Experiences of autistic transgender and gender diverse adults undergoing gender‐affirming hormone therapy and the influence on occupational identity outcomes

Abstract

Introduction

Autistic transgender and gender diverse (TGD) adults often report additional barriers to health‐care access and occupational participation. Gender‐affirming hormone therapy (GAHT) consists of hormonal medications a person may choose to take to increase alignment of physical features with their gender identity.

Consumer and Community Involvement

This research project was conducted in response to patient and clinician feedback; however, no consumers were involved in the setup or analysis of the study.

Methods

Six autistic TGD adults undergoing GAHT at a statewide tertiary gender endocrinology clinic participated in in‐depth semi‐structured interviews and underwent an Adolescent/Adult Sensory Profile (AASP) assessment. Secondary analysis of qualitative data utilised thematic analysis and triangulation with AASP results through the lens of the doing, being, becoming, belonging framework to understand how autistic TGD adults achieve occupational identity.

Results

Autistic TGD adults experienced improved quality of life, mental health, and occupational identity outcomes as a result of GAHT. Being TGD and autistic posed unique challenges for autistic TGD adults in doing tasks associated with GAHT, including navigating health‐care and social environments. Gender‐affirming physical changes and experiences increased participants' engagement in gendered occupations and roles.

Conclusion

For autistic TGD adults who choose to medically transition, GAHT can be an important gender‐affirming occupation in enabling occupational identity acquisition. The results of this study highlight a role for occupational therapists within gender‐affirming care settings to enhance patient care.

PLAIN LANGUAGE SUMMARY

Trans and gender diverse (TGD) refers to individuals who identify with a gender that differs from their sex assigned at birth. This includes trans men (people assigned female at birth who identify as men) and trans women (people assigned male at birth who identify as women), as well as other gender identities such as non‐binary (people assigned male or female at birth whose gender identity exists outside of the typical gender binary) and agender (people who do not identify as having a gender). Many TGD adults desire either masculinising or feminising gender‐affirming hormone therapy (GAHT) to help align their physical characteristics with their identified gender. There is a well‐recognised link between autism and gender diversity; however, there is limited understanding of the experiences of autistic TGD individuals on GAHT. This study is a detailed analysis of interviews and sensory profile results from six autistic TGD adults currently on GAHT. We show that autistic TGD adults experience unique challenges related to taking GAHT as prescribed, as a result of sensory processing and executive function difficulties, societal stigma, and often fragmented care. Physical changes with GAHT increased participants' engagement in occupations and roles typically associated with their gender and affirmed their sense of identity and belonging. Our study demonstrates that accessing gender‐affirming care and taking GAHT are gender‐affirming occupations for many autistic TGD individuals. Providing autistic TGD adults with access to occupational therapy input may improve their occupational outcomes on GAHT.

Key Points for Occupational Therapy.

• The role of occupational therapists within gender‐affirming care is an emerging area.

• Positive occupational identity formation for autistic TGD adults requires supportive institutional and sociocultural environments.

• Occupational therapists would enhance gender‐affirming care by supporting positive occupational outcomes and improving health‐care accessibility, including through the creation of patient‐centred resources and optimisation of clinic processes.

1. INTRODUCTION

Gender incongruence refers to the experience of persistent incongruence between an individual's birth‐assigned sex and their gender identity, and for some, this may include dysphoria (American Psychiatric Association [APA], 2013). Individuals with gender incongruence and/or gender dysphoria (GI/GD) include those who are binary or non‐binary transgender, agender and gender diverse (APA, 2013). Approximately 0.5%–4.5% of the population are trans and gender diverse (TGD) (Zhang et al., 2020), and many use gender‐affirming hormone therapy (GAHT) to help align their physical characteristics to their gender identity.

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder characterised by significant challenges in social communication and restricted repetitive behaviour, interests or activities (APA, 2013). The prevalence of GI/GD is greater among autistic populations when compared with the general population (Kallitsounaki & Williams, 2023). The intersection of ASD and GI has been shown to exacerbate the marginalisation of autistic TGD individuals due to stigma surrounding their capacity to understand the impacts of their gender identity and transition (Gratton et al., 2023). Recognition of the intersection of autism and TGD identity has grown in recent years. Some TGD and autistic community members highlight however that the diagnostic criteria for GI/GD and ASD are outlined by structures predominantly populated by neurotypical and cisgender identities (Gratton et al., 2023; Williams, 2018). Societal stigmatisation of ASD may also contribute to implicit bias and assumptions pertaining to autistic TGD individuals, and some authors challenge the existence of the autistic TGD intersection (Egner, 2018; Maroney & Horne, 2022). Community and academic dialogue on research and advocacy for autistic and TGD identities acknowledges the impact of stigmatisation, pathologisation and other marginalising identity‐related experiences on autistic TGD individuals (Gratton et al., 2023). Although an ASD diagnosis should not preclude an individual from accessing gender‐affirming care (Bo et al., 2024), there is limited understanding of how to optimise use of GAHT in autistic patients. The need for neuro‐affirming, appropriate health care is evident in the research; however clinical research identifying the strengths and positives of the intersection of GI/GD and ASD is currently limited (Gratton et al., 2023).

Prescribing GAHT involves giving oestrogen (for feminising effects) or testosterone (for masculinising effects) so an individual's physical features are better aligned with their gender identity (Hembree et al., 2017). In addition to physical changes, there are demonstrated improvements in the mental health and quality of life (QOL) outcomes of TGD individuals who want and have chosen to undergo GAHT (Aldridge et al., 2021; Moody et al., 2015). Preliminary research among autistic TGD young adults also reflects these findings (Genovese et al., 2023).

The World Professional Association of Transgender Health recommends health‐care professionals (HCPs) receive training to ensure interventions meet the needs of autistic TGD adolescents (Coleman et al., 2022). Additionally, Strang et al. (2018) outline initial clinical guidelines recommending HCPs consider the impacts of sensory processing difficulties, as well as changes in routine, and how these may impact administration of GAHT among autistic TGD adolescents. However, practical clinical guidance for those providing gender‐affirming care is currently lacking (Bo et al., 2024). Gender identity is integral to one's overall identity, lifestyle and life choices and impacts health, wellbeing and occupations. Hence, occupational therapists may offer key expertise to support autistic TGD adults.

2. DOING, BEING, BECOMING AND BELONGING

The occupational science Occupational Perspective of Health theory, originally developed by Wilcock (2006), identified doing, being, becoming and belonging (DBBB) as core concepts of occupation. Occupational therapy conceptual frameworks guiding practice and rationale are underpinned by the DBBB concepts (Hitch & Pepin, 2021). Understanding of the concepts of DBBB has shifted over time, with Hitch et al. (2014a) further defining each concept within the theory. Doing is the means of participation and engagement in meaningful occupations and roles, inclusive of skill acquisition over time (Hitch et al., 2014a). Being is the sense of meaning and self as a person, and occupational being (Hitch et al., 2014a). Becoming denotes the continuous growth process, development and changes throughout an individual's life (Hitch et al., 2014a). Belonging denotes the context in which the occupation occurs and the individual's sense of connection to others, place, cultures, communities and times (Hitch et al., 2014a). Hitch et al. (2014a, 2014b) highlight that the DBBB concepts are complex, idiosyncratic and interdependent upon one another.

3. OCCUPATIONAL IDENTITY

Occupational identity has long been a core concept in occupational therapy and denotes the intersection between what we do and our sense of identity, subsequently influencing overall health and wellbeing (Kielhofner, 1985). A consistent pattern of choice, habits and routines and performance capacity (doing) must be maintained within a supportive environment for occupational identity formation (O'Brien & Kielhofner, 2017). Challenges to an individual's performance capacity, a sense of inefficiency, difficulties implementing values and environmental barriers have the potential to negatively impact occupational identity (O'Brien & Kielhofner, 2017).

Transgender individuals often experience barriers to safely expressing their identity in vocational and leisure occupations as a result of societal stigma and discrimination. Transgender participants in Budge et al.'s (2010) study expressed fears that disclosing their gender identity would lead to discrimination and job insecurity. The United States Transgender Survey (James et al., 2016) found that 75% of respondents reported masking their gender identity due to fears of experiencing verbal, physical and sexual abuse or assault at work. Bailey et al. (2024) investigated participation in sports and fitness occupations among 664 TGD individuals over 16 years of age in Australia. Internal barriers (anxiety and body dysphoria), physical environmental barriers (inadequate bathroom/changing facilities), institutional factors (exclusionary rules and regulations surrounding gender, invasive/uncomfortable policies and procedures) and social factors (discrimination and gender‐based bullying) were found to negatively impact participation (Bailey et al., 2024). Social affirmation of one's gender identity was found to positively impact occupational participation, as well as identity, outcomes for TGD individuals in work and school occupations (Becerra‐Culqui et al., 2024). Gender and occupational identities are positively influenced by the gender and social affirmation experienced as a result of community participation both in‐person and online (Poliwoda et al., 2025).

4. RATIONALE

The overall project investigated TGD adults' experience of adherence and tolerability to GAHT administration methods. This project was configured in response to a clinical issue in which autistic TGD adults were observed to be experiencing difficulties adhering to GAHT. Results found that autistic TGD adults experience greater difficulties adhering to and tolerating sensory aspects of GAHT when compared with non‐autistic adults, due to sensory processing differences and executive function challenges. Qualitative data highlighted that the experience of undergoing GAHT is multifaceted and individualistic for autistic TGD adults, influenced by sensory, cognitive, health‐care and social factors. The original study by Miller et al., 2026 (under review), provided an overall insight into the occupational experiences of TGD autistic adults undergoing GAHT; therefore, a secondary analysis was completed.

Research exploring the occupational experiences of autistic TGD individuals is scarce. To our knowledge, no research has investigated how the experience of undergoing GAHT impacts the occupational identity of autistic TGD individuals. Despite experiencing challenges undergoing GAHT, the participants in our study experienced improved mental health, QOL and gender‐affirming identity outcomes, which they all deemed to be ‘Worth it’ (Miller et al., 2026). This secondary analysis aimed to better understand the occupational experiences of autistic TGD participants.

4.1. Aims

To investigate how autistic TGD adults on GAHT achieve occupational identity utilising the DBBB concepts to understand their experiences.

5. METHODS

5.1. Design

Initially, a convergent, parallel, mixed‐methods design was applied to the project that explored autistic TGD adults' experience of GAHT adherence and tolerability (Miller et al., 2026). The current study is a secondary detailed analysis of the qualitative data. Semi‐structured interview data were collected by the research team. The study was conducted within a statewide tertiary hospital Gender Endocrinology clinic in Victoria, Australia, exploring the experience of GAHT adherence and tolerability among TGD autistic adults. The study was approved by the Human Research Ethics Committee of Monash Health (104175) and Monash University (42523), and informed consent was obtained from all participants.

5.2. Positionality

The authors are researchers and practitioners with backgrounds across various fields including occupational therapy, endocrinology, neurological disorders, ASD, mental health, psychiatry, disability and paediatrics. At the time of data collection, Author 1 was an occupational therapy honours student undertaking research for the first time. Author 2 is an occupational therapy professor who possesses both research and clinical experience among individuals with ASD. Author 3 was a doctoral candidate in occupational therapy, with both clinical and research experience in the fields of mental health and psychiatry. Author 4 is an experienced endocrinologist with clinical and research experience in transgender health, endocrinology and andrology. Authors 1, 2 and 3 had no relationship to participants prior to the commencement of the study. Author 4 was employed at the clinic in which data collection occurred prior to and throughout this study. The authors share an interest in promoting diversity, equity and inclusion of individuals who identify as TGD and/or autistic. They also value the real‐world experiences of TGD and autistic TGD individuals accessing gender‐affirming care as central to informing improvements in gender‐affirming care service quality.

5.3. Research setting

The Monash Health Gender Endocrinology Clinic is a statewide tertiary hospital public health specialist clinic for the TGD community residing in Victoria, Australia.

5.4. Participants and recruitment

Purposive sampling methods were used to recruit autistic adults (diagnosed or self‐identifying) for the qualitative interviews. The inclusion criteria were as follows: (1) over 18 years of age, (2) current attendance at the Monash Health Gender Endocrinology Clinic, (3) those currently or previously prescribed and taking GAHT, (4) adequate literacy skills to complete a questionnaire and (5) a self‐identification or formal diagnosis of ASD. Rationale for the inclusion of self‐identifying autistic participants was informed by research outlining that many adults have undiagnosed ASD due to modifications to the diagnostic criteria made in 2013 (Lai & Baron‐Cohen, 2015); in addition, in our clinical experience, access to funded diagnostic services is very limited. Participant recruitment consisted of posters displayed in clinic rooms, verbal invitations following clinical consultations and an email sent to all current clinic patients. Participants contacted the research team via email to express interest in the study. In total, 27 enquiries were received; all participants were provided with participant information and invited to ask additional questions or engage in a phone discussion with the first and/or last author. Six participants returned the written consent form, and interviews were scheduled.

5.5. Data collection and methods

Qualitative data were collected via semi‐structured, open‐ended interviews with questions designed to prompt discussion. The Adolescent/Adult Sensory Profile (AASP) in paper form was completed at the beginning of the interview with all participants and used to further guide questions relating to sensory preferences. The first author administered the AASP and conducted the interviews. The interview questions were developed based on a review of existing literature concerning ASD and in conjunction with expert opinion from members of the research team. Data collection methods included face‐to‐face or video interviews, based on participants' communication preference. Informed by the Autism Cooperative Research Centre participatory and inclusive autism research practice guides (den Houting, 2021), sensory toys were made available to participants and environmental adaptations made where possible to meet individual participants' needs, for example, seating positions, offering breaks and audio‐only online interviews.

5.6. Measures

The AASP is a self‐report questionnaire that assesses an individual's sensory preferences and functional performance impacts (Pearson, 2019). The AASP provides a summary of sensory preferences across four sensory quadrants: low registration, sensation seeking, sensory sensitive and sensory avoiding (Pearson, 2019). Low registration refers to the amount of sensory stimuli required to elicit a neurological response, with high scores indicating the greater sensory input is required for a response. Sensation seeking refers to behaviours aimed at seeking out additional sensory input to meet the neurological threshold. Sensory sensitivity refers to those with low neurological thresholds, resulting in an increased response to sensory stimuli. Sensation avoiding refers to the rate at which an individual avoids sensory stimuli in their everyday life.

5.7. Trustworthiness

Data were triangulated by converging participants' AASP results with interview data. The four concepts of trustworthiness within qualitative research were applied to the qualitative interviews: credibility, dependability, confirmability and transferability. Credibility was achieved through memo‐writing, reflective notes (first author) and an audit trail. Additionally, member‐checking was completed with participants through verification of the accuracy of interview transcript data. Verification of accuracy was obtained from all participants, and no additional responses were received. Researcher collaboration throughout the research process promoted the confirmability of results. Participant demographics and the setting in which the research was conducted are provided to assist with the transferability of results.

5.8. Data analysis

Braun and Clarke's (2022) six‐phase thematic analysis procedure was used to interpret, describe and summarise the secondary analysis of data collected from Study A (see Figure 1). Inductive codes were created and progressively converted into categories and broader themes. Data analysis was led by the first author, with multiple research team meetings facilitating researcher triangulation. This process consisted of discussions between team members, including differing interpretations of the transcripts, to reach a consensus. Secondary analysis was completed by Authors one, two and three. Initial codes were generated guided by the research aim and the lens of the DBBB framework. Analysis of the AASP was completed utilising the scoring sheet provided with the questionnaire. Themes were clarified via in‐depth discussions and triangulation of the data in relation to the DBBB concepts. Analysis of AASP and interview data occurred simultaneously with constant cross‐referencing between results and the interview to promote triangulation of data.

FIGURE 1.

Data analysis steps.

The researchers acknowledge the overlap and transferability between the themes and the DBBB framework and the concept of occupational identity utilised to analyse the data. These findings demonstrate the complexities of the autistic TGD experience as well as the interconnectedness between the concepts that informed data analysis. Researchers investigated what occupations participants were doing, what occupations were important and necessary to achieve being, and what occupations were identified to promote the becoming and belonging that each participant desired to achieve occupational identity.

5.9. Results

Five participants were interviewed on video and one participant in person. Interviews ranged from 39 to 75 minutes. Thematic analysis was completed through the lens of the DBBB concepts (see Figure 2).

FIGURE 2.

Doing, being, becoming and belonging analysis.

Participants were aged 18–65 years, consisting of one White non‐binary person, one White trans man, two Asian trans men and two White trans women (see Table 1 for characteristics of participants). Five participants were employed, and one participant was unemployed.

TABLE 1.

Characteristics of participants.

participant demographics
Pseudonym	Age	Gender identity	Location	Diagnoses	AASP
					SQ	Result	Adherence impact/strategy
Charlotte	56–64 years	Trans woman (AMAB)	Regional Victoria	Diagnosed ASD, ADHD, PTSD, CRPS	LR	+	SHS and SAv to texture of gel, challenges remembering tablet administration. Motivational self‐talk, health literacy, insight into SP, maintaining routine, habit stacking, collaboration with HCPs
					SSk	=
					SSe	++
					SA	++
Tom	18–25 years	Trans man (AFAB)	Metropolitan Melbourne	Self‐identifying autistic, depression, anxiety, body dysmorphia	LR	++	SHS and SAv to texture and smell of gel, EF challenges (routine) Motivational self‐talk, health literacy, insight into SP, collaboration with HCPs, involving loved ones in appointments, peer support
					SSk	=
					SSe	++
					SA	++
Ryan	18–25 years	Trans masculine (AFAB)	Regional Victoria	Self‐identifying autistic, depression, anxiety	LR	=	No impact on GAHT adherence. Motivational self‐talk, health literacy, insight into SP, collaboration with HCPs, involving loved ones in appointments, peer support, tensing leg muscles following administration of mGAHT injection, limiting physical activity for 1–2 days following mGAHT administration to reduce pain
					SSk	=
					SSe	=
					SA	+
Evan	26–34 years	Non‐binary (AFAB)	Regional Victoria	Self‐identifying autistic, anxiety	LR	+	SHS and SAv to texture of gel. Motivational self‐talk, health literacy, insight into SP, collaboration with HCPs, involving loved ones in appointments, peer support, limiting physical activity for 1–2 days following mGAHT administration to reduce pain.
					SSk	=
					SSe	=
					SA	++
Amelia	18–25 years	Trans woman (AMAB)	Regional Victoria	Diagnosed with ASD, depression	LR	++	No impact on GAHT adherence. Health literacy, creating a routine, peer support.
					SSk	−
					SSe	++
					SA	++
Jeff	46–55 years	Trans man (AMAB)	Metropolitan Melbourne	Diagnosed ASD, ADHD, fibromyalgia	LR	++	SHS and SAv to pain associated with mGAHT injection, EF challenges (routine). Motivational self‐talk, health literacy, insight into SP, collaboration with HCPs, involving loved ones in appointments, peer support, limiting physical activity for 1–2 days following mGAHT administration to reduce pain.
					SSk	=
					SSe	++
					SA	++

Note: Sensory profile interpretations: ++: much more than most people, +: more than most people, =: similar to most people, −: less than most people, −−: much less than most people.

Abbreviations: AASP: Adolescent/Adult Sensory Profile, ADHD: attention‐deficit hyperactivity disorder, AFAB: assigned female at birth, AMAB: assigned male at birth, ASD: autism spectrum disorder, CRPS: chronic regional pain syndrome, EF: executive function, mGAHT: masculinising gender‐affirming hormone therapy, PTSD: post‐traumatic stress disorder, SAv: sensory aversion, SHS: sensory hypersensitivity, SP: sensory preferences, SQ: sensory quadrant. Sensory quadrants: LR: low registration, SA: sensation avoiding, SSe: sensory sensitive, SSk: sensation seeking.

5.10. Doing

5.10.1. Doing occupations as advised in the gender‐affirming care processes

Experiences of navigating the public health‐care system to access gender‐affirming care differed among participants. Four participants expressed frustrations with the current systems in place to access gender‐affirming care, which were fragmented, with differing advice about how to navigate the different systems to access safely prescribed and monitored GAHT. Amelia had been undergoing oral tablet feminising GAHT (fGAHT) for 1 year and stated ‘there should be more [health services] cause at the moment … [there] are really the only two viable places’.

Evan had been undergoing masculinising GAHT (mGAHT) for 3 years, previously prescribed gel and currently prescribed injections. Following a 12‐month waitlist for mental health assessment to access GAHT, Evan felt the current processes were atomistic, and this made them feel like ‘a name on a piece of paper’.

Charlotte had been undergoing f‐GAHT for 2 years, previously prescribed tablet fGAHT and androgen blockers, currently prescribed gel. She stated:

We couldn't find any help at all, we had to do a lot of searching on the Internet because we didn't know enough about it ourselves, there was no help. There was no direction … There was nothing, zero.

5.10.2. Sensory experiences whilst doing GAHT administration

All participants described varying degrees of tolerability to the sensory aspects of GAHT administration. Three participants reported the experience of injectable mGAHT administration was dependent on HCPs' knowledge and experience. Two participants described the sensory aspects of injectable mGAHT as tolerable, whereas Jeff stated:

It burns, I don't know how else to describe it other than it burns. … because it's such a thick liquid it … takes a long time, … and then it just kind of keeps going and keeps going, you reach … a limit as somebody who's very sensory based …

In comparison, Tom, who had been undergoing mGAHT for 2 years and prescribed gel mGAHT for the same duration, stated:

I don't think it impacts on me taking it, but … when I'm looking at it, I'd feel indifferent towards it, and then, when I put it on, I realise how much I hate the smell and how much I hate the feeling of it. It … leaves, as it's drying, … this … kind of dry but also sticky … residue behind before it completely dries.

5.10.3. Routine

Changes to routine attributed to competing life demands presented GAHT adherence challenges for two participants. Tom experienced difficulties maintaining GAHT adherence when experiencing changes to routine:

I'm having a lot of changes to my routine and I'm just finding it a lot more difficult to get it done. … so, it's, it's dependent on what my day looks like … it's all just kind of based on what my routine is.

Jeff and Tom both found strategies such as using a calendar and alarms prompting GAHT administration were at times ineffective:

Being neurodiverse, if I don't use my calendar strictly, I do forget. … I have just had some little things around just remembering my appointments … I do put in my calendar, but if I don't make the appointment as soon as I get the reminder, I forget again’.—Jeff

Despite not experiencing challenges to adherence resulting from changes to routine, Evan stated routine changes could mean ‘everything's just gone out the window’. Charlotte stated that she ‘keep[s] going with a routine, because … it's when I get thrown off the routine, then other things happen, or don't happen’.

5.11. Being

5.11.1. Being neurodivergent and undergoing GAHT

Participant's experiences on GAHT emphasised the uniqueness of the neurodivergent experience and the need for HCPs to understand autistic needs. Tom felt his autistic needs were misunderstood by HCPs, stating that ‘when it comes to things like remembering, especially … as a neurodivergent person, I really struggle with that, and I really struggle with change’. Jeff emphasised the impact of sensory processing difficulties upon executive function, stating: ‘notoriously neurodiver[gent] people love routine, … [but] we struggle with the self‐care side of routine, and a lot of that is sensory based’.

In comparison, Evan and Charlotte incorporated gel mGAHT into their routines prior to sleep, expressing there would be ‘no chance’ of remembering it if it was not stored in plain sight as ‘It gets [their] attention’ (Charlotte). Both Charlotte and Jeff expressed that receiving an autism diagnosis increased their self‐understanding whilst undergoing GAHT. Charlotte stated, ‘It makes me more aware of the fact that there's other underlying things besides hormonal fluctuations that are at work in me’.

5.11.2. Being gender‐diverse

The experience of being TGD brought with it a sense of insecurity in public spaces for participants as a result of societal stigma. Jeff stated:

I do think men who are … transitioning to female don't get the understanding … or the acceptance … I think it's harder for them, and there's a lot of judgement … that's where education at an earlier stage is really good for people that are going into the medical field.

Tom stated:

I go to my family GP and …he's known me since I was a kid … he's seen me go through these changes, but [my gender transition is] … this unspoken thing that we never talk about. … I think there's also … these … general stereotypes that I have in my mind of … traditional people not understanding it and then treating me differently because I am a neurodivergent trans person.

Ryan, who had been undergoing mGAHT with injections for 5 years, stated:

There was a lot of anxiety about being perceived as a woman that made me anxious about doing anything I wanted to do. … I'd wander around a shopping centre … just looking across the room at the different clothing aisles, like, “do I have the courage to go in there? Is there someone else there?” I don't worry about that anymore.

5.11.3. Maintaining my health in order to be me

Participants expressed that undergoing GAHT is a valued, gender‐affirming occupation required to maintain their mental health. Participants were aware of their needs as an autistic TGD person, whilst also considering their mental and physical health outcomes. Two participants expressed being motivated to maintain GAHT adherence to relieve feelings of gender dysphoria.

I don't have to worry about my periods … to a significantly lesser degree, those were quite distressing when I was younger. … being able to essentially be free and not have to worry about that … it's definitely a big weight off.—Ryan

Initiating GAHT with gel mGAHT allowed Evan to manage anxiety and assess their comfort with gender‐affirming physical changes. They stated, ‘I think, having [gel mGAHT allowed me to] … ease into it and once … I started taking it and the effects started … I was … confident to … lock in to a 12‐week injection’.

Participants also considered the physical health impacts as an important variable when choosing their GAHT administration method.

5.11.4. There are many aspects to being me

All participants had co‐occurring medical conditions that required self‐insight to manage alongside GAHT. Jeff reported his co‐occurring attention deficit hyperactivity disorder (ADHD) could make medication management difficult: ‘it's a very common thing with [ADHD]…it's very hard for me to make it a priority, and I try, but I do often forget it’.

Charlotte reported that managing her physical and mental health whilst on GAHT could be a rollercoaster of emotions and difficult to manage at times, ‘once … the PTSD stuff kicked in, and the … autistic burnout, and all the … chronic regional pain … that showed up all at the same time […] that centeredness disappeared’.

All participants reported experiencing improved mental health outcomes as a result of improved occupational engagement and gender‐affirming physical changes resulting from GAHT. Tom stated, ‘my depression has gone way down, which I'm very happy about. … I would say … that being on the hormones … is the best decision I made’.

5.12. Becoming

5.12.1. Managing expectations of becoming

Participants expressed experiencing feelings of hopefulness for the potential of gender‐affirming physical changes when commencing GAHT. Acknowledging that GAHT is ‘very much a long‐term thing’ (Tom) for some, participants described needing to manage their expectations of GAHT, alongside their desired self‐image. Charlotte stated, ‘When you begin it, you kind of have, I suppose, a little bit of a expectation of what you might be able to achieve, which is, like, really ridiculous, because … who sets that rule?’

Ryan mirrored this, stating

… at the beginning, I was … a bit desperate for some facial hair, because I thought it would help me … feel more comfortable and pass [as a male] better. But getting more comfortable with … who I am and properly understanding genetics … it's not something I'm concerned about anymore.

The gender‐affirming physical changes GAHT provided further enabled participants to physically express and build confidence in their sense of self. Jeff stated, ‘having spent … most of your life not really being comfortable with who you were, and hating your body, like really hating yourself … to just be able to …, look in the mirror and be quite happy with what you see looking back … I'm able to start the day feeling okay with who I am’.

5.12.2. There is a journey to becoming that begins much earlier in life

Although not a universal experience, participants in our study all recalled recognising their gender identity in early life and reported their desire to transition did not alter as they aged. Participants' journeys to understanding their gender identities varied greatly. Jeff stated, ‘my whole life … even when I was very young … I knew I was different, something wasn't quite right and it took many years. I identified as a lesbian for many, many, many years before I … really started to understand that … I was actually a trans man’.

Amelia reported being certain of her gender identity at 8 years old and ‘wanting to get on the waiting list’ for GAHT 4 years later. Charlotte reported being aware of and suppressing her gender identity as a result of stigma:

I'd suppress my being transgender. Well, [I] probably first became aware of it when I was six … I tried to come out when I was 15. That was a source of my major trauma, how that was treated. So, I buried it and by the time [I was middle‐aged] I was going mad. … But I was married, I had kids … And so, the unpredictability of all the circumstances, the marriage, the relationships, the jobs … meant that I had to.

5.12.3. Gender‐affirming occupations and roles

Participants expressed that GAHT resulted in increased participation in, and external acknowledgement of, gendered roles, such as father, boyfriend, son, daughter and TGD, or autistic TGD, friend. Jeff stated:

I wake up every, every day, and I look in the mirror, and I see the person that I know I am. … People see me as male, … they call me a he … I'm seen as, as a father … I don't tell most people that I'm transgender unless they know me, and it's not because I'm ashamed of it, it's just because I don't want to be seen as a transgender person. I just wanna be seen as me.

All participants reported increased social confidence as a result of experiencing gender‐affirming physical changes. Ryan stated, ‘Once …my voice had dropped considerably, that's when I started feeling more comfortable, not sneaking, but like walking into the men's bathroom’. Two participants reported that although their social confidence had increased, their level of confidence differed depending on the social environmental context due to fears of discrimination and vocal dysphoria. Tom stated, ‘I hate being on a phone call, I hate talking to people on public transport and, and I think I worked that down to having voice dysphoria’. Jeff described witnessing and experiencing discrimination and transphobia on social media sites, stating ‘[transgender women] just weren't given the same acceptance, or, you know, the same respect, and often, like little passive aggressive jokes were made at their expense’.

Although participants undergoing injectable mGAHT all acknowledged benefits, they all stated that their participation in meaningful occupations was impeded in the days following administration:

it's just sore for a few days […] I made the mistake once of going to the gym the next day, and then that just […] made it so much worse. So, I do have to […] not do a lot in those days, which can be difficult’.—Evan

5.13. Belonging

5.13.1. Advocating for health care that accepts my identity

Participants advocated for neuro‐ and gender‐affirming care to be the norm. Participants advocated for increased HCP knowledge pertaining to transgender health and ASD in order to form collaborative relationships. Fed up with experiencing a service that may recognise their autistic needs but has limited strategies as to how to enable and support medication adherence. Tom stated: ‘a lot of the recommendations [e.g. setting alarms, written reminders] I was given … none of them worked for me’.

Participants expressed fear of discrimination when accessing health care outside of their GAHT prescribers:

It shouldn't matter whether you know you're trans, biracial, …, neurodivergent, whatever. Shouldn't matter what you are, you should be getting the health care that you need as a human being, and I think that … [HCPs] don't understand, so then they don't give the same care to people. And then a lot of people get into that … struggle of not being looked after.

Jeff stated, ‘when somebody comes in to start hormone therapy, I think it's important to ascertain if they do have sensory issues and then go through each option with them … so they can make an informed choice’. Charlotte mirrored this, and recommended ‘doctors [be] more sensitive to the fact that … we are … not typical in our sensory arena … taking that into account [and] looking at well, how do we orient the hormones to that? Whether it's via an [occupational therapist], or … somebody who … knows about these things’.

5.13.2. Shared experiences and acceptance

Participants expressed the importance of feeling understood and supported in their gender transition. All participants described feeling understood, accepted and reassured when hearing the lived experiences of autistic and non‐autistic TGD peers. Tom felt that his friendships with other TGD individuals were ‘very much a support network’. Evan described feeling reassured ‘going on the internet … [as] whatever your question is … you'll find someone who'd be like, “Yeah, this happened to me”, and it's like, “Oh, okay. Well, then, that's alright” ’.

For Ryan, relationships of reciprocal social support provided a sense of connection and belonging:

I was the one helping them, because I started [GAHT] before both of them. … They've had it a bit harder than I have in terms of getting the medication, paying for and getting appointments. … it definitely makes it a bit easier than … if I was to talk to one of my cis[‐gender] friends.

5.13.3. I want to feel safe; I am safe

The increased congruence between participants' physical appearance and gender identity made participants feel seen and accepted for who they were. Evan stated, ‘I think it is, like, a general sense of being … more secure. … I … have this vision of … who I am … and [mGAHT] is … changing my body, and so that other people can see that version as well’.

Participants expressed that the gender‐affirming physical changes they experienced as a result of undergoing GAHT provided an increased sense of safety and confidence to do the things they want to do. Charlotte stated, ‘Going out into the community … it's kind of given me the confidence to do some things that I've never [done] before’. Ryan stated that others using ‘small gender‐affirming language’ provide him with ‘reassurance and the confidence that I belong here, I'm not doing anything wrong’ when engaging in gendered occupations and environments.

5.13.4. Participating in life as I want

Participants predominantly participated in the same occupations that they did prior to commencing GAHT; however, the quality of their engagement has increased. Jeff expressed feeling increased confidence and comfort engaging in social leisure occupations, stating ‘I think as much as my neurodiver[gent] brain will allow me to be social, cause …, that stops me from being social often more than anything else now. But I am able to be comfortable’.

Three participants reported that their participation and engagement in social environments had increased as a result of increased feelings of confidence, happiness and safety. Charlotte participated in new occupations as a result of increased congruence with her gender identity. She stated, ‘I always like going to pubs and seeing bands, that was fine. But would I ever dance? Hell no! Like not in a thousand years. But now, even if no one else is, I still do’.

6. DISCUSSION

This study presents research pertaining to the occupational experiences of autistic TGD adults on GAHT. The DBBB concepts provide an occupational lens in which to conceptualise the impacts of environmental factors, as well as the intersection of ASD and GI/GD, upon occupational identity outcomes. Societal gender norms encompass occupations that have assigned gender meanings that influence interactions, routines and occupational engagement (Swenson et al., 2021) demonstrating a ‘doing’ aspect to gender that is influenced by psychological and sociocultural factors (West & Zimmerman, 1987). Participants in this study described experiencing positive impacts on their mental health, QOL and identity outcomes as a result of undergoing GAHT. However, participants also described challenges to ‘doing’ meaningful gender‐affirming occupations when navigating health‐care and social environments. Sensory processing difficulties and executive function challenges created a challenge to doing that appears to be unique to the autistic TGD population. The survey completed alongside this study found that autistic TGD individuals experience greater challenges administering GAHT as a result of sensory and executive function demands (Miller et al., 2026). Participants described feeling a need to mask their gender and/or autistic identity with HCPs, or needing to strongly advocate for their health‐care concerns to be addressed. This experience translated to the broader social environment in which participants expressed varying degrees of confidence and insecurity engaging in occupations in social environments depending upon the context.

A structured search was conducted to investigate what has been published about occupational identity outcomes of autistic TGD, autistic and/or TGD communities. The yield included one article pertaining to transgender women (Bar et al., 2016) and two articles already identified (Beagan et al., 2012; Devor, 2004). Bar et al. (2016) highlight that the ‘doing’ and exploration of occupations typically considered feminine positively influenced the occupational participation and identity outcomes of transgender women. Although the positive changes in occupational identity outcomes were lower among transgender women compared with cisgender women, these findings suggest that gender‐affirming physical and occupational changes positively influence identity outcomes (Bar et al., 2016). The author suggested that lower occupational identity outcomes among transgender women may be attributable to restricted ‘doing’ of occupations culturally considered feminine (gendered occupations) in childhood (Bar et al., 2016). This in turn may impact upon occupational competence in gendered occupations, subsequently limiting opportunities for occupational identity development. Devor et al. (2004) suggested that cisgender women typically have greater opportunities to explore gendered occupations throughout their lives, and their occupational identity may be further developed as a result. Beagan et al. (2012) posed that identity formation among transgender individuals could be negatively impacted as a result of societal expectations of gender norms prior to transition, stigma and individuals participating in occupations associated with their assigned gender at birth to mask feelings of confusion. These preliminary findings emphasise the importance of enabling the ‘doing’ of gendered occupations for transgender individuals to improve occupational identity outcomes.

Although participants in this study experienced challenges in relation to doing, the gender‐affirming physical changes participants experienced as a result of undergoing GAHT affirmed participants' doing of gender‐affirming occupations and roles and consequently their occupational identities. The key concepts of DBBB are shown to be interdependent on one another, particularly doing upon the outcomes of being, becoming and belonging (Hitch et al., 2014b). The results of this study show that positive outcomes in being, becoming and belonging occurred in response to positive experiences ‘doing’. Participants' progress in acquiring their desired physical characteristics alleviated, in some contexts, the institutional, social and cultural environmental challenges experienced, which all participants described as ‘Worth it’ (Miller et al., 2026).

People who experience GI/GD have unique physical and mental health needs and subsequently unique occupational needs; however, research and clinical guidance for occupational therapists relating to transgender health is limited. Occupational therapy practitioners can draw on the values and frameworks underpinning practice to support TGD individuals whilst transitioning (Beagan et al., 2013). Previous research highlights the relevance of occupational therapy involvement in gender‐affirming care settings to support meaningful occupational outcomes for autistic TGD adults. Sensory‐based and executive function interventions are commonly implemented by occupational therapists working with autistic populations and adults in mental health settings (Kandlur et al., 2023; Patil & Kaple, 2023). Sensory integration is commonly utilised with autistic children to modify a sensory response and reduce distress, promoting positive adaptive responses, improved focus and social interactions (Patil & Kaple, 2023; Randell et al., 2019). In contrast, sensory modulation refers to the regulatory ability of the central nervous system in response to environmental sensory stimuli, providing the opportunity for a behavioural response (Brown et al., 2019). Sensory modulation has been shown to enable emotional regulation, thereby improving occupational participation and functional outcomes among adults experiencing mental ill health (Kandlur et al., 2023). Although research is limited, autistic, TGD and autistic TGD populations are shown to experience higher rates of mental ill health when compared with the general population (Dhejne et al., 2016; Hedley et al., 2017; Simpson et al., 2024; Zwickl et al., 2021). These findings provide rationale for the inclusion of occupational therapy within gender‐affirming care settings to enable the ‘doing’ of gender‐affirming occupations.

Occupational engagement is essential for the authentic expression of one's gender identity and is heavily influenced by the interaction between an individual and their environment (Bar et al., 2016; Dowers et al., 2019; McCarthy et al., 2022; Schneider et al., 2019; Swenson et al., 2021). Dowers et al. (2019) outlined that the cis‐normative cultural ideals of Western society result in social, physical and institutional environments that limit equitable occupational participation for TGD populations. Research shows that TGD populations experience occupational injustice resulting from societal stigma and discrimination, often resulting in occupational performance difficulties in self‐care, leisure and productive occupations (Bar et al., 2016). Although productive occupations were not explored in this study, participants described challenges engaging in health‐care and social environments due to their TGD and/or autistic identification.

The occupational therapy profession holds a unique view and understanding of humans as occupational beings whose health is influenced by what they do within their environment (Wilcock & Hocking, 2015). The occupational concepts of DBBB were conceived through the lens of population health (Wilcock & Hocking, 2015), which posits that social, cultural and physical barriers to occupational participation and engagement can be addressed at a population level (Braveman, 2016). Occupational justice frameworks address diverse health needs, roles and choices (Taff & Blash, 2017), inclusive of transgender and autistic populations (Patten et al., 2024; Steuer & Walker, 2025). Emerging evidence suggests that TGD and autistic TGD adults experience societal stigma, discrimination and health‐care inaccessibility that impact occupational participation and engagement. Our study corroborates past findings, highlighting a role for the occupational therapy profession in advocating for improved occupational outcomes for autistic TGD populations in Australia. Potential population health areas include advocating for improved health‐care accessibility, including HCP education and informing stigma and discrimination reduction strategies at community, organisational and population levels.

Participants reported feeling an increased sense of belonging and confidence when engaging in occupations and subsequently positive occupational identity outcomes. These results further highlight that the meaning of gender‐affirming occupations is multifaceted. Participants described engaging in gendered occupations as both a means of self‐expression and, in some instances, as a protective factor against stigma in health‐care and social environments. Qualitative research finds autistic TGD individuals report feelings of ‘otherness’ resulting from non‐conformity to gender norms and ableist hierarchies that negatively impact identity and mental health outcomes (Cain & Velasco, 2021; Kanfiszer et al., 2017). Five participants in this study identified as binary transgender and expressed a desire to socially ‘pass’ as the gender they identify with. However, this sentiment was not expressed by the one non‐binary participant. Previous research highlights that TGD individuals report using adaptive strategies such as medical transition and gendered clothing to suppress or accentuate their gendered features in public spaces (Dowers et al., 2019). Participants in this study described experiences in which they suppressed or guarded their gender identity in social situations when perceiving potential stigma. Participants experienced unique occupational performance difficulties as a result of the intersection of ASD and GI/GD. Self‐managing GAHT, accessing health care and engaging in social leisure occupations were negatively impacted as a result of sensory processing difficulties, executive function challenges and actual and perceived societal stigma. These unique challenges were shown to influence participants' expression and experience of occupational and gender identity and may reflect the experiences of others.

Limitations for this study include single clinic recruitment and the potential for self‐selection bias. Additionally, the sample consisted of predominantly binary transgender participants. Therefore, these findings may not be an accurate reflection of the experiences of non‐binary individuals. Future research into the occupational experiences of Australian autistic and non‐autistic TGD populations is recommended to better understand helpful environmental supports as well as barriers to inclusion. Areas worth further exploration include: Australian autistic TGD individuals' experiences of productive occupations, the occupational experiences of autistic TGD adults who choose not to medically transition; cultural differences in the desire for GAHT and the impact of ethnicity upon engagement in current clinic services; the efficacy of sensory, cognitive and environmental interventions within gender‐affirming care settings and in home and community settings; and exploring the experience of autistic self‐identification alongside systemic changes that may assist formal diagnosis where this is desired. Additionally, exploration of the intersection of age and ethnicity upon the occupational identity outcomes of autistic TGD individuals is also recommended to increase understanding of occupational experiences.

7. CONCLUSIONS

With a long history in the foundations of DBBB, the occupational therapy profession aims to promote equitable inclusion for all (Hammel, 2014; Hitch et al., 2014a; Wilcock, 2006). The occupational therapy profession's role in enabling positive health outcomes among TGD adults undergoing gender‐affirming surgery is developing in international settings (Steuer & Walker, 2025). Additionally, the profession's values and frameworks are well placed to inform interventions aiming to reduce environmental stigma and discrimination to enable positive occupational participation and subsequently occupational identity acquisition. This research highlights the unique experiences of autistic TGD adults undergoing GAHT, including sensory and executive function challenges, experiences of stigma and fears of discrimination in health‐care and social environments. Consequently, the inclusion of occupational therapy professionals within gender affirming care settings in Australia is indicated to enable improved occupational outcomes for autistic TGD adults.

AUTHOR CONTRIBUTIONS

Sarah Louise Miller: Completed this research project in partial completion of Bachelor of Occupational Therapy (Honours). Data collection, storage, management, analysis, write‐up. Helen Bourke‐Taylor: Research design, methods, data collection, storage, management, analysis, academic guidance and write‐up. Karen Dixon: Facilitated fieldwork opportunities, research methods, data storage, management, analysis and write‐up. Rita Upreti: Instigated this research project, research design and methods, data collection, storage, management, analysis and write‐up.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Miller, S. L. , Bourke‐Taylor, H. , Dixon, K. , & Upreti, R. (2026). Experiences of autistic transgender and gender diverse adults undergoing gender‐affirming hormone therapy and the influence on occupational identity outcomes. Australian Occupational Therapy Journal, 73(5), e70121. 10.1111/1440-1630.70121

DATA AVAILABILITY STATEMENT

Research data are not shared as per ethics/participant consent.