Effective Treatment for Transgender Autistic Adults

Effective Treatment for Transgender Autistic Adults

by Lisa Macafee
I reviewed eight articles discussing treatments effective for transgender adults, three articles discussed best practices for autistic adults, and ten articles specifically addressed serving the complex needs of transgender autistic adults. Implications for effective and informed treatment for the adult gender expansive autistic population found in this literature review are many. Two main themes emerged. Theme one centers on the need for clinician acceptance of gender expansiveness outside the binary and acceptance of transgender identities and more effective evaluation of autism. Theme two centers on the complex care needs of autistic adults and how best to serve them.

According to Davies (2023), due to up to 65% of autistic adults having one or more mental health diagnosis and 60% having chronic physical health concerns, autism costs the United States economy over $460 billion dollars each year due to care required around these conditions and difficulty finding work accommodating to the needs of autistic individuals. These significant economic impacts point towards the social responsibility to support autistic adults to live healthy and fulfilling lives (Strang et al., 2021).

There are small modifications to care yielding great results, such as respecting the language a person uses to identify themselves, whether it is as “autistic”, “person with autism”, “transgender”, “non-binary”, “bi-gender”, or any other phrase a practitioner may be less familiar with (Tankersley, 2021), and more complex care adjustments such as working through post-traumatic stress disorders through a neurodiversity and gender-affirming lens to benefit autistic transgender clients (Saffie & Bauerle, 2023), but our current system can be alienating and harmful to autistic transgender adults and would benefit from being updated (Pinna et al., 2022).

Theme One: Clinician Acceptance of Gender Expansiveness and Evaluation of Autism
Nine articles used discuss the importance of clinicians better understanding and accepting transgender and non-binary identities as a crucial component to receiving appropriate care, four articles focus on the importance of effective and open-minded autism evaluations, and four articles focus on a need for better research to support effective care programs for autistic transgender people. “There are a number of barriers to accessing services as a TNG autistic person due to limited affirming providers or services… I’ve experienced providers who use autism to undermine gender identity, fail to affirm my identities, or overexplain unrelated challenges” (Maroney & Horne, 2022).

Autistic clients may not embrace a binary male or female identity due to neurocognitive and hormonal differences and it may benefit for clinicians to embrace viewing gender as a spectrum (Cooper et al., 2022; George & Stokes, 2018; Strang et al., 2023). Gender is often expressed differently by autistic people and may be fluid over the lifespan (Ehrensaft, 2018) and it is important to understand someone’s assigned sex at birth is not necessarily the same as someone’s gender identity (Libsack, 2021). Due to the impact of hormones expression in autism, sex should be considered on a bimodal continuous spectrum instead of a concrete binary (McKenna et al., 2021). Much of the peer-reviewed research to date does not include transgender identities, and those which do often ignore much of the autistic experience of non-binary gender identities, for example, one study on AFAB autistics noted 11% of the participants identified as “other” for gender, but did not comment on this finding (Allely, 2018).

Supports could be better adapted for autistic populations, such as ensuring LGBTQ-affirming providers partake in training and education for transgender and non-binary identities and research includes gender spectrums and not exclusively binaries (Walker, 2021). Providers should be aware of transgender or non-binary identities in themselves are not mental illnesses and individuals expressing these ideas should not be stigmatized or marginalized (Bowman et al., 2022). Autistic people are often transgender and should not be denied gender care due to their autism (Maroney & Horne, 2022; Thrower et al., 2019) and conversion, reorientation, and restorative therapies are often harmful (Gomes et al., 2021).

Evidence exists to recommend evaluation of autism for clients with gender dysphoria and gender dysphoria for autistic clients, especially those AFAB (Jones et al., 2011; Kallitsounaki & Williams, 2022; Tankersley, 2021). Pursuing an autism diagnosis may yield insights into mental health care and treatment otherwise unmet by gender dysphoria treatment alone (Jones et al., 2011). Core features of autism may predispose people to identify outside their assigned gender at birth, more research is needed to explore why this association exists (Kallitsounaki & Williams, 2022). Effective evaluation of autism requires practitioners broaden their scope of understanding as the “frustration participants experienced for being made to feel that there was something inherently wrong with them for living authentically as neurodivergent, and TNG was evident” from research and these cause barriers to treatment and diagnosis (Maroney & Horne, 2022).

Theme Two: Complex Care Needs
Two articles discuss the complex physical health care needs of autistic transgender adults, and ten articles discuss the complex mental health care needs of autistic transgender adults. Gender diversity and autism interact with each other to yield complexities often resulting in trauma needing to be addressed in a culturally competent way to avoid further harm (Pinna et al., 2022). Both autistic populations and transgender populations have increased risks of suicide, substance abuse, and mental health concerns and need effective care (Kallitsounaki & Williams, 2022). Provided mental health care should be done with awareness of autistic people often needing more processing time to work through their gender identity, autistic identity, and articulate complex emotional reactions (Cooper et al., 2022). Autistic adults may need support in identity development and differentiating gender incongruence from special interests, compulsions, or rigidity associated with autism (Saffie & Bauerle, 2023).

Peer community, family, and community connection serve as resilience factors buffering the harms of trauma and stigma and should be encouraged and supported (Mezzalira, 2022; Tankersley, 2021) and transgender autistic people benefit especially from having a gender divergent role model to explore and affirm gender with (Strang et al., 2021). “Generally, interviewees found it easier and more comfortable to connect, seek advice, and communicate on a “deeper level,” with other LGBTQ+ autistic individuals” (Maroney & Horne, 2022). “Additionally, autistic people often experience chronic pain which should be discussed by providers (Davies, 2023) and medications currently used to treat conditions such as PCOS may be helpful in treating unwanted aspects of hyperandrogenism in autism (Gasser et al. 2021). Higher quality of life with less suicidal ideation and mental health concerns, can be achieved with dedicated work towards self-efficacy, acceptance, and improving self-concept (Mezzalira, 2022).

Providing access to gender affirming care and supporting social transitioning with mental health care for autistic adults may reduce distress (Bowman et al., 2022; Tankersley, 2021), but most autism tools are not validated to include gender diverse people (Heylens et al., 2018). As a result of interacting with cisgender neurotypical people, may autistics “described that these interactions with NT or cisgender people made them feel as if they were not human, using metaphors such as being ‘a computer,’ ‘a robot,’ or ‘an insect,’ as ‘normative culture’ viewed them strangely” (Maroney & Horne, 2022). Approximately 80% of transgender people pursue gender transition and those who do see a direct tie to well-being (Gomes et al., 2021) and 77% of transgender people desire supportive mental health care around transition but express a lack of qualified providers (Holt et al., 2021).

Discussion 
Many associations of autism care require further investigation.  More research is needed to investigate the correlations between autism and gender diversity and if autism contributes to the development of gender diversity or if gender diversity is caused something else (Kallitsounaki & Williams, 2022). Gender for autistic adults is better understood as a spectrum (Strang et al., 2023). It should be noted autistic people have complex needs surrounding working through intersectional stigma around gender diversity and autism (Pinna et al., 2022). 

Summary
Research demonstrates an overrepresentation of autistic traits among gender diverse individuals (Ehrensaft, 2018; Heylens et al., 2018; Kallitsounaki & Williams, 2022). Rates vary study to study, but between 23% to 75% of gender-affirming seeking care patients show significant levels of autistic traits (Ehrensaft, 2018; Strang et al., 2021; Thrower et al., 2019) and 11% to 23% (Kallitsounaki & Williams, 2022; Thrower et al., 2019) having an autism diagnosis. Higher rates of gender non-conformity are present among autistic people (Cooper et al., 2022; Davies, 2023; George & Stokes, 2018) with approximately 15% of autistic people identifying as transgender or non-binary (Kallitsounaki & Williams, 2022; Maroney & Horne, 2022; Strang et al., 2021), seven times more than average populations (Tankersley, 2021; Thrower et al., 2019).

These findings seem to tie in with sexuality flexibility among autistic adults (Attanasio et al., 2021) as a lack of internalizing of social norms around gender may also be extrapolated to lacking internalizing social norms around sexuality (George & Stokes, 2018). Many autistic gender divergent individuals identify as something other than binary transmen or transwomen, pointing to an importance for providers to understand gender as a spectrum and not a binary (George & Stokes, 2018; McKenna et al., 2021; Pinna et al., 2022).

High androgen exposure in the womb is tied to higher rates of autism (Jones et al., 2011; Kirkovski et al., 2013; Shah & Bobade, 2018), gay, lesbian, and bisexual sexualities (Attanasio et al., 2021), which led to the extreme male brain theory of autism linking androgen and autism (Gasser et al., 2022; McKenna et al., 2021; Nobili et al., 2018).  There are a number of biological markers lending towards AFAB autistic people having higher testosterone and masculine characteristics (Gasser et al. 2021; Jones et al., 2011; Kirkovski et al., 2013) and AMAB autistics having more feminine characteristics leading some to posit autism as a gender defiant disorder due to convergent physical sex features present in autism and higher androgynous traits among autistics (Kirkovski et al., 2013; McKenna et al., 2021).

While there is research linking gender diversity and autism, some studies present up to 11% of their participants identifying as transgender and not commenting on it at all (Allely, 2018), which may contribute to a lack of understanding of the significance of these findings in professional communities (Heylens et al., 2018; Holt et al., 2021; Maroney & Horne, 2022). Some providers deny autistic people gender affirming care due to writing off the person’s gender dysphoria as autistic rigidity, compulsion, or special interest (Saffie & Bauerle, 2023; Thrower et al., 2019). More research is needed to determine the nature of these associations (Kallitsounaki & Williams, 2022) and more training is needed for providers to provide effective care around gender diversity (Walker, 2021). Autistic gender divergent people having community interaction, peer connections, gender divergent role models, and family bonds support them to thrive instead of simply survive (Tankersley, 2021). Autistic transgender people have complex care needs due to their intersecting identities; patient, thoughtful, and affirming care will support individuals to have a higher quality of life (Kallitsounaki & Williams, 2022; Mezzalira, 2022; Strang et al., 2021).

References

Allely, C.S. (2019), Understanding and recognising the female phenotype of autism spectrum disorder and the “camouflage” hypothesis: a systematic PRISMA review, Advances in Autism, 5(1), 14-37. https://doi.org/10.1108/AIA-09-2018-0036

Attanasio, M., Masedu, F., Quattrini, F., Pino, M. C., Vagnetti, R., Valenti, M., & Mazza, M. (2022). Are Autism Spectrum Disorder and Asexuality Connected?. Archives of sexual behavior, 51(4), 2091–2115. https://doi.org/10.1007/s10508-021-02177-4

Bowman, S. J., Casey, L. J., McAloon, J., & Wootton, B. M. (2022). Assessing gender dysphoria: A systematic review of patient-reported outcome measures. Psychology of Sexual Orientation and Gender Diversity, 9(4), 398–409. https://doi.org/10.1037/sgd0000486

Cooper, K., Mandy, W., Butler, C., & Russell, A. (2022). The lived experience of gender dysphoria in autistic adults: An interpretative phenomenological analysis. Autism, 26(4), 963-974. https://doi-org.csu.idm.oclc.org/10.1177/13623613211039113

Davies, C., Moosa, M., McKenna, K., Mittal, J., Memis, I., Mittal, R., & Eshraghi, A. A. (2023). Quality of Life, Neurosensory Disorders and Co-Occurring Medical Conditions in Individuals on the Spectrum, with a Special Focus on Females Diagnosed with Autism: A Systematic Review. Journal of clinical medicine, 12(3), 927. https://doi.org/10.3390/jcm12030927

Ehrensaft, D. (2018). Double Helix Rainbow Kids. Journal of Autism and Developmental Disorders, 48(12), 4079-4081. https://doi-org.csu.idm.oclc.org/10.1007/s10803-018-3716-5

Gasser, B. A., Buerki, S. F., Kurz, J., & Mohaupt, M. G. (2021). Hyperandrogenism? Increased 17, 20-Lyase Activity? A Metanalysis and Systematic Review of Altered Androgens in Boys and Girls with Autism. International journal of molecular sciences, 22(22), 12324. https://doi.org/10.3390/ijms222212324

Gasser, B., Kurz, J., Escher, G., Mistry, H. D., & Mohaupt, M. G. (2022). Androgens Tend to Be Higher, but What about Altered Progesterone Metabolites in Boys and Girls with Autism?. Life (Basel, Switzerland), 12(7), 1004. https://doi.org/10.3390/life12071004

George, R., & Stokes, M. A. (2018). Gender identity and sexual orientation in autism spectrum disorder. Autism : the international journal of research and practice, 22(8), 970–982. https://doi.org/10.1177/1362361317714587

Gomes, S. M., Jacob, M. C., Rocha, C., Medeiros, M. F., Lyra, C. O., & Noro, L. R. (2021). Expanding the limits of sex: a systematic review concerning food and nutrition in transgender populations. Public health nutrition, 24(18), 6436–6449. https://doi.org/10.1017/S1368980021001671

Heylens, G., Aspeslagh, L., Dierickx, J., Baetens, K., Van Hoorde, B., De Cuypere, G., & Elaut, E. (2018). The Co-occurrence of Gender Dysphoria and Autism Spectrum Disorder in Adults: An Analysis of Cross-Sectional and Clinical Chart Data. Journal of autism and developmental disorders, 48(6), 2217–2223. https://doi.org/10.1007/s10803-018-3480-6

Holt, N. R., Ralston, A. L., Hope, D. A., Mocarski, R., & Woodruff, N. (2021). A systematic review of recommendations for behavioral health services for transgender and gender diverse adults: The three-legged stool of evidence-based practice is unbalanced. Clinical Psychology: Science and Practice, 28(2), 186–201. https://doi-org.csu.idm.oclc.org/10.1037/cps0000006.supp (Supplemental)

Jones, R. M., Wheelwright, S., Farrell, K., Martin, E., Green, R., Di Ceglie, D., & Baron-Cohen, S. (2012). Brief report: female-to-male transsexual people and autistic traits. Journal of autism and developmental disorders, 42(2), 301–306. https://doi.org/10.1007/s10803-011-1227-8

Kallitsounaki, A., & Williams, D. M. (2023). Autism Spectrum Disorder and Gender Dysphoria/Incongruence. A systematic Literature Review and Meta-Analysis. Journal of Autism & Developmental Disorders, 53(8), 3103–3117. https://doi-org.csu.idm.oclc.org/10.1007/s10803-022-05517-y

Kirkovski, M., Enticott, P. G., & Fitzgerald, P. B. (2013). A review of the role of female gender in autism spectrum disorders. Journal of autism and developmental disorders, 43(11), 2584–2603. https://doi.org/10.1007/s10803-013-1811-1

Libsack, E. J., Keenan, E. G., Freden, C. E., Mirmina, J., Iskhakov, N., Krishnathasan, D., & Lerner, M. D. (2021). A Systematic Review of Passing as Non-autistic in Autism Spectrum Disorder. Clinical child and family psychology review, 24(4), 783–812. https://doi.org/10.1007/s10567-021-00365-1

Lim, M., Carollo, A., Dimitriou, D., & Esposito, G. (2022). Recent Developments in Autism Genetic Research: A Scientometric Review from 2018 to 2022. Genes, 13(9), 1646. https://doi.org/10.3390/genes13091646

Maroney, M. R., & Horne, S. G. (2022). “Tuned into a different channel”: Autistic transgender adults’ experiences of intersectional stigma. Journal of Counseling Psychology, 69(6), 761–774.

McKenna, B. G., Huang, Y., Vervier, K., Hofammann, D., Cafferata, M., Al-Momani, S., …  Michaelson, J. J. (2021). Genetic and morphological estimates of androgen exposure predict social deficits in multiple neurodevelopmental disorder cohorts. Molecular Autism, 12, 1-18. doi:http://dx.doi.org/10.1186/s13229-021-00450-w

Mezzalira, S., Scandurra, C., Mezza, F., Miscioscia, M., Innamorati, M., & Bochicchio, V. (2022). Gender Felt Pressure, Affective Domains, and Mental Health Outcomes among Transgender and Gender Diverse (TGD) Children and Adolescents: A Systematic Review with Developmental and Clinical Implications. International journal of environmental research and public health, 20(1), 785. https://doi.org/10.3390/ijerph20010785

Nobili, A., Glazebrook, C., Bouman, W. P., Glidden, D., Baron-Cohen, S., Allison, C., Smith, P., & Arcelus, J. (2018). Autistic Traits in Treatment-Seeking Transgender Adults. Journal of Autism & Developmental Disorders, 48(12), 3984–3994. https://doi-org.csu.idm.oclc.org/10.1007/s10803-018-3557-2

Pinna, F., Paribello, P., Somaini, G., Corona, A., Ventriglio, A., Corrias, C., Frau, I., Murgia, R., El Kacemi, S., Galeazzi, G. M., Mirandola, M., Amaddeo, F., Crapanzano, A., Converti, M., Piras, P., Suprani, F., Manchia, M., Fiorillo, A., Carpiniello, B., & Italian Working Group on LGBTQI Mental Health (2022). Mental health in transgender individuals: a systematic review. International review of psychiatry (Abingdon, England), 34(3-4), 292–359. https://doi.org/10.1080/09540261.2022.2093629

Rojas Saffie, J. P., & Eyzaguirre Bäuerle, N. (2023). Etiology of gender incongruence and its levels of evidence: A scoping review protocol. PloS one, 18(3), e0283011. https://doi.org/10.1371/journal.pone.0283011

Shah, D., Bobade, S. (2018).  Polycystic Ovarian Syndrome and Autism. Journal of Psychosocial Research; New Delhi 13(2), 435-442. DOI:10.32381/JPR.2018.13.02.18
 
Strang, J. F., Kenworthy, L., Dominska, A., Sokoloff, J., Kenealy, L. E., Berl, M., Walsh, K., Menvielle, E., Slesaransky-Poe, G., Kim, K. E., Luong-Tran, C., Meagher, H., & Wallace, G. L. (2014). Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Archives of sexual behavior, 43(8), 1525–1533. https://doi.org/10.1007/s10508-014-0285-3

Strang, J. F., Knauss, M., van der Miesen, A., McGuire, J. K., Kenworthy, L., Caplan, R., Freeman, A., Sadikova, E., Zaks, Z., Pervez, N., Balleur, A., Rowlands, D. W., Sibarium, E., Willing, L., McCool, M. A., Ehrbar, R. D., Wyss, S. E., Wimms, H., Tobing, J., Thomas, J., … Anthony, L. G. (2021). A Clinical Program for Transgender and Gender-Diverse Neurodiverse/Autistic Adolescents Developed through Community-Based Participatory Design. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 50(6), 730–745. https://doi.org/10.1080/15374416.2020.1731817

Strang, J. F., Wallace, G. L., Michaelson, J. J., Fischbach, A. L., Thomas, T. R., Jack, A., Shen, J., Chen, D., Freeman, A., Knauss, M., Corbett, B. A., Kenworthy, L., Tishelman, A. C., Willing, L., McQuaid, G. A., Nelson, E. E., Toomey, R. B., McGuire, J. K., Fish, J. N., Leibowitz, S. F., … Yang, J. S. (2023). The Gender Self-Report: A multidimensional gender characterization tool for gender-diverse and cisgender youth and adults. The American psychologist, 78(7), 886–900. https://doi.org/10.1037/amp0001117

Tankersley, A. P., Grafsky, E. L., Dike, J., & Jones, R. T. (2021). Risk and Resilience Factors for Mental Health among Transgender and Gender Nonconforming (TGNC) Youth: A Systematic Review. Clinical child and family psychology review, 24(2), 183–206. https://doi.org/10.1007/s10567-021-00344-6

Thrower, E., Bretherton, I., Pang, K. C., Zajac, J. D., & Cheung, A. S. (2020). Prevalence of Autism Spectrum Disorder and Attention-Deficit Hyperactivity Disorder Amongst Individuals with Gender Dysphoria: A Systematic Review. Journal of autism and developmental disorders, 50(3), 695–706. https://doi.org/10.1007/s10803-019-04298-1

Walker, M. (2021). Exploring The Cyc Cis-Tem: A Literature Review Of Queer And Trans Topics In Child And Youth Care. International Journal of Child, Youth and Family Studies 12(3-4), 23–54. https://doi.org/10.18357/ijcyfs123-4202120333  ​