“I had this fear that as an autistic person, they would take me less seriously”: Trans autistic experiences of epistemic (in)justice in gender-affirming care

Abstract

Background

A disproportionate number of transgender and nonbinary people are autistic, and research suggests that trans autistic people experience significant barriers and challenges to accessing gender-affirming care. Much of the existing research in this area focuses on determining why trans people are more likely to be autistic, and less research has attended to trans autistic people’s lived experiences of accessing gender-affirming care.

Methods

To better understand these barriers and their impacts, I conducted qualitative interviews with 12 trans autistic people who had recently accessed gender-affirming medical care in the province of Ontario, Canada. Interviews were analyzed using reflexive thematic analysis.

Results

Participants reported being frequently not believed, listened to, or taken seriously by healthcare providers, which I conceptualize as instances of epistemic injustice. I identify how medical discourses, ideologies, and clinical guidelines create conditions for gender-affirming care in which trans autistic people experience pervasive epistemic injustice. For example, participants felt pressure to conform to a transnormative and neuronormative narrative in order to be taken seriously by gender-affirming care providers. Some providers misinterpreted autistic communication styles and unfairly discredited their client’s knowledge, eroding their trust in health care. While participants used creative self-advocacy strategies to access care, some providers felt threatened by this challenge to their epistemic power and medical authority. Conversely, participants also had positive experiences of epistemic justice when providers took their knowledge and lived experience seriously.

Conclusion

I argue that gender-affirming care providers must practice epistemic humility by listening deeply and acknowledging the limits of their knowledge to deliver patient-centered care for trans autistic people. Systemic changes to the healthcare system and disrupting transnormativity and neuronormativity are necessary to improve trans autistic people’s experiences of gender-affirming care and enable epistemic justice.

Introduction

Research demonstrates that transgender¹ people are much more likely to be autistic than cisgender people. A recent meta-analysis estimated that 11% of people with gender dysphoria or gender incongruence have autism, compared to 1-2% of the general population (Kallitsounaki & Williams, 2023). As such, Warrier et al. (2020) estimate that transgender and gender-diverse individuals are between 3 and 6 times more likely to have an autism diagnosis than cisgender individuals. While research in this area is growing, much of the existing research focuses on determining why trans people are more likely to be autistic and little research has attended to trans autistic people’s experiences accessing health care. The research that does exist suggests that trans autistic people experience worse overall health, greater unmet healthcare needs, and greater barriers to accessing care than their cisgender and allistic (non-autistic) peers (Adams et al., 2025; George & Stokes, 2018; Green et al., 2025; Hall et al., 2020). Particular challenges exist for autistic people seeking gender-affirming care (GAC), which refers to medical interventions such as hormones or surgeries that help trans people affirm or express their gender. These challenges include navigating complex healthcare bureaucracies, lacking accommodations to meet their sensory and communication needs, and providers being uneducated or misinformed about autism, trans identities, and the intersection of the two (Bruce et al., 2023; Coleman-Smith et al., 2020; Cooper et al., 2022; Glackin et al., 2024). Research has found that some trans autistic participants are disbelieved or infantilized because of their autism, including being denied GAC (Bruce et al., 2023; Coleman-Smith et al., 2020; Cooper et al., 2022; Glackin et al., 2024). Even individuals who have not experienced gatekeeping or invalidation often make significant efforts to prevent these experiences, such as by avoiding disclosing their autism diagnosis, masking their autistic traits, and doing extensive research and self-advocacy (Adams et al., 2025; Bruce et al., 2023; Cooper et al., 2022).

In sum, a limited body of research indicates that trans autistic people experience pervasive and significant barriers to accessing GAC, including denial, restriction, and delays. Nic Rios (2025) conceptualizes these barriers as a mechanism for GAC providers and systems to hold trans autistic people accountable to neuronormativity—the discourse that privileges neurotypical ways of thinking, feeling, and communicating (Walker, 2021). In this article, I extend Rios’ work using the framework of epistemic injustice to highlight the importance of credibility and knowledge in neuronormativity’s impact on trans autistic people accessing GAC.² I develop this argument through a reflexive thematic analysis of qualitative semi-structured interviews with 12 trans autistic people who had recently accessed GAC in the province of Ontario, Canada. Participants described frequently being not believed, listened to, or taken seriously by healthcare providers, which I conceptualize as instances of epistemic injustice. I identify how medical discourses, ideologies, and clinical guidelines create conditions in which trans autistic people experience pervasive epistemic injustice when accessing GAC. I argue that systemic changes to the healthcare system and disrupting transnormativity, pathologization, and ableism are necessary to improve trans autistic people’s experiences of GAC.

Background

The main theoretical concept guiding this analysis is epistemic injustice. Epistemic injustice describes instances where a person or group is unfairly prevented from contributing to collective practices of generating and sharing knowledge (Fricker, 2007; McKinnon, 2016). Scholars have identified various forms of epistemic injustice. For example, testimonial injustice occurs when an individual’s knowledge is discredited because of prejudice related to who the person is (Fricker, 2007). Hermeneutical injustice occurs on a larger scale, and results from a lack of shared epistemic resources to name, articulate, and make sense of a particular social experience (Fricker, 2007). Willful hermeneutical ignorance occurs when marginalized groups have developed language and concepts to understand their experiences, but dominant groups refuse to use these epistemic resources (Pohlhaus, 2012). While epistemic oppression often flows from the same social power structures that produce other forms of oppression, attending to the uniquely epistemic dimensions of injustices is essential to overcoming their harms (Dotson, 2014).

The power structures of healthcare systems produce many experiences of epistemic injustice for patients (Carel & Kidd, 2017). In particular, the evidence-based medicine paradigm privileges objective scientific knowledge produced by methodologies such as randomized controlled trials and devalues the subjective experiential knowledge of patients (Carel & Kidd, 2017; Heggen & Berg, 2021). Patients may also be unfairly discredited by healthcare providers due to prejudiced stereotypes about particular health conditions (Carel & Kidd, 2017). Despite the growing push toward patient-centered care practices that value lived experience as an important source of knowledge, the epistemic hierarchies of medicine are not easily changed, and patients continue to experience epistemic injustice—particularly patients who are marginalized based on their diagnosis or social identity (Donnelly, 2024).

I now briefly review the history of GAC to explain why the historical pathologization of transness makes trans people particularly vulnerable to epistemic injustice in contemporary GAC. The model of GAC used in Ontario today developed in the 1950s and 60s, when GAC was justified as a form of social rehabilitation that would improve trans people’s socioeconomic prospects (Marrow, 2023a; Matte, 2014; Shuster, 2021). Endocrinologists and surgeons required prospective patients undergo a psychiatric evaluation to prove they were not mentally ill, complied with medical authority, and were capable of successfully assimilating into cisnormative society after their transition (Marrow, 2023a, 2023b; Shuster, 2021; Velocci, 2021). By only permitting patients who were likely to succeed according to these strict normative criteria, endocrinologists and surgeons treating trans patients could ensure that patient success stories would reflect well on their treatment and assessment practices, thereby increasing their professional credibility and legitimacy (Marrow, 2023a, 2023b; Shuster, 2021; Velocci, 2021). In 1979, the first clinical guidelines for GAC were published (the Standards of Care) codifying the importance of the mandatory pre-transition mental health assessment (Marrow, 2023b).

Scholars have described the normative expectations enforced during these psychiatric evaluations as transnormativity—the ideology that holds trans people accountable to a strict binary-based narrative and grants legitimacy to those who adhere to it (Bradford & Johnson, 2021). In the transnormative narrative, trans people believe they were “born in the wrong body,” experience intense dysphoria about their body’s gendered characteristics, and seek medical interventions to transition to the opposite binary gender (Bradford & Johnson, 2021). Nicholas Matte (2014) has argued that American trans communities in the 1960s and 70s strategically developed transnormativity in order to gain access to gender-affirming care and public recognition of trans identities. In doing so, trans activists borrowed tactics from other burgeoning civil rights movements, including the disability rights movement, to construct trans people as legitimate, rights-bearing citizens with a medical condition in need of treatment (Matte, 2014).

Transnormativity originally developed in conjunction with medical authority and constructed transness as a pathological condition, but over time, trans advocates have adapted transnormativity to depathologize transness. In 2013, the diagnosis of Gender Dysphoria was created to replace Gender Identity Disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). Gender Dysphoria pathologizes the distress of being trans in order to preserve insurance coverage of gender-affirming medical interventions while asserting that trans identity itself is not pathological (Johnson, 2019). This approach to partial depathologization relies on distancing transness from disability—asserting that trans people are credible rights-bearing subjects because they are not mentally ill leaves unquestioned the pathologization and mistreatment of mentally ill people (Awkward-Rich, 2022; Pyne, 2020). Of course, trans communities can never fully disavow disability because many trans people are disabled. Trans PULSE Canada, a large survey of trans and nonbinary people in Canada, found that 19% of participants identified as disabled, 30% as neurodivergent, 14% as autistic, and 43% as a psychiatric survivor, mad, or a person with a mental illness (The Trans PULSE Canada Team, 2020). As such, even while transnormative discourses seek to shed stigma by denouncing disability, trans lives and communities are intertwined with disability, madness, and neurodivergence.

While current clinical guidelines no longer require rigid adherence to the strict criteria developed in the 1960s, transnormativity continues to shape trans people’s experiences of GAC. The World Professional Association for Transgender Health (WPATH) recently published the 8^th edition of the Standards of Care (SOC) (Coleman et al., 2022). While the SOC can be interpreted flexibly and adapted to local contexts, it is a guiding text for providers and policy-makers in many jurisdictions, including Ontario (Bourns, 2019; Coleman et al., 2022). The criteria for access to GAC have relaxed significantly in recent decades, but the legacy of pathologization and gatekeeping continues to inform the SOC and their interpretation. Some providers use an informed consent model for hormones that gives patients greater decision-making power (Coleman et al., 2022), but mental health or readiness assessments are still widely used and are mandatory in Ontario for gender-affirming surgeries. As GAC assessors hold the power to grant or deny health care that is very important to many trans people’s authenticity and wellbeing, many trans people are distrustful and suspicious of assessors (Dewey, 2015; Fraser et al., 2021; Lane, 2018). To construct themselves as credible and legitimate, many trans people feel they must emphasize gender dysphoria and distress during their readiness assessment and avoid discussing identities and experiences that do not conform to transnormativity, such as gender fluidity (Dewey, 2015; Fraser et al., 2021; Lane, 2018; Shook et al., 2022). Canadian research by MacKinnon et al. (2020) found that trans people with complex mental health work hard to prove to providers that they exhibit enough distress that GAC is deemed necessary, but not so much distress that they will be deemed too complex or unstable to access care. Readiness assessments are particularly fraught sites of epistemic injustice, given that their purpose is to corroborate the trans person’s desire for medical interventions through the epistemic power of the assessing clinician. However, research by Gabriel Enxuga (2022) found that participants who were not required to undergo a formal readiness assessment to access gender-affirming hormones still experienced epistemic injustice, suggesting that epistemic oppression of trans people pervades medicine far beyond the readiness assessment.

The historical pathologization of transness casts trans people’s claims to knowledge as suspect and unreliable. By identifying themselves as trans, an individual becomes vulnerable to having their very claim to be trans scrutinized and discounted (Awkward-Rich, 2022). While trans identity itself is no longer pathologized, trans people continue to face epistemic injustice in health care. The education and professional status of healthcare providers, especially physicians, grants them considerable epistemic power—the power to define, name, and explain and to be treated as legitimate, credible, and influential knowledge-holders (Dotson, 2014). Yet since providers rarely receive sufficient training in GAC, trans people often know much more about their own health care than their typically-cisgender doctors (Mikulak, 2021). When sources of knowledge conflict, the evidence-based medicine paradigm typically prioritizes providers’ professional expertise and research evidence over patients’ self-knowledge, which can lead to epistemic injustice for trans patients.

Trans people who are also autistic may be especially vulnerable to epistemic injustice due to the pathologization of autism. Catala et al. (2021) have argued that autistic people experience epistemic injustice interpersonally, when autistic communication that defies neurotypical norms is dismissed or misunderstood, as well as systemically, in that an autism diagnosis is seen as precluding an individual from participating fully in social and intellectual life as a legitimate speaker and knower. Neuronormativity casts autistic communication as suspicious, abnormal, and unreliable. The medicalization of autism as a disorder defined by social communication deficits constructs autistic people as lacking insight into their own and other people’s thoughts, beliefs, and experiences (Yergeau & Huebner, 2017). But critical autism studies scholar Damian Milton (2012) has argued that while autistic people may struggle to understand the social norms of communication with allistic people, allistic people equally struggle to understand autistic culture and communication. This double empathy problem conceptualizes the social communication challenges experienced by autistic people as relationally produced in the communication gap between autistic and allistic people, rather than the result of a pathological deficit inherent to autism. Catala et al. (2021) therefore use the double empathy problem to argue that autistic people are epistemically disabled through relational and social processes.

Shaw et al. (2024) apply the double empathy problem to understand how interactions between individuals’ autistic traits and their social environment create barriers to accessing health care and result in epistemic injustice. They theorize the triple empathy problem, which adds specialized medical terminology and knowledge as an additional barrier on top of mutual misunderstandings in autistic-allistic communication. As such, Shaw et al. (2024) argue that typically-allistic healthcare providers struggle to understand the perspectives of their autistic patients who lack medical knowledge and communicate differently, and autistic patients similarly struggle to articulate themselves in ways that are intelligible from a medical perspective. Applied to GAC, the triple empathy problem posits that the barriers trans autistic people experience are produced relationally in their interactions with healthcare systems and providers. The lens of epistemic disablement and injustice draws our attention to the ways in which autistic people are marginalized and discredited as epistemic agents not just in individual interactions with allistic healthcare providers, but also as part of a larger neuronormative healthcare system.

To summarize, the historical pathologization of transness has produced conditions where trans people’s credibility is questioned and providers benefit from inflated epistemic authority. This is exemplified in readiness assessments, where trans people seeking GAC must prove their credibility, legitimacy, and need for care in ways that align with transnormativity. Autistic people also frequently experience epistemic injustice in healthcare. In particular, autistic communication that defies the unwritten rules of neuronormative social interaction can cast doubt on an autistic patient’s trustworthiness and compromise their epistemic agency. The dual pathologization of transness and autism therefore means that trans autistic people appear especially likely to experience epistemic injustice in healthcare settings. While previous research has documented the challenges faced by trans autistic people when accessing gender-affirming care, this article applies the theoretical lens of epistemic injustice to highlight the role of knowledge, authority, and credibility in producing these barriers and challenges.

Methods

The analysis presented here is excerpted from a research project on trans autistic people’s experiences of GAC in Ontario, Canada. The research questions were: What are trans autistic people’s positive and negative experiences with accessing gender-affirming health care? What are the impacts of these experiences on trans autistic people’s lives? How can gender-affirming healthcare providers better support trans autistic people? To answer these questions, I conducted qualitative, semi-structured interviews with 12 trans autistic adults (19+) who had accessed GAC in the past five years in Ontario while an adult. Participants had to be able to communicate in English verbally, in writing, or using an AAC (augmentative and alternative communication) device. Recruitment was conducted online through social media groups and community organizations that serve trans and/or autistic people. After agreeing to an informed consent document, interested individuals completed a short demographic survey. As there were more potential participants than the researcher had capacity to interview, individuals were purposively selected to participate in an interview to ensure a diverse sample in terms of gender, race, age, autism diagnosis status, and socioeconomic status. The final sample of 12 participants ranged in age from 20 to 45, with an average age of 30 years old. Four participants identified as white, three as Indigenous, and five as a person of color or mixed race. Most participants identified as a transmasculine nonbinary person or trans man, with only three identifying as transfeminine or a trans woman. Two participants also identified as Two-Spirit. Half of participants had a college or university degree, and most were currently employed or attending school. Four participants had a formal autism diagnosis and eight others self-identified as autistic or were in the process of assessment. Of these eight participants, one was diagnosed with Social Communication Disorder, and another had been diagnosed with autism as a child but later had the diagnosis removed from their chart. In terms of types of GAC, ten participants were on hormones, six had had chest surgery and an additional two were on a waitlist for this. No participants had had genital surgery, but one was on a waitlist to do so. A few participants had undergone reproductive-system related procedures, and a few had accessed or were pursuing laser hair removal or electrolysis.

Ten interviews were conducted using Zoom video conferencing and lasted 90 min on average, while two interviews were conducted in writing using Microsoft Teams chat. At the start of the interview, the author confirmed the participant’s consent for the interview. All interviews used a semi-structured interview guide that inquired about participant’s GAC journeys, experiences with healthcare providers, and ideas for improving GAC. Zoom interview recordings were transcribed using NVivo transcription and edited for readability. Identifying information, such as names and locations, was redacted from all transcripts and pseudonyms were assigned. Participants had an opportunity to review their transcript, and a few identified transcription errors or potentially identifying information to be corrected. Interview participants received a $40 honorarium. The Carleton University research ethics board reviewed and approved the study protocol.

Interviews and data analysis were conducted by the author, a white transmasculine nonbinary autistic graduate student with lived experience of GAC. As research on both autistic and trans experiences has historically been led by allistic cisgender outsiders and rooted in pathologizing paradigms, many trans and autistic people are distrustful of academic researchers (Adams et al., 2017; Pukki et al., 2022). Disclosing my trans autistic identity in recruitment materials and during interviews helped built trust and rapport with participants and granted me epistemic privilege to understand participants’ experiences in ways that cisgender allistic researchers may not have been able to. Throughout the research process, I reminded myself not to make assumptions about my participants experiences or opinions based on my own and regularly wrote reflexive memos.

I analyzed the interview transcripts using reflexive thematic analysis (Braun & Clarke, 2022). This method allowed me to use inductive coding that stayed close to participants’ interpretations of their experiences as well as to apply existing theoretical concepts in later stages of interpretive analysis. Given my aims to provide both pragmatic suggestions for healthcare providers as well as contribute to broader theories, reflexive thematic analysis offered the necessary flexibility to conduct analysis for multiple aims. In line with a constructivist perspective, I conceptualize the knowledge produced through interviews as inextricable from the specific context of the interview encounter rather than as objective truth.

I first inductively coded all interviews using NVivo. I prioritized capturing unique meaning over using codes consistently, which resulted in over 300 codes after all interviews had been coded once. I then organized these codes into categories and created a mind map to group codes into preliminary themes. At this stage, the concept of epistemic injustice was identified as as a central overarching theme and used to guide analysis. I then reviewed the coded data extracts for each theme, using NVivo’s coding stripes to identify redundant, duplicate, and overlapping codes. Coding and themes evolved significantly at this stage as I created and deleted themes and subthemes, updated my thematic map, and wrote reflective memos. I then reviewed each transcript in its entirety to ensure I was applying themes consistently both within an interview and across the dataset. The final analysis resulted in four overarching themes, each encompassing two to four themes.

The analysis presented in this article focuses on the largest overarching theme—epistemic (in)justice—which included three subthemes. The first, “How dare they think that they know us more than we know ourselves?”: Medical authority leads to epistemic injustice, illustrates how neuronormativity and transnormativity combined with medical authority to produce epistemic injustice for participants. The second, “You have to be very strategic”: Resisting epistemic injustice through advocacy and concealment, describes how participants worked to protect themselves from epistemic injustice by selecting sharing or withholding information with healthcare providers. Finally, Being listened to, believed, and taken seriously: Epistemic justice through collaborative care; includes examples of collaborative, patient-centered care that cultivated epistemic justice for participants and respected their self-knowledge.

Findings

“How dare they think that they know us more than we know ourselves?”: Medical authority leads to epistemic injustice

Epistemic injustice pervaded participants’ accounts of accessing health care. Participants experienced epistemic injustice when they were unfairly discredited, not believed, not taken seriously, or invalidated by healthcare providers—often, though not necessarily, because they were trans and autistic. For example, Molly explained how her former family doctor “obviously felt very uncomfortable even talking about trans issues.” He also attributed her physical health concerns to her mental health, telling Molly that “it could just be that your ADHD is really bad, or it could be that your anxiety is putting these ideas in your head.” Her doctor’s refusal to investigate her symptoms made Molly feel “stupid” and “like an alien,” highlighting the epistemic and dehumanizing consequences of her doctor’s invalidation. The doctor’s actions seem driven by anti-trans stigma and diagnostic overshadowing, where Molly’s mental health diagnoses eclipsed the possibility of undiagnosed physical health concerns. Epistemic injustice is evident in two harms here: first, that Molly’s description of her symptoms was unfairly discredited because of other diagnoses she held, and second, that Molly was unable to access diagnostic assessment of her physical health concerns and relevant information about treatment.

In other cases, participants had negative experiences with clinicians because of neuronormative misinterpretations of their autistic communication and behavior. For example, Bowen felt that mental health professionals had taken advantage of perceived weaknesses in their communication and self-advocacy skills. While the power imbalance between clinicians and their patients may lead to epistemic injustice for anyone, this is especially true for autistic people like Bowen who may struggle with asserting their needs and setting boundaries. Alternatively, clinicians may perceive an autistic individual’s self-advocacy and assertive communication as hostile or threatening. Ellis described an endocrinologist who described him in chart notes as a “know-it-all” who was “narcissistic” and “foolish” for asserting that an anti-anxiety medication hadn’t worked for him in the past. Ellis explained that “this was entirely because I was behaving autistic and frustrated, and he was either ignorant or dismissive of that fact. I was just blunt and didn’t want his opinions on my unrelated medical history.” Consequently, the endocrinologist threatened to reduce Ellis’ testosterone dose if he didn’t better control his anxiety. Ellis’ assertion of self-knowledge in a way that failed to conform to neuronormative communication standards was perceived as an intentional threat to the endocrinologist’s epistemic authority. These misinterpretations of autistic communication reveal the harmful consequences of neuronormativity. Autistic people therefore face a precarious double bind: if they don’t advocate for themselves and their healthcare needs, they may not be taken seriously or get the care they need, but conversely, their self-advocacy may be punished for threatening medical expertise and authority.

In addition to being misinterpreted through a neuronormative lens, participants also described being explicitly discredited because of ableism and transphobia. For example, several participants had been told they “didn’t look autistic” or were denied a referral for an autism assessment because they made eye contact during an appointment and appeared to be high functioning. Clinicians’ disbelief that the individual could be autistic often reflected outdated stereotypes that ignore the wide variety of ways that autism can present. As Avery explained, “every time I have brought up autism in the past, like it’s always been met with a lot of surprise, and I feel like unwillingness to budge on their preconceived notions of autism.” Mason challenged the power that clinicians hold to determine the legitimacy of individuals’ trans autistic identity, asking “how dare they think that they know us more than we know ourselves?” Mason positions lived experience and introspection as a more legitimate foundation for self-identifying as autistic than the brief assessment of an allistic clinician. While clinicians may know much less about autism than their patients, the epistemic power granted to clinicians by their medical training and professional status lends legitimacy to their knowledge, even when it is biased or incorrect.

Many participants feared that providers would doubt, discredit, or dismiss them if they disclosed their autism. This reflects ableist discourses that position autistic people as having an impaired ability to understand themselves and the world around them. Bowen connected this to the infantilization of autistic people: “I had this fear that as an autistic person, they would take me less seriously. Because I have heard stories like that, that like, it’s almost like you’re denied your agency as an [autistic] adult.” Participants were often afraid that disclosing their autism would jeopardize their access to GAC in particular. Several participants said they had heard about people being denied GAC because of their autism. Other participants linked their fear to US politicians that have cited the prevalence of autism among trans people as reason to ban GAC. Spencer explained that “even though I know that’s not a law that’s happening here, it’s affecting the rhetoric and that made me anxious.” Participants recognized that autism seemed to reduce the credibility of their stated desire for GAC and anticipated experiencing epistemic injustice as a result.

Interview participants described how they felt pressured by health care providers to confirm to a transnormative and neuronormative narrative. Ellis described his experience of being diagnosed with gender dysphoria:

It was a series of questions that felt a bit outdated. Asking me if I’ve felt this way all my life (no, but I half lied about that), if I felt like I was in “the wrong body” (not really, I just had no connection to my body at all), if I felt like a man (I never have, but luckily I was skewing more nonbinary than [sic] so I didn’t have to try to lie about something so big), stuff about my childhood. Nothing horribly ignorant, just things that made me feel like I had to give the answers she wanted to hear instead of the more vague answers I actually felt. […] I hope it makes sense if I say that I was too busy being autistic as a child, to be a trans child, so my experiences weren’t very convincing to professionals.

Ellis felt that the provider’s questions about his gender carried unspoken right and wrong answers and that only the ‘right’ answers would unlock a gender dysphoria diagnosis and access to care. Ellis points out that transnormativity excludes autistic people. In particular, Ellis explains that he felt alienated from his body in general and therefore didn’t feel like he was born in the wrong body. As many autistic people have alexithymia—difficulty identifying emotions—and poor interoception—understanding of internal bodily signals and sensations—Ellis and other autistic people might not identify and articulate feelings of gender dysphoria in the same ways as non-autistic people. The stakes of the gender dysphoria diagnosis placed Ellis in an adversarial relationship with his doctor where he felt he needed to ‘convince’ them that he was trans. As such, the pressure to conform to transnormativity and neuronormativity required Ellis to self-censor himself in order to be deemed a credible and legitimate trans person.

Illustrating the power of providers’ epistemic power, some participants experienced epistemic injustice when providers used their professional experience and education to overrule their patient’s request or self-knowledge. Jay’s experience with being prescribed estradiol exemplifies this. Based on research and discussions within the trans community, Jay strongly believed that taking estradiol sublingually was more effective than swallowing it, but their provider disagreed and insisted they keep taking oral estradiol. To justify this, Jay said the provider “literally pulled out the book of recommendations on trans care and said, look, we’re following the book, you know, this is what it says.” Here, the provider draws on clinical guidelines as a source of epistemic power and medical authority in order to deny Jay’s request. While the research evidence on oral compared to sublingual estradiol is limited and mixed, the Rainbow Health Ontario Guidelines for gender-affirming primary care with trans and nonbinary patients state that sublingual administration “may have benefits over oral dosing, and could be considered as an alternative … when patients are dissatisfied with their degree of feminization and are seeking to explore alternative strategies.” (Bourns, 2019, p. 44). None of the 6^th, 7^th, or 8^th editions of the WPATH SOC make any suggestions regarding sublingual estrogen. Despite this, Jay’s provider points to clinical guidelines as an authoritative information source which apparently disprove Jay’s belief about the efficacy of sublingual estrogen. This is an example of what stef shuster describes as a “close follower”: GAC providers who maintain their medical authority when faced with uncertainty by rigidly adhering to clinical guidelines (2021, p. 106). Indeed, the rhetorical power of the guidelines appears so strong that this provider can use them to justify denying Jay’s request regardless of what the actual guidelines say.

While we cannot know why Jay’s provider was opposed to sublingual estradiol or what guidelines they were pointing to, misinterpretations of Jay’s communication through a neuronormative lens may have contributed to this refusal. Jay explained that “in some ways I might be seen as being obstinate or being aggressive or being any number of things and it just stems from my autism.” While Jay’s direct and straight-forward communication style is common among autistic people, directness may be perceived as stubborn arrogance and threatened Jay’s credibility when viewed through a neuronormative lens. This example illustrates how the epistemic authority of clinical guidelines in GAC combines with neuronormativity to produce epistemic injustice for trans autistic people. After repeated refusals to grant Jays’ request for sublingual estrogen, Jay lost trust in their provider and eventually left their care in favor of self-administering hormones without a prescription. Regardless of the specific risks and benefits of oral compared to sublingual estradiol, Jay is undoubtedly at greater risk on unsupervised hormone therapy than they would have been on prescribed sublingual estradiol. Jay’s experience underscores the harmful impacts that clinicians can have when they misuse their epistemic power to overrule patients’ requests for individualized, patient-centered care.

Overall, participants felt that providers often unfairly viewed them with suspicion, doubt, and disbelief. In some cases, this was explicitly related to being trans and autistic, such as when participants were told they were not autistic. In other cases, participants’ autistic communication methods and self-advocacy were perceived as threats to the provider’s expertise and authority. Regardless of whether the participant had a formal autism diagnosis or if their provider was aware of it, participants experienced epistemic injustice when neuronormative misinterpretations of autistic communication implicitly discredited their knowledge. Whether or not autism was explicitly named, epistemic injustice also occurred when providers used their professional status to inappropriately position their knowledge as more accurate or authoritative than their client’s self-knowledge. Consequently, participants lost trust in their providers, damaging their relationship and, in at least one case, causing the participant to avoid care altogether.

“You have to be very strategic”: Resisting epistemic injustice through advocacy and concealment

In response to their experiences of epistemic injustice, participants developed strategies to protect and advocate for themselves in healthcare settings and prevent epistemic injustice. Often, these strategies involved selecting withholding information in order to be granted credibility under transnormative and neuronormative logics. Many participants felt there were right and wrong answers to provider’s questions and worked hard to determine what these answers were. Ellis explained:

I’ve felt like I couldn’t be honest with doctors frequently, especially about how being autistic has affected my gender and transition, due to the fear of not being taken seriously. My process has been a lot more about saying what I think should be said to get the care I need.

Participants learned from other trans people and their own research what kinds of narratives providers expected to hear—often a transnormative narrative centered around body-based gender dysphoria and a binary gender identity—and tailored their communication accordingly. Some individuals altered their gender expression when attending GAC appointments. Daniel noted: “I purposefully wore a more masculine outfit so that I could be taken seriously.” Another participant told their provider they identified as nonbinary rather than explain their complicated and nuanced relationship to gender. However, it was not always easy for participants to identify what the “correct” answers to provider’s questions were. Ivan explained, “It was sort of like playing 3D chess because I wasn’t exactly sure what the correct answer was or the answer I was supposed to be giving, so I just sort of made shit up on the spot.” Interpreting a provider’s question required not just understanding the literal meaning of the question, but also deducing what the ‘correct’ answer was, anticipating the consequences of giving the ‘wrong’ answer, and framing an answer that conformed to the script. This “3D chess” required a lot of epistemic labor for Ivan.

Many participants explained that they would wait to build trust with a new provider before disclosing their autism. Others would only disclose being autistic if they were directly asked or if it was specifically relevant to the appointment topic. Almost all participants had avoided disclosing their autism in at least some contexts. One participant, Chris, avoided discussing autism with medical providers because he felt providers already devalued his knowledge because of his multiple sclerosis diagnosis. Consequently, he described his approach to accessing health care as “I’m going to be very cis and neurotypical at this appointment.” Participants also described masking or camouflaging their autistic traits during appointments, such as by making eye contact and avoiding stimming or fidgeting. Several participants described masking as a privilege because it allowed them to access care with less risk of experiencing ableism or epistemic injustice. Racialized participants who were white-passing also described this as a privilege that bolstered their credibility in healthcare settings. Notably, nearly all participants described themselves as being able to mask well or appearing high-functioning, and many had employment and education that they felt improved their credibility. Trans autistic individuals who are less able to mask and are more frequently perceived as autistic may have different or worse experiences of epistemic injustice in health care.

Many participants had very little trust in health care providers and services and were selective about when, how, and where they sought care. One approach some participants took was to compartmentalize their health care needs, such as avoiding disclosing their trans status when accessing specialist care for a chronic health condition or not recording a mental health diagnosis on a gender-affirming surgery referral form. Ivan felt that being a trans autistic person in general involved constantly anticipating and preparing for possible barriers and challenges: “you have to preplan basically all of your solutions to get out of different problems that might come up.” They noted that this approach was also shaped by their experience as a child of Asian immigrants, explaining that “the second-generation immigrant experience teaches you to be very strategic about everything all the time.” Jay echoed this strategic approach, explaining that “I kind of just need to be measured in how I interact with the system, and I need to manage my expectations and my feelings very carefully and or I will just not be supported in any way whatsoever.” As Jay and Ivan highlight, navigating the healthcare system as a trans autistic person involves anticipating potential injustices and carefully tailoring interactions with services and providers to get one’s needs met while minimizing the risk of iatrogenic harm.

Many of participants’ strategies involved concealing their identities and experiences in order to be treated as credible and legitimate knowledge-holders and survive the health care system. However, participants also described using self-advocacy strategies to pro-actively assert their needs and communicate in ways that conformed to clinical expectations. For example, Bowen described using assertiveness skills they had learned in dialectical behavioral therapy to communicate with their psychiatrist. In doing so, Bowen turns the epistemic tools of psychiatry back on itself to defend themselves against psychiatric authority. Some participants brought a support person to appointments to bridge communication barriers with providers. For example, Avery often brought their partner, explaining that “because she gets an external point of view, it’s easier for her to speak sometimes when they ask questions and I don’t know the answer to them.” Their partner’s “external point of view” is perhaps taken more seriously by providers as it is seen as less biased or suspicious than subjective autistic testimony. Several participants indicated that they would write notes for themselves before, during, and after appointments. As Noah explained, “it’s always good to write down what you want to address with your doctor, because especially if you’re more of the nervous autistic type, you might forget things or just be too flustered to think straight.” Chris suggested audio recording an appointment or “following up with like a written email that starts with ‘as per our earlier conversation.’” In addition to serving as a communication and memory aid, creating an external record of the healthcare encounter resists epistemic injustice by appealing to provider’s trust in written information and external perspectives and circumvents their distrust of autistic people’s subjective testimony.

Another way that participants resisted epistemic injustice was by doing extensive research about GAC before booking an appointment with a provider. Some participants brought a written report of their research to their provider to demonstrate that they were taking responsibility for their own care and were capable of making informed decisions. Mason explained that their autistic strengths in intensive, systematic information-gathering “fueled that research and the things I needed to know and to find the information and who I needed to email because I would hyperfixate on it.” Ivan explained that having access to information before seeing a clinician was crucial: “Looking back on trans history, there have been a lot of times where it’s like, if you went to the doctor and then you told them the wrong thing, they would just block you forever.” To avoid the dire consequences of saying the “wrong thing” to doctors, Ivan identifies access to information outside of the control of medical providers as a key aspect of epistemic justice and self-determination. Doing research allows individuals to arm themselves with the epistemic resources of medicine to defend themselves against the epistemic injustice embedded in doctor-patient power dynamics. However, while online research can help an individual learn about GAC before an appointment, it doesn’t guarantee they will be taken seriously. As described above, some providers perceived knowledgeable patients as a threat to their epistemic power as clinicians. Further, many participants described drawing on their professional training and post-secondary degrees to conduct their own research—education that not all trans autistic people have and should not be necessary to access GAC. Thus, while independent research can be a powerful tool for resisting epistemic injustice, it also highlights the unjust burden placed on trans autistic individuals to prove their credibility.

Overall, participants strategically considered when to assert their needs and when to use concealment or selective disclosure in order to be taken seriously by healthcare providers without threatening providers’ epistemic authority. While participants had many resourceful and effective strategies, they could not undo the systemic inequities that produced the conditions for epistemic injustice to occur in the first place. True epistemic justice for trans autistic people requires multiple accessible sources of information and supportive providers who ensure their clients have the resources necessary to make informed decisions about GAC, as discussed in the next section.

Being listened to, believed, and taken seriously: Epistemic justice through collaborative care

While participants reported numerous instances of epistemic injustice in health care, all participants also reported at least one positive experience of epistemic justice with a gender-affirming care provider. Participants described times when providers respected their knowledge, took their identities and experiences seriously, and collaborated with them to provide the best possible care. Demonstrations of deep listening were also valued, such as when providers referenced something the client had said in a past appointment. Participants also appreciated when a provider asked the client what they already knew about the hormones or surgery they were interested in. However, when providers repeated information the participant already knew and had stated, this felt invalidating and condescending. Conversely, participants felt understood when providers took their prior knowledge seriously. Avery explained that when they started testosterone, their doctor began by asking what method and results they were seeking. This signaled that he valued Avery’s knowledge and perspectives and allowed the doctor to tailor the medical information he subsequently provided. Rather than feeling like they needed to say the right answers, Avery was able to “completely freely talk to him.” Similarly, Molly explained that her doctor “really took my word for everything and seemed to appreciate the fact that I had done my own research and knew what I was talking about.” Avery and Molly’s doctors viewed their client’s existing knowledge as a positive indication of their readiness to make an informed decision about GAC, rather than as a threat to their medical expertise or authority.

Many participants were reassured when providers demonstrated relevant knowledge, such as being able to interpret hormone-related bloodwork or suggesting a particular gender-affirming surgical center. However, several participants also had positive experiences with providers who had no previous experience with GAC. These providers were honest about their lack of knowledge and were willing to educate themselves and follow their client’s lead. Molly described why she was so thankful for her primary care provider:

She doesn’t really know what she’s doing, but she’s willing to sit and talk to me about any trans-related problem I have for as long as I need to talk about it and search for every possible solution, and is very forthcoming about her knowledge gaps and limitations.

Molly identifies this provider’s honesty about her lack of knowledge as a sign that she could trust her. Rather than relying on her epistemic power as a clinician, this provider demonstrated epistemic humility by acknowledging the limitations of her training and creating space for Molly to share her knowledge. This transforms the clinical encounter into a collaborative space for problem-solving by framing patient and clinician knowledge as complimentary rather than oppositional. Ivan argued that “If you do not take people seriously, it just doesn’t matter how much you know, because it’s better to know less and be more willing to learn than know more and not take people’s words seriously.” This highlights the importance of communication and interpersonal skills in delivering trans-competent health care, beyond specific knowledge of trans health.

Finally, enacting epistemic justice required providers to answer their client’s questions and provide information in advance about what to expect, such as the timeline of expected effects of hormones or the steps in a referral. Some participants identified information needs specific to being autistic. For example, Spencer struggled to follow instructions when they didn’t understand the reasoning behind them. They found it easier to cope with the discomfort and overstimulation caused by the binder they wore after top surgery when they understood its purpose and the consequences of not wearing it. Knowing what to expect helped reduce some participants’ anxiety about accessing health care. For example, Ivan stated: “I think with my autism, I cannot stand being surprised.” Access to relevant, detailed information is therefore essential for trans autistic people to make informed decisions about their healthcare.

Overall, participants identified transparency, respect, collaboration, and communication as important foundations for epistemic justice. Many of these qualities are widely acknowledged as important features of patient-centered care in general. But as neuronormativity and transnormativity often implicitly reduce trans autistic people’s credibility in the eyes of clinicians, a trusting and collaborative health care provider was unexpected for many participants. When clinicians value their client’s self-knowledge and lived experience and recognize the limitations of their professional expertise, trans autistic people can trust their providers and work together toward collaborative, patient-centered care. Affirming and validating that trans autistic people are experts of their own experiences paves the way for epistemic justice in health care.

Discussion

These findings illustrate how the interlocking discourses of transnormativity, neuronormativity, and medical authority can lead to epistemic injustice for trans autistic people in accessing GAC. Interview participants used various tactics to increase their perceived credibility when seeking healthcare, such as doing research in advance and tailoring what and how they communicated with clinicians. Participants experienced epistemic justice when providers recognized the value of client’s self-knowledge and the limitations of their clinical expertise, and worked together with the client in a collaborative, patient-centered way.

Figure 1 visualizes the processes that lead to epistemic justice or injustice in healthcare settings for trans autistic people. The model identifies how the overarching discourses of transnormativity and neuronormativity govern trans autistic people’s experiences of gender-affirming care. To maintain their epistemic credibility, participants worked hard to conform to neuronormativity and transnormativity. Research has widely documented how trans people must shape their self-narratives to conform to transnormativity in order to be granted credibility and legitimacy by gender-affirming healthcare providers (Bradford & Johnson, 2021; Dewey, 2008; Shook et al., 2022). My findings confirm this phenomenon: many interview participants felt steered toward a transnormative script by the questions asked during readiness assessments. My research also found that trans autistic people engage in similar work to conform to neuronormativity by avoiding disclosing their autism and masking their autistic traits to ensure their access to desired care. This echoes Rios (2025) analysis of how trans autistic people are held accountable to neuronormativity by the threat of denial or delays in accessing GAC. Trans autistic peoples’ efforts to conform to neuronormativity and transnormativity by selectively disclosing their lived experiences can be understood as an instance of what Dotson (2011) terms testimonial smothering: the epistemic injustice that occurs when a speaker self-censors their speech because they expect that they will not be believed or understood by the listener. Neuronormativity also led to epistemic injustice when clinicians perceived an individual’s autistic communication style as manipulative or arrogant and took their knowledge less seriously. This perpetuates the stereotype that autistic people are unreliable narrators of their own experiences and is an example of what Catala et al. (2021) describe as the epistemic disablement of autistic people. Overall, trans autistic people are held accountable to transnormativity and neuronormativity in gender-affirming healthcare through both preemptive self-censoring and explicit instances of being unfairly discredited or misunderstood by clinicians, resulting in epistemic injustice.

Figure 1.

Visual model of the processes that lead to epistemic justice and injustice for trans autistic people accessing gender-affirming care.

Guidelines and protocols for gender-affirming care also shape experiences of epistemic justice and injustice for trans autistic people. In Ontario, patients must apply for prior approval of funding for gender-affirming surgery, including at least one assessment from a qualifying health care provider recommending surgery and confirming a diagnosis of Gender Dysphoria (Bourns, 2019). This requirement to apply in advance for funding frames gender-affirming surgery as exceptional, outside the bounds of ordinary medical care. Further, requiring a Gender Dysphoria diagnosis reinforces the medicalization of transness and cements the transnormative narrative. The criteria for surgery funding approval in Ontario are based on the WPATH SOC, though many clinicians also use the local Rainbow Health Ontario guidelines. While both documents are intended to be flexible guidelines rather than strict rules, the epistemic power afforded to clinical guidelines in evidence-based medicine grants them outsized power. Indeed, their epistemic authority is so strong that the guidelines can be invoked to justify decisions that are not supported by the guidelines, such as Jay’s experience of being denied sublingual estrogen, as described previously. Further, at the time of writing three years after the publication of SOC-8, Ontario continues to use the outdated SOC-7 to determine surgery eligibility, which requires two assessments for genital surgery. The rhetorical power of the WPATH SOC is such that claiming to follow them grants legitimacy and authority regardless of whether the practices are aligned with the SOC-8. Under the evidence-based medicine paradigm, clinical guidelines consolidate epistemic power and can be used to bolster the authority of healthcare providers.

These discourses, ideologies, and clinical guidelines result in trans autistic people and their healthcare providers arriving at appointments with unequal epistemic power. Providers benefit from the authority afforded by their professional expertise and use of clinical guidelines, while trans autistic people suffer reduced credibility if they fail to conform to transnormativity and neuronormativity. This power imbalance is mitigated when providers listen to and value their clients’ experiences, knowledge, and perspectives in decision-making, leading to epistemic justice and collaborative, patient-centered care. Alternatively, providers may rigidly enforce rules, doubt an individual’s lived experience, or otherwise reinforce their own epistemic power and medical authority, resulting in epistemic injustice for their trans autistic client. Figure 1 illustrates how discourses and ideologies impact patient-provider interactions both directly by informing perceptions of credibility, and indirectly through their influence on clinical guidelines. While neuronormativity and transnormativity are a prominent influence on trans autistic experiences of gender-affirming care, broader discourses of medical authority and evidence-based medicine and ideologies such as racism, misogyny, ableism, and classism also shape patient experiences. Clinical guidelines in turn are both shaped by transnormativity and neuronormativity and reinforce and codify these discourses. Trans autistic people and their healthcare providers then negotiate interactions in ways that can lead to either epistemic justice or injustice.

This study’s findings align with previous research documenting that trans autistic people anticipate and experience numerous barriers to accessing GAC (Adams et al., 2025; Bruce et al., 2023; Rios, 2025). Further, my findings suggest that trans autistic people work hard to shield themselves from discrimination and harm in medical settings by concealing and masking their autism, doing their own research, and engaging in self-advocacy. Despite this, participants frequently experienced invalidation, dismissal, denial, and other forms of epistemic injustice from healthcare providers. While previous research has identified mandatory mental health assessments as particularly problematic for neurodivergent and disabled trans people (MacKinnon et al., 2020), participants in this study experienced epistemic injustice across a range of clinical settings. This suggests that reforming or abolishing formal readiness assessments may be insufficient to create epistemic justice for trans autistic people if providers continue to devalue trans autistic people’s knowledge and autonomy.

These findings also contribute to a growing body of literature on autistic people’s experiences of health care. As previously described, Shaw et al. (2024) use the triple empathy problem to conceptualize how misunderstandings between autistic patients and their typically allistic clinicians lead to epistemic injustice for autistic patients. Consistent with this theory, I found that mutual misunderstanding of autistic and allistic communication styles contributes to epistemic injustice, and the specialized language and logics of medicine create additional barriers to effective communication between providers and trans autistic patients. However, I diverge from the triple empathy problem in that I emphasize the asymmetrical power relations between trans autistic people and their healthcare providers. Many of my participants were highly educated and knowledgeable about GAC, yet still experienced invalidation, dismissal, and epistemic injustice in healthcare settings. I argue that even when patients possess more relevant knowledge than their provider, the epistemic power afforded to providers by their professional status grants greater authority to the provider’s knowledge. Further, I move beyond the triple empathy problem’s micro-level focus on interpersonal communication by highlighting the role of larger discourses, ideologies, and power structures in creating epistemic injustice for autistic people in healthcare settings.

My research suggests that offering adaptations and accommodations or educating healthcare providers about autism without challenging neuronormativity and epistemic power imbalances will be insufficient to improve health care for trans autistic people. Chapman and Carel (2022) have called for non-autistic healthcare providers to practice neurotypical epistemic humility—recognizing the inherent limitations and biases of oneself as a neurotypical person and seeking to learn from autistic people. Buchman et al. (2017) have similarly called for clinicians to practice epistemic humility to prevent the epistemic injustice frequently experienced by patients with chronic pain. My findings suggest that providers demonstrating epistemic humility is key to collaborative patient-centered care for trans autistic people. While structural changes are necessary to create an epistemically just healthcare system, gender-affirming care providers can still take action to improve trans autistic people’s experiences of care. Table 1 summarizes the epistemic injustices experienced by interview participants, their underlying causes according to the proposed theoretical model, and pragmatic recommendations for gender-affirming healthcare providers.

Table 1.

•••.

Epistemic injustice experienced by trans autistic people in gender-affirming care	Why it happens	Recommendations for gender-affirming healthcare providers
Being told “you don’t look autistic.”	Stereotypes and misconceptions about autism and lack of knowledge of the wide variety of ways that autism presents.	Offer training for gender-affirming care providers on autism, neurodiversity, and autistic masking. Training should be developed and delivered in partnership with trans autistic people themselves.
Hiding autism from healthcare providers because of a fear of being denied gender-affirming care or other negative impacts on care	Belief that autistic people identify as trans due to social contagion or rigid/obsessive thinking and are not ‘truly’ trans, or that autistic people do not have the capacity to consent to gender-affirming care. Hearing about autistic people who have been denied gender-affirming care because of these ideas may make individuals afraid this will happen to them.	Be transparent with patients about the criteria for accessing gender-affirming care, including the impact of having autism or another diagnosis. Signal a neurodiversity-affirming approach by proactively asking all clients about accommodations and access needs, offering fidget and stim tools, and displaying neurodiversity symbols in healthcare environments.
Rigid application of clinical guidelines to overrule a patient’s request for individualized care	The epistemic power of clinical guidelines allows providers to maintain their medical authority in the face of uncertainty.	When making a decision involving uncertain scientific evidence, weigh the risks and benefits in collaboration with the patient. Consider the risk of lost trust and future healthcare avoidance. Using an ethical framework to guide decision-making, such as principles-based ethics or relational ethics, may be helpful.
Readiness assessments implicitly expect a particular set of answers and identity narrative that excludes some trans autistic people’s experiences	Transnormativity grants legitimacy and credibility to trans people who conform to a binary-based, “born in the wrong body” linear narrative. Transnormativity combines with neuronormativity (the discourse that privileges neurotypical ways of thinking, feeling, and communicating) to produce normative expectations of how trans people experience and articulate gender dysphoria and euphoria.	Implement informed consent models of care that do not include readiness assessments. Emphasize that there are no wrong answers and be transparent about the assessment process, purpose, and criteria. Focus on how gender-affirming medical interventions can best support an individual’s embodiment goals, rather than assessing the legitimacy of their gender identity.
Unfairly discrediting patient’s knowledge	Highly knowledgeable patients threaten provider’s epistemic authority.	Practice epistemic humility by recognizing the limits of one’s clinical expertise. Ask patients what they already know about the gender-affirming care they are seeking and tailor information provided accordingly.
Negative misinterpretations of autistic direct or blunt communication styles	When interpreted through a neuronormative lens, autistic communication may be perceived as arrogant or aggressive and a threat to the provider’s epistemic authority.	Offer training for gender-affirming care providers on autistic communication styles from a neurodiversity-affirming approach.

Conclusion

This research provides empirical evidence of how the pathologization of transness and autism leads to epistemic injustice in gender-affirming care for trans autistic people. The findings contribute to broader scholarship on epistemic injustice by illustrating how normative discourses and clinical guidelines can lead to epistemic injustice for marginalized patients. Additionally, I have illustrated what epistemic justice in healthcare can look like for trans autistic patients. The findings suggest that cultivating transparent, respectful, and collaborative relationships that recognize the unique knowledge and expertise of both patients and their providers is the foundation for epistemic justice. Successful strategies for epistemic justice must operate at multiple levels, from individual patient-provider encounters to systemic changes to healthcare systems. Research should evaluate how various strategies aimed at promoting epistemic justice in healthcare (Côté, 2024) apply to the unique context of GAC.

Despite the important findings and implications, this research is not without limitations. All participants communicated verbally, and most were highly educated and described themselves as high-functioning or having low support needs. Future research should explore the experiences of autistic people with higher support needs. Additionally, no participants had completed genital surgery, though one was on the waiting list. As accessing genital surgery in Ontario requires two readiness assessments rather than the single one required for chest surgery, autistic people may experience even greater gatekeeping and epistemic injustice when pursuing genital surgery. Finally, this research was specific to Ontario, and future research should explore trans autistic experiences in other places.

Overall, I have demonstrated how transnormativity, neuronormativity, the medicalization of transness and autism, and the epistemic authority granted to healthcare providers create the conditions for epistemic injustice for trans autistic people seeking GAC. Providers and patients can resist these conditions, but true epistemic justice for trans autistic people in GAC requires changes to clinical guidelines and protocols and challenging transnormativity, pathologization, and ableism in society broadly. While this research focused on the impact of transnormativity and neuronormativity on autistic people, neuronormativity also compels non-autistic trans people to conform to neurotypical norms of thinking, feeling, and communicating to access medical care essential for their bodily autonomy and wellbeing. Given the large percentage of trans people who identify as neurodivergent or live with a mental health condition, most trans people are included in Nick Walker’s definition of neurodivergent as “having a mind that functions in ways which diverge significantly from the dominant societal standards of ‘normal’” (2021, p. 27). As such, embedding neuronormativity in transnormativity harms many—if not all—trans people.

Cameron Awkward-Rich argues that trans people must refuse to “consent to medicolegal norms of emotion and cognition as the basis for securing dignity and epistemic authority” (2022, p. 34). Put another way, we must refuse neuronormativity as a prerequisite for access to medical care, bodily autonomy, and self-determination. Any strategy for preserving access to gender-affirming care that requires trans people to experience a straightforward linear trajectory from dysphoria and distress to euphoria and happiness will always perpetuate neuronormativity and ableism. As trans activists and scholars, we must be brave enough to forge new strategies for trans liberation that do not require the performance of neuronormative affects. Such strategies must involve solidarity with neurodiversity and disability justice movements and be grounded in the fundamental human right to bodily autonomy and self-determination. Trans autistic people are leading the way in this movement.

Funding Statement

This article draws on research supported by a Social Sciences and Humanities Research Council Canada Graduate Scholarship—Master’s, an Ontario Graduate Scholarship, and an Autism Scholars Award from the Council of Ontario Universities. Kai Jacobsen is supported in part by a Vanier Canada Graduate Scholarship from the Canadian Institutes of Health Research.

Disclosure statement

The author has no conflict of interest to declare.

Ethics statement

This study was reviewed and approved by the Carleton University Research Ethics Board-A (Project # 119889). All interview participants provided informed consent.