Autistic and non-autistic transgender youth are similar in gender development and sexuality phenotypes

Increasing rhetoric regarding the common intersection of autism and gender diversity has resulted in legislation banning autistic transgender youth from accessing standard of care supports, as well as legislative efforts banning all youth gender care in part justified by the proportional over-occurrence of autism. Yet, no study has investigated whether autistic and non-autistic transgender youth present fundamentally different gender-related phenotypes. To address this gap, we extensively characterized autism, gender diversity, and sexuality among autistic and non-autistic transgender binary youth (N = 66, Mage = 17.17, SDage = 2.12) in order to investigate similarities and/or differences in gender and sexuality phenotypes. Neither autism diagnostic status nor continuous autistic traits were significantly related to any gender or sexuality phenotypes. These findings suggest that the developmental and experiential features of gender diversity are very similar between autistic and non-autistic transgender adolescents. Future research is needed to determine whether the similarity in profiles is maintained over time into adulthood.

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

BACKGROUND

Psychosis spectrum symptoms (PSSs) occur in a sizable percentage of youth and are associated with poorer cognitive performance, poorer functioning, and suicidality (i.e., suicidal thoughts and behaviors). PSSs may occur more frequently in youths already experiencing another mental illness, but the antecedents are not well known. The Toronto Adolescent and Youth (TAY) Cohort Study aims to characterize developmental trajectories in youths with mental illness and understand associations with PSSs, functioning, and suicidality.

METHODS

The TAY Cohort Study is a longitudinal cohort study that aims to assess 1500 youths (age 11-24 years) presenting to tertiary care. In this article, we describe the extensive diagnostic and clinical characterization of psychopathology, substance use, functioning, suicidality, and health service utilization in these youths, with follow-up every 6 months over 5 years, including early baseline data.

RESULTS

A total of 417 participants were enrolled between May 4, 2021, and February 2, 2023. Participants met diagnostic criteria for an average of 3.5 psychiatric diagnoses, most frequently anxiety and depressive disorders. Forty-nine percent of participants met a pre-established threshold for PSSs and exhibited higher rates of functional impairment, internalizing and externalizing symptoms, and suicidality than participants without PSSs.

CONCLUSIONS

Initial findings from the TAY Cohort Study demonstrate the feasibility of extensive clinical phenotyping in youths who are seeking help for mental health problems. PSS prevalence is much higher than in community-based studies. Our early data support the critical need to better understand longitudinal trajectories of clinical youth cohorts in relation to psychosis risk, functioning, and suicidality.

Cognitive and Developmental Profiles Associated with Self-Reported Sexual and Gender Minority Stigmatization Among Binary Transgender Adolescents

OBJECTIVE

Sexual and gender minority (SGM) stigmatization is a key factor related to transgender adolescent mental health. While previous research has focused on direct associations between stigmatization and mental health, the present study of transgender youth, equitably recruited across the autism spectrum, examines cognitive and developmental factors in relation to the self-report of experienced and perceived SGM stigmatization.

METHOD

65 binary transgender adolescents (43% transfeminine; ages 13-21 years) were intentionally recruited across the spectrum of autism traits from no traits to full criteria autism. Participants completed measures of autism-related social differences, cognitive abilities, and self-reported directly experienced and perceived SGM stigma. Autism-related social differences, cognitive abilities, and age were studied in relation to both SGM stigma factors.

RESULTS

Autism-related social differences were negatively associated with level of directly experienced SGM stigma but unassociated with perceived stigma. Greater cognitive ability was positively associated with level of perceived SGM stigma, but unassociated with report of directly experienced stigma. Older age was positively associated with level of perceived SGM stigma. There was a statistical trend toward older age positively associated with level of directly experienced stigma.

CONCLUSIONS

The present study identifies candidate cognitive and developmental influences on self-reported SGM stigmatization among transgender adolescents, evenly recruited across the autism spectrum. The factors which may impact the perception and experience of stigmatization have been notably under-explored in the mental health field. The examination of these individual characteristics may allow for more precise predictive models for research with transgender youth, and ultimately, in clinical care.

Demographics and gender-related measures in younger and older adolescents presenting to a gender service

Transgender adolescents may present to gender identity specialty services earlier or later in adolescence. The aim of this study was to examine whether, 'younger' and 'older' presenters could be identified in a large cohort of transgender adolescents and if differences exist between the two groups. The study sample consisted of 1487 adolescents (506 birth-assigned males, 981 birth-assigned females) referred between 2000 and 2018. The distribution of age at intake was evaluated. Demographic, diagnostic, and treatment characteristics, the Recalled Childhood Gender Identity/Gender Role Questionnaire (RCGI) to measure childhood gender nonconformity and the Body Image Scale (BIS) to measure body image were collected. Based on a stem-and-leaf plot and a histogram, two groups were identified: adolescents presenting at ≤ 13.9 years ('younger presenters') and adolescents presenting at 14 years or older ('older presenters'). The sex ratio was more extreme in the group of older presenters favoring birth-assigned females (Χ2(1, N = 1487) = 19.69, p < 0.001). Furthermore, more adolescents from the younger presenting group lived with both biological parents (Χ2(1, N = 1427) = 24.78, p < 0.001), were diagnosed with gender dysphoria and started with medical gender-affirming treatment (Χ2(1, N = 1404) = 4.60, p = 0.032 and Χ2(1, N = 1487) = 29.16, p < 0.001). Younger presenters showed more gender nonconformity in childhood (β 0.315, p < 0.001, 95% CI 0.224-0.407). Older presenters were more dissatisfied with various aspects of their bodies (p < 0.001). The differences between older and younger presenting adolescents suggest that there may be different developmental pathways in adolescents that lead to seeking gender-affirming medical care and argues for more tailored care.

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

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

Body Image in Adolescents with Gender Incongruence and Its Association with Psychological Functioning

During adolescence, many individuals with gender incongruence (GI) experience distress related to body dissatisfaction. This study aims to describe the body (dis)satisfaction of Dutch adolescents referred for GI and to describe the influence of body image on their psychological functioning. Self-report measures on body satisfaction (Body Image Scale) and psychological functioning (Youth Self-Report) were obtained from 787 adolescents (aged 10-18) who were referred to the Center of Expertise on Gender Dysphoria at the Amsterdam University Medical Centers between 1996 and 2016. First, a general description of body satisfaction in adolescents with GI was developed. Secondly, multiple linear regression analyses were performed to determine the association between body image and psychological functioning, both for total problems and for internalizing and externalizing problems separately. Third, regression analyses are repeated for body area subscales. Adolescents with GI report the greatest dissatisfaction with the genital area, regardless of birth-assigned sex. For all other body areas, there were birth-assigned sex differences in satisfaction. The analyses showed that body satisfaction was significantly related to total psychological problems and both internalizing and externalizing problems. Greater body dissatisfaction is significantly associated with worse psychological functioning in adolescents with GI. Clinicians should monitor the body image of adolescents with GI over time, especially during puberty and medical interventions.

Self-Perception of Transgender Adolescents after Gender-Affirming Treatment: A Follow-Up Study into Young Adulthood

Purpose: Early medical treatment for transgender adolescents should contribute to healthy psychological development, including the development of positive self-perception. However, at present, there are no longitudinal studies that have examined whether current treatment approaches meet this expectation. Therefore, the aim of this single-arm retrospective study was to examine transgender adolescents' self-perception changes over the course of irreversible medical gender-affirming treatment. Method: The total study sample consisted of 70 adolescents (49 trans men and 21 trans women). Self-perception was assessed before the start of gender-affirming hormone treatment (mean age = 14.65, standard deviation (SD) = 2.08) and at least 6 months after gender-affirming surgeries (mean age = 20.70, SD = 1.49) by Self-Perception Profile for Adolescents (SPPA). The SPPA is a self-report measure that examines self-perception on seven different domains: Scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, close friendship, and global self-worth. Multilevel modeling (random intercepts model) was conducted to determine the effect of time for all domains of self-perception. Results: It was found that the domains of physical appearance and global self-worth improved significantly over the course of treatment. No domain worsened significantly over the course of treatment. The domains of scholastic competence, social acceptance, athletic competence, and close friendship remained stable over time. Conclusion: This study provides the first suggestive evidence that irreversible gender-affirming treatment for adolescents could contribute to the development of a more positive self-perception.

Childhood Gender Variance and the Autism Spectrum: Evidence of an Association Using a Child Behavior Checklist 10-Item Autism Screener

Childhood gender variance (GV) is associated with autism spectrum disorder (ASD) diagnosis/traits; however, this association has mainly been investigated in clinical samples. An ASD screening measure based on 10 items from the commonly used Child Behavior Checklist (CBCL) might enable investigation of this association in a wider variety of (non-clinical) populations where the CBCL and a measure of GV are available. We investigated whether GV in 6- to 12-year-olds (N = 1719; 48.8% assigned male at birth) from a community sample showed an association with the CBCL 10-item ASD screener. The Gender Identity Questionnaire for Children measured GV. The CBCL 10-item ASD screener measured ASD traits. The remaining CBCL items provided a measure of children's general emotional and behavioral challenges. Higher GV was associated with higher CBCL ASD screener scores, including when controlling for the remaining CBCL items. The CBCL 10-item ASD screener can be useful for investigating the link between GV and ASD traits in 6- to 12-year-olds. Given that the CBCL is commonly employed, secondary analyses of existing datasets that also included a measure of GV could enable investigation of how widely the association between GV and ASD applies across a variety of populations.

Assessing Medical Decision-Making Competence in Transgender Youth

BACKGROUND

According to international transgender care guidelines, an important prerequisite for puberty suppression (PS) is transgender adolescents' competence to give informed consent (IC). In society, there is doubt whether transgender adolescents are capable of this, which in some countries has even led to limited access to this intervention. Therefore, this study examined transgender adolescents' medical decision-making competence (MDC) to give IC for starting PS in a structured, replicable way. Additionally, potential associated variables on MDC, such as age, intelligence, sex, psychological functioning, were investigated.

METHODS

A cross-sectional semistructured interview study with 74 transgender adolescents (aged 10-18 years; 16 birth-assigned boys, 58 birth-assigned girls) within two Dutch specialized gender-identity clinics was performed. To assess MDC, judgements based on the reference standard (clinical assessment) and the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), a validated semistructured interview, were used.

RESULTS

Of the transgender adolescents, 93.2% (reference standard judgements; 69 of 74) and 89.2% (MacCAT-T judgements; 66 of 74) were assessed competent to consent. Intermethod agreement was 87.8% (65 of 74). Interrater agreements of the reference standard and MacCAT-T-based judgements were 89.2% (198 of 222) and 86.5% (192 of 222), respectively. IQ and sex were both significantly related to MacCAT-T total score, whereas age, level of emotional and behavioral challenges, and diagnostic trajectories duration were not.

CONCLUSIONS

By using the MacCAT-T and clinicians' assessments, 93.2% and 89.2%, respectively, of the transgender adolescents in this study were assessed competent to consent for starting PS.

Examining the Relation Between Gender Nonconformity and Psychological Well-Being in Children: The Roles of Peers and Parents

No study to date has simultaneously tested how poor peer relations, generic risk factors, and parental attitudes impact the behavioral and emotional challenges of children who vary in their gender expression. In a community sample, the present study investigated various hypothesized psychosocial and generic risk factors regarding the association between childhood gender nonconformity (GNC) and psychological well-being. Canadian parents/guardians reported on their children aged 6-12 years (N = 1719, 48.8% assigned male at birth) regarding their child's GNC, measured by the Gender Identity Questionnaire for Children; behavioral and emotional challenges, measured by the Child Behavior Checklist (CBCL); and peer relations, measured by the CBCL and Strength and Difficulties Questionnaire. Parent/guardian gender-stereotypical attitudes toward child-rearing were assessed using an adapted version of the Child-Rearing Sex Role Attitude Scale, and attachment between the parent/guardian and child was measured with an adapted version of the Child-Rearing Practices Report. Based on regression analyses, GNC was related to elevated behavioral and emotional challenges, and this association was stronger for those who experienced poor peer relations as well as for those whose parents/guardians endorsed gender-stereotyped attitudes and were less willing to serve as a secure base for the child. Recommendations are provided for ways in which social environments can be altered to improve psychological well-being among gender-nonconforming children.

INSAR Special Interest Group Report: Stakeholder Perspectives on Priorities for Future Research on Autism, Sexuality, and Intimate Relationships

The number of empirical studies on sexuality and intimate relationships in autistic people has grown over the last years with the increasing awareness that sexuality and intimate relationships are an important part of life and well-being for autistic people. Further, expression and enjoyment of sexuality is a fundamental, basic human right. This paper reports on needs for future research in this area based on the input of autistic adults, researchers, and other stakeholders (e.g., parents and professionals). Utilizing the nominal group technique, 65 individuals participated in eight groups in which they brainstormed on research questions they deemed most important. Responses were categorized into themes and ranked according to importance based on the level of priority attributed by participants. Findings suggest that future research should focus on developing ways to support sexual and relationship well-being and getting a better understanding of sexuality and relationships in autistic people. Also, attention was drawn to the need for studying the influence of stereotypical societal views, and stigma. Finally, the importance of participatory research to include perspectives of autistic people in research and practice was stressed. LAY SUMMARY: Sexuality and romantic relationships are part of daily life for most people, including autistic people. For this study, groups of autistic people, professionals, and autism researchers discussed which research on autism, sexuality, and relationships is needed and can help autistic adolescents and adults. The group discussions revealed that more research is needed on how to support well-being relating to romantic relationships and sexuality in autistic people and how the people around them can contribute to this. Therefore, we also need to learn more about how autistic people of all ages and throughout their lives experience sexuality and relationships. Finally, the need for attention to the role of stereotypical ideas and stigma about autism, sexuality, and relationships was pointed out. Attention to the experiences of autistic people can help professionals, researchers, and policy makers to offer and organize attuned support and do relevant research. Autism Res 2020, 13: 1248-1257. © 2020 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals LLC.

Community attitudes on genetic research of gender identity, sexual orientation, and mental health

Sex is an important factor in mental health, and a non-binary view of how variation in sex and gender influence mental health represents a new research frontier that may yield new insights. The recent acceleration of research into sexual orientation, gender identity, and mental health has generally been conducted without sufficient understanding of the opinions of sexual and gender minorities (SGM) toward this research. We surveyed 768 individuals, with an enrichment of LGBTQ+ stakeholders, for their opinions regarding genetic research of SGM and mental health. We found that the key predictors of attitudes toward genetic research specifically on SGM are 1) general attitudes toward genetic and mental health research 2) tolerance of SGM and associated behaviors and 3) age of the participant. Non-heterosexual stakeholder status was significantly associated with increased willingness to participate in genetic research if a biological basis for gender identity were discovered. We also found that heterosexual, cisgender participants with a low tolerance for SGM indicated their SGM views would be positively updated if science showed a biological basis for their behaviors and identities. These findings represent an important first step in understanding and engaging the LGBTQ+ stakeholder community in the context of genetic research.

Separation anxiety and gender variance in a community sample of children

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

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

Objective

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

Method

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

Results

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

Conclusions

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

Gender Variance and the Autism Spectrum: An Examination of Children Ages 6-12 Years

Gender variance (GV) and autism spectrum disorder (ASD) frequently co-occur in clinical populations. We investigated GV in association with ASD characteristics in nonclinical children and in children with developmental/mental health diagnoses. In 6-12-year-olds (N = 2445; 51% birth-assigned boys), the Gender Identity Questionnaire for Children measured GV and the Children's Social Behavior Questionnaire measured six subdomains of ASD characteristics. Among nonclinical children, GV was associated with parent-reported difficulties orienting socially and stereotyped behaviors. GV was also associated with parent-reported clinical diagnoses of ASD, sensory processing disorder, and oppositional defiant disorder. These findings suggest associations between specific ASD characteristics and GV in nonclinical children. Also, childhood GV should be further examined in a range of clinical populations, including ASD individuals.

Is There a Link Between Gender Dysphoria and Autism Spectrum Disorder?

In their Translations article in the January issue of the Journal, Turban and van Schalkwyk provide a critical evaluation of the recently published literature on co-occurring gender dysphoria (GD) and autism spectrum disorder (ASD).¹ In addition, they refer to this flux in interest as part of a larger increase in publications on transgender people, which are mostly reviews and do not contain new data. Given the low-grade evidence in this field for most clinical recommendations,² good-quality research is of great relevance. We support the debate on the GD-ASD literature and acknowledge that translations of the findings to the lay press such as "Do transgender children just have autism?" are not helpful. Also, we agree with many of the limitations brought forward by the authors and acknowledge that, at present, sound underlying evidence for a GD-ASD link is lacking. However, we believe that some nuance in argumentation could help forward the debate of this clinically important topic.

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

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

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

OBJECTIVE

To examine childhood gender nonconformity (GNC) and psychological well-being in a community-based sample using measures that bridge clinical and nonclinical literature.

METHOD

Caregivers reported on the GNC (Gender Identity Questionnaire for Children [GIQC]) and behavioral and emotional problems (Child Behavior Checklist [CBCL]) of their children aged 6 to 12 years (N = 1719, 48.8% boys). The GIQC was compared to the commonly used single-item proxy, CBCL Item 110 ("wishes to be of the opposite sex").

RESULTS

Using the GIQC, 2.3% of boys and 2.8% of girls showed GNC levels comparable to those of children referred clinically for gender dysphoria (GD). Item 110 was endorsed for 1.7% of boys and 1.8% of girls. These measures corresponded, but Item 110 endorsement was biased toward more extreme GNC. Among boys, increased GNC on the GIQC, but not Item 110, corresponded with increased clinical-range CBCL problems. Among girls, Item 110 endorsement was associated with increased clinical-range Externalizing problems, whereas the GIQC indicated that intermediate gender expression was associated with fewer externalizing problems. Overall, rates of clinical-range CBCL problems among GNC children were consistent with those reported for GD-referred children.

CONCLUSION

The scope of mental health risk among community children who exhibit GNC is likely considerably greater than previously recognized. A substantial minority of community children show GNC and mental health risk levels comparable to those seen among GD-referred children. Also, compared to the GIQC, a more comprehensive GNC measure, CBCL Item 110 is likely useful only for detecting extreme manifestations of GNC, which may affect associations with mental health.