Supporting the health and wellbeing of trans autistic school-aged youth: a systematic literature review

Figures & data

Figure 1. PRISMA flow diagram of review search for research question.

Table 1. Search strategy.

Database	Search terms
EBSCOHost Megafile Ultimate	(neurodiverg* OR autist* OR Asperger*) AND (child* OR teenager* OR adolescen* OR youth OR “young people”) AND (transgender)
PubMed	(neurodiverg* OR autist* OR Asperger*) AND (child* OR teenager* OR adolescen* OR youth OR “young people”) AND (transgender)
University of Southern Queensland library database	(neurodiverg* OR autist* OR Asperger*) AND (child* OR teenager* OR adolescen* OR youth OR “young people”) AND (transgender)

Table 2. Characteristics of reviewed studies.

Reference	Country	Design and Quality	Sample	Key findings
Cooper, K., Butler, C., Russell, A., & Mandy, W. (2023). The lived experience of gender dysphoria in autistic young people: a phenomenological study with young people and their parents. European Child & Adolescent Psychiatry, 32(9), 1655-1666. https://doi.org/10.1007/s00787-022-01979-8	UK	Qualitative – multi-perspectival interpretative phenomenological (IPA) analysis design, in-depth interviews 10/10	15 autistic people aged 13–17 years and their parents	Parental support is important to psychological well-being of gender diverse young people -protective factor. Preference is for clinical support groups for both autistic and gender needs, particularly fostering social connections with other gender diverse autistic young people and supporting parents. Young people and their parents described the need for gender and mental healthcare to be adapted to meet their needs as autistic and gender diverse young people. Support needed to assist difficulties communicating and connecting with gender clinicians - self-described clashes of communication styles were common. Post-diagnostic support groups are needed to help young people make sense of their autism diagnoses. Consideration needed for the practicalities and physical environments of clinics - adaptions needed such for sensory support such as having a quiet waiting area, and considering lighting, noise and temperature as well as having a consistent clinician and local clinic.
Cooper, K., Mandy, W., Russell, A., & Butler, C. (2023). Healthcare clinician perspectives on the intersection of autism and gender dysphoria. Autism, 27(1), 31-42. https://doi.org/10.1177/13623613221080315	UK	Qualitative – Interpretative Phenomenological Analysis (IPA) 10/10	16 clinicians from range of professional backgrounds and clinical settings − 8 work with adults, and 8 work with adolescents	Clinicians should: Change communication style by not expecting immediate answers (give take up time). Increase use of written and visual resources including videos, charts, pros and cons lists, tables, diagrams, and gender maps to explore gender in more detail. Adapt the clinical setting - consider short initial introduction session, structural changes to length, frequency, number of sessions, ordering the agenda of sessions to not overwhelm patients. Consider the sensory aspects of the physical environment including the waiting area and toilets. Receive training on autism adaptations and the intersection of autism and gender dysphoria. Focus on understanding what is causing the patient distress on an individual basis and support those needs.
Corbett, B. A., Muscatello, R. A., Klemencic, M. E., West, M., Kim, A., & Strang, J. F. (2023). Greater gender diversity among autistic children by self-report and parent-report. Autism, 27(1), 158–172. https://doi.org/10.1177/13623613221085337	USA	Cross-sectional 8/8	140 autistic and 104 non-autistic children aged 10-13 years	Interventions should include: Many autistic trans youth experience anxiety and depression, rate exceeds general population. Therapy to identify the impact of daily experiences on health and wellbeing, attempting to improve understanding of sources for and risk factors of emotional distress. Social communication and self-advocacy skills - neurodiversity may complicate or magnify challenges with gender discernment and advocacy. Training in psychosexual education that includes information about gender expression and gender identity diversity. Tackling Teenage Training is a commercial program specifically designed for autistic adolescents.
de Vries, A. L., Noens, I. L., Cohen-Kettenis, P. T., van Berckelaer-Onnes, I. A., & Doreleijers, T. A. (2010). Autism Spectrum Disorders in Gender Dysphoric Children and Adolescents. Journal of Autism Developmental Disorders, 40, 930–936. https://doi.org/10.1007/s10803-010-0935-9	The Netherlands	Cross-sectional 7/8	204 children and adolescents	An individual approach is most effective, particularly when support services consider the rigid and concrete thinking around gender roles and difficulty developing aspects of personal identity. It is important to address the broader traits that are similar to the characteristics of autism when supporting gender dysphoric children and adolescents as a full autism diagnosis will not always be applicable.
Greenspan, S. B., Carr, S., Woodman, A. C., Cannava, A., & Li, Y. (2023). Identified protective factors to support psychological well-being among gender diverse autistic youth. Journal of LGBT Youth, 20(2), 407-440. https://doi.org/10.1080/19361653.2022.2119188 ^*	USA	Cross-sectional 8/8	31 children 13-17 years	LGBTQ Inclusive programs, policies and interventions in schools including access to safe and supportive spaces. EF support including, breaking down abstractions, avoid ‘dense’ questions, avoid idiomatic language, use social narratives, structured self-management strategies. Connectedness with friends, family, and the community - this correlated with well-being and life satisfaction. Free or low-cost services that provides gender affirming healthcare, including medical care, is crucial whenever possible. Targeted interventions to enhance social skills and peer relationships, social cognition, and social communication may support autistic youth in schools.
Hilton, M. N., Boulton, K. A., Kozlowska, K., & McClure, G. (2022). The co-occurrence of neurodevelopmental disorders in gender dysphoria: Characteristics within a pediatric treatment-seeking cohort and factors that predict distress pertaining to gender. Journal of Psychiatric Research, 149, 281-286. https://doi.org/10.1016/j.jpsychires.2022.02.018	Australia	Cross-sectional 8/8	64 children (mean age 12.91 years)	Higher rates of psychological distress – mental health support needed Contextual factors may contribute to distress in individuals experiencing gender dysmorphia: stigma, discrimination, socioeconomic status, peer relationships, family stress, adverse childhood experiences, and insecure attachment. Individual stressors should be sought so support can be applied. Findings highlight both the need to consider the contextual factors and the awareness of increased rate of co-occurring neurodevelopmental disorders to shape the assessment and treatment planning of individuals experiencing gender dysphoria.
Jacobs, L. A., Rachlin, K., Erickson-Schroth, L., & Janssen, A. (2014). Gender dysphoria and co-occurring autism spectrum disorders: Review, case examples, and treatment considerations. LGBT Health, 2(00), 1-6. https://doi.org/10.1089/lgbt.2013.0045	USA	Case Report 8/8	2 cases – one autistic trans youth and one autistic trans adult	Individuals may have intolerance of ambiguity, cognitive rigidity, difficulty articulating gender, persistent deficits in social communication and interaction - in client-centred treatment, clinicians need to be flexible and adapt techniques/strategies to work within the clients’ framework and conversation styles to help them navigate the real world and guide the limited understandings they may have. The clinician should meet the client where they are at and guide them through treatment at their own pace – individuals must understand options and have support to integrate changes into their sense of self. Individuals may have decreased understanding of Theory of Mind – conversation styles should be matched in clinical settings but discussions about social awareness and thoughts and feelings of others should occur.
Janssen, A., Huang, H., & Duncan, C. (2016). Gender Variance Among Youth with Autism Spectrum Disorders: A Retrospective Chart Review. Transgender Health, 1(1), 63-68. https://doi.org/10.1089/trgh.2015.0007	USA	Cross-sectional – retrospective chart review 7/8	492 children	Personalised treatment plans that consider the social, cognitive, and developmental pathways ensure that individuals with ASD are able to maintain their autonomy and have equal access to gender-related care. Screening for Autism should be a consideration given the increased prevalence of GV and ASD cooccurring, but practitioners need to be careful not to infer a direct relationship with their patient.
Kahraman, K. B., Topcu, Z., Yavuz, D., Direnc, E., & Erdogdu, A. B. (2021). Autistic traits, emotional recognition and empathy in adolescents with gender dysphoria. Dusunen Adam The Journal of Psychiatry and Neurological Sciences, 34, 329-336. https://doi.org/10.14744/DAJPNS.2021.00155	Türkiye	Cross-sectional 8/8	36 adolescents: 17 case group, 17 control	Establishing preventative programs, policies and supportive systems in schools and the media concerning bullying and stigmatization. Counseling in multidisciplinary centers: psychological guidance units in schools, counseling centers, social-workers and psychiatry clinics can prevent difficulties in social interaction and improve quality of life. Family therapy and individual psychotherapy should occur in conjunction.
Kuvalanka, K. A., Mahan, D. J., McGuire, J. K., & Hoffman, T. K. (2018). Perspectives of Mothers of Transgender and Gender-Nonconforming Children with Autism Spectrum Disorder. Journal of Homosexuality, 65(9), 1167-1189. https://doi.org/10.1080/00918369.2017.1406221	USA	Qualitative – Open-ended interviews 8/10	3 Mothers of trans and autistic children	Parents may need education about the co-occurrence of autism and GD and the ways in which ASD may influence youth’s expression of gender nonconformity. Supportive parents of TGNC youth may advocate for schools and communities to increase awareness and inclusion, enhance support systems and implement appropriate accommodations to meet the needs of GD and ASD children and their families. Medication can help calm some of social anxiety and ASD behaviors. Clinicians, teachers, and others working with TGNC/ASD youth could assist these children in gaining awareness of social situations and cues that could escalate situations, as well as role-play responses and actions that can help facilitate positive social interactions. Clinicians and other professionals can help parents to accept their child’s developmental processes, while critically evaluating their own feelings about their child’s gender identity and expression. Online TGNC-related resources may provide opportunities for social communication without the challenges that face-to-face interactions may produce.
Lehmann, K., Rosato, M., McKenna, H., & Leavey, G. (2020). Autism trait prevalence in treatment seeking adolescents and adults attending specialist gender services. European Psychiatry, 63(1), 1–8. https://doi.org/10.1192/j.eurpsy.2020.23	Northern Ireland	Cross-sectional 6/8	123 individuals (38 adolescents and 69 adults) currently attending or who previously attended specialist gender services	Individuals need additional social skills training to develop empathy. Gender clinicians need the skills to recognize and screen for autism traits. Future pathway aspirations - individuals should be able to access autism specific services alongside their gender affirming treatments, including gender affirming medical care.
Mahfouda, S., Panos, C., Whitehouse, A. J., Thomas, C. S., Mayber, M., Strauss, P., Zepf, F. D., O’Donovan, A., van Hall, H-W., Saunders, L. A., Moore, J. K., & Lin, A. (2019). Mental Health Correlates of Autism Spectrum Disorder in Gender Diverse Young People: Evidence from a Specialized Child and Adolescent Gender Clinic in Australia. Journal of Clinical Medical, 8, 1503-1517. https://doi.org/10.3390/jcm8101503	Australia	Cross-sectional - Retrospective chart review 8/8	104 youth (mean age 14.62 years)	Services working with gender diverse young people should screen for ASD, and also provide pathways to appropriate care for the commonly associated mental health difficulties especially internalizing disorders. If hormone treatment is commenced, it should be introduced gradually – often hypersensitivity to sensory inputs and changes in routine are challenging. Awareness of other co-occurring difficulties and/or disorders that may be present in this subgroup are also critical considerations that can help inform clinical decision-making and improve quality of life outcomes. It is crucial that there is sufficient education amongst health providers working with GD young people, particularly related to current guidelines and psychological support with co-occurring ASD and their families (lower rates of parental support commonly seen). Support is needed for difficulties with communication, cognitive flexibility, organization, and future planning.
Russell, I., Pearson, B., & Masic, U. (2021). A Longitudinal Study of Features Associated with Autism Spectrum in Clinic Referred, Gender Diverse Adolescents Accessing Puberty Suppression Treatment. Journal of Autism and Developmental Disorders, 51, 2068–2076. https://doi.org/10.1007/s10803-020-04698-8	UK	Cross sectional/longitudinal 6/8	122 youth (mean age 13.6 years)	Ongoing psychosocial support is needed for adolescents accessing specialist gender services – most participants scored highly on restrictive and repetitive behavior and interests subtests. Increasing the likeness to identified gender may lead to improved wellbeing and relationships – gonadotropin-releasing hormone analogues (GnRHa) should be considered in early puberty. Features associated with autism spectrum need to be screened early in the referral process so needs can be supported. Additional investigations that are accessed promptly may improve an individual’s ability to communicate and think about their gender needs.
Shumer, D. E., Reisner, S. L., Edwards-Leeper, L., & Tishelman, A. (2016). Evaluation of Asperger Syndrome in Youth Presenting to a Gender Dysphoria Clinic. LGBT Health, 3(5), 387-390. https://doi.org/10.1089/lgbt.2015.0070	USA	Cross-sectional study - retrospective chart review 6/8	39 patients 8-20 years	Anxiety, depression, suicidality seen at an increased rate in gender clinics – psychological monitoring needed ASD screening should be included as part of comprehensive gender assessments. A patient with ASD and GD may require specialized interventions that focus on the unique social challenges during hormonal and social transition to their affirmed gender. To reduce any risk of misclassifying GD with ASD patients, thorough attention to the range of symptoms during ASD diagnostic evaluation in youth presenting for gender dysphoria is needed.
Strang, J. F., Powers, M. D., Knauss, M., Sibarium, E., Leibowitz, S., Kenworthy, L., Sadikova, E., Wyss, S., Willing, L., Caplan, R., Pervez, N., Nowak, J., Gohari, D., Gomez-lobo, V., Call, D., & Anthony, L. G. (2018). “They Thought It Was an Obsession”: Trajectories and Perspectives of Autistic Transgender and Gender-Diverse Adolescents. Journal of Autism and Developmental Disorders, 48, 4039–4055. https://doi.org/10.1007/s10803-018-3723-6	USA	Qualitative – Semi-structured Interview 10/10	22 autistic TGD adolescents, 14 TGD women, 6 TGD men	Nearly all participants stressed the importance of living as their affirmed gender and having the required medical support – many linking affirming gender to an improvement in mental health. Schools need to be a gender-accepting setting, a safe space to affirm gender publicly. Inclusion and bullying policies must be considered. Majority reported worry about bias and harassment which made exploring and expressing gender uncomfortable. Some felt affirmed gender was questioned because of their autism – ‘not heard’ by clinicians. Many separated autism-related characteristics and felt they were more difficult to navigate than gender. Due to communication and executive functioning challenges many need support with self-advocacy and navigating the complexities of gender affirmation. Therapeutic techniques should be combined to incorporate gender and ASD support including executive function, self- and social-awareness.
Strang, J. F., Knauss, M., van der Miesen, A., McGuire, J. K., Kenworthy, L., Caplan, R.,. .. Anthony, L. G. (2021). A Clinical Program for Transgender and Gender-Diverse Neurodiverse/Autistic Adolescents Developed through Community-Based Participatory Design. Journal of Clinical Child & Adolescent Psychology, 50(6), 730-745. https://doi.org/10.1080/15374416.2020.1731817	USA	Qualitative - multi-stage community-based participatory procedure 10/10	20 ND/GD youth, 33 parents 29 youth, 44 parents	Interventions and development of social, executive and flexible thinking skills are among the most important targets related to neurodiverse individuals. Connecting with other autistic/neurodiverse-gender-diverse youth, gender-diverse role models and the use of concrete language can reduce the ambiguity of abstract gender-related concepts (access to online connections and support for rural families also needs to be available). Providing a safe space for autistic/neurodiverse-gender-diverse youth to flexibly explore a range of gender paths and other gender-related supports and teaching are important. Emphasized the importance of also providing support to parents to support their psychoeducational and emotional needs. It is important that a range of learning. experiences to support autistic/neurodiverse-gender-diverse adolescents, modeling flexibility and openness to explore gender no matter where their gender journey ultimately leads.
Strang, J. F., Chen, D., Nelson, E., Leibowitz, S. F., Nahata, L., Anthony, L. G., Song, A., Grannis, C., Graham, E., Henise, S., Vilain, E., Sadikova, E., Freeman, A., Pugliese, C., Khawaja, A., Maisashvili, T., Mancilla, M., & Kenworthy, L. (2022). Transgender Youth Executive Functioning: Relationships with Anxiety Symptoms, Autism Spectrum Disorder, and Gender-Affirming Medical Treatment Status. Child psychiatry and human development, 53(6), 1252-1265. https://doi.org/10.1007/s10578-021-01195-6	USA	Cross-sectional 8/8	124 TGD aged 11-21 years old	Individuals with autism and GD may have EF dysregulation, improving EF may improve overall wellbeing. EF support should include: Skill monitoring, individualized supports may support mental health by reducing the EF load, allowing individuals to focus on other areas. Interventions that reduce internalizing of thoughts. Additional structures, routines, reminders, organizational supports, planning tools, structured step by-step explanations including how to navigate gender care systems, and supports for self-regulation. School-based gender-affirming supports needed include use of correct name and pronouns, gender-affirmed inclusion in extracurriculars/sports, EF accommodations and supports for learning when needed. Family-based EF supports can be helpful given the additional demands related to supporting gender-diverse child such as coordinating gender affirming medical care, navigating gender diversity within the family, support around gender minority stressors.
Strang, J. F., Anthony, L. G., Song, A., Lai, M-C., Knauss, M., Sadikova, E., Graham, E., Zaks, Z., Wimms, H., Willing, L., Call. D., Mancilla. M., Shakin, S., Vilain, E., Kim, D-Y., Maisashvili, T., Khawaja, A., & Kenworthy, L., (2023). In Addition to Stigma: Cognitive and Autism-Related Predictors of Mental Health in Transgender Adolescents. Journal of clinical child and adolescent psychology, 2, 212-229. https://doi.org/10.1080/15374416.2021.1916940	USA	Cross-sectional 8/8	93 adolescents aged 13–21, evenly divided between autistic-transgender, autistic-cisgender, and allistic-transgender groups	39% of TGD/ASD youth reported self-harming behaviors. TGD/ASD women (AMAB) greatest reported suicidality – monitoring Connecting with gender-related mentors and other adult role models could reduce the EF load of social interactions in health-care settings. The use of concrete approaches and resource can help transgender neurodiverse youth process and organize clinical information and reduce the experience of EF-related barriers to advancing one’s gender needs and goals. Pre-rehearsed scripts for interacting with gender-care providers, and an online health portal summarizing session visits could decrease EF load and improve wellbeing.
van der Miesen, A. I., Hurley, H., Bal, A. M., & de Vries, A. L. (2018). Prevalence of the Wish to be of the Opposite Gender in Adolescents and Adults with Autism Spectrum Disorder. Archives of Sexual Behavior, 47, 2307-2317. https://doi.org/10.1007/s10508-018-1218-3	The Netherlands	Cross-sectional 8/8	573 adolescents (469 AMAB and 104 AFAB) and 807 adults (616 AMAB and 191 AFAB) with GV	Clinicians working with individuals referred for GD as well as for ASD should pay attention to this possible co-occurrence – directs individual supports including support for common self-destructive behaviors and suicidal risk. Although the wish to be of the opposite gender is not the same as a clinical diagnosis of GD, this is relevant for clinical practice because clinicians working with clients with ASD should be aware of the possible co-occurrence when a wish to be of the opposite gender is expressed or endorsed in self-report measures.
Zupanicˇ, S., Kruljac, I., Šoštaricˇ Zvonar, M., & Drobnicˇ Radobuljac, M. (2021). Case Report: Adolescent With Autism and Gender Dysphoria. Frontiers in Psychology, 12(671448), 1-8. https://doi.org/10.3389/fpsyt.2021.671448	Slovenia	Case report 7/8	One 16.5 AFAB youth with GD	The assessment and treatment of GD should be multidisciplinary, longitudinal, and individualized. MH clinicians should directly assess GD, provide family counseling and supportive psychotherapy to reduce distress expressed by the client, reducing additional distress related to the GD and any other coexisting mental health concerns. Thinking about future pathways for the client should be the main rule to guide decision-making during assessment and treatment procedures. Clinicians should provide individuals with GD and their families with information and referral for peer support. Having supportive parents is a significant protective factor – family therapy may be needed. Assessment protocol should take into account: cognitive skills, communication skills, emotional functioning, social cognition, and capacity for self-advocacy, structured interview to assess the intensity and pervasiveness of GD and an additional report from outside sources (parents). Assessment protocol should be followed by a treatment checklist: putting together the clinical team, providing psychoeducation. Two key clinical questions should be answered before medical transition: (1) Is the GD clear, urgent, pervasive, and persistent over time? (2) Does GD increase or decrease with intervention?

Acronyms and abbreviations used in Table 2 are as follows: AMAB = assigned male at birth; ASD = autism spectrum disorder; EF = executive functioning; GV = gender variance; GD = gender dysphoria; TGD = transgender and gender diverse; TGNC = transgender and gender-nonconforming.