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

Abstract

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.

Many transgender people are autistic.¹ The common intersection of autism and gender diversity (i.e., gender identity diversity) reflects a distinctive contour of human diversity in which two apparently individual experiences (i.e., gender diversity and autistic neurodivergence)^* naturally tend to intersect and overlap.^3–6 The contributions of autistic transgender people have been impactful at many levels of society.^7–10 Yet, autistic transgender people face striking challenges related to marginalization and the doubts of others.^11,12 Even their existence has been questioned (i.e., the genuine co-occurrence of being autistic and transgender).

For example, although community expressions of the common co-occurrence abound,^13,14 some commentators have asserted that autistic transgender people may not, in fact, be autistic, but instead that pseudoautistic features might arise from “environmental factors related to social deprivation” in transgender individuals, namely “a high prevalence of minority stress, poor peer relationships, and familial non-acceptance.”^15,16 Work by some of the members of this roundtable has directly challenged such assertions, demonstrating that autism among transgender individuals is related to brain functional connectivity profiles consistent with previously established neural characteristics of autism, whereas gender minority stress indicators are not.¹⁷

Attempts to deny autism among transgender people may reflect ongoing societal stigmatization of autism,¹⁸ which may drive implicit bias and assumptions about autistic transgender people,¹⁹ including challenges to whether this intersection even exists.²⁰ Also of concern are clinical assumptions that the autistic transgender intersection reflects at its root confusion by autistic people about their gender.²¹ Yet no published study has demonstrated that autistic transgender people typically experience regret regarding their gender-related decisions and/or detransition.

Of note, a recent study found that autistic transgender and nonautistic transgender young people were equally likely to show stability versus instability of gender and gender-related need over time.²² Further, roundtable member Aimilia Kallitsounaki has reported that autistic and nonautistic transgender individuals show no differences in implicit measures (i.e., outside of conscious control) of gender identity, with both groups demonstrating implicit genders that align with affirmed gender and not assigned sex at birth.²³

Adding additional complexity is the current politicized atmosphere that transgender and nonbinary people, including autistic transgender and nonbinary people, face. The common intersection of autism and transgender identity has entered the political fray surrounding gender diversity and gender care,^24–27 again, likely due to ongoing stigmatization and distrust of autistic people, their inner experience, and their ability to know who they are. Yet, within the autistic community, and increasingly within the transgender community as well, the presence and contributions of autistic transgender people are more and more recognized and celebrated.^13,28,29 This roundtable brings together researchers, academics, and expert practitioners to consider the current state of the field and key next steps for research and advocacy with this highly marginalized sector of our communities.

It must be noted that this roundtable is occurring in the context of a great deal of upheaval regarding transgender rights, which panelists highlight as having a profound impact on not only autistic transgender individuals and communities, but also research with these communities.

Dr. John Strang: Thank you everyone for joining today's panel on the common intersection of autism and gender diversity. There are eight of us today representing research, clinical care, and advocacy. Each of you has played a role in moving forward the understanding of the common intersection of autism and gender diversity. To get started, please take a moment to introduce yourself and say a bit about your work with this intersection, including what you've done and your goals for future contributions to this field. If you would like to share anything about your background or identities, feel free to do so.

Dr. Wenn Lawson: I am a British Psychologist, a member of the Australian Psychological Society and Australian Association of Social Work, an autistic lecturer, advocate, researcher, writer, and poet. I am passionate about autism research and intersections with gender diversity. I work with the Curtin University Autism Research Group (Western Australia) and Macquarie University (New South Wales). I am also a Tutor Practitioner with the University of Birmingham's (United Kingdom) Master's in Education and an ambassador for “I CAN,” Australia's largest network of autistic-led mentoring and training services for youth, young adults, and organizations. I am on the Board for “Good Autism Practice” United Kingdom, Editorial Board for Autism in Adulthood, and the U.S. Autism Association's Advisory Board. In 2021, I was awarded the Lesley Hall National Lifetime Achievement Award for Disability Leadership. I am an autistic transgender family man with autistic offspring and autistic grandchildren.

Dr. Harriette Wimms: I am a Maryland-licensed clinical psychologist who provides care to children, adolescents, adults, and families—with a focus on working with people of color, neurodivergent individuals (primarily autism spectrum disorder [ASD] and attention-deficit/hyperactivity disorder [ADHD]), LGBTQ+ people, and neuro- and gender-expansive clients across the life span. I have worked in outpatient, pediatric, rehabilitation, and community psychology settings. I've served as the founder and director of child, adolescent, and family therapy programs within outpatient mental health, federally qualified health centers, inpatient pediatric hospitals, LGBTQ+ specialty clinics, and school settings. I'm an adjunct professor at the Loyola University Maryland and Academy of Jewish Religion. I am most proud of being mother to my 18-year-old neurodivergent, gender-diverse teen.

Dr. Anna van der Miesen: I am a White queer medical doctor in Child and Adolescent Psychiatry and a postdoctoral researcher with the Center of Expertise on Gender Dysphoria in Amsterdam, The Netherlands. My clinical work has focused on autistic children, adolescents, and young adults with gender incongruence who are seeking medical gender-affirming care. My research has also focused on the intersection of autism and gender diversity in addition to research on the mental health of gender-diverse individuals, community-based participatory research, and cross-cultural research. From a personal perspective, my partner is late-diagnosed autistic, and I am therefore very supportive of adequate gender/gender-diversity sensitive autism assessment.

Dr. Meng-Chuan Lai: I am a child and youth psychiatrist at the Centre for Addiction and Mental Health in Toronto, Canada, providing mental health care for neurodivergent children, youth, young adults, and their families. I am also a researcher at the University of Toronto studying the intersections of autism, mental health, sex, and gender—from biology, cognition, individual development, to health service experience. I have worked clinically in Taiwan with youth of a range of sexual and gender identities for their mental health and been involved in social advocacy for the LGBTQ+ communities and the first school-based survey on gender dysphoric feelings in Taiwan.

My current research stems from the training I received in the United Kingdom working with autistic women, whose lived experiences have greatly enriched my understanding of the intersections of gender and autism. I work clinically with autistic girls/women, boys/men, nonbinary, and gender-diverse youth for mental health, and part of our team's research is to understand the gender journeys and developmental needs of autistic people to design more tailored support. I am cisgender and nonautistic and have a nibling who is neurodivergent.

Dr. Aimilia Kallitsounaki: I am a nonautistic cisgender psychologist with an MSc degree in Developmental Psychology and a PhD in Psychology. I currently work as a postdoctoral research associate at the University of Kent in the United Kingdom on a project that explores the intersection of autism and gender diversity in children and young people as well as in their families. Before this, the focus of my research was on the adult population. Specifically, during my PhD, I examined the common intersection of autism and gender diversity taking an individual differences approach. I also conducted case–control studies with autistic and nonautistic transgender and gender-diverse adults. In the future, I hope my research will produce evidence that will increase our understanding of this intersection so that autistic gender-diverse children and adults can receive more timely and specialized support and care.

Mx. Finn Gratton: I am a White, autistic, queer, and agender somatic psychotherapist and consultant based in California. In addition to my psychotherapy practice, I write and provide training on neurodiversity- and gender-affirming care. I am deeply engaged in supporting connection and capacity among trans, queer, neurodivergent, and allied practitioners through international group consultation. Additionally, I am engaged in an initiative in autistic and ADHD somatic practices.

Dr. Kate Cooper: I am a clinical psychologist and academic based at the University of Bath in the United Kingdom. I'm White, cisgender, and not autistic. I recently completed my doctorate, which aimed to understand the experiences of autistic people with gender dysphoria. I've worked clinically within mental health settings with gender-diverse and neurodivergent young people who were experiencing distress and conducted qualitative interviews with a range of stakeholders with perspectives on the co-occurrence.

Dr. John Strang: I am a clinical neuropsychologist and founder and Director of the Gender and Autism Program at Children's National Hospital. I identify as neurodivergent and within the LGBTQ+. I am interested in pushing the field to focus more on the community and clinical supports and approaches that are most helpful to autistic transgender people. I am active within the World Professional Association for Transgender Health (WPATH) and served on the Standards of Care 8 (SOC-8) revision groups for the child and adolescent WPATH care standards. Through WPATH, I colead specialized training in the Global Education Institute on the intersection of neurodivergence and gender diversity.

Mx. Finn Gratton: We know that the inner experiences of autistic people, as well as the authenticity of their self-report, are often doubted and even denied. Such beliefs and perspectives have resulted in delayed or denied gender-related care for some autistic trans folx. Currently, some of you are engaged in research to better understand the nature of the autism gender diversity intersection. What have we learned in these efforts that might inform a shift in societal and medical understanding to provide more ethical and attuned care for autistic, transgender, and nonbinary people?

Dr. Wenn Lawson: I think we have learned a number of things from research, but even more so from anecdotal experiences. We need to listen to the autistic voice, including the autistic gender-diverse voice. And realize that sometimes we self-recognize our autism—it doesn't necessarily mean a clinical diagnosis because those can be expensive and have quite long waiting lists. Importantly, we've learned that autism diagnoses are more common among gender-diverse individuals than among their cisgender peers. We've also learned that we need to take what autistic transgender people say seriously. For me, going to the psychiatrist and talking about gender dysphoria wasn't taken seriously because of my autism, and they really were very reluctant to pursue gender-affirming care with me.

There was a strong focus by the mental health specialists on whether my gender experience was authentic, like they thought it was due to my autism or some mental health issue. It took 8 months and seeing two psychiatrists to have what I was saying about my gender confirmed.

We need to get more serious about the needs of autistic transgender people and the disparities they face. I think this is one of the ways we can address the concerning suicidality experienced by so many in our community. We also need research that engages and deeply includes the autistic transgender community in its design. Currently, I'm involved with research exploring intersections between autism, gender identity, and mental fitness. I'm also working with a team at a large Australian mental health organization, looking at the issues of coproduction, which means bringing all the voices together from the very beginning of something that we're exploring, so we make sure we get that autistic voice included.

I don't think that, in general, researchers have included the autistic transgender voice very seriously, but this is something that is beginning to happen. And that's really important because autistic and autistic transgender people are emphasizing the need to be heard.

Dr. Meng-Chuan Lai: I would first like to acknowledge that science about humans cannot really ever be neutral, because the design of scientific studies and the interpretation of the findings are all affected by the presumptions, biases, stereotypes, hopes, beliefs, and ideologies held by the person who conducts the study or reads the findings. Although scientific findings have been used to inform social, medical, and policy changes, what's actually driving the changes is not the findings alone, but also the presumptions held about the findings. What I'm going to share is definitely also affected by my own biases, presumptions, and ideologies.

I will emphasize three things from my research and clinical experiences. First of all, autistic people have identities, period. Their identities include gender identities. Autistic people have a range of gender and sexual identities, as do neurotypical people; of note, autistic people's gender and sexual identities may be even more varied. The diversity of gender and sexuality experienced by autistic people enriches our understanding of human identities.

Second, identity is by definition personal. The person themselves is the authority of their identity. It is subjective and comes from one's agency; that has to be understood, respected, and acknowledged in any case. One's identity is very much related to well-being. We now know that early identification with an autistic identity shapes later well-being for kids and youth.^30,31 A neurodivergent lens brings better self-compassion, self-understanding, and subjective well-being for autistic people. This is clearly also the case in the gender and sexuality literature.³² We also know that identities may not always be linear and may be fluid for some people.

Third, coping with one's identity development is so crucial and there are many things going on related to the shaping of identity, including gender identity. This involves a lot of exploration, thinking and decision-making, advocating for one's own needs, and mental health-related issues. These processes may be influenced by one's neurotype and whether the environment is supportive and understanding of the person's neurotype.

Dr. Kate Cooper: I want to emphasize the need to focus on people's lived experience. In my research, I interviewed autistic gender-diverse young people and adults to capture their lived experiences, building upon the research conducted by people at this roundtable and others. One finding was that both adults and adolescents strongly asserted that they knew their own gender identities.³³ But what was different between the young people and adults was that the adults were much more likely to reflect on autism as an important part of who they were,³⁴ whereas the young people that I spoke to were more focused on their gender-related needs and were less likely to think of autism as an important part of themselves.³⁵ So, I think we need to help foster self-acceptance of both gender- and neurodiversity.

We have the opportunity to help reduce feelings of self-stigma and shame after the autism diagnostic process. To make the most of this opportunity, clinicians could support individuals to make sense of autism in relation to their sense of self, as well as explore their gender experiences.

As a society, we need increased acceptance of difference. Many of the autistic gender-diverse people I've spoken with describe the challenges of feeling different, both in relation to gender- and neurodiversity. I have wondered about how the experience of discrimination related to both identities impacts sense of self in autistic and transgender people. Unfortunately, many individuals described their experiences at school of being bullied, feeling isolated, and being othered, which is incredibly challenging and distressing. And these negative social experiences and related distress pulled focus away from the important process of making sense of who they are and what identities are important to them.

Dr. Harriette Wimms: I will point out a few more things we need to consider as researchers and clinicians. First, many individuals who are autistic do not necessarily use speech as their primary mode of communication, and therefore, our clinical efforts to characterize gender based on communication and responses to verbal queries may be ineffective. For people who do not or cannot use verbal language for communication, behavioral observation, in addition to verbal language (and input from members of the social network), would be ideal.

I also think often about the intersections of ethnic and racial backgrounds with neuro- and gender diversity. This is akin to the notion of intersectionality: Kimberly Crenshaw's viewpoint that intersections of marginalized identities can lead to increasingly negative outcomes due to complex societal impacts on individuals at the nexus of marginalized identities.³⁶ I believe we also need to study in what ways there are differences in identification and identity development for individuals who are at the crossroads of these identities, and how these differences impact access to the needed supports and services and the pacing of this access.

Dr. Aimilia Kallitsounaki: Using quantitative methodology, my research has shown that transgender and gender-diverse adults identify with their experienced gender, not only explicitly but also implicitly, regardless of whether they are autistic or not.²³ To put it simply, they report a diverse gender identity, but also, and importantly, this identity is incorporated into their self-concept, outside of conscious awareness or control. My research has also shown a developmental continuity of gender-diverse feelings in both autistic and nonautistic transgender and gender-diverse adults.²³ I believe that these findings provide counter evidence to the hypothesis that autistic trans experiences are not “true transgender experiences.”

Dr. John Strang: In addition to Dr. Kallitsounaki's important contributions regarding explicit and implicit gender in autistic and nonautistic people, we can also look to the broad literature that shows that the autism gender diversity intersection and the proportional “overoccurrence” exist not only for young people,³⁷ who may be exploring lots of identities, but also exist across the age range into adulthood.¹ People who doubt autistic transgender people's identities often suggest that the gender-related experience might represent “confusion”—that there may be some lesser authenticity to gender diversity experiences in autistic people.

But when we see that this common co-occurrence exists across ages and into adulthood, I think we are called to step back and consider that this may very well be one of the beautiful contours of human diversity: that autism and gender diversity often intersect, and that there is an authenticity to this pattern, which is observed across ages^1,37 as well as across countries and cultures.^3,38–42 Research from my own institution reported on autistic gender-diverse compared with nonautistic gender-diverse young people.²² We found that in these two groups reported on over time, autistic trans young people were no more likely to experience shifts in their gender-related medical requests than nonautistic trans people. Of course, research like this needs to be extended over years and decades; that will help to move us toward a more ethical and informed care practice.

Dr. Anna van der Miesen: You are all doing an incredible job increasing awareness for the gender diversity autism intersection. However, I am worried about the heightened politicization of transgender people in general, and those with intersecting autistic gender-diverse identities in particular. In many parts of the world, new laws are arising that restrict access to gender-affirming medical care, which may disproportionately affect autistic trans youth given the extra barriers that autistic gender-diverse people already face in accessing care.

As researchers, we always operate in a social, political, and cultural context. But the intergroup polarization happening alongside this politicization worries me, as it causes people and societies to define themselves as allies or opponents to trans people. We are losing a middle ground, and this is affecting the potential for nuanced conversations, including in scientific circles. I don't know how to solve this, but I've learned that we really need to keep on going through this changing context and continue working together and producing meaningful scientific research.

Mx. Finn Gratton: I want to note that the research you all and others are doing has motivated many autism care and gender care providers to seek greater understanding and to begin addressing accessibility issues for autistic trans and nonbinary people. However, research-based understanding has not filtered through to many medical and mental health providers, who are often gatekeepers to more specialized care. Social stigmatization of both autism and trans identities seems too often unmoved by scientific research. Further, as Dr. van der Miesen was referencing, medical care is affected by social bias-fueled politics, such as legislation, lawsuits, and threats of violence. Autistic trans people, particularly those with higher support needs, are at greater risk of losing timely access to medical and social transition support.

Dr. Meng-Chuan Lai: From a general medical perspective, if there is any care to be provided, this requires a process of informed consent. The informed consent and the capacity to receive care are not—and should not be—determined by the diagnosis given to a person, no matter if this is autism, schizophrenia, intellectual disability, or other diagnoses. Although on paper and in bureaucratic systems, people use diagnostic categorization all the time, it is very important to recognize that clinically, a person's capacity and care planning should not be solely based on their diagnosis. We should all insist on personalization, and we should fight against the stereotype of who is capable or not owing to a particular diagnostic label they have.

Dr. John Strang: There has been an increasing spotlight on the common intersection of autism and gender diversity among major academic journals, advocacy organizations, and clinical policy associations. The intersection of autism and gender diversity has also received heightened attention in the press as well as in legal and political debates. What is the impact of this increased attention? Could you offer thoughts about the helpful and potentially harmful effects this spotlight has had for trans and nonbinary autistic people?

Dr. Wenn Lawson: When anything is spotlighted or highlighted, people can be quite fearful and there's potential for some serious harm if we operate from fear. But if we step back and take a more balanced look at things and we talk about it, then we can put the intersection of autism and gender diversity into context. Also, because so much of gender identity and autism is ingrained in who we are, some autistic people don't think to separate these things.

Mx. Finn Gratton: My first thought follows Dr. Kallitsounaki's research showing no difference between autistic and nonautistic trans people in their experience of implicit gender.²³ If this is true, then why put a spotlight on autistic trans people, referring them for autism assessment that might delay or cause denial of gender care, as their gender identity has been shown to be incorporated into their self-concept, outside of conscious awareness? I know that anti-trans groups have picked up on the autistic trans intersection and used statements in WPATH SOC-8 adolescent and child sections about the autistic trans overlap to fuel their rhetoric, feeding the incorrect belief that autistic people are inherently impaired in their ability to know their gender or provide informed consent.^†

There has been a history of autistic people being infantilized and/or not having their needs honored, and many are wary of gender care providers or insurance providers delaying or denying their care because of an autism diagnosis—which, in my experience, has and continues to occur for some autistic people. I know that, within the autistic community, some people are choosing to try to hide their autistic traits and to avoid pursuing a medical autism diagnosis until they've gone through social and medical transition.

While recommendations of assessment for autistic or other neurodivergent characteristics may be intended to serve autistic and otherwise neurodivergent people by securing better supports and understanding, it may also present a dilemma for some patients and their providers, as this assessment might be used against their gender needs by uninformed medical or insurance systems. In some locations, gender care could be legally restricted due to an autism diagnosis.^43,44 One way to approach these barriers, while also supporting the access and effectiveness of medical and mental health care, would be an inclusive, or a universal design-guided, approach to mental and medical health services. It should be anticipated that autistic and other neurodivergent people will be common in our patient/client population, as are disabled people, immigrants, and others with different care delivery needs.

Universal design principles do not single out specific populations but include the needs of all populations in health care systems.⁴⁵ By designing forms, protocols, communication options, and physical and online environments to be welcoming and effective for people with a variety of executive functioning, sensory, and communication needs, we improve access for everyone, not just those diagnosed as autistic. When we improve the clinical experience, we improve communication, trust, and, ultimately, treatment. Such a universal, rather than diagnosis-segregating approach would support diagnosed autistic people, as well as those who do not yet know, or are unwilling to share, that they may be autistic, along with the many people who do not meet clinical criteria yet have communication, environment, and cognitive processing needs than are included in most standard gender protocols.

Dr. John Strang: With the spotlight on not only autistic trans people, but trans care in general, there has been a great deal of confusion regarding what people mean when they say “evaluation” or “assessment.” I have observed that there are many different motivations people have in conducting and receiving assessments: Some assessment approaches may be extremely helpful to the individual, while others may not. In gender care circles, the term “assessment” has often focused on seeking to understand the nature of a person's gender experience and the “readiness” to commence requested medical care. However, as Mx. Gratton notes, an additional motivation for assessment focuses on the individualized needs of the trans person, and this is not exclusive to autistic trans people.

In fact, in our research, we have identified that even beyond the autism gender diversity intersection, trans young people often experience undue gender barriers related to executive function differences.⁴⁶ And we've identified that these executive function barriers are very much related to greater suicidality. Some of these barriers may arise in relation to the underlying neurodivergence and the impact of a “disabling” society. And other challenges may stem from the impact of marginalization on the well-being and functioning of the individual. With these perspectives, a model of assessment and related accommodation and advocacy that seeks to characterize the personalized gender, advocacy, and accommodation needs of individuals may be profoundly helpful in improving outcomes for neurodivergent trans folx. This kind of broad and collaborative assessment does not typically get discussed in the larger conversations regarding clinician-driven gender evaluation.

Dr. Meng-Chuan Lai: I think the pros of increased attention may be more opportunities for advocacy because when there's increased attention, it comes with increased awareness. Depending on the resources available, political debates can provide the momentum to make changes and facilitate discussions. The cons may be, paradoxically, reduced room for exploration and calm types of discussion due to the polarization. I worry a lot that the variety and richness of the lived experiences can be overly simplified and flattened in the polarized debate to find a solution, cause, or fix. And then the richness of experiences that's needed for identity development for a person, especially the exploration, and sometimes detours, gets compressed and there is limited room to discuss and reflect on things. I worry about the flattened and overly simplified discourses.

I want to also bring up the intersectionality aspect that Dr. Wimms pointed out earlier, because again, flattened and simplified discussions often leave out intersectionality with race, ethnicity, poverty, and sociocultural contexts. Thinking from a global perspective, similar to the consideration of intersectionality, it is important to consider the cultural and political contexts and the state of the society when discussing topics under polarized debates, such as in many North American and European countries. These topics may not receive the same kind of attention currently in other countries. For example, I was recently talking with my Taiwanese psychiatrist, pediatrician, and social advocacy friends about gender care and gender diversity awareness among professionals. I learned that much of the social advocacy for transgender rights at this moment in Taiwan is centering around the right to change one's gender on legal identification documents without also having to have received gender-affirming surgery.

At the same time, despite being one of the most LGBTQ+ friendly countries, attention to what medical gender care might be like for teenagers in the local context is just emerging. There is no systematic implementation of the Dutch model⁴⁷ in Taiwan yet, for instance. Prescribing pubertal blockers to gender-diverse teens has just been piloted recently and inconsistently. Even topics with pronoun use have different implications due to linguistic differences. The current debates in the United States, Australia, the United Kingdom, Sweden, and Canada may not be immediately “relatable” and translatable for clinicians (and even autistic people and their families) in other parts of the world, as there are immediate local contexts at play in each society and jurisdiction.

There are historical, cultural, social, political, and legal reasons as to how and when a society attends to, discusses, and makes changes to best care models for autistic gender-diverse people in their local contexts. There are lots of differences that affect what the attention and the focus of social advocacy might be at the moment. People around the globe experience different statuses and paths. I think it is very important to acknowledge that.

Dr. Anna van der Miesen: Dr. Lai made a good point about the pros and cons of increased visibility. However, I think the nuance gets lost. An advantage of a spotlight is of course that more people know about the common intersection: More clinicians know about it, and autistic people are being asked about their gender identity, which a few years ago, was not happening. But a disadvantage is that when something is spotlighted, people tend to be either in favor of or against it. So, it becomes really dichotomized. While intersectionality is not something that is an opinion for which we should be in favor of or against, it has nuanced layers of experiences that we need to look at from different angles, and we need to stay away from dichotomies. And I think that's a disadvantage of the spotlight.

Dr. John Strang: Dr. van der Miesen, can you say more about the type of nuance you are speaking of?

Dr. Anna van der Miesen: I'll give you an example. Mental health is an intersectional experience that may need clinical attention. And we know from our initial studies in The Netherlands that when transgender people have access to puberty suppression and gender-affirming hormones, their mental health improves.⁴⁸ But some clients I have known for years continue to struggle with their mental health even after receiving gender-affirming medical care. These struggles may stem from environmental challenges and nonacceptance and discrimination related to neurodivergence and/or gender diversity.

Mental health challenges may also arise due to existential concerns over not being born the way they wanted to be born. I think access to gender-affirming care can help mental health, but there may be still mental health challenges even with access to medical gender-affirming care. So, I think we need to be able to handle the nuance that people may still struggle, and that should not be a reason to deny care.

Dr. Harriette Wimms: In my clinical work, I have seen that the focus on mental health and wellness has made a difference for some of my younger clients and their families. For example, some of the young children I work with, who have received diagnoses of autism and who are also gender-diverse, are communicating gender- and neuro-expansiveness through behavior. Additionally, when they are affirmed as being gender- and neuro-expansive, externalizing behaviors decrease.

I'd also like to broach the topic of ASD, ADHD, and race/ethnicity. Earlier in my career, autism was not being diagnosed among African American and Latinx people at the same rate that it was being diagnosed among White children. Black and Brown children with the same diagnostic criteria as White children with autism were more likely to receive incorrect diagnoses of ADHD and/or conduct disorder.⁴⁹ Recent studies suggest that the diagnostic chasm is shrinking and that children of color are receiving more diagnoses of autism.⁵⁰ Yet, Black and Latinx communities are still less likely to receive information about early intervention and long-term planning for autism supports.^51,52 We have a long, long arc of reckoning to erase bias in the diagnosis and treatment of autism based on race.

Lastly, with regard to supporting gender-diverse and neurodivergent youth, my hope is that in the same way we have beautiful books now about being nonbinary and transgender, that one day soon we will have the same kind of affirming materials for families who are raising gender-diverse neurodivergent kids—especially kids of color.

Dr. Kate Cooper: As Dr. Lai mentioned regarding various cultural contexts, I'll offer some thoughts on the United Kingdom, where I am based. There was a judicial review recently about whether under 16s could provide informed consent to access puberty blockers, and one of the claimants was the mother of an autistic teenager.⁵³ From the clinical and research work that I've done, I know that a lot of families have been keenly aware of that judicial process, as well as the wider societal discourse in this area, and this awareness has caused additional challenges to families. These are families who have a child in distress, who is dealing with understanding themselves and their gender and being autistic and all the challenges that can bring to young people.

But then these families also have this sense of being in the spotlight and a real fear that access to health care services will be reduced, adding additional distress. As others have pointed out, this can lead to less space for exploration and can lead to polarization within family units, mirroring the wider discourse. And, because services are changing quite a lot at the moment, there has been some uncertainty as to what services will look like in the United Kingdom in the future. Obviously, that uncertainty would be challenging for any family, but it's especially challenging for autistic people. So that has very much been present in my research and my work, and I think it has made people feel the need to really assert that they do know their gender identities and spend a lot of time doing that.

Dr. Aimilia Kallitsounaki: I would like to add here one more point about the positive impact of the increasing spotlight on the common intersection of autism and gender diversity. I think this will help clinicians and researchers to secure funding more easily, which is of paramount importance. The more research we conduct, the better we understand autistic gender-diverse people, and eventually, we will be able to provide better support and care. Of course, we cannot disregard the potential harmful effects of this publicity.

Catchy headlines, misleading translations of research findings in the press, and political and legal debates lead to misconceptions in the general public and a general fear to engage with research related to the intersection of autism and gender diversity. For example, institutions that would typically be open to participate in psychological research are often less willing to engage with researchers from this field out of fear of becoming associated with any type of publicity and the scrutiny that comes with it. This is counterproductive and delays the emergence of positive outcomes for the autistic gender-diverse community.

Dr. John Strang: For almost a decade, I have been running the Gender and Autism Program or a forerunner of that program that didn't have an official name. And I think a positive of the national and international spotlight is that we are seeing a much more diverse group of young people in recent years. We are seeing lots of little ones coming in and getting supports that they need. And for the first time, we're seeing autistic gender-expansive young people who also have intellectual disabilities. I think the word is getting out to schools and providers, and the community is now learning that there are some specialized services available for young people at this intersection, allowing for diversification in our referrals.

Mx. Finn Gratton: There's a great deal of focus on autistic gender-diverse youth, especially teens. And perhaps this is due to the ongoing clinical and political dialogue regarding gender-related medical decisions in youth, including autistic youth. But this focus on youth and teens has drawn attention away from autistic, trans, and nonbinary adults, and their needs. Given the current lack of research and advocacy for autistic trans and nonbinary adults, what are your top research and advocacy priorities for the adult community over the next decade?

Dr. Wenn Lawson: If it were up to me, and I know it isn't, I would prioritize direct funding toward autistic adults and appropriate adult care. In Australia, we have very little support medically or socially for autistic adults who are also trans. For example, I had to travel abroad for a lower surgery and had issues with that, specifically in trying to find medical care back in my own country of Australia. It was really difficult because people wouldn't see me since they hadn't worked on me surgically. And I was really at a point of severe need for surgical intervention. I did find help eventually, but without respect or understanding. I was certainly made to feel less than. I'd love to see research highlight the medical and social needs for autistic transgender adults.

This theme we've talked about throughout this roundtable of being listened to for respect and mutuality highlights that we are human and adults, and we need the same afforded understanding. Further, adults are in even more need quite often because we've had years of accumulation of issues that are impacting us. We need supportive clinics and services for various adult issues. I think this would also contribute to fewer mental health issues, like suicidality, but we need research and advocacy to highlight these links. These are an absolute priority, and there has to be care for autistic and transgender people's entire lives.

Dr. John Strang: In addition to Dr. Lawson's offering, which would be an absolute priority in my mind, I'm also concerned about late or missed autism identification among gender-diverse people. And absolutely, not every autistic person needs to be clinically identified or diagnosed, but we do know that there are associated greater risks for people who are late to receiving their diagnosis or identifying as autistic.⁵⁴ We have noticed clinically, and we're beginning to document this in our research, that there is an apparent intersection of late autism diagnosis and gender diversity. So, this brings me to my first additional research priority. We need to better understand how autism may be differently experienced and expressed by gender, especially in our work by gender-diverse folx, and how this might lead to a missed diagnosis.

Another priority area involves moving away from the deep pathologization to a focus on research to better understand how this intersection may be protective and associated with great and meaningful lives. The extreme pathologization that has occurred around this intersection is so different from the day-to-day experience I have collaborating with autistic transgender people in their care. We have a vibrant and creative community of autistic transgender people who are part of our program and larger community offerings, and I can tell you that the spirit of our community is hopeful and not one of despair. Positive and hopeful aspects of the intersection have been largely lost in the clinical literature. And this is an area where we as researchers need to do better in telling the whole story.

Dr. Aimilia Kallitsounaki: I just want to add that over the next decade, research might usefully focus more on the clinical characteristics of autistic transgender and gender-diverse adults. Not only will this help to identify the specific needs of relatively homogenous subgroups within the autistic gender-diverse population, but it will also help in the design of educational and training programs for health care professionals to provide additional and specialized support and care attuned to individual needs. The ultimate goal of this research should be to promote the well-being of autistic transgender and gender-diverse adults and to support their quality of life.

Dr. Kate Cooper: I was thinking about people I interviewed for my research who were autistic trans people in their forties plus, who spoke about really feeling the lack of role models of people like them aging and not really having heard stories of people like them.³⁴ So, there is a real need for more focus on the lived experience of what it's like to grow older as an autistic trans person. Also, that group had the experience of not having their neurotypes or their gender diversity acknowledged or mirrored back to them in society when they were growing up, which had a profound impact on their sense of self and self-knowledge.

Hopefully, younger people will have more role models and examples of different ways to be in the world as an autistic gender-diverse person. However, there is a generation of people who really didn't have that, and we need to be thinking about how to support them and their particular needs as they get older.

Dr. Harriette Wimms: Although rates of identification in kids is becoming much more equal in the States between White kids and kids of color, particularly Latinx and African American kids,⁵⁰ there is still a tremendous delay in service provision and family education about autism.^51,52 It is also a sad fact that special education is often a prison pipeline for Black and Brown young people, an issue also known as the school-to-prison pipeline.^55–57 When autism and gender expansivity are also considered, the outcomes can become bleaker. Therefore, prison reform to ensure safety and wellness for autistic transgender individuals in prison is an absolute necessity. I'm especially considering Black trans women and the ways that mental health and social justice initiatives still fail to serve them.

We need to identify mechanisms that support these vulnerable populations. I also think that, as Dr. Lawson mentioned, access to long-term care planning is essential. When we consider individuals who are people of color, disabled, and gender-expansive, we need to consider access to financial resources, or lack thereof. We must also consider that some adults with disabilities continue to be cared for by their families—placing a burden on aging parents. Reform is needed to make long-term care affordable for the families of disabled individuals, and this planning involves services of support when parents pass away.

There must be systems that ensure access to resources to promote good adulthoods in the same way that we want teens and young children to have access to good lives and optimal development. Autism doesn't end when a person reaches 21. Autism is a lifelong disability, and programs supporting aging autistic individuals who are gender-diverse are crucial.

Mx. Finn Gratton: I want to echo what Dr. Wimms said about the impact of the special education-to-prison pipeline for Black, Indigenous, and People of Color (BIPOC) trans autistic people. Both gender care and affirming autism services serve disproportionally White and economically privileged people over BIPOC and low-income people. If we want to find the trans autistic people we're missing, we're going to find many in the carceral system and in disabled and unhoused, or fragilely housed, communities. The later the recognition and support for both trans and autistic experiences, the greater the chronic physical and mental health issues.^54,58,59 Adding the allostatic load from racism^60,61 to the loads from trans and autistic discrimination is a triple hit to health and life expectancy.

Almost all my trans autistic clients over the age of 15 are dealing with significant and chronic health issues: chronic fatigue, fibromyalgia, migraines, and many more. While some of these diseases may be related to high sensitivity associated with autism, I suspect most are due to the extremely high allostatic loads related to discrimination and oppression, along with poor access to responsive care.

In the future, I want to see more autistic and academic collaborative research and program development initiatives, with BIPOC and disabled trans autistic people in leadership positions and directing program and research priorities. I'd like to see the development of gender-affirming education and protocols for care providers of autistic youth and adults with higher support needs, as well as gender- and neurodiversity-affirming training and protocol development for the incarcerated and the unhoused populations. I'd love to see the inclusion of autistic transgender or nonbinary “standard patients” in medical training and the development of instruments for earlier identification and support for chronic health issues. I'd like to see more medical and mental health strategies driven by autistic experiences of what works and doesn't work for them in health care settings and interventions.

Dr. Anna van der Miesen: Everyone has shared extremely valuable future directions. In addition, I'm hoping we could learn from research and clinical work with children and adolescents in the sense that we're a bit more inclined to take the developmental perspective or lens with youth, but as soon as someone is 18 years old, that gets totally lost and we're only looking at sneak peeks, or cross-sectional parts of their lives.

But human beings keep on developing through their life span and different experiences, different intersectional experiences, could shape people's lives. So, I'm hoping for future research on gender-diverse and autistic adults to take a more developmental approach. I think Dr. Cooper has done an amazing job with the interviews, but I hope we continue to look at everyone from a developmental perspective and not solely one cross-sectional view of an adult's life, because we continue to develop. We need to walk together through time to understand longer term trajectories and outcomes.

Dr. Meng-Chuan Lai: I echo so much with what people have shared, from the focus on mental health and well-being to the developmental and life span perspectives to understand individual differences and journeys related to gender and neurodiversity. In terms of mental health and well-being, I really want to see more integration of individual-focused and environment- or context-focused approaches.⁶² Environment and context here span from the family, the school, and the community to how stigma and discrimination in the society have an impact. Drawing on Dr. van der Miesen's example, many gender-diverse people, autistic or nonautistic, even after receiving adequate gender-affirming care, may still struggle with a lot of things in life. Many of these challenges might heavily originate from the context or environment. When it comes to autistic gender-diverse people, there is an added layer. There are heightened mental health challenges faced by autistic people.⁶³

Although these may, in part, be related to biological factors and cognitive styles, there's evidence that they are also the results of a poor fit between the environment and the autistic person. Many of these challenges are due to nonautistic people's poor understanding of autistic people.^64–66 Research using the minority stress model helps to understand why there are heightened mental health challenges.⁶⁷ We need to take that forward to make changes to “treat the environment” or “help the environment to help the autistic person” from childhood to adulthood. The other important aspect is what Dr. van der Miesen emphasized: the richness of the developmental perspectives and the variety of individual journeys. The life stories pointed out by Dr. Cooper are so rich and inspiring. We as researchers and clinicians need to be familiar with these experiences of autistic and gender-diverse people.

Finally, I really want to see more global liaison, coordinated and integrated with local grassroots advocacy efforts. This is because there could be different contextual factors and different battlefields for different societies. I want to dedicate more to global liaison and joint work, based on shared values and beliefs about basic human rights. My view on the study of gender is to deconstruct gender and make it a better context for people around the world.

Dr. John Strang: As we begin to wrap up this roundtable, do you have any concluding thoughts to share?

Dr. Wenn Lawson: Research is pointless unless it is integrated translationally into practice. We must in this work incorporate research findings into practice across the lifespan developmentally, including for services, funding, insurance coverage, and other real-world priorities. The intersection of autism and gender diversity needs to be highlighted at the grassroots level and incorporated into practical translation.

Mx. Finn Gratton: I've always wanted to turn the investigation into the “overrepresentation of trans identity amongst autistic people” inside out. I want research about why nonautistic people are so commonly cisgender and heterosexual. What is it about them? What causes the high prevalence of gender and sexuality rigidity among nonautistic people? Why can't they have the kind of fluidity or openness that is common with autistic people? That this question has not been asked reveals an unexamined implicit bias clinically and academically against those who can't or won't comply with normative expectations.

Dr. Harriette Wimms: Our fields of intervention are often focused on evidence-based practice—to the exclusion of considering practice-based evidence. What can be learned by listening to individuals and making practice recommendations based on lived experience? Additionally, while I am delighted that research is more and more available from clinics and research initiatives, I worry that we are making empirical conclusions and finding evidence only from a group of clients who have access to hospitals and clinics. What about the individuals and families that don't have access to care, can't or won't access clinics, or are barred from seeking support for autism and gender expansivity. What can be learned from these populations? Who are they? How do we reach them? What do they need? They are a very important part of our community that does not have a voice in the empirical literature.

Dr. Anna van der Miesen: As a research community—but also as a clinical community—we need to look at intersectionality from various social and cross-cultural perspectives. This is something that can only be reached by collaboration and the exchange of ideas and perspectives not only between researchers, but also between researchers, clinicians, policy makers, and people with lived experience. This roundtable is a good example of a starting point.

Dr. John Strang: I want to mention that, in addition to all the complexity related to the marginalization of autistic transgender people, individual gender journeys can be complex. In this all-or-nothing politicized world, we don't leave a lot of space for people for whom the gender journey is flexible or changes over time. For people whose gender experience is flexible or changes over time, their needs may change sometimes in subtle ways or sometimes in really striking ways, and these journeys are not well understood.⁶⁸ What has happened is that these nuanced gender journeys are pulled into the political wars on this topic as evidence against providing care.

And more complex gender journeys are sometimes dismissed by our community, but as someone who has worked in gender care for a long time, I have absolutely seen gender-related needs shift over time for some people, and this includes nonautistic and autistic people. I'm concerned there are barriers to doing research in this area due to controversy and politicization. I am also concerned with the stigmatization of people whose gender needs change, as they're generally not included in the larger dialogues. I will say that in our research, we have been fortunate to work with people who have had these kinds of experiences, and they've really helped us to expand and enrich the work.^11,69 So, as we move forward in research, my hope is we will be inclusive of all gender journeys over time, and not just the straightforward ones.

Dr. Aimilia Kallitsounaki: We are all coming from different backgrounds and have different perspectives on the intersection of autism and gender diversity. Yet, we had an honest, thoughtful, and reflexive conversation. This is something that is currently rare in this field, but it is crucial in order for new knowledge to emerge. Engaging with all of you today has helped me gain a deeper understanding of this intersection and be mindful of certain aspects that I should incorporate into my future research. I am a quantitative researcher, and I deal mostly with surveys and numbers, so when I speak directly with autistic transgender and gender-diverse people as well as with clinicians and qualitative researchers about their experiences and perspectives, it highlights how impactful and important research in this field is.

Dr. Kate Cooper: My final thought is simple: we need to listen to the individual experiences of autistic and gender-diverse people, without imposing our own ideas of how they should experience or enact any of their unique identities. The polarized media narratives imply that professionals and researchers in this area are applying one-size-fits-all approaches, but of course, we need to listen and respond compassionately to each individual. It has been great talking today with a group who agree that we need to put autistic and gender-diverse people's voices at the center of this work.

Dr. John Strang: Thank you, everyone, for sharing important perspectives and research on the intersection of autism and gender diversity. Here is a summary and integration of key ideas from this discussion:

• When considering and studying the common intersection of autism and gender diversity, it is important to recognize and honor the wellness and resilience of trans autistic people, while also acknowledging the impact of pathologization and stigmatization of these and other marginalized identity experiences on trans autistic people.

• Autistic transgender and nonbinary people hold the authority of their identity and gender experiences. As researchers and providers in this field, it is of utmost importance that we prioritize autistic gender-diverse perspectives from a range of intersectional experiences in research and clinical care. Not to do so risks harms to autistic gender-diverse people. This collaboration—which should include codeveloping research goals; cocreating measures, studies, and policies; and cointerpreting and disseminating findings and outcomes—is essential to meaningful and appropriate research, clinical care, and policy.

• Work is needed to better understand disparities faced by autistic transgender adults related to autism, gender diversity, and their intersection. For example, there are concerns regarding ongoing, and even increasing,⁴³ barriers and limits to accessing gender-affirming care for autistic adults.

• There is increasing politicization regarding the autism and gender diversity intersection in the context of larger contemporary movements seeking to restrict access to gender care and other related civil rights.^43,44 Yet, there is no current evidence indicating that autistic transgender people typically regret their gender-related decision-making. Further, polarized political debates may eclipse nuance and subtlety regarding gender experience, gender development, and the common intersection with autism.

• Currently, the concept and practice of assessment for gender-related care have taken on a range of different meanings among gender care providers for autistic individuals. Assessment for gender-related medical treatment should be focused on determining the capacity of individuals to provide true informed consent, including recognition of their gender needs. The use of universal or inclusive design practices in gender care settings could help to ensure that communication methods and care protocols support an effective informed consent process and attuned accommodations for navigating gender discernment and gender care. Gender care providers should support trans autistic individuals by working together to assess barriers to care.

• Our panel today is limited in its global representation. Attunement to sociopolitical and cross-cultural perspectives will be required to advance best care practices for autistic transgender people in diverse local contexts. This can only be achieved via collaboration and advocacy efforts among community members, researchers, providers, and policy makers. Importantly, there are many circumstances and contexts in which transgender people, autistic or not, cannot express their gender-related needs for fear of safety, and where autistic people are not safe in revealing their neurodivergence.

• The perspectives, experiences, and needs of BIPOC autistic gender-diverse people have not been sufficiently included in research and advocacy. What understanding we have of the disparities faced by autistic transgender adults has a White bias, as almost no work has been done to understand and address disparities related to intersectional ethnoracial identities. To move forward equitably in this field, we will need collaborative research and clinical initiatives led or coled by and/or including BIPOC autistic transgender individuals.

• Whereas adolescent gender diversity and autism research has begun to include a developmental perspective, work with autistic transgender adults has yet to appropriately consider the developmental milestones of adulthood. We need to take a life span approach to understanding the trajectories of autistic transgender people through adulthood, including their health, well-being, gender and gender-related needs, and broader needs. As with all research areas in this field, the equitable and intentional inclusion of BIPOC autistic transgender perspectives will be critical.

Authorship Confirmation Statement

F.V.G., J.F.S., and M.S. planned the roundtable. M.S. invited each of the discussants. F.V.G. and J.F.S. served as moderators. F.V.G., J.F.S., K.C., A.K., M-C.L., W.L., A.I.R.v.d.M., and H.E.W. participated in the roundtable discussion. M.S. made significant contributions to the synthesizing of ideas across discussants and conducted a thematic analysis to optimize the continuity and flow of ideas in the final article. M.S. also coordinated with each discussant to discern appropriate citations for research referred to in the discussion. All authors edited and approved the final article. The content is solely the responsibility of the authors and does not necessarily represent the official views of any of the funders.

Author Disclosure Statement

J.F.S. was a coauthor of the Child and Adolescent chapters of the Standards of Care 8 revision through the World Professional Association for Transgender Health (WPATH). F.V.G., J.F.S., and A.I.R.v.d.M. are faculty members with the WPATH Global Education Institute (GEI); they receive financial remuneration for their WPATH GEI services.

Funding Information

No funding sources directly supported this project.