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

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

Brief Report: An Exploration of Alexithymia in Autistic and Nonautistic Transgender Adults.

Background: Research has shown that many autistic people have alexithymia, a psychological trait characterized by difficulties in identifying and describing emotions. It is also now clear that there is a high rate of autism among transgender people, but we know little about the intersection of autism and gender diversity or about the clinical features of autistic transgender individuals. Methods: Seventy-eight nonautistic transgender, 56 autistic transgender, 106 nonautistic cisgender, and 107 autistic cisgender adults completed the Toronto Alexithymia Scale-20 and the Autism-spectrum Quotient as part of an online study. We also used the General Alexithymia Factor Score-8 as an additional alexithymia score. Results: We found that nonautistic transgender participants reported significantly higher mean levels of alexithymia than nonautistic cisgender participants, and that there was a significant overrepresentation of individuals in this group who met the clinical cutoff for alexithymia. The difference in alexithymia between autistic cisgender and autistic transgender participants was nonsignificant, with >50% of each group scoring above the clinical cutoff point. Of note, when we used the General Alexithymia Factor Score-8, the difference between autistic transgender participants and autistic cisgender participants was significant, with autistic transgender participants reporting higher mean levels of alexithymia. Conclusion: Results suggest that nonautistic transgender individuals might be more prone to experience alexithymia (including at clinically significant levels) than nonautistic cisgender people. When autism occurs in transgender people, the average level and clinical rate of alexithymia is higher than among nonautistic transgender people and potentially higher than among autistic cisgender people. Our findings are in keeping with evidence of a subgroup of transgender people with "subclinical autism" and inconsistent with the notion that autism among transgender and gender diverse people is a "phenomimic" of autism. Lastly, our study highlights the potential importance of screening autistic and nonautistic transgender people for alexithymia.

Why is this an important issue?: Alexithymia is when a person has difficulty recognizing and describing their emotional feelings. It also includes an externally oriented thinking style. Research has shown that many autistic people experience alexithymia. Autistic people with alexithymia might require additional and specialized support and care. What was the purpose of this study?: There are a large number of transgender and gender diverse people who are autistic. However, we know little about the intersection of autism and gender diversity or about the clinical characteristics of autistic people who identify as transgender. The purpose of this study was to explore alexithymia in autistic and nonautistic transgender individuals. What did the researchers do?: We conducted an online study that included questions about people's ability to recognize and describe their emotional feelings as well as about their preference to engage with the world around them than the world inside them. Participants also answered questions that tap characteristics of autism. What were the results of the study?: We found that nonautistic transgender adults had more difficulty identifying and describing their emotional feelings than nonautistic cisgender adults. We also found that autistic transgender adults reported significantly higher levels of alexithymia than nonautistic transgender adults and potentially higher than autistic cisgender adults. What do these findings add to what was already known?: This study showed, for the first time, that (1) it is not always easy for nonautistic transgender people to identity and describe their emotional feelings and (2) autistic transgender people find at least as difficult as autistic cisgender individuals to describe and identify their emotional feelings. What are potential weaknesses in the study?: We did not examine depression and anxiety in our participants. People with depression and/or anxiety might score high on the scale we used to measure alexithymia. This was also an exploratory study, so other researchers should replicate our findings before we draw strong conclusions. How will these findings help autistic adults now or in the future?: Our findings are consistent with the notion that autism in transgender people is "real," meaning that it has the same underlying basis in autistic cisgender and autistic transgender people, and suggest that autistic transgender people might benefit from receiving support for difficulties related to autism independently of the support and treatment they might receive for gender-related needs.

Autism Spectrum Disorder and Gender Dysphoria/Incongruence. A systematic Literature Review and Meta-Analysis.

The suggested overlap between autism spectrum disorder (ASD) and gender dysphoria/incongruence (GD/GI) has been much disputed. This review showed a relationship between ASD traits and GD feelings in the general population and a high prevalence of GD/GI in ASD. Our meta-analyses revealed that the pooled estimate of the prevalence of ASD diagnoses in GD/GI people was 11% (p < .001) and the overall effect size of the difference in ASD traits between GD/GI and control people was significant (g = 0.67, p < .001). Heterogeneity was high in both meta-analyses. We demonstrated that the chances that there is not a link between ASD and GD/GI are negligible, yet the size of it needs further investigation.

Implicit and Explicit Gender-Related Cognition, Gender Dysphoria, Autistic-Like Traits, and Mentalizing: Differences Between Autistic and Non-Autistic Cisgender and Transgender Adults.

Evidence indicates a link between autism spectrum disorder (ASD) and gender diversity, yet this intersection remains insufficiently understood. Here, we investigated whether (1) ASD affects gender-related cognition (i.e., mental processes of perceiving and interpreting one's own gender self-concept), (2) autistic people have increased gender dysphoria and recall limited gender-typed behavior from childhood, and (3) transgender individuals have increased ASD-like traits and difficulties in mentalizing. A total of 106 non-autistic cisgender (51 birth-assigned female), 107 autistic cisgender (57 birth-assigned female), 78 non-autistic transgender (41 birth-assigned female), and 56 autistic transgender adults (27 birth-assigned female) participated in the study. The mean age of participants was 31.01 years (range = 18 to 70). Using an explicit as well as an implicit measure, for the first time, we found that ASD affected gender-related cognition only in autistic cisgender people. Sex differences were also observed in this group. Whereas autistic cisgender birth-assigned males showed a stronger implicit gender-group identification than non-autistic cisgender birth-assigned males, autistic cisgender birth-assigned females showed a weaker gender-group identification than non-autistic cisgender birth-assigned females. Furthermore, autistic cisgender people reported significantly more gender dysphoric feelings and recalled significantly less gender-typed behavior from childhood than non-autistic cisgender individuals. No difference was observed between non-autistic and autistic transgender people. We also found that relative to non-autistic cisgender individuals, both non-autistic transgender and autistic transgender people reported significantly more ASD-like traits. However, mentalizing difficulties were observed only in the latter group. This research enhances our understanding of the link between ASD and gender diversity.

Links Between Autistic Traits, Feelings of Gender Dysphoria, and Mentalising Ability: Replication and Extension of Previous Findings from the General Population.

Gender nonconformity is substantially elevated in the autistic population, but the reasons for this are currently unclear. In a recent study, Kallitsounaki and Williams (Kallitsounaki and Williams, Journal of Autism and Developmental Disorders, 2020; authors 1 and 2 of the current paper) found significant relations between autistic traits and both gender dysphoric feelings and recalled cross-gender behaviour, and between mentalising ability and gender dysphoric feelings. The current study successfully replicated these findings (results were supplemented with Bayesian analyses), in sample of 126 adults. Furthermore, it extended the previous finding of the role of mentalising in the relation between autistic traits and gender dysphoric feelings, by showing that mentalising fully mediated this link. Results provide a potential partial explanation for the increased rate of gender nonconformity in the autistic population.

Mentalising Moderates the Link between Autism Traits and Current Gender Dysphoric Features in Primarily Non-autistic, Cisgender Individuals.

The co-occurrence between autism and gender dysphoria has received much attention recently. We found that, among 101 adults from the general population number of autism traits, as measured using the autism-spectrum quotient was associated significantly with recalled and current gender dysphoric traits. Furthermore, performance on an objective measure of mentalising, such as the "Reading the Mind in the Eyes" test was associated with current gender dysphoric traits, but most importantly it moderated the relation between number of autism traits and number of current gender dysphoric traits, such that the association was significant only when mentalising ability was relatively low. Results suggest mentalising may represent a contributing factor to the relation between autism and gender dysphoric traits in the general population.

A Relation Between Autism Traits and Gender Self-concept: Evidence from Explicit and Implicit Measures.

A link between autism spectrum disorder (ASD) and gender identity difficulties has been suggested. In this study, we found that, among adults from the general population (N = 101) ASD traits (measured using the Autism-spectrum Quotient) were associated negatively and significantly with the strength of both explicit gender self-concept (measured using the Personal Attributes Questionnaire) and implicit gender self-concept (measured using an Implicit Association Task). Further analyses showed that a subgroup with high/clinically significant ASD traits showed significantly weaker explicit and implicit gender self-concepts than a subgroup with low ASD traits. Results were similar in both males and females, although there was some evidence of a selective influence of ASD traits on implicit gender self-concept among females only.

Interoception is Impaired in Children, But Not Adults, with Autism Spectrum Disorder.

Interoception (the ability to sense what's going on inside one's body) is considered integral to many higher-order cognitive processes. Some have speculated that impaired interoception may underpin some features of ASD. Yet, in Experiment 1, we found no evidence of a between-group difference in either cardiac or respiratory interoceptive accuracy among 21 adults with ASD and 21 matched controls. Bayesian analyses suggested the data strongly supported the null hypothesis. In Experiment 2, we measured cardiac interoceptive accuracy in 21 children with ASD and 21 matched controls. Here interoceptve accuracy was significantly diminished in the ASD group and was associated with a moderate-to-large effect size. Results suggest early interoception difficulties are resolved or compensated for by adulthood in people with ASD.