Gender and Autism Program: A novel clinical service model for gender-diverse/transgender autistic youth and young adults

Abstract

Objective: Situated in Children’s National Hospital (CNH)’s Neuropsychology Division, the Gender and Autism Program (GAP) is the first clinical service dedicated to the needs of autistic gender-diverse/transgender youth. This study describes GAP clinical assessment profiles and presents a multi-perspective programmatic review of GAP evaluation services. Method: Seventy-five consecutive gender- and neuropsychologically-informed GAP evaluations were analyzed, including demographics, gender and autism characterization, and primary domains evaluated. Three program-based Delphi studies were conducted and identify: clinician priorities and challenges in providing care, program administrator lessons learned and ongoing barriers, and considerations adapting this model for a rural academic medical center. Results: Nearly two-thirds of referrals were transfeminine. Most youth had existing autism diagnoses; of those undiagnosed, three-quarters were found to be autistic. Five goals of evaluations were identified: Mental health was always assessed, and most evaluations also assessed gender-related needs in the context of autism neurodiversity. Neuropsychological characterization of strengths and challenges informed personalized accommodations to support youth gender-related self-advocacy. Clinicians emphasized frequent youth safety concerns. Administrators emphasized the need for specialized training for working with families. Components for adaptation of the GAP in a rural academic medical center were identified. Conclusions: Since its founding, the GAP has proven a sustainable neuropsychology-based service with consistent referral flow and insurance authorizations. Capturing staff perspectives through rigorous Delphi methods, and addressing the GAP’s feasibility and replicability, this study provides a road map for replicating this service. We also highlight GAP training of specialist clinicians, fundamental to addressing the desperate shortage of providers in this field.

Keywords:

• Transgender
• autistic
• autism spectrum disorder
• neuropsychology
• gender-affirming care

Acknowledgments

We would like to thank the families who participated in this research.

Disclosure statement

John F. Strang, PsyD, was a co-author of the Child and Adolescent chapters of the Standards of Care 8 revision through the World Professional Association for Transgender Health (WPATH). John F. Strang, PsyD and Anna I. R. van der Miesen, MD PhD, are both faculty members with the WPATH Global Education Institute, and co-leads of the specialized WPATH training program for care for individuals at the intersection of autism, broader neurodivergence, and gender diversity. The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. References to non-Federal entities or products do not constitute or imply a Department of Defense or Uniformed Services University of the Health Sciences endorsement. The authors report there are no further competing interests to declare.

Author contributions

John F. Strang: Conceptualization, data curation, formal analysis, funding acquisition, investigation, Methodology, project administration, supervision, writing – original draft, writing – review & editing. Abigail L. Fischbach: data curation, formal analysis, project administration, supervision, visualization, writing – original draft, writing – review & editing. Sharanya Rao: formal analysis, writing – original draft, writing – review & editing. Ann Clawson: conceptualization, data curation, methodology, writing – review & editing. Megan Knauss: conceptualization, methodology, writing - original draft, writing – review & editing. Sarah N. Bernstein: conceptualization, data curation, formal analysis, writing – original draft, writing – review & editing. Anna I. R. van der Miesen: formal analysis, writing – original draft, writing – review & editing. Anne P. Inge: conceptualization, writing – review & editing. Kenia Alonzo: conceptualization, writing – review & editing. Julia Zeroth: conceptualization, writing – review & editing. Lauren Kenworthy: conceptualization, supervision, writing – review & editing. Colleen I. Morgan: conceptualization, writing – review & editing. Abigail Brandt: conceptualization, writing – review & editing. Christina C. Moore: conceptualization, project administration, writing – review & editing. Kaitlyn Ahlers: conceptualization, project administration, writing – review & editing. Mary K. Jankowski: conceptualization, project administration, writing – review & editing. Lucy S. McClellan: data curation, visualization, writing – review & editing. Shane B. Henise: conceptualization, data curation, methodology, writing – review & editing. Caitlyn J. Cap: conceptualization, writing - review & editing. Shannon L. Exley: conceptualization, writing – review & editing. Amy Youmatz: conceptualization, data curation, supervision, writing – review & editing. Minneh Song: writing - original draft, writing – review & editing. Jennifer L. McLaren: conceptualization, project administration, writing – review & editing. Benjamin Parchem: Conceptualization, data curation, formal analysis, methodology, project administration, writing – original draft, writing – review & editing.

Additional information

Funding

This work was supported by the Clinical and Translational Science Institute, Children’s National Hospital (UL1TR001876) and a National Institutes of Health Clinical and Translational Science Award (KL2TR001877).