John F Strang1,2,3,4, Laura G Anthony5,6, Amber Song1,2,3, Meng-Chuan Lai7,8,9,10,11, Megan Knauss2,12, Eleonora Sadikova13, Elizabeth Graham14, Zosia Zaks15, Harriette Wimms16, Laura Willing1,4, David Call1,4, Michael Mancilla17, Sara Shakin18, Eric Vilain19,20,21, Da-Young Kim2, Tekla Maisashvili2, Ayesha Khawaja2, Lauren Kenworthy2,3,4. 1. Gender Development Program, Children's National Hospital. 2. Center for Autism Spectrum Disorders, Division of Neuropsychology, Children's National Hospital. 3. Center for Neuroscience, Children's National Research Institute, Children's National Hospital. 4. Departments of Pediatrics, Psychiatry, and Behavioral Sciences, George Washington University School of Medicine. 5. Department of Psychiatry, University of Colorado School of Medicine. 6. Pediatric Mental Health Institute, Children's Hospital of Colorado. 7. The Margaret and Wallace McCain Centre for Child, Youth & Family Mental Health, Azrieli Adult Neurodevelopmental Centre, and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health. 8. Department of Psychiatry, The Hospital for Sick Children. 9. Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto. 10. Autism Research Centre, Department of Psychiatry, University of Cambridge. 11. Department of Psychiatry, National Taiwan University Hospital and College of Medicine. 12. Alliance of Community Health Plans. 13. Curry School of Education, University of Virginia. 14. The Arc of the United States National Council of Self-Advocates. 15. Hussman Center for Adults with Autism, Towson University. 16. Youth Gender Care Services, The Village Family Support Center of Baltimore. 17. Youth Pride Clinic, Adolescent and Young Adult Medicine, Children's National Hospital. 18. Department of Pediatrics, Sinai Hospital of Baltimore. 19. Center for Genetic Medicine Research, Children's National Hospital. 20. Department of Genomics and Precision Medicine, George Washington University. 21. Epigenetics, Data, & Politics at Centre National de la Recherche Scientifique.
Abstract
Objective: Autism spectrum disorder (ASD) is significantly over-represented among transgender adolescents. Independently, ASD and gender diversity are associated with increased mental health risks. Yet, mental health in autistic-transgender adolescents is poorly understood. This study investigates mental health in the largest matched sample to date of autistic-transgender, non-autistic (allistic) transgender, and autistic-cisgender adolescents diagnosed using gold-standard ASD diagnostic procedures. In accordance with advancing understanding of sex/gender-related autism phenotypes, slightly subthreshold autistic diagnostic presentations (common in autistic girls/women) are modeled.Method: This study includes 93 adolescents aged 13-21, evenly divided between autistic-transgender, autistic-cisgender, and allistic-transgender groups; 13 transgender adolescents were at the margin of ASD diagnosis and included within a larger "broad-ASD" grouping. Psychological and neuropsychological evaluation included assessment of mental health, IQ, LGBT stigma, ASD-related social symptoms, executive functioning (EF), and EF-related barriers to achieving gender-related needs. Results: Autistic-transgender adolescents experienced significantly greater internalizing symptoms compared to allistic-transgender and autistic-cisgender groups. In addition to stigma-related associations with mental health, ASD-related cognitive/neurodevelopmental factors (i.e., poorer EF and greater social symptoms) were associated with worse mental health: specifically, social symptoms and EF gender barriers with greater internalizing and EF problems and EF gender barriers with greater suicidality. Comparing across all ASD and gender-related groups, female gender identity was associated with greater suicidality.Conclusions: Parsing the heterogeneity of mental health risks among transgender youth is critical for developing targeted assessments and interventions. This study identifies ASD diagnosis, ASD phenotypic characteristics, and EF-related gender barriers as potential risks for poorer mental health in transgender adolescents.
Objective: Autism spectrum disorder (ASD) is significantly over-represented among transgender adolescents. Independently, ASD and gender diversity are associated with increased mental health risks. Yet, mental health in autistic-transgender adolescents is poorly understood. This study investigates mental health in the largest matched sample to date of autistic-transgender, non-autistic (allistic) transgender, and autistic-cisgender adolescents diagnosed using gold-standard ASD diagnostic procedures. In accordance with advancing understanding of sex/gender-related autism phenotypes, slightly subthreshold autistic diagnostic presentations (common in autistic girls/women) are modeled.Method: This study includes 93 adolescents aged 13-21, evenly divided between autistic-transgender, autistic-cisgender, and allistic-transgender groups; 13 transgender adolescents were at the margin of ASD diagnosis and included within a larger "broad-ASD" grouping. Psychological and neuropsychological evaluation included assessment of mental health, IQ, LGBT stigma, ASD-related social symptoms, executive functioning (EF), and EF-related barriers to achieving gender-related needs. Results: Autistic-transgender adolescents experienced significantly greater internalizing symptoms compared to allistic-transgender and autistic-cisgender groups. In addition to stigma-related associations with mental health, ASD-related cognitive/neurodevelopmental factors (i.e., poorer EF and greater social symptoms) were associated with worse mental health: specifically, social symptoms and EF gender barriers with greater internalizing and EF problems and EF gender barriers with greater suicidality. Comparing across all ASD and gender-related groups, female gender identity was associated with greater suicidality.Conclusions: Parsing the heterogeneity of mental health risks among transgender youth is critical for developing targeted assessments and interventions. This study identifies ASD diagnosis, ASD phenotypic characteristics, and EF-related gender barriers as potential risks for poorer mental health in transgender adolescents.