Skip to main content

Prevalence of Autism Spectrum Disorder and Attention-Deficit Hyperactivity Disorder Amongst Individuals with Gender Dysphoria: A Systematic Review

Abstract

Autism spectrum disorders (ASD) and attention-deficit hyperactivity disorder (ADHD) can compromise health and may be more prevalent amongst individuals with gender dysphoria (GD). Symptoms such as attention or social difficulties can impact assessment of GD, understanding of health information, and engagement in clinical care. To ensure neurodevelopmental conditions are adequately considered in gender health services, we aimed to systematically review the literature examining the prevalence of ASD and ADHD amongst individuals with GD. In this systematic review based on the PRISMA guidelines. MEDLINE and PsycINFO databases were searched for studies examining the prevalence of ASD and/or ADHD in individuals with GD or investigated the rate of GD in cohorts with ASD or ADHD. All English peer-reviewed publications were included. The search strategy identified 179 studies. After applying exclusion criteria, a total of 30 studies were identified, 22 studies which examined the prevalence of ASD or ADHD in people with GD. A further 8 studies examined the reverse; prevalence of GD in people with ASD. The few studies employing diagnostic criteria for ASD suggest a prevalence of 6–26% in transgender populations, higher than the general population, but no different from individuals attending psychiatry clinics. Few studies examine prevalence of ADHD. Low-level evidence exists to suggest a link between ASD and GD. Further population-based and controlled studies using diagnostic criteria for ASD and ADHD are required.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  • Akgul, G. Y., Ayaz, A. B., Yildirim, B., & Perdahli Fis, N. (2018). Autistic traits and executive functions in children and adolescents with gender dysphoria. Journal of Sex and Marital Therapy,44, 619.

    Article  Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

    Book  Google Scholar 

  • Booth, T., Murray, A. L., McKenzie, K., Kuenssberg, R., O’Donnell, M., & Burnett, H. (2013). Brief report: An evaluation of the AQ-10 as a brief screening instrument for ASD in adults. Journal of Autism and Developmental Disorders,43(12), 2997–3000. https://doi.org/10.1007/s10803-013-1844-5.

    Article  PubMed  Google Scholar 

  • Cheung, A. S., Ooi, O., Leemaqz, S., Cundill, P., Silberstein, N., Bretherton, I., et al. (2018). Sociodemographic and clinical characteristics of transgender adults in Australia. Transgender Health,3(1), 229–238.

    Article  Google Scholar 

  • Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., et al. (2012). Standards of care for the health of trans-sexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism,13, 165–232.

    Article  Google Scholar 

  • Dawson, A. E., Wymbs, B. T., Gidycz, C. A., Pride, M., & Figueroa, W. (2017). Exploring rates of transgender individuals and mental health concerns in an online sample. International Journal of Transgenderism,18(3), 295–304.

    Article  Google Scholar 

  • 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 and Developmental Disorders,40(8), 930–936.

    Article  Google Scholar 

  • Delahunt, J. W., Denison, H. J., Sim, D. A., Bullock, J. J., & Krebs, J. D. (2018). Increasing rates of people identifying as transgender presenting to endocrine services in the Wellington region. New Zealand Medical Journal,131(1468), 33–42.

    PubMed  Google Scholar 

  • Dewinter, J., De Graaf, H., & Begeer, S. (2017). Sexual orientation, gender identity, and romantic relationships in adolescents and adults with autism spectrum disorder. Journal of Autism and Developmental Disorders,47(9), 2927–2934. https://doi.org/10.1007/s10803-017-3199-9.

    Article  PubMed  PubMed Central  Google Scholar 

  • Dickerson Mayes, S., Calhoun, S. L., Mayes, R. D., & Molitoris, S. (2012). Autism and ADHD: Overlapping and discriminating symptoms. Research in Autism Spectrum Disorders,6(1), 277–285.

    Article  Google Scholar 

  • Ebejer, J. L., Medland, S. E., van der Werf, J., Gondro, C., Henders, A. K., Lynskey, M., et al. (2012). Attention deficit hyperactivity disorder in australian adults: Prevalence, persistence, conduct problems and disadvantage. PLoS ONE,7(10), e47404. https://doi.org/10.1371/journal.pone.0047404.

    Article  PubMed  PubMed Central  Google Scholar 

  • Fielding, J., & Bass, C. (2018). Individuals seeking gender reassignment: Marked increase in demand for services. Bjpsych Bulletin,42(5), 206–210.

    Article  Google Scholar 

  • George, R., & Stokes, M. A. (2017). Gender identity and sexual orientation in autism spectrum disorder. Autism. https://doi.org/10.1177/1362361317714587.

    Article  PubMed  Google Scholar 

  • Heylens, G., Aspeslagh, L., Dierickx, J., Baetens, K., Van Hoorde, B., De Cuypere, G., et al. (2018). The co-occurrence of gender dysphoria and autism spectrum disorder in adults: An analysis of cross-sectional and clinical chart data. Journal of Autism and Developmental Disorders,48, 2217–2223.

    Article  Google Scholar 

  • Heylens, G., Elaut, E., Kreukels, B. P., Paap, M. C., Cerwenka, S., Richter-Appelt, H., et al. (2014). Psychiatric characteristics in transsexual individuals: Multicentre study in four European countries. British Journal of Psychiatry,204(2), 151–156.

    Article  Google Scholar 

  • Hisle-Gorman, E., Landis, C. A., Susi, A., Schvey, N. A., Gorman, G. H., Nylund, C. M., et al. (2019). Gender dysphoria in children with autism spectrum disorder. LGBT Health,6(3), 95–100.

    Article  Google Scholar 

  • Holt, V., Skagerberg, E., & Dunsford, M. (2016). Young people with features of gender dysphoria: Demographics and associated difficulties. Clinical Child Psychology and Psychiatry,21(1), 108–118. https://doi.org/10.1177/1359104514558431.

    Article  PubMed  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Jones, R. M., Wheelwright, S., Farrell, K., Martin, E., Green, R., Di Ceglie, D., et al. (2012). Brief report: Female-to-male transsexual people and autistic traits. Journal of Autism and Developmental Disorders,42(2), 301–306.

    Article  Google Scholar 

  • Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health,9, 9. https://doi.org/10.1186/s13034-015-0042-y.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kraemer, B., Delsignore, A., Gundelfinger, R., Schnyder, U., & Hepp, U. (2005). Comorbidity of Asperger syndrome and gender identity disorder. European Child and Adolescent Psychiatry,14(5), 292–296. https://doi.org/10.1007/s00787-005-0469-4.

    Article  PubMed  Google Scholar 

  • Kristensen, Z. E., & Broome, M. R. (2015). Autistic traits in an internet sample of gender variant UK Adults. International Journal of Transgenderism,16(4), 234–245. https://doi.org/10.1080/15532739.2015.1094436.

    Article  Google Scholar 

  • Landen, M., & Rasmussen, P. (1997). Gender identity disorder in a girl with autism: A case report. European Child and Adolescent Psychiatry,6(3), 170–173.

    Article  Google Scholar 

  • Leef, J. H., Brian, J., VanderLaan, D. P., Wood, H., Scott, K., Lai, M.-C.,… Zucker, K. J. (2019). Traits of autism spectrum disorder in school-aged children with gender dysphoria: A comparison to clinical controls. Clinical Practice in Pediatric Psychology, No Pagination Specified

  • Lemaire, M., Thomazeau, B., & Bonnet-Brilhault, F. (2014). Gender identity disorder and autism spectrum disorder in a 23-year-old female. Archives of Sexual Behavior,43(2), 395–398. https://doi.org/10.1007/s10508-013-0141-x.

    Article  PubMed  Google Scholar 

  • Leung, R. C., Vogan, V. M., Powell, T. L., Anagnostou, E., & Taylor, M. J. (2016). The role of executive functions in social impairment in autism spectrum disorder. Child Neuropsychology,22(3), 336–344. https://doi.org/10.1080/09297049.2015.1005066.

    Article  PubMed  Google Scholar 

  • Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A.,… Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: Explanation and elaboration. BMJ (Clinical research ed.), 339, b2700-b2700. https://doi.org/10.1136/bmj.b2700

    Article  Google Scholar 

  • May, T., Pang, K., & Williams, K. J. (2017). Gender variance in children and adolescents with autism spectrum disorder from the National Database for Autism Research. International Journal of Transgenderism,18(1), 7–15.

    Article  Google Scholar 

  • Moul, C., Cauchi, A., Hawes, D. J., Brennan, J., & Dadds, M. R. (2015). Differentiating autism spectrum disorder and overlapping psychopathology with a brief version of the social responsiveness scale. Child Psychiatry and Human Development,46(1), 108–117. https://doi.org/10.1007/s10578-014-0456-4.

    Article  PubMed  Google Scholar 

  • Nahata, L., Quinn, G. P., Caltabellotta, N. M., & Tishelman, A. C. (2017). Mental health concerns and insurance denials among transgender adolescents. LGBT Health,4(3), 188–193. https://doi.org/10.1089/lgbt.2016.0151.

    Article  PubMed  Google Scholar 

  • Nobili, A., Glazebrook, C., Bouman, W. P., Glidden, D., Baron-Cohen, S., Allison, C.,… Arcelus, J. (2018). Autistic traits in treatment-seeking transgender adults. Journal of Autism and Developmental Disorders, 48(12), 3984-3994

    Article  Google Scholar 

  • Parkinson, J. (2016). Gender dysphoria and autism spectrum disorders: A note of caution. LGBT Health,3(2), 175.

    Article  Google Scholar 

  • Pasterski, V., Gilligan, L., & Curtis, R. (2014). Traits of autism spectrum disorders in adults with gender dysphoria. Archives of Sexual Behavior,43(2), 387–393.

    Article  Google Scholar 

  • Pine, D. S., Guyer, A. E., Goldwin, M., Towbin, K. A., & Leibenluft, E. (2008). Autism spectrum disorder scale scores in pediatric mood and anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry,47(6), 652–661. https://doi.org/10.1097/CHI.0b013e31816bffa5.

    Article  PubMed  PubMed Central  Google Scholar 

  • Reisner, S. L., Biello, K. B., White Hughto, J. M., Kuhns, L., Mayer, K. H., Garofalo, R., et al. (2016). Psychiatric diagnoses and comorbidities in a diverse, multicity cohort of young transgender women: Baseline findings from project lifeskills. JAMA Pediatrics,170(5), 481–486.

    Article  Google Scholar 

  • Reisner, S. L., Vetters, R., Leclerc, M., Zaslow, S., Wolfrum, S., Shumer, D., et al. (2015). Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. Journal of Adolescent Health,56(3), 274–279.

    Article  Google Scholar 

  • Russell, G., Rodgers, L. R., Ukoumunne, O. C., & Ford, T. (2014). Prevalence of parent-reported ASD and ADHD in the UK: Findings from the Millennium Cohort Study. Journal of Autism and Developmental Disorders,44(1), 31–40. https://doi.org/10.1007/s10803-013-1849-0.

    Article  PubMed  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child and Adolescent Psychiatry,47(8), 921–929.

    Article  Google Scholar 

  • Skagerberg, E., Di Ceglie, D., & Carmichael, P. (2015). Brief report: Autistic features in children and adolescents with gender dysphoria. Journal of Autism and Developmental Disorders,45(8), 2628–2632.

    Article  Google Scholar 

  • Stagg, S. D., & Vincent, J. (2019). Autistic traits in individuals self-defining as transgender or nonbinary. European Psychiatry: The Journal of the Association of European Psychiatrists,61, 17–22.

    Article  Google Scholar 

  • Strang, J. F., Janssen, A., Tishelman, A., Leibowitz, S. F., Kenworthy, L., McGuire, J. K.,… Anthony, L. G. (2018). Revisiting the link: Evidence of the rates of autism in studies of gender diverse individuals. J Am Acad Child Adolesc Psychiatry, 57(11), 885-887. https://doi.org/10.1016/j.jaac.2018.04.023

    Article  Google Scholar 

  • Strang, J. F., Kenworthy, L., Dominska, A., Sokoloff, J., Kenealy, L. E., Berl, M.,… Wallace, G. L. (2014). Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Archives of Sexual Behavior, 43(8), 1525-1533.

    Article  Google Scholar 

  • Strang, J. F., Meagher, H., Kenworthy, L., de Vries, A. L. C., Menvielle, E., Leibowitz, S.,… Anthony, L. G. (2018). Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents. J Clin Child Adolesc Psychol, 47(1), 105-115. https://doi.org/10.1080/15374416.2016.1228462

    Article  Google Scholar 

  • Tateno, M., Tateno, Y., & Saito, T. (2008). Comorbid childhood gender identity disorder in a boy with Asperger syndrome. Psychiatry and Clinical Neurosciences,62(2), 238. https://doi.org/10.1111/j.1440-1819.2008.01761.x.

    Article  PubMed  Google Scholar 

  • Tateno, M., Teo, A. R., & Tateno, Y. (2015). Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood. Psychiatry and Clinical Neurosciences,69(10), 658. https://doi.org/10.1111/pcn.12328.

    Article  PubMed  PubMed Central  Google Scholar 

  • Taylor, L. J., Eapen, V., Maybery, M. T., Midford, S., Paynter, J., Quarmby, L.,… Whitehouse, A. J. O. (2016). Diagnostic evaluation for autism spectrum disorder: A survey of health professionals in Australia. BMJ Open, 6(9), e012517. https://doi.org/10.1136/bmjopen-2016-012517

    Article  Google Scholar 

  • Turban, J. L. (2018). Potentially reversible social deficits among transgender youth. Journal of Autism and Developmental Disorders,48(12), 4007–4009. https://doi.org/10.1007/s10803-018-3603-0.

    Article  PubMed  Google Scholar 

  • Turban, J. L., & van Schalkwyk, G. I. (2018a). Drs. Turban and van Schalkwyk reply. Journal of the American Academy of Child and Adolescent Psychiatry,57(11), 887–889. https://doi.org/10.1016/j.jaac.2018.07.881.

    Article  PubMed  Google Scholar 

  • Turban, J. L., & van Schalkwyk, G. I. (2018b). “Gender dysphoria” and autism spectrum disorder: Is the link real? Journal of the American Academy of Child and Adolescent Psychiatry,57(1), 8–9.e2. https://doi.org/10.1016/j.jaac.2017.08.017.

    Article  PubMed  Google Scholar 

  • van der Miesen, A. I. R., Cohen-Kettenis, P. T., & de Vries, A. L. C. (2018a). Is there a link between gender dysphoria and autism spectrum disorder? Journal of the American Academy of Child and Adolescent Psychiatry,57(11), 884–885. https://doi.org/10.1016/j.jaac.2018.04.022.

    Article  PubMed  Google Scholar 

  • van der Miesen, A. I. R., de Vries, A. L. C., Steensma, T. D., & Hartman, C. A. (2017). Autistic symptoms in children and adolescents with gender dysphoria. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-017-3417-5.

    Article  PubMed Central  Google Scholar 

  • van der Miesen, A. I. R., Hurley, H., Bal, A. M., & de Vries, A. L. C. (2018b). Prevalence of the wish to be of the opposite gender in adolescents and adults with autism spectrum disorder. Archives of Sexual Behavior,47(8), 2307–2317.

    Article  Google Scholar 

  • VanderLaan, D. P., Leef, J. H., Wood, H., Hughes, S., & Zucker, K. J. (2015a). Autism spectrum disorder risk factors and autistic traits in gender dysphoric children. Journal of Autism and Developmental Disorders,45(6), 1742–1750.

    Article  Google Scholar 

  • VanderLaan, D. P., Postema, L., Wood, H., Singh, D., Fantus, S., Hyun, J.,… Zucker, K. J. (2015). Do children with gender dysphoria have intense/obsessional interests? Journal of Sex Research, 52(2), 213-219.

    Article  Google Scholar 

  • Vermaat, L. E. W., van der Miesen, A. I. R., de Vries, A. L. C., Steensma, T. D., Popma, A., Cohen-Kettenis, P. T., et al. (2018). Self-reported autism spectrum disorder symptoms among adults referred to a gender identity clinic. LGBT Health,5(4), 226–233.

    Article  Google Scholar 

  • Walsh, R. J., Krabbendam, L., Dewinter, J., & Begeer, S. (2018). Brief report: Gender identity differences in autistic adults: Associations with perceptual and socio-cognitive profiles. Journal of Autism and Developmental Disorders,48(12), 4070–4078.

    Article  Google Scholar 

  • Williams, P. G., Allard, A. M., & Sears, L. (1996). Case study: Cross-gender preoccupations with two male children with autism. Journal of Autism and Developmental Disorders,26(6), 635–642.

    Article  Google Scholar 

  • Woodbury-Smith, M. R., Robinson, J., Wheelwright, S., & Baron-Cohen, S. (2005). Screening adults for Asperger Syndrome using the AQ: A preliminary study of its diagnostic validity in clinical practice. Journal of Autism and Developmental Disorders,35(3), 331–335.

    Article  Google Scholar 

  • Zucker, K. J., Nabbijohn, A., Santarossa, A., Wood, H., Bradley, S. J., Matthews, J., et al. (2017). Intense/obsessional interests in children with gender dysphoria: A cross-validation study using the Teacher’s Report Form. Child and Adolescent Psychiatry and Mental Health,11(1), 51.

    Article  Google Scholar 

Download references

Acknowledgments

Ada Cheung is supported by an Australian Government National Health and Medical Research Council Early Career Fellowship (#1143333) and receives research support from the Viertel Charitable Foundation Clinical Investigator Award, Endocrine Society of Australia Postdoctoral Award and the Royal Australasian College of Physicians Vincent Fairfax Family Foundation. Ken Pang is supported by the Royal Children’s Hospital Foundation and receives research support from the Royal Australasian College of Physicians.

Author information

Authors and Affiliations

Authors

Contributions

ET, IB, KCP, JDZ, and ASC made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Ada S. Cheung.

Ethics declarations

Conflict of interest

The authors have nothing to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Thrower, E., Bretherton, I., Pang, K.C. et al. Prevalence of Autism Spectrum Disorder and Attention-Deficit Hyperactivity Disorder Amongst Individuals with Gender Dysphoria: A Systematic Review. J Autism Dev Disord 50, 695–706 (2020). https://doi.org/10.1007/s10803-019-04298-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10803-019-04298-1

Keywords

  • Transgender persons
  • Gender dysphoria
  • Attention-deficit hyperactivity disorder
  • Autism disorders