What does all the Research on Gender Non-Conformity in Autistics Mean?

What does all the Research on Gender Non-Conformity in Autistics Mean?

by Lisa Macafee
This research was conducted to explore the relationship between gender diversity and autism through a neurodiversity lens, emphasizing autism as a natural biological divergence which should not be stigmatized (Fung et al., 2022). The problem addressed herein is the disproportionate negative mental and physical health outcomes for autistic gender diverse adults, which are more than double those of the typical population (Hall, et al., 2020; Nobili, et al., 2018) and lack of effective care strategies (Strang, et al., 2019; Zener, 2019). The purpose was to elucidate the experiences of autistic transgender adults, illuminate the issues they experience, and explore options for treatment (Nobili, et al., 2018; Walsh, et al., 2018).

Research Questions
RQ1. What does research data demonstrate as to the relationship between autistic adults (especially those AFAB) and non-binary and transgender identities? 
RQ2. How do autistic adults’ sex, gender, and gender identity differences develop?
RQ3. What mental health treatment methods and practices are recommended to best serve the transgender and non-binary autistic population?

Approximately 15% of autistic adults identify under the transgender umbrella (Maroney & Horne, 2022; Walsh, et al., 2018) and there are biological markers influencing these identities, such as high testosterone rates among autism (Kung, 2020; Nobili, et al., 2018). This systematic literature review is situated in neurodiversity framework which asserts autistic people are simply a form of natural biological diversity in the human genome that have both strengths and weaknesses, like any other variation, and should not be viewed as problematic in itself (Enoka, 2022; Fung et al., 2022; Legault et al., 2021) and explores culturally sensitive and effective treatment options for gender diverse autistic adults, as misinformation or misunderstandings of autism or gender can be harmful (Maroney & Horne, 2022; Strang, et al., 2019). The systematic literature review conducted contains the results from thirty peer-reviewed research articles using methodology of the PRISMA model (Tawfik et al., 2019).

Findings
Findings for research question one on gender diversity and autism seem to be congruent between the findings described in Chapter Two and the results in Chapter Four. In the United States, only about 0.6% of people identify as transgender (Bowman et al., 2022) and autistic people have an overrepresentation of transgender identities (Kung, 2020; Strang et al., 2021), with roughly 11% of gender divergent people being autistic (Strang et al., 2023). While AFAB autistics have the highest rate of transgender identity at 21.6% (Walsh et al., 2018), autistic people in general report transgender identities roughly 15% of the time (Kallitsounaki & Williams, 2022; Maroney & Horne, 2022; Strang et al., 2021), about eight to eleven times more often as neurotypical people (Janssen et al., 2016; Pinna et al., 2022; Strang et al, 2014).

While it was found in the literature review is AFAB autistics tend to be more gender flexible (Kung, 2020), with 21.6% identifying as transgender or non-binary (Walsh et al., 2018) compared to 15% of the general autistic population (Strang et al., 2021), results from Chapter Four indicate AFAB and AMAB autistics both experience significant rates of gender diversity (Strang et al., 2023; Thrower et al., 2019) and transgender people are disproportionately autistic (Maroney & Horne, 2022). Multiple studies demonstrate AFAB transgender and non-binary people demonstrate the highest rates of autistic traits (Kallitsounaki & Williams, 2022; Pinna et al., 2022) with 30%-45% of transgender AFAB people having autistic traits (Jones et al., 2011; Nobili et al., 2018) while other studies show AMAB having higher rates of autistic traits at 31.2% versus 22.2% of AFAB (Heylens et al., 2018).

It is speculated autistic adults experience higher rates of gender diversity for a number of reasons, but the most commonly cited example is autistic people do not internalize social norms and expectations in the same way as neurotypical people, do not feel pressure to conform to unspoken norms in the same way, resist social conditioning, and are more likely to embrace atypical identities (Cooper et al., 2022; Ehrensaft, 2018). Autistic people can also hyper-fixate on gender as a special interest in a way neurotypical people do not experience gender, which can make treatment complicated (Cooper et al., 2022; Davies, 2023) and the rigidity and intolerance for ambiguity many autistic people experience can make the intricacies of gender identity difficult to discuss (Saffie & Bauerle, 2023). AFAB autistics may relate with more ease to male peers as compared to women, where communication barriers can cause unease and prompt gender non-conformity (Jones et al., 2011).

Research question two findings indicate, in addition to social aspects of gender, there are significant factors of physical influence on autistics towards gender convergence (Gasser et al. 2021; Kung, 2020). The extreme male brain theory of autism was developed in response to noting correlating levels of androgens present in fetal development of autistic children and the overrepresentation of testosterone-related disorders in both mothers of autistic children and AFAB autistics (Gasser et al., 2022; McKenna et al., 2021; Shah & Bobade, 2018). Fetal testosterone correlates with the development of autism and AFAB autistics have sex-linked traits similar to AMAB people, such as handedness patterns (Jones et al., 2011; Kirkovski et al., 2013). It is also thought AFAB autistics may be more sensitive to androgen exposure, autistic AFAB have significant levels of bioactive testosterone as compared to neurotypical AFAB, while AMAB autistics have similar rates to neurotypical AMAB (Kirkovski et al., 2013).

Interestingly, atypical androgen exposure does result in correlating masculinization of AFAB autistics, but it results in correlating feminization of AMAB autistics, with AFAB autistic faces and digit ratios being more masculine and AMAB more feminine (McKenna et al., 2021). Sexual dimorphisms can be expected in autistic people (Kirkovski et al., 2013), leading some to describe autism as a gender defiant disorder due to its androgynous correlations and the function hormonal levels have on gender development, which are comparable to the chromosomal genetic sex impact (McKenna et al., 2021). Additionally, a high birth weight is correlated with both gender non-conformity and autism (Heylens et al., 2018; Tankersley, 2021). Further research is needed to determine any causal determinates of gender diversity among autistic people.  It is not clear if autistic people experience the development of gender identity in similar ways to neurotypical people or if very different mechanisms are at work (Kallitsounaki & Williams, 2022).

Findings for research question three indicate there is a focus on gender and sexuality to be viewed as spectrums found in both Chapters Two and Four (Ehrensaft, 2018; Kung, 2020). Autistic people seem to have more flexibility when it comes to sexuality and identity, with roughly 30% of autistic adults identifying with an identity on the asexual spectrum (Attanasio et al., 2021). Having more flexibility when thinking on the individual’s own gender can result in similar flexibility in sexual orientation, with autistic people stating their sexuality is directly related to their gender experience (George & Stokes, 2018; Tankersley, 2021).

Research on gender identities in the past five years encourages practitioners to view gender as bimodal and continuous instead of binary and unchanging (McKenna et al., 2021). Treatment and support of autistic adults should take transgender and non-binary identities into consideration as these two identities are so commonly linked are associated with greater physical and mental healthcare needs (Davies, 2023; Hall et al., 2022; Kallitsounaki & Williams, 2022). Social supports can be especially impactful for transgender autistic people, who may benefit from social groups of peers, community interaction, gender divergent autistic role models, and family connection allowing individuals to see a path forward in their identity (Mezzalira, 2022; Strang et al., 2021; Tankersley, 2021).

The issue of gender convergence may be something to investigate for practitioners working with autistic people as gender identity may be conflated with autistic people being physically more masculinized or feminized, and these identities and realities should be differentiated before jumping to conclusions or treatment avenues (Jones et al., 2011). It will be crucial to separate gender identity disorder from any compulsions or obsessive thinking dominating autistic thought at times (Saffie & Bauerle, 2023). Practitioners would be advised to choose their words with care so as to prevent alienation of clients and support mental well-being (Davies, 2023; Gomes et al., 2021; Pinna et al., 2022).

Approximately 80% of transgender people pursue gender transition and it is directly linked to well-being but does not have to be medical for results to be shown, as name choice and clothing can be helpful (Gomes et al., 2021) with 77% of transgender adults desiring therapy throughout their gender transition to work through intense challenges to their mental health (Holt et al., 2021). It should not be assumed services developed for gay and lesbian clients are applicable to autistic transgender client needs, and services will likely need to be adapted appropriately to both transgender and autistic demands (Walker, 2021). Regardless of services being discussed, practitioners should differentiate between biological sex and gender identity, especially when working with autistic people (Libsack, 2021) and reducing internalized stigma while working to improve self-acceptance can help promote a better self-concept and positive quality of life (Mezzalira, 2022). Autistic people have rights to gender affirming care, just as neurotypical people do, and receiving care may be more impactful on mental health due to the intersectional stigma of being gender divergent and autistic (Maroney & Horne, 2022; Mezzalira, 2022; Thrower et al., 2019).

This literature review has limitations in research as it is still difficult to gauge the rates and experiences of non-binary identities in autism research as some researchers only use binary gender markers of male and female and do not allow for participants to enter their gender identity in the research collection (Allely, 2018; Strang et al., 2023). Research including transgender identities, where gender is not the focus of the research may use phrasing and language which is not inclusive and may cause underreporting of gender divergent identities among literal-minded autistics (Attanasio et al., 2021). For example, the literal meaning of “trans” is from Latin, meaning “journey,” and if an autistic person identifies as non-binary, they may not feel appropriate to list their gender as “trans” because they are not journeying to the opposite binary gender identity, but rather not partaking of gender binaries at all (Attanasio et al., 2021).

Implications for Professional Practice
There are several areas wherein autistic gender diverse clients are being underserved and a number of ways in which practitioners could be more inclusive and accessible for this population. One autistic and non-binary AFAB person asked their healthcare provider about the possibility of doing a chromosome test for intersex identity and it was stated because they did not have a penis, they were not a hermaphrodite (Macafee, 2024).  The word “hermaphrodite” itself is an offensive term to most intersex people and is not current terminology to be used in the medical field either (Walker, 2021).  The lack of understanding on the part of the practitioner caused the individual to never go back to the provider again and to never repeat their request to another provider (Macafee, 2024). The stigma autistic people in particular feel in the health care field is already problematic and causes communication barriers to care, denial of care, and avoidance of seeking care (Libsack, 2021). Adding doubly marginalized identities of autistic and gender divergent makes seeking care increasingly difficult, the fear of persecution or unkind treatment makes it a daunting process (Holt et al., 2021; Kallitsounaki & Williams, 2022; Pinna et al., 2022).

One of the first and most basic areas for practitioners to improve upon is learning more about gender diversity, especially as related to autism (Ehrensaft, 2018; Strang et al, 2014) and autistic sexuality being more likely to identify as LGB or asexual (Attanasio et al., 2021; George & Stokes, 2018). Gender for many autistic people is a fluid concept which can be expressed and experienced differently (Ehrensaft, 2018; Heylens et al., 2018) and may impact development of sexuality (George & Stokes, 2018; Tankersley, 2021). Additionally, autistic biology trends towards androgynous features, with AMAB autistics having more feminine physical features than typical AMAB people and AFAB autistics having more masculine features (Jones et al., 2011; McKenna et al., 2021).

Practitioners working with autistic people should expect there may be gender non-conformity or sexual dimorphisms (Kirkovski et al., 2013; Tankersley, 2021). Practitioners are advised to differentiate between autistic people’s gender identity and gender assigned at birth (Libsack, 2021; Strang et al., 2023), know approximately 15% of autistic people identify as transgender (Lim et al., 2022; Maroney & Horne, 2022), with AFAB autistics being more likely to identify as transgender compared to AMAB (Nobili et al., 2018). Practitioners may also work to better understand the impact of hormonal differences present in a number of autistic people which have similar effects on development of gender as chromosomes and gender assigned at birth (McKenna et al., 2021).

Many practitioners have been trained in LGBTQ+ competencies which do not provide sufficient information on transgender identities and appropriate care and may result in stigmatizing language being used which could turn autistic people away from receiving care (Holt et al., 2021; Pinna et al., 2022; Walker, 2021), such as describing an autistic person’s transgender identity as autistic obsession instead of taking the clients gender dysphoria seriously (Maroney & Horne, 2022; Saffie & Bauerle, 2023). An autism diagnosis should in no way bar someone from receiving gender affirming care, as withholding such care is correlated with negative mental health outcomes (Thrower et al., 2019). It is important for practitioners to be aware of the language they use, current preferred terminology (Gomes et al., 2021; Pinna et al., 2022), and be aware of how beneficial social transitioning of gender can be for individuals experiencing gender dysphoria, whether they choose to physically transition or not (Bowman et al., 2022; Gomes et al., 2021; Strang  et al., 2021).

Through social transition, it is possible for autistic transgender people to experience “gender euphoria,” wherein the person feels comfort and joy in the expression of their gender when aligned with their gender identity (Strang et al., 2023). Social supports, such as autistic and transgender role models, community engagement, family sense of belonging, and autistic peers support the development of a healthy sense of self and are linked to improved mental health (Mezzalira, 2022; Strang et al., 2021). While in therapy, practitioners should be aware of autistic people’s need for more time in therapy to process through feelings and trauma and work to develop and understand their identities (Cooper et al., 2022) due to both increased difficulties communicating effectively and recognizing emotions (Kallitsounaki & Williams, 2022). Practitioners working with autistic clients may wish to explore gender identity with autistic clients (Tankersley, 2021).

Autistic people are more likely to experience physical health problems related to central sensitivity syndromes and hormone imbalances (Gasser et al. 2021; Shah & Bobade, 2018). As such, pain should be discussed and managed when practitioners are meeting with autistic clients (Davies, 2023), especially among AFAB autistics among whom 76% report chronic pain (Walker, 2021) and are more likely to have conditions like PCOS, dysmenorrhea, ovarian cancer, and uterine cancer associated with elevated rates of androgens (Gasser et al., 2022; Kirkovski et al., 2013).

Recommendations for Research
While there has been an increase of research published in the last ten years on transgender issues and on autistic issues, rarely has the intersection of transgender autistic people been the focus of research. Even in studies where 11% of AFAB autistics reported a transgender identity, researchers fail to remark upon details such as this at all, begging the question of how a finding such as this is not worth noting, or if it may be researcher bias lending towards not remarking upon these findings (Allely, 2018). Regardless of why researchers do not focus on the high correlations of gender diversity and autism, future research is needed to explain this correlation and how it has come about (Attanasio et al., 2021), as 0.6% of adults in the United States identify as transgender (Bowman et al., 2022) but approximately 15% of the autistic population identifies as autistic (Maroney & Horne, 2022), with LGB sexuality being related to gender diversity for some autistic people (George & Stokes, 2018).

When conducting research among autistic individuals, language choice is important to ensure accurate data, with different gender identities as options to choose from, including man, woman, trans man, trans woman, non-binary, and “fill in the blank” as use of the word “other” can be stigmatizing (Gomes et al., 2021; Heylens et al., 2018; Libsack, 2021). Diagnostic criteria for autism would benefit from adjustments for evaluation of AFAB people and transgender people, the norm for diagnosis was modeled on young AMAB clients and practitioners may need to adapt the diagnosis process for adults, AFAB clients, and transgender people (Lim et al., 2022; Tankersley, 2021).

Research into serving the complex care needs of autistic transgender individuals is needed as autistic people may have more difficulty expressing intersecting needs and may struggle to express complex emotional ideas and make sense of their identity (Cooper et al., 2022; Tankersley, 2021; Thrower et al., 2019). Up to 77% of transgender people want therapeutic care to support transition (Holt et al., 2021), but many are unable to find practitioners effective among autistic transgender clients and provide effective supports (Jones et al., 2011; Pinna et al., 2022; Walker, 2021). As both transgender populations and autistic populations are both at greater risk of suicide, up to nine times greater than typical populations, research into supporting this population with timely supports is crucial (Kallitsounaki & Williams, 2022). Research on autistic peer support groups may be helpful as multiple studies show the benefit of having autistic transgender role models and peer engagement, but few supports are provided to meet this need (Mezzalira, 2022; Strang et al., 2021; Tankersley, 2021).

Research on autistic identity development would be helpful, as neurodivergent people may experience identity development in very different ways than neurotypical models the world of psychology relies upon (Ehrensaft, 2018; Kallitsounaki & Williams, 2022). Additional research exploring the conceptualization of gender for autistic people could be beneficial as some researchers posit for some autistic people, their transgender identity could be described as a special interest and not necessarily something the person needs to act upon, while for others, society’s binary definitions chafe against autistic rigidity and these autistic people find themselves self-describing as transgender because the strict binary roles do not feel comfortable (Maroney & Horne, 2022; Saffie & Bauerle, 2023).

Research into autism and hormone differences, chromosomal differences, and physical sex dimorphisms relating to intersex identities would be useful as some researchers posit autism as a gender defiant disorder due to biological markers leading towards physical sex convergence in autism, rather than only one’s mental concept of gender identity (Gasser et al. 2021; Gasser et al., 2022; Kirkovski et al., 2013). Additional research noting how much of influence hormonal differences have on autistic development of gender identity could help differentiate gender identity and physical sex differences, which could support effective decision making in treatment (McKenna et al., 2021). The relationship between autism and chronic pain is not well understood, other than through increased physical and emotional stress due to marginalization and further research to attenuate the points of chronic pain would be beneficial (Davies, 2023; Shah & Bobade, 2018; Walker, 2021).

Conclusions
The thirty peer reviewed research papers on gender diversity and autism analyzed as part of this systematic literature review demonstrate a connection between autism and gender defiance (Gasser et al. 2021; Kung, 2020). Approximately 15% of autistic adults identify as gender divergent (Maroney & Horne, 2022; Strang et al., 2021; Thrower et al., 2019) and between 11% to 45% (Strang et al., 2023; Thrower et al., 2019) of transgender and non-binary individuals are autistic. Autistic people demonstrate gender convergent physical traits, such as facial features and digit ratios (McKenna et al., 2021), along with atypical androgen rates in AFAB autistics (Attanasio et al., 2021; Gasser et al. 2021; Gasser et al., 2022) and autistic diagnosis correlating with androgen exposure in utero (Attanasio et al., 2021; Kirkovski et al., 2013; McKenna et al., 2021). It is likely these factors contribute to atypical development of gender and sexual identities in autism, but more research is needed to identify and understand contributing factors to this atypical gender and sexuality development in autism (Kallitsounaki & Williams, 2022; Mezzalira, 2022; Saffie & Bauerle, 2023). Autistic people have more complex needs in physical and mental health care due to communication challenges associated with the diagnosis, and practitioners serving autistic individuals would benefit from understanding how better to accommodate to autistic communication needs (Libsack, 2021; Maroney & Horne, 2022; Strang et al., 2021; Walker, 2021).

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