, and TRIP medical database, as well as reference mining and expert recommendation. Evidence was synthesised by narrative synthesis, recommendation mapping, and reference frequency analysis. Out of the identified 31 clinical guidance documents, only eleven specifically mentioned the intersection between autism and TGD. Key concepts among the available recommendations included advocating for a multidisciplinary approach; emphasising the intersectionality of autism and gender-diverse experiences during assessments; and-importantly-recognising that autism, in itself, does not serve as an exclusion criterion for receiving gender-related care. However, detailed and practical clinical guidance is lacking due to a gap in evidence. Empirical research into the care experiences and outcomes of autistic TGD individuals using a developmental, lifespan, and strengths-based approach is needed to generate evidence-informed and tailored guidance.

Funding

This study was funded through a Canadian Institutes of Health Research Sex and Gender Science Chair program (GSB 171373) awarded to M-CL.

Suicidal Thoughts and Behaviors Among Autistic Transgender or Gender-Nonconforming US College Students

Importance

Suicide risk is a global public health crisis, with suicide ranking as a consistent leading cause of death among adults in the US. Autistic individuals and transgender or gender-nonconforming (TGNC) individuals represent populations with notably elevated rates of suicidal thoughts and behaviors (STBs).

Objective

To characterize suicidal thoughts and behaviors among TGNC and autistic individuals, using a large, nationally representative sample.

Design, Setting, and Participants

This study is a secondary analysis of cross-sectional data from students at colleges and universities throughout the US who participated in the American College Health Association National College Health Assessment from 2019 to 2023.

Exposures

Autistic and TGNC identities were self-reported by participants.

Main Outcomes and Measures

The frequency of intersectionality of autism and TGNC identities and whether those who had intersectional marginalized identities had increased likelihood of STBs were examined. STBs were self-reported by participants. A series of moderated regression analyses were performed to examine how the interaction between autism and possessing a marginalized gender identity (ie, TGNC status) was associated with STBs.

Results

The sample included 41 507 college students with a mean (SD) age of 23.35 (6.83) years. A total of 2410 participants (5.81%) identified as being TGNC. Overall, 326 TGNC participants (13.53%) also identified as autistic, whereas 625 of those who identified as cisgender (1.58%) also identified as autistic. Gender identity and autism were associated with greater odds of STBs. For suicidal ideation, gender identity had an odds ratio (OR) of 3.34 (95% CI, 2.99-3.73), and autism had an OR of 2.06 (95% CI, 1.76-2.42). For suicide attempts, gender identity had an OR of 2.74 (95% CI, 2.13-3.52), and autism had an OR of 2.39 (95% CI, 1.62-3.52). A significant interaction existed for attempts (OR, 0.51; 95% CI, 0.27-0.97); nonautistic cisgender individuals had the lowest attempt rate.

Conclusions and Relevance

This cross-sectional study addresses the dearth of information on how intersectionality in gender and autism status impacts the risk of STBs, and the results confirm the elevated risk of STBs among TGNC and autistic populations. Interventions are needed to support college students with these identities.

Socialization, Education, and Learning for the Internet (SELFI): A Pilot RCT of a Social Media Skills Group Program for Autistic Adults

Many autistic adults report preference for computer-mediated communication and social media use. Despite many benefits to online socialization, there are many challenges including anxiety and cyber-victimization. To date, support is limited related to helping autistic adults with safe and effective internet use. The purpose of this study was to evaluate the feasibility, acceptability, and preliminary efficacy of the novel SELFI program. This pilot study utilized a randomized controlled trial design. A total of 25 autistic adults enrolled in the study and were randomized to the nine-week SELFI program or a waitlist control condition. Feasibility assessed enrollment, attrition, and fidelity of delivery. Acceptability examined attendance and feedback from participants and peer mentors. Efficacy evaluated change in Facebook activity, social media utility/anxiety, and individualized goals. Regarding feasibility, the recruitment goal was met within one month, there was limited attrition, and therapists delivered the program with high fidelity. Participants attended a majority of scheduled sessions and feedback from participants reflected high levels of agreement with several facets of the program. Compared to the control group, more participants assigned to the SELFI condition were perceived by autistic and non-autistic raters as having improved Facebook activity. SELFI participants also reported reduced difficulty meeting their individualized goal. Findings support the piloted SELFI program as feasible and acceptable with signals of preliminary efficacy. This study establishes an exciting foundation regarding an innovative social media skills program, however more research is necessary.

Peri-operative care of transgender and gender-diverse individuals: guidance for clinicians and departments

INTRODUCTION

The objective of this document is to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. While transgender and gender-diverse people may have specific health needs in relation to gender dysphoria, their health requirements go beyond their gender identity. Most doctors will provide care to someone who is transgender or gender-diverse at some stage in their career. It is therefore important that all anaesthetists are educated on specific considerations when caring for these patients.

METHODS

A working party was assembled consisting of individuals with experience in direct clinical care of the relevant patient group, those who have expertise in endocrinology and gender-affirming hormones, educators on the topic of transgender and gender-diverse healthcare, and authors of both cisgender and transgender identities. After discussion among the working party, targeted searches of literature were undertaken.

RESULTS

The authors initially came up with a list of over 25 recommendations which was subsequently revised to a list of 15 recommendations after further review by the working party. These included airway assessment and management; management of hormonal therapy; relevant issues in obstetric anaesthesia; and hospital infrastructure and processes.

CONCLUSIONS

This document provides the first guidance produced to advise on best practice to ensure the safety and dignity of trans and gender-diverse individuals in the peri-operative period.