European Psychiatry 61 (2019) 17–22

Contents lists available at ScienceDirect

European Psychiatry
journal homepage: http://www.europsy-journal.com

Original article

Autistic traits in individuals self-defining as transgender or nonbinary

Steven D. Stagg* , Jaime Vincent
Anglia Ruskin University, East Road, Cambridge, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Background: Autism spectrum traits are increasingly being reported in individuals who identify as
Received 27 February 2019 transgender, and the presence of such traits have implications for clinical support. To-date little is known
Received in revised form 5 June 2019 about autism traits in individuals who identify as nonbinary.
Accepted 11 June 2019
Aims: To empirically contribute to current research by examining autistic traits in a self-identifying
Available online 28 June 2019
transgender and nonbinary gender group.
Method: One hundred and seventy-seven participants responded to a survey consisting of the Autism
Keywords:
Spectrum Quotient (AQ), the Empathy Quotient (EQ), the Systematising Quotient (SQ) and the Reading
Autism
Nonbinary
the Mind in the Eyes Task (RME). Comparisons were made between cisgender, transgender and
Transgender nonbinary groups.
Gender Results: Individuals with autism spectrum disorder (ASD) or meeting the AQ cut-off score for ASD were
Autistic traits over-represented in both the transgender and nonbinary groups. The key variables differentiating the
transgender and nonbinary groups from the cisgender group were systematising and empathy. Levels of
autistic traits and cases of ASD were higher in individuals assigned female at birth than those assigned
male at birth.
Conclusions: A proportion of individuals seeking help and advice about gender identity will also present
autistic traits and in some cases undiagnosed autism. Lower levels of empathy, diminished theory of
mind ability and literalness may impede the delivery of effective support. Clinicians treating transgender
and nonbinary individuals, should also consider whether clients, especially those assigned female at
birth, have an undiagnosed ASD.
© 2019 Elsevier Masson SAS. All rights reserved.

1. Introduction population [5–7]. In gender dysphoric children, de Vries et al.

[5] reported a rate of ASD approximately 37 times higher than
Gender dysphoria refers to a mismatch between the biological would be expected in the general population. Research into this
sex and gender assigned at birth and the individuals felt gender area has the potential to provide new therapeutic approaches to
identity. The felt mismatch may result in a strong desire to be treating individuals with gender dysphoria who display a high
treated as the other gender or to transition to the other gender [1]. level of ASD traits and to also confirm or challenge the current
Studies suggest a prevalence rate for transsexualism of 4.6 in theoretical understandings of ASD.
100,000 individuals; 6.8 for transgender women and 2.6 for ASD traits in transgender individuals may be higher in
transgender men [2]. Autism spectrum disorder (ASD) is charac- transgender men than in transgender women [6]. The Extreme
terised by deficits in social communication and repetitive and Male Brain theory [8] suggests that individuals with ASD display
stereotyped behaviours [1] with research suggesting a prevalence an extreme version of the male cognitive profile and its associated
rate of 1 in 59 with occurrences between three and four times behaviours, and hypothesises that ASD individuals assigned
higher in boys [3,4]. Both ASD and gender dysphoria are relatively female at birth (AFB) should display hyper-masculinised traits
rare conditions, and comorbidity rates would be expected to be low [8]. Scores on the Autism Quotient (a screening tool for ASD) are
for this population; however, studies suggest that the full criteria reported to be higher in transgender males than transgender
for ASD, or the presence of elevated autistic traits, is higher in females [6], and transgender males score lower on measures of
individuals identifying as transgender than in the general empathy than cisgender females [9]. It has been suggested that
this hypermasculine state may lead women with ASD to feel
separated from their traditional gender identity [10] and may lead
* Corresponding author. some women to develop gender dysphoria. Although the theory
E-mail address: [email protected] (S.D. Stagg). does not explicitly make predictions about sexuality, it might be

http://dx.doi.org/10.1016/j.eurpsy.2019.06.003
0924-9338/© 2019 Elsevier Masson SAS. All rights reserved.
18 S.D. Stagg, J. Vincent / European Psychiatry 61 (2019) 17–22

expected that in ASD individuals assigned male at birth (AMB) was collected. Of those participants identifying as transgender, 74%
hypermasculinity would lead to fewer cases of gender dysphoria. were receiving or had received support from a gender identity
However, research has shown that within individuals with gender clinic, 22% had received no support, and 4% preferred not to say. In
dysphoria, both those AMB and AFB show an overrepresentation the nonbinary group, 42% were receiving or had received support
of autism traits as measured on the Autism Quotient and Social from a gender identity clinic, 54% had not, and 4% preferred not
Responsiveness scale [11]. to say.
Research into gender fluidity and ASD has tended to focus on
individuals who see their gender in terms of binary distinctions, 2.2. Ethics
although historically attempts have been made to categorise
individuals with gender dysphoria along the lines of sexual Ethical approval for the survey was received from the
preference and age of onset [12]. The Extreme Male Brain theory Psychology Departmental Research Ethics Panel (DREP) at Anglia
has been criticised for stereotyping behaviour as either exclusively Ruskin University (Approval code: EH16-025), in conformity with
male or female [13], and research into gender identity and ASD has the British Psychological Society’s ethical guidelines and the World
often excluded nonbinary individuals. Research suggests that there Medical Association Helsinki Declaration.
are higher occurrences of homosexuality, bisexuality and asexual-
ity in ASD samples [14], gender-nonconformity is higher in 2.3. Materials
individuals with ASD [15] and especially so in women [16]. At
present, little is known about individuals who self-identify as The Autism Spectrum Quotient [24] comprises 50 statements
nonbinary. Research conducted in the Netherlands [17] reported and is designed to screen for ASD. A cut-off of 32 was used to
that 4.6% of individuals AMB and 3.2% of individuals AFB reported denote potential cases of ASD. A threshold score of 32 out of 50 has
an ‘ambivalent gender identity’ (defined as equal identification good discriminative validity for detecting adults with autistic traits
with the other sex as with their sex assigned at birth); similar (sensitivity = 76.71% and specificity = 74.07% [28]. The test has good
findings have been reported in a Belgian sample [18]. Concerning internal consistency (α = 79), and good test-retest reliability
autistic traits, one of the few published papers in this area reported (r = .84; [29].
that individuals who identified as ‘genderqueer’ (a nonbinary The Empathy Quotient [25] measures both affective and
identity), scored higher on measures of autistic traits than both cognitive aspects of empathy across 40 items. Individuals with
cisgender and binary transgender participants [19]. ASD score lower on this measure than typically developing
While best practice for treating and assessing transgender individuals, with the majority of ASD individuals scoring less than
individuals has included many areas of concern [20], there has 30 [25]. The EQ has been shown to have good test-retest reliability
been a neglect of possible autistic traits and their impact on (r = .78–.97) and good internal consistency (α = .78–.92) [30].
treatment within this community [21,22]. Problems in interpreting The Systemising Quotient-Revised [26] is a self-report
social signals, a literal understanding of language and problems in measure consisting of 75 items, with a maximum score of 150.
recognising and interpreting one’s own emotions may mean that Individuals with ASD have a strong drive to systematise (analyse,
transgender individuals displaying high ASD traits struggle with control and utilise rule-based systems) and score higher on this
therapeutic interventions [23]. Therefore, research is needed to measure than typically developing individuals. The SQ has good
establish the core ASD traits that are apparent in both transgender internal consistency (α = .79–.90) and good test-retest reliability
and nonbinary individuals. This paper investigates autistic traits (r = .79) [30].
and cases of autism in individuals who do not identify as cisgender The ‘Reading the Mind in the Eyes’ Test-Revised [27] is a
and further explores the differences between binary and nonbinary measure of advanced theory of mind, and individuals with ASD
categories. To establish a profile of autism, the study used the register scores lower than typically developing individuals. The
Autism Quotient [24], the Empathy Quotient [25], the Systemising RME test consists of 36 black and white photographs of facial
Quotient [26] and the Reading the Mind in the Eyes task [27]. expressions that are cut-off at the nose region, focusing on the eyes
Furthermore, we examined the impact of gender assigned at birth and forehead. Each expression is presented with four answer
on these measures. options. Reported internal consistency for the test ranges from
α = .63 to 0.77 and the test has a test-retest reliability of r = .83 [31].
2. Method
2.4. Procedure
2.1. Participants
Once distributed within the Facebook groups, any members
Data were collected using Qualtrics from 196 participants over could access the link to the survey from a computer. Informed
the age of 18 who self-identified as either cis-gender, binary consent was collected from all participants. The survey was
transgender (male or female) or nonbinary, constituting three completed in the following order: Autism Quotient, Empathising
groups in all. In total, 19 participants failed to complete the survey, Quotient, Systemising Quotient-Revised and the Reading the Mind
and their data were removed. These incomplete responses were in the Eyes test. Once the last response was submitted from the
across all six gender identities: cisgender male (n = 3), cisgender RME, the participant was redirected to the debrief sheet, where
female (n = 3), binary transgender male (n = 6), binary transgender they could either submit their results or withdraw by closing the
female (n = 2), nonbinary AMB (n = 1) and nonbinary AFB (n = 4). browser.
Within the remaining 177 participants, 66 were AMB and 111 were
AFB; the three groups were matched on age (F(1,2) = .23, p = .98). 2.5. Statistical analysis
The survey was distributed on eight Facebook groups, which acted
as support groups for transgender individuals. Two of these groups Chi-square was used to test for associations between gender at
were secret groups which are untraceable online and were birth and ASD status, and self-identified gender and ASD status and
provided to the study through members of the transgender results are provided with odds ratios. To maximise statistical
community; the remainder were closed groups. The survey was power, MANOVA was used for the first step in the analyses, with
also shared on three other general Facebook groups which targeted post hoc tests applied where appropriate. Bonferroni corrections
Anglia Ruskin students, where data from cisgender participants were applied in the following manner. To control for Type 1 errors,
 S.D. Stagg, J. Vincent / European Psychiatry 61 (2019) 17–22 19

when testing the multiple univariate interaction effects and the for ASD, and none of the cisgender participants met this point. A
simple main effects for group, the alpha level was adjusted to 0.01. chi-square test was conducted to investigate whether a relation-
Bonferroni corrections were also applied to pairwise comparisons ship existed between AQ cut-off and self-defined gender, excluding
and p-values automatically adjusted in SPSS. Data met assump- the cisgender group. The chi-square result was not significant
tions for MANOVA but violated the assumption of equal variances x2(1) = .69, p = .41, w = .08.
and covariances (< .001); since participant numbers in each cell When gender at birth was examined, 10% of AFB participants
were similar the MANOVA is robust to this violation [32], and the reported having an ASD diagnosis, compared to 11% of AMB
Pillai’s trace statistic was reported, which is robust to unequal participants. A chi-square test of association demonstrated that
covariance matrices [33]. Groups were analysed in relation to their there was no significant association between ASD diagnosis and
current gender identity and gender assigned at birth. gender at birth x2(1) = .22, p = .88. For AFB participants not
reporting an ASD diagnosis, 19% met the cut-off for ASD; in AMB
3. Results participants, this figure was 9%. A chi-square test demonstrated
that there was no significant association between ASD cut-off and
3.1. Overview gender assigned at birth x2(1) = 1.82, p = .18.

Table 1 presents an overview of the data for each group. The

3.3. Group comparisons on autism traits
question of whether the participant had a diagnosis of ASD was left
blank by 18% of the respondents. A chi-square analysis demon-
A two-way MANOVA was run with two independent variables
strated a significant association between the response to the
(gender at birth and self-identified gender) and four dependent
question and group x2(2) = 8.18, p = .02, w = .22. The odds ratio of
variables (AQ, EQ, SQ and RME); the combined dependent variables
not responding in the cisgender group versus the transgender
were used to assess the levels of autistic traits.
group is 4.23, 95% CI [1.46, 13.42] and in the cisgender group versus
The interaction effect between gender assigned at birth and
the nonbinary group 3.50, 95% CI [1.19, 10.69] and in the
self-identified gender on the combined variables was significant F
transgender versus nonbinary groups 0.80, 95% CI [0.30, 1.94].
There was also a statistically significant association between (8338) = 2.57, p = .01, Pillai’s Trace = .12, h2 = .06. Examining the
providing an answer to the question and gender assigned at birth individual measures revealed a statistically significant interaction
x2(1) = 12.25, p < .001, w = .26. The odds ratio of not responding in effect between self-identified gender and gender at birth for EQ F
the AMAB versus the AFAB group is 7 .08, 95% CI [2.06, 24.36]. (2171) = 4.21, p = .01, h2 = .05 and SQ F(2171) = 6.80, p = .001,
h2 = .07. No significant interaction effects were observed for either
3.2. Rates of ASD AQ F(2171) = 2.87, p = .06, h2 = .03 or RMA F(2171) = 2.28,
p = .11, h2 = .03.
Within the combined transgender and nonbinary groups, 14% of To understand the nature of the interactions, these effects were
participants reported having an ASD diagnosis, and in the cis- explored further. In relation to gender assigned at birth, there was a
gender group, this figure was 4%. A chi-square test demonstrated a statistically significant difference between males and females on
significant association between reported ASD diagnosis and self- EQ scores in the cisgender group, with females scoring higher than
defined gender, x2(2) = 15.78, p < .001, w = .33. The odds ratio of males F(1171) = 4.79, p = .03, h2 = .03, and on SQ scores with males
reporting an ASD diagnosis in the cisgender versus transgender scoring higher than females F(1171) = 9.53, p = .002, h2 = .05.
group is 1.14, 95% [.18, 7.18] and in the cisgender versus nonbinary Gender differences on EQ scores for the transgender F(1171) = 3.03,
group 7.89, CI 95% [2.09, 29.65] and in the transgender versus
p = .08, h2 = .02 and nonbinary groups F(1171) = .59, p = .44,
nonbinary group 6.89, CI 95% [1.45, 32.90]. Of those reporting an
h2 = .003 were not significant, nor were there any statistically
ASD diagnosis, three participants from the cisgender group (all
significant differences in SQ for the transgender group F
AMAB), one participant from the transgender group (AMAB) and
(1171) = 2.92, p = .09, h2 = .02 or nonbinary group F(1171) = 1.31,
one participant from the nonbinary group (AFAB) had AQ scores
below 32. The analyses were run including and excluding these p = .25, h2 = .008.
participants without a change in the results. The subsequent In relation to self-defined gender, the post hoc analyses suggest
analyses reported include these five participants. that these results were driven by gender assigned at birth. There
From those participants who did not report an ASD diagnosis, was a statistically significant difference between the three groups
28% of the combined transgender and nonbinary groups met the for those AFAB for EQ F(2171) = 16.49, p < .001, h2 = .16, and SQ F
AQ cut-off score that would suggest the need for further screening (2171) = 19.21, p < .001, h2 = .18, but not for those AMAB for either

Table 1
Mean scores on each of the survey measures.

n Age AQ EQ SQ RME EQ < 30 ASD AQ CF

Cis-male 28 32 (16) 19 (8) 38 (9) 61 (20) 28 (4) 3 (11%) 3 (11%) 0
Cis-female 40 23 (7) 18 (7) 45 (13) 45 (18) 28 (3) 6 (15%) 0 0
Transgender male 31 24 (8) 31 (8) 28 (13) 69 (22) 25 (7) 18 (58%) 1 (3%) 16 (52%)
Transgender female 19 31 (14) 24 (7) 35 (13) 59 (12) 28 (3) 8 (42%) 1 (5%) 3 (16%)
Nonbinary (AMAB) 19 29 (14) 27 (10) 35 (13) 64 (19) 27 (2) 10 (52%) 3 (16%) 7 (37%)
Nonbinary (AFAB) 40 25 (7) 30 (12) 32 (14) 71 (24) 24 (7) 18 (44%) 10 (25%) 20 (50%)
AMAB 66 31 (14) 23 (9) 36 (13) 61 (18) 28 (4) 20 (30%) 7 (11%) 6 (11%)
AFAB 111 24 (7) 26 (11) 36 (15) 61 (24) 26 (6) 42 (38%) 11 (10%) 14 (19%)

Autism Quotient (AQ), Empathising Quotient (EQ), Systematising Quotient (SQ), Reading the Mind in the Eyes Test (RME), Autism Quotient cut off (AQ CF). Absolute ranges: AQ
(0–50), EQ (0–80), SQ (0–150), RME (0–36). Transgender male refers to individuals assigned female at birth abs transgender female refers to individuals assigned male at birth.
In relation to the question asking participants whether they had a diagnosis of ASD 31 participants did not respond representing 18% of the data. These figures breakdown as:
Cis- male 1(4%), cis female 4 (10%); transgender male 12 (39%), transgender female 1 (5%), nonbinary (AMAB) 1 (5%), nonbinary (AFAB) 12 (30%).
20 S.D. Stagg, J. Vincent / European Psychiatry 61 (2019) 17–22

Table 2
Group main effect comparisons on the AQ, SQ, EQ, and RME measures.

Univariate Tests Comparisons Mean Difference & 95% CI Effect Size

F p hr
2 d

AQ 21.21 .004 .20 cisgender v. transgender*** 9.72 [-14, -6] 1.17

cisgender v. nonbinary*** 10.53 [-14, -7] 1.14
transgender v. nonbinary .80 [-5, 3] 0.30
EQ 9.25 .004 .10 cisgender v. transgender*** 11.58 [5,18] 0.96
cisgender v. nonbinary*** 9.06 [3,15] 0.73
transgender v. nonbinary 2.52 [-9, 4] 0.15
SQ 8.39 .004 .09 cisgender v. transgender*** 13.78 [-23, -5] 0.80
cisgender v. nonbinary*** 17.17 [-26, -8] 0.95
transgender v. nonbinary 3.39 [-13, 6] 0.19
RME 3.79 .08 .04 cisgender v. transgender 2.06 [-.24, 4] 0.39
cisgender v. nonbinary ** 3.02 [.82 5] 0.59
transgender v. nonbinary .96 [-1.42, 3] 0.17
**
p < .01.
***
p < .001.

EQ F(2171) = .41, p = .66, h2 = .005 or SQ F(2171) = .34, Finally, the main effect of group was significant F(8338) = 5.40,
p = .72, h2 = .004. p < .001, h2 = .11. The groups differed significantly on AQ, EQ
Follow up tests demonstrated that EQ scores for those AFAB and SQ, but not on RME. Post hoc analyses showed that these
were 17.12 (95% CI: 11–23.25) higher in the cisgender group than differences were between the cisgender and transgender
the transgender group (p < .001), and 12.95 (95% CI: 7–18.89) group and the cisgender and nonbinary group on each of the
higher than the nonbinary group (p < .001). SQ scores for those dependent variables. There were no significant differences
AFAB were 24.02 (95% CI: -32.72 to -14.31) lower in the cisgender between the transgender and nonbinary groups on any of the
group than the transgender group (p < .001), and 25.65 (95% CI: dependent variables. The full results are presented in Table 2
-35.12 to -16.18) lower than the nonbinary group. (Figs. 1 and 2).

Fig. 1. Levels of autistic traits in individuals identifying as transgender.

Fig. 2. Levels of autistic traits in individuals identifying as nonbinary.

 S.D. Stagg, J. Vincent / European Psychiatry 61 (2019) 17–22 21

4. Discussion this area can be achieved and guidelines established [22]. Focus on
ASD traits is pertinent, given that the UK Gender Identity
4.1. Main findings Development Service reports that AFB individuals are nearly
two times more likely to be referred to specialist gender clinics
Both transgender and nonbinary groups participating in this than AMB individuals [39]. Our study confirmed reports of lower
study scored significantly higher on measures associated with ASD EQ scores in transgender and nonbinary AFB participants
traits than a cisgender comparison group. Both groups also compared to cisgender females [9], and this group also demon-
contained a higher than expected number of individuals who strated higher SQ scores when compared to cisgender females. This
either had a diagnosis of ASD or met the AQ cut-off for ASD; AFB rigid cognitive profile relies on rule-based processing rather than
participants primarily drove these differences. the ability to intuit meaning from the non-verbal communication
of others and so may create challenges in therapy and counselling
4.2. Meaning of the results [23]. Rigidity of thought may also render the acceptance of gender
variant feelings difficult [40]. Clinicians and healthcare providers
The findings concur with the extant literature that suggests a need to be prudent with their choice of words; implied meanings,
higher number of autism traits in individuals who identify as metaphors or idiomatic language might not be understood in the
transgender. The rate of potential ASD in our study was higher than manner in which it is intended [41]. High scores on the SQ suggest
the prevalence of 0.6–1% of ASD in the general population [34]. Of that the transgender and nonbinary AFB groups would benefit
note is the fact that the proportion of individuals who either from precise causal explanations, and they may seek simple or
already had an ASD diagnosis or met the cut-off for ASD was higher overly logical explanations of complex matters, thus resulting in
in the nonbinary group than the transgender group; similarly, this frustration when unequivocal answers are not possible. Under-
group was also less likely to have visited a gender identity clinic. standing of this cognitive style may reduce frustration, miscom-
Given the gender repartition in ASD is thought to be one female munication and withdrawal from support.
to every three males [4] finding an equivalent number of self-
reported cases of ASD in AFAB and AMAB participants suggests that 4.4. Limitations
ASD is overrepresented in transgender and nonbinary AFAB
individuals contrary to the conclusions of previous research [5]. As with all internet surveys, self-selection and participants’
Similarly, there was no association between reaching the AQ cut off understanding of the survey requirements are difficult to gauge.
and gender assigned at birth. However, these figures come from a Participants self-defined their gender, and while the study
self-selecting sample and need to be treated with caution. These benefited from reaching participants that may never present at
result suggests the existence of a population of women reaching a gender identity clinic, we cannot be sure that all participants fully
adulthood without their autism being formally detected and understood the gender categories. For example, the nonbinary
concords with current thinking that a significant proportion of identity is an emerging term in gender research, and it is possible
women with ASD go undiagnosed [35]. Although the AQ does not that some participants may have failed to identify binary and
confer a diagnosis of ASD, our findings suggest ASD screening nonbinary identities as separate categories. We also acknowledge
would be beneficial in specialist gender clinics, and the formal that gender identity is not stable and that the individuals taking
identification of ASD could potentially lead to a more appropriate part in our study are likely to define their identity differently at
level of support. varying stages in their lives; for example, gender may be defined
The gender analyses reported in our study potentially supports differently when socially transitioning (e.g. coming out) and/or
the Extreme Male Brain theory of ASD. However, it is noted that medically transitioning (e.g. using hormones/surgery).
transgender and nonbinary AMB individuals also had elevated AQ
scores, with 11% of this group reaching the cut-off for ASD; this
Contributions
suggests a more nuanced theory is needed.
While our findings suggest that there may be a high number of
SS contributed to the design of the study, data analysis and the
undiagnosed individuals with ASD in transgender and nonbinary
final write up of the study and final approval of the manuscript.
populations, an alternative interpretation is plausible. Raised
JV contributed to the design of the study, data collection and
scores on the AQ and SQ, and lower scores on the EQ, rather than
data analysis and final approval of the manuscript.
being unique to ASD, may be a feature of any condition where the
developing individual has experienced feedback counter to their
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