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AUTISTIC GENDER IDENTITY DIFFERENCES 1
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Gender Identity Differences in autistic adults:
Associations with perceptual and socio-cognitive profiles
Reubs J Walsh1*, Lydia Krabbendam1, Jeroen Dewinter2 3, Sander Begeer1
1. Faculty of Behaviour and Movement Sciences, Vrije Universiteit Amsterdam,
Amsterdam, The Netherlands
2. Scientific Centre for Care & Welfare (Tranzo), Tilburg University, Tilburg,
The Netherlands
3. GGzE Centre for Child & Adolescent Psychiatry, Eindhoven, The Netherlands
*corresponding author: r.j.walsh@vu.nl
Abstract
Prior research has shown an elevation in autism traits and diagnoses in individuals
seen for gender related consultation and in participants self-identifying as transgender.
To investigate this relationship between autism and gender identity from a new angle,
we compared the self-reported autism traits and sensory differences between
participants with autism who did or did not identify with their assigned sex (i.e.
cisgender or trans and nonbinary, respectively). We found broad elevation of most
cognitive autism traits in the trans and non-binary group (those who identified with a
gender other than their assigned gender), and lower visual and auditory
hypersensitivity. We contrast these data to existing hypotheses and propose a role for
autistic resistance to social conditioning.
Keywords:
Autism, Gender Identity, Transgender, Gender Dysphoria, Perception, Bayesian
Cognition
Published in Journal of Autism and Developmental Disorders (2018)
DOI: 10.1007/s10803-018-3702-y
AUTISTIC GENDER IDENTITY DIFFERENCES 2
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There is increasing interest in the relationship between transgender identities (gender
identities incongruent with assigned sex which may result in gender dysphoria and/or
require medical gender affirmation), and autism spectrum disorders (referred to
collectively here as autism). So far, investigations have recruited samples of gender
variant and transgender (often abbreviated to ‘trans’) individuals through gender
identity clinics (Pasterski et al, 2014; de Vries et al, 2010; Skagerberg, Di Ceglie &
Carmichael, 2015) or the internet (Kristensen & Broome 2016, Jones et al, 2012).
The earliest studies to find an above-population-average rate of autism
characteristics and diagnoses within people with gender dysphoria focused on those
seeking medical gender affirmation (Pasterski et al, 2014; de Vries et al, 2010;
Skagerberg, Di Ceglie & Carmichael, 2015). Most of these studies’ samples were
rather small and participants were often responding as part of clinical investigations.
These characteristics might reduce the reliability of responses in that population due
to fear of being denied treatment (Adams et al, 2017). There is also the possibility that
these studies have identified specific important trends in those with the most urgent
need for clinical attention related to gender identity. The research on this topic was
extended into a broader trans population by gathering a larger sample using the
internet and community networks to recruit participants (Kristensen & Broome,
2016). Of this sample, 14% had an autism diagnosis versus a population average of
0.62% (Elsabbagh et al, 2012). More recent findings in online samples demonstrated
elevated symptoms of depression, anxiety and stress (George & Stokes, 2018) in
participants with increasing numbers of minority group membership, including those
who are both autistic and transgender, making understanding of this phenomenon all
the more important. The present study adds another perspective by examining the
AUTISTIC GENDER IDENTITY DIFFERENCES 3
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self-reported autistic profiles of transgender, nonbinary and cisgender participants
with an autism diagnosis, in an existing database of autistic adults.
Several authors have proposed that autistic traits may in some way cause, or
create an illusion of, trans identity. For example, de Vries et al (2010) suggested as
one possibility that rigid thinking could cause misinterpretation of gender-atypical
interests, and others have proposed touch-hypersensitivity could lead to clothing
preferences that violate gender norms (Williams, Allard & Sears, 1996; see also Jones
et al, 2012; Jacobs et al, 2014). This interpretation would predict a selective elevation
within the trans and nonbinary subsample of the proposed mediating autistic trait (i.e.
rigid thinking or touch-hypersensitivity respectively). Others have proposed that
individuals with autism are more prone to reject ideas they perceive as flawed or
logically inconsistent (Kristensen & Broome, 2016), such as social conditioning and
social norms (Ansara & Hegarty, 2011), and this facilitates ‘coming out’. This
interpretation, by contrast, would predict an (not necessarily selective) elevation of
autistic traits associated with social learning.
There is also substantial work investigating the biological basis of both gender
identity (especially in trans people) and autism, however there’s very limited research
on the overlap of both, nor overlapping findings in both groups. One example is
congenital adrenal hyperplasia (CAH), a condition in which XX-genotype individuals
produce an excess of androgens from their adrenal gland; this gives rise to an
elevation in both autism traits (Knickmeyer et al, 2006), and masculine gender
expression (as female), but only very slight elevation in non-female identity versus
control XX-genotype individuals without CAH (Berenbaum et al, 2003). However,
research into biological correlates of gender identity (typically focussed on
transgender individuals) offers indications that there may be a biological basis for
AUTISTIC GENDER IDENTITY DIFFERENCES 4
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gender identity that is not inherently dependent upon karyotype, genital anatomy or
gender of rearing (Swaab, 2004).
Neuroanatomical correlates of gender in cisgender participants could be
related to either gender or karyotype, or both, and while most of these findings are
intermediate in transgender people, many are more assigned-sex congruent, for
example brain volume (Hahn et al, 2015) and cortical thickness (Luders et al, 2012;
Zubiaurre-Elorza et al, 2013). However, several others are much more congruent with
gender identity than assigned sex, most notably volume of and neuron number in the
central subdivision of the bed nucleus of the stria terminalis (Zhou et al, 1995;
Kruijver et al, 2000). Ramachandran & McGeogh (2007, 2008) found a correlation
with gender identity in rates of pre- and postsurgical experiences of phantom genitals,
suggesting possible implications for somatosensory cortex functional connectivity.
Direct findings in functional neuroimaging also exist. For example,
hypothalamic responses to androstedianone odour are sex-differentiated, an effect
which emerges later, and congruent with identity in transgender individuals (Burke et
al, 2014). There are also a number of findings that relate resting state functional
connectivity to gender identity with potentially interesting findings (Manzouri,
Kozidou & Savic, 2015; Feusner et al, 2016). However, elevated rates of depression,
and anxiety (see Dhejne, 2016 for review) in this population may distort findings
(Yeng et al, 2015; Rabany et al, 2017), and screening related to gender identity
consultation is unreliable (see above; Adams et al, 2017; Edmiston, 2018). Therefore
this field of work remains inconclusive at present and requires further corroboration.
To relate these physiological findings to the groups of hypotheses we
described above, those that propose that autism can cause gender identity differences,
or an illusion thereof, would predict qualitative differences in this area between
AUTISTIC GENDER IDENTITY DIFFERENCES 5
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typical and autistic trans people, whereas hypotheses that view autism as a facilitator
to ‘coming out’ would predict only quantitative differences.
To attempt to understand the relationship between gender identity
development and autism, we sought to investigate the most likely connections
between the differences in perception and cognition associated with autism, and
experienced and expressed gender identity. For the purposes of this study, we will
refer to AMAB for assigned male at birth and AFAB for assigned female at birth.
Autism is more commonly diagnosed in AMABs, with ratio estimates between
1.33:1 and 15.7:1 (ADDM"CDC,"2012) and consensus estimates resting around 4:1
(AMAB:AFAB) (Werling"&"Geschwind,"2013,"c.f."Looms, Hull & Mandy, 2017).
Therefore, we were interested in gender identities not only in the total sample but also
in the AMAB and AFAB subgroups. Likewise, because of the reduced propensity of
autistic people to engage in reputation management (e.g. by following social
conventions; Cage et al, 2013), and the increasing public awareness and acceptance of
the idea that gender does not follow a binary (man/woman) system, we were
interested in what proportion of people in our sample identified outside of that binary.
The term ‘nonbinary’ refers to individuals whose gender identity is not entirely
male/man nor entirely female/woman. Nonbinary individuals may reject identification
with their assigned sex entirely or to a limited extent, and likewise may partially or
entirely embrace or reject identification with terms usually associated with binary
genders, such as “man” and “woman”. There are few attempts so far to glean a
systematic estimate of the prevalence of nonbinary identity in the general population,
but 3.9% of respondents to a large survey of Dutch adults reported an intermediate,
nonbinary gender identity (Kuyper & Wijsen, 2014).
AUTISTIC GENDER IDENTITY DIFFERENCES 6
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To further probe the hypotheses discussed above, we compared self-reported
autistic traits and sensory sensitivity between the ‘cisgender’ (assigned-females and
assigned-males who identify as women and men, respectively) and ‘trans and non-
binary’ groups. We assessed their traits with the Autism Quotient (AQ-28; Baron-
Cohen et al, 2001; Hoekstra et al, 2011), and the Sensory Perception Quotient (SPQ;
Tavassoli, Hoekstra & Baron-Cohen, 2014). These comparisons were then used to
shed further light on the relationship between autism and gender identity. We
obtained data on rates and correlates of trans and nonbinary gender identity in a pre-
existing sample of autistic people, the Netherlands Autism Register. While the
prevalence findings within these data have been reported elsewhere (Dewinter, De
Graaf & Begeer, 2017), this paper is the first to study the autistic traits of the cis
versus trans autistic individuals, to elucidate possible mechanisms behind the elevated
co-occurrence between trans and autistic groups.
Methods
Participants
The sample was recruited via the Netherlands Autism Register (NAR), which is a
large database of information provided by autistic individuals and their families and
consisted of 669 participants (322 AMABs and 347 AFABs). All participants reported
having received a formal diagnosis of Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) pervasive developmental disorder or DSM-5 autism spectrum
disorder by a qualified clinician unaffiliated to this study. Participants’ mean age was
44.67 years (SD= 12.63, range = 15.92 to 80.14). Participants self-reported normal
intelligence (IQ >70) and educational attainment. These and other demographics are
given in Table 1.
AUTISTIC GENDER IDENTITY DIFFERENCES 7
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Measures
In addition to demographic questions including age, education and occupation,
participants completed the following:
Autism-Spectrum Quotient; Short. (AQ) (Baron-Cohen et al, 2001; Hoekstra et
al, 2011; Chronbach’s alpha = 0.86), assesses autism traits with 28 self-report ratings
of statements describing autistic traits (or their absence). Five subscales include
Attention to detail (α = .63/.68); Social skill(α = .76/.68); Attention switching (α =
.63/.62); Communication (α = .52/.49); and Imagination (α = .63/.52).
Sensory Processing Questionnaire. (SPQ) (Tavassoli, Hoekstra & Baron-
Cohen, 2014; Chronbach’s alpha =0.93), assesses sensory hypersensitivity with
statements (7 statements per each of 5 sensory domains; psychometrics were not
provided for the subscales in the original dataset) about sensory experiences.
Gender identity. This question was a multiple choice between (translated from
Dutch); “man”, “woman”, “somewhat man, somewhat woman”, “neither man nor
woman”, “I don’t (yet) know”, and “Other” with a free-text entry, which was then
classified according to the content of the write-in. (This follows the two-step method
recommended by GenIUSS Group, 2014; Tate,"Ledbetter"&"Youssf,"2013.)
Analyses
We first categorized the participants as cisgender, binary-trans (AFABs and AMABs
identifying solely as a man or a woman, respectively) and nonbinary-trans (those with
identities not encapsulated in “man” or “woman”) based on their relative answers to
the assigned gender and gender identity questions, and examined the distribution of
such identities by assigned sex. Due to a very small number of binary-trans classified
participants (N=6), we merged the binary and non-binary trans groups to form one
AUTISTIC GENDER IDENTITY DIFFERENCES 8
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‘trans and nonbinary’ sample. 613 provided complete answers to the questionnaires
assessed here, and the other 56 were excluded from subsequent analyses.
Our post-hoc analyses examined the differences between cisgender and trans
and nonbinary participants in AQ and SPQ score with a MANCOVA (covariate; age).
To examine whether the role played by sensory differences in the autistic profiles of
trans and nonbinary autistic participants differed from the cisgender autistic
participants, we also performed pairwise comparisons on the bivariate correlation
between AQ and SPQ between the four assignation*congruence groups (Fisher r-to-z
transformation). To minimise any effect of selection bias we weighted the data to
obtain equal groups, and repeated each of the above analyses.
Compliance with Ethical Standards
All procedures performed in studies involving human participants were in accordance
with the ethical standards of the institutional research ethics committee and with the
1964 Helsinki declaration and its later amendments. Informed consent was obtained
from all individual participants included in the study. Each author declares that s/he
has no conflict of interest. This research was funded in part by a European Research
Council Consolidator Grant (grant number 648082).
Results
AQ-28 scores in the sample were close to previously published values for self-
referred samples with an autism diagnosis (M=84.10, SD=11.55) (Hoekstra et al,
2011). Trans and nonbinary participants scored higher than cisgender participants on
all AQ factors except Routine (MANCOVA, covarying age: Wilks’ lambda = 0.982,
AUTISTIC GENDER IDENTITY DIFFERENCES 9
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p =0.045), a pattern which persists when the data are weighted to account for different
proportions of assigned-gender (Wilks’ lambda = 0.962, p <0.001) (see Table 2).
However, the size of these effects was overall small.
SPQ-Short scores in the sample were close to previously published values for
self-referred samples with an autism diagnosis (M=43.33, SD=14.73) (Tavassoli,
Hoekstra & Baron-Cohen, 2014). The trans and nonbinary participants scored lower
(i.e. less hypersensitive) than cisgender participants on the SPQ (MANCOVA: Wilks’
lambda = 0.979, p =0.002 weighted) in the Vision and Hearing subscales only (Table
3), a pattern which again persists when weighted.
The correlation between AQ and SPQ did not statistically differ between
cisgender and trans participants (Cisgender; R = -0.202, p<0.001. Trans; R= -0.200, p
= 0.056. Fisher’s Z = 0.02, p=0.984). We performed post-hoc Fisher’s tests of all
possible combinations of all the gender groups with p-values ranging from 0.718
(AMAB trans vs. cisgender males) to 0.960 (AFAB trans vs. cisgender males).
We found a high rate of trans and especially nonbinary identities in this
sample (100 out of 675 participants, 15%). AFAB participants reported such identities
(21.6%) more frequently than AMABs (7.8%), t(673)=5.14, p < 0.001. Furthermore,
just 6% (n=6) of all trans participants identified as binary (4% (n=?) of trans AFABs
identified as binary men, and 12% (n=?) of trans AMABs identified as binary
women). This was a significantly higher rate of both trans (χ2 = 125.14, p<0.001) and
nonbinary (χ2 = 149.39, p<0.001) than the Dutch population sample of Kuyper and
Wijsen (2014)1.
""""""""""""""""""""""""""""""""""""""""""""""""""""""""
1"Kuyper"and"Wijsen"(2014)"used"the"terms"“ambivalent”"and"“incongruent”."We"interpret"both"of"
these"for"inclusion"in"comparison"to"our"trans"participants,"and"“ambivalent”"(defined"as"equal"or"
greater"identification"with"the"sex"not"assigned"at"birth"than"the"sex"assigned"at"birth)"for"
inclusion"in"comparison"to"our"nonbinary"participants."
AUTISTIC GENDER IDENTITY DIFFERENCES 10
"
Discussion
Our results show that trans and nonbinary participants scored a little higher on all AQ
subscales except routine, and a little lower on the SPQ subscales for vision and
hearing. As previously reported (Dewinter, De Graaf & Begeer, 2017), in our sample
of autistic adults, trans and nonbinary identities are significantly elevated compared to
the Dutch population as a whole, and AFAB participants were significantly more
likely than AMABs to identify outside the binary female-male categories.
The finding that nonbinary identities are most elevated seems to support
hypotheses focussed on autistic resistance to social conditioning, which are consistent
with existing evidence of the same effect with respect to self-description of sexual
orientation (Rudolf et al, 2017). Perhaps elevated rates of trans identity in autism
might result from a rejection of the binary cisgenderist norm, which combined with a
below-typical concern for social norms could promote the disclosure of the identity.
Formulated this way, the reduced impact of the binary cisgenderist norm could be
seen as another example of a ‘flattened prior’ (Pellicano & Burr, 2012). Within
Bayesian models of cognition (e.g. Sanbourne & Chater, 2016), past information
generates predictions about the likely content of future stimuli as a probability
distribution known as a ‘prior’. The prior is convolved with a probability distribution
of possible interpretations of (sensory) data. The resulting distribution is known as the
‘posterior’. The percept is derived directly from the posterior (e.g. the peak).
Flattened priors, then, would describe a cognitive system that does not assign as much
significance to past knowledge as to present experience. Learned patterns from the
past, such as social norms (modelled as a prior) are less significant in autistic people,
and therefore attenuate extreme experiences less, resulting in an increased subjective
AUTISTIC GENDER IDENTITY DIFFERENCES 11
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salience (Pellicano and Burr, 2012). This seems consistent with the evidence that
autistic people are more prone to extreme moods (Mazefsky et al, 2013; Lecavalier,
2006) and alexithymia (Gaigg, Cornell & Bird, 2016). Extant evidence that automatic
imitation is more sensitive to self-similarity in autism (Bird, Leighton & Press, 2007)
and that the reward system is preferentially activated by own-gender imitation (Losin
et al, 2012) may offer one possible route for this proposed mechanism.
We would therefore propose for future investigation the possibility that the
relationship between autism and gender incongruence is better understood as gender
incongruence being suppressed in the typically-developing by priors including the
social schema of cisgenderism (that is, the assumptions that gender is binary, fixed
and defined by genital anatomy). If this hypothesis can be confirmed, it seems
probable that the transgender experience of autistic trans people is qualitatively the
same as that of typically developing trans people, and that autism is also qualitatively
the same in transgender as in cisgender autistic people. Indeed, the very low number
of participants identifying exclusively as the sex opposite to their assigned sex is close
to earlier estimates of prevalence of transgender identities in the population – perhaps
indicating that greater awareness of non-binary identities is a driving force behind
recent exponential increases in referrals (Reed et al, 2011; Lyons, 2016). One might
take this further by suggesting, as our ‘Flattened Priors’ (Pellicano & Burr, 2012) –
based interpretation might imply, that being autistic doesn’t make people appear trans
– being typically developing can make people appear cisgender. A similar effect has
been seen with sexual orientation as LGB orientations have become increasingly
accepted, rates of LGB identitification have risen (Cox & Jones 2015).
That the rate of trans and nonbinary identities is higher in AFABs may suggest
that the diagnostic biases in autistic AFABs have distorted our results (by biasing the
AUTISTIC GENDER IDENTITY DIFFERENCES 12
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AFAB part of the sample to have more autistic traits), a difference in the rates of trans
and nonbinary gender identities by assigned sex between autistic and typically
developing populations, which remains to be explained, or a complementary role of
experiences of cultural misogyny in facilitating the above described process.
Several hypotheses have been proposed to explain the correlation between
autism and trans gender identities. Williams, Allard and Sears (1996) hypothesised
that restricted and repetitive interests may lead males with autism to become
preoccupied with a range of things which “happen to be predominantly feminine in
nature”, positioning autistic trans identities as qualitatively different from those of
neurotypicals’. Other authors (e.g. de Vries et al, 2010, Jacobs et al, 2014) have
discussed the possibility that rigid thinking in autism may lead individuals to
misinterpret whatever gender nonconformity they experience, as an indication that
they are ‘in the wrong gender’. These hypotheses would be compatible with finding a
selective elevation of autism traits (Routine and Switching on the AQ, and in the
former, Touch Sensitivity on the SPQ) in our trans participants, which we did not
find. However, to properly test this hypothesis a rather higher degree of specificity
would be needed in the measures to compensate for the heterogeneity of autistic and
trans populations. The elevated rates of nonbinary identities compared to the typical
trans population also undermine these hypotheses. Somewhat conversely, Ansara and
Hegarty (2011) suggested that autistic individuals’ tendency to direct communication
and disinterest in social norms reduces the likelihood that cisgenderism and
transphobia will prevent them from disclosing their identities. This hypothesis would
predict elevation of the Communication and Social-Skill AQ subscales, which we did
find, albeit nonselectively. Kristensen and Broome’s (2016) study similarly proposed
that autistic individuals’ “systematising” approaches to a range of cognitive tasks
AUTISTIC GENDER IDENTITY DIFFERENCES 13
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(Auyeung et al, 2009; Golan & Baron-Cohen, 2006; Baron-Cohen 2002) would lead
them to regard cisgenderist, binary gender norms as an ‘imperfect system’, which
would also predict that differences more related to cognition and logical thinking –
autism traits as measured by the AQ, but not the perception differences on the SPQ –
would be elevated in our trans and nonbinary subsample. This, too, is consistent with
our finding of elevation across the whole AQ except the Routine subscale2.
The trans and non-binairy members of our sample reported higher autism
characteristics, but lower sensory hypersensitivity. These findings are small and
therefore difficult to interpret, but do help better contextualise several existing
theories, and lead to the formulation of our priors-based theoretical proposal. They
might be further understood within a framework of multiple developmental processes
underlying autism differently in different individuals, with the resultant heterogeneity
of said population, and therefore the exact mechanisms giving rise to consciously
experienced gender incongruence may also differ along the same lines.
Limitations
While the unusually high proportion of AFAB participants in this autism sample
could be driven by the relative willingness of females to participate in questionnaire-
based research, it does raise questions about the equivalence of the AMAB and AFAB
portions of the sample. We addressed this by statistically resampling the data;
however, there remains some ambiguity about how best to interpret the differing
prevalences found here. Future research should use a sample from referrals to autism
services.
""""""""""""""""""""""""""""""""""""""""""""""""""""""""
2"Corbett"et"al"(2009)"argue"that"the"desire"for"routine"may"be"driven"by"the"anxiety"that"the"
unpredictability"of"social"environments"can"cause."Therefore,"it"seems"likely"that"this"is"
suppressed"relative"to"overall"AQ"scores"in"our"sample"because"those"individuals"with"the"highest"
scores"may"also"be"those"least"likely"to"‘come"out’"or"acknowledge"their"atypical"gender"
identities."
AUTISTIC GENDER IDENTITY DIFFERENCES 14
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The AQ-28 and even the SPQ are general measures developed for screening.
These might be too general to test for differences between groups pertaining to very
specific characteristics. Implicit cognitive-behavioural task measures may be able to
probe the ‘flattened priors’ more directly.
Autisitic individuals sometimes struggle with insight in their own functioning,
and this could impact on the ability of some participants to report accurately on these
measures, although these effects are most robust in those with co-occurring
intellectual disability (Huang et al, 2017), who are not included in the present study.
Autistic trans individuals also experience greater levels of emotional distress
that may influence the impact of their symptomatology (George & Stokes, 2018). It is
therefore possible that the elevated AQ total scores in our trans and nonbinary
participants were influenced by these effects. However, this would be unlikely to
explain the distinct pattern at the subscale level.
Implications for clinical practice
Attention to gender identity, and how this is experienced by adolescents and adults
with ASD by parents and professionals is advisable, independent from which
explanation might hold. Exploring and discussing how autistic adolescents and adults
identify their genders might help in offering support, and when needed, gender
clinicians should be ready to discuss how to communicate and deal with gender in a
cisgenderist, neurotypical world. Therefore, autistic patients of gender clinics, like all
patients, will need to know that clinicians will trust in the reliability and authenticity
of their descriptions of their gender identities. Autistic people with a gender identity
that does not align with their gender assigned at birth may need access to specialized
gender teams, who should therefore seek to cultivate expertise in working together
with autistic people.
AUTISTIC GENDER IDENTITY DIFFERENCES 15
"
Conclusions
The present results show that trans and especially nonbinary identities were elevated
in a sample of adults diagnosed with autism, particularly among AFAB participants;
and show some differences in their autism traits. Various explanations have been
suggested, and remain unsupported. An interesting, and still understudied hypothesis,
is the notion that elevated trans or non-binary identities in autism result from an
increased likelihood that the identity is recognised and disclosed. We further propose
the testable hypothesis that a reduced impact of the cisgenderist binary social norm is
an example of a flattened prior, resulting in a greater likelihood of the individual
becoming aware of their gender identity.
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