In Addition to Stigma: Cognitive and Autism-Related Predictors of Mental Health in Transgender Adolescents

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.

Disclosure Statement

No potential conflicts of interest were reported by the authors.

Supplementary Material

Supplemental material for this article can be accessed online at https://doi.org/10.1080/15374416.2021.1916940

Additional information

Funding

This work was supported by the CTSI-CN [UL1TR001876]; the NIH CTSA [KL2TR001877]; the Fahs-Beck Foundation; an Academic Scholars Award from the Department of Psychiatry, University of Toronto; the Canadian Institutes of Health Research (CIHR) Sex and Gender Science Chair [GSB 171373]; and the CAMH Foundation.