Mental Health Among LGBT Youth

Abstract

Lesbian, gay, bisexual, and transgender (LGBT) youth report disproportionately high rates of mental health problems when compared to their heterosexual and cisgender peers, including suicidality, depression, and substance use. These mental health disparities likely result from experiences of minority stress, such as bullying and victimization, discrimination, and internalized homo/transnegativity. Many of these stressors are modifiable, as are the protective factors and coping strategies that provide most LGBT youth with resilience in the face of minority stress. A comprehensive review of the literature on LGBT youth mental health is beyond the scope of this brief chapter, and we do not provide a systematic review here. Rather, our goal is to provide an overview of the state of this emerging literature. Specifically, we will provide an overview of minority stress theory as it relates to the experiences of LGBT youth, review current knowledge of mental health disparities among LGBT adolescents, describe how minority stress experiences are related to the mental health of LGBT youth, and summarize our current understanding of resilience and protective factors within this population.

Appendices

Spotlight Feature: Mental Health and Minority Stress Experiences Among Gender-Nonconforming Children

• Laura N. MacMullin &
• Doug P. VanderLaan 

1. Department of Psychology, University of Toronto Mississauga, Mississauga, ON, Canada

   Laura N. MacMullin & Doug P. VanderLaan

Recently, there has been increased research attention devoted to the psychological well-being of gender-nonconforming children (i.e., children whose gender expression and/or identity differ from culturally defined gender norms based on their sex assigned at birth; Adelson, 2012; Turban & Erhensaft, 2018). Community-based studies using either parent-report or child-interview measures of children’s gender expression indicate that approximately 0.9–16.3% of children assigned female at birth (AFAB) and 1.0–7.8% of children assigned male at birth (AMAB) are gender-nonconforming (Martin et al., 2017; van Beijsterveldt et al., 2006; van der Miesen et al., 2018). As such, gender-nonconforming children appear to represent a substantial minority among children overall.

Similar to its application in LGB youth, the minority stress model (Hendricks & Testa, 2012; Meyer, 1995, 2003) provides an important foundation upon which one can understand the mental health challenges faced by gender-nonconforming children. Relatedly, it is vital to consider how proximal factors, such as peer and parental relations, impact gender-nonconforming children’s psychological well-being. Research has shown that children often appraise violations of gender norms negatively and respond to their gender-nonconforming peers with social rejection and derision (e.g., Kowalski, 2007; Wallien et al., 2010). In addition, adults have been shown to negatively appraise gender-nonconforming children and discourage children from behaving in gender-nonconforming ways (e.g., Coyle et al., 2016; Langlois & Downs, 1980; Sullivan et al., 2018). These proximal factors, discussed further below, place gender-nonconforming children at risk of poor mental health outcomes.

Previous research has shown that gender-nonconforming children have elevated scores on measures of clinical-range behavioral and emotional challenges (van der Miesen et al., 2018) and internalizing and externalizing difficulties (e.g., van Beijsterveldt et al., 2006). Past research also shows that children who identify with the “other” gender show high levels of social anxiety (Martin et al., 2017). A particularly key mental health concern for gender-nonconforming children is self-harm/suicidality. In a study on self-harm/suicidality in 6- to 12-year-old children clinic-referred for gender dysphoria, children with gender dysphoria had significantly higher scores on measures of self-harm/suicidality than siblings and non-referred children (Aitken et al., 2016). Specifically, 19.1% of the children referred for gender dysphoria had a history of suicidal ideation and 6.5% had self-harmed and/or attempted suicide (vs. 1.8% and 0.2%, respectively, of 6- to 12-year-old comparison children based on parent-report using the Child Behavior Checklist; Achenbach & Rescorla, 2001; Aitken et al., 2016). Further, a recent study found that self-harm/suicidality was also heightened in a non-clinical, community sample of 6- to 12-year-old gender-nonconforming children who did not have a diagnosis of gender dysphoria (MacMullin et al., 2020). Specifically, among children who expressed gender nonconformity most markedly, 9.1% had attempted suicide and/or self-harmed and 6.8% had suicidal ideation. These rates were not statistically different from those reported by Aitken et al. for children who experienced gender dysphoria.

Importantly, findings in several studies have highlighted that shared experiences of minority stress put children who express gender nonconformity at increased risk of mental health challenges, including self-harm/suicidality. Risk and protective factors for gender-nonconforming children include aspects of both peer and parental relationships. Poor peer relations have been consistently related to behavioral and emotional challenges as well as self-harm/suicidality in community (e.g., MacMullin et al., 2020, 2021; Jewell & Brown, 2014) and clinical (e.g., Aitken et al., 2016; Cohen-Kettenis et al., 2003; Steensma et al., 2014) samples of gender-nonconforming children and adolescents. Relatedly, in children, feeling low levels of contentment to one’s sex assigned at birth is related to lower scores on measures of both acceptance by peers and global self-worth (Yunger et al., 2004). Importantly, clinical and community studies have found that gender-nonconforming children AMAB (vs. those AFAB) are rated less favorably by peers and are more likely to be rejected (e.g., Braun & Davidson, 2017; Cohen-Kettenis et al., 2003; Steensma et al., 2014). Further, children AMAB (vs. those AFAB) are subject to more pressure to behave in gender-stereotypical ways (e.g., Spivey et al., 2018). These findings may be explained by the fact that stereotypically masculine traits and behaviors are afforded with social value (Braun & Davidson, 2017; Coyle et al., 2016).

As it relates to parental attitudes, recent research relying on a community sample identified authoritative parenting, closeness in the parent-child relationship, parental willingness to serve as a secure base, and low levels of gender-stereotypical parenting attitudes as protective factors in the relationship between gender nonconformity and separation anxiety in children (Santarossa et al., 2019). Further, less gender-stereotypical parental attitudes and willingness of the parent to provide a secure base for their child were protective factors in the relationship between gender nonconformity and poor psychological well-being among 6- to 12-year-olds (MacMullin et al., 2021). Relatedly, another study found that parents of gender-nonconforming children who contacted an affirmative program (vs. a community sample of parents and university students) reported more tolerant and accepting attitudes of gender nonconformity, and gender nonconformity was not a predictor of children’s behavioral and emotional challenges in this sample (Hill et al., 2010).

Given previous findings highlighting the impact that social variables have on the relationship between gender nonconformity and poor psychological well-being in children, it is vital that future work aim to increase societal acceptance. In particular, intervention work is needed to improve children’s appraisals of gender nonconformity as well as to support parents in providing a secure base for their child and implementing gender-liberal parenting practices (MacMullin et al., 2021). A recent study found that children who had undergone a social gender transition experienced comparable rates of behavioral and emotional challenges to children who were cisgender and gender-nonconforming (Wong et al., 2019). Thus, it is important that efforts made to reduce the mental health risks faced by gender-nonconforming children apply to all children who vary in their gender expression and/or identity, independent of their transition status.

Notably, Kwan et al. (2020) recently showed that it is possible to improve 8- to 9-year-old children’s appraisals of gender-nonconforming peers. Kwan et al. implemented an experimental vignette design that involved showing children hypothetical peers who displayed some gender-nonconforming preferences, some gender-conforming preferences, and gender-neutral positive attributes. This experimental vignette design was associated with more positive appraisals of gender-nonconforming peers (see the Spotlight Feature in Chapter 10 for more details). Additionally, Lamb et al. (2009) taught children to challenge peers’ sexist remarks, which led children to challenge peers’ sexist remarks more frequently. Future intervention work aiming to build off of these approaches may be one important means of enhancing social acceptance and well-being of gender-nonconforming children.

Spotlight references

• Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms and profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families.

• Adelson, S. L. (2012). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. The American Academy of Child and Adolescent Psychiatry, 51(9), 957–974.

• Aitken, M., VanderLaan, D. P., Wasserman, L., Stojanovski, S., & Zucker, K. J. (2016). Self-harm and suicidality in children referred for gender dysphoria. Journal of the American Academy of Child Adolescent Psychiatry, 55(6), 513–520.

• Braun, S. S., & Davidson, A. J. (2017). Gender (non)conformity in middle childhood: A mixed methods approach to understanding gender-typed behavior, friendship, and peer preference. Sex Roles, 77(1–2), 16–29.

• Cohen-Kettenis, P. T., Owen, A., Kaijser, V. G., Bradley, S. J., & Zucker, K. J. (2003). Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: A cross-national, cross-clinic comparative analysis. Journal of Abnormal Child Psychology, 31(1), 41–53.

• Coyle, E. F., Fulcher, M., & Trübutschek, D. (2016). Sissies, mama’s boys, and tomboys: Is children’s gender nonconformity more acceptable when nonconforming traits are positive? Archives of Sexual Behavior, 45(7), 1827–1838.

• Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43(5), 460–467.

• Hill, D. B., Menvielle, E., Sica, K. M., & Johnson, A. (2010). An affirmative intervention for families with gender variant children: Parental ratings of child mental health and gender. Journal of Sex & Marital Therapy, 36, 6–23.

• Jewell, J. A., & Brown, C. S. (2014). Relations among gender typicality, peer relations, and mental health during early adolescence. Social Development, 23, 137–156.

• Kowalski, K. (2007). The development of social identity and intergroup attitudes in young children. In O. N. Saracho & B. Spodek (Eds.), Contemporary perspectives on social learning in early childhood education (pp. 51–84). Charlotte, NC: Information Age Publishers.

• Kwan, K. M. W., Shi, S. Y., Nabbijohn, A. N., MacMullin, L. N., VanderLaan, D. P., & Wong, W. I. (2020). Children’s appraisals of gender nonconformity: Developmental pattern and intervention. Child Development, 91(4), 780–798.

• Lamb, L. M., Bigler, R. S., Liben, L. S., & Green, V. A. (2009). Teaching children to confront peers’ sexist remarks: Implications for theories of gender development and educational practice. Sex Roles, 61, 361–382.

• Langlois, J. H., & Downs, A. C. (1980). Mothers, fathers, and peers as socialization agents of sex-typed play behaviors in young children. Child Development, 51, 1237–1247.

• MacMullin, L. N., Aitken, M., Nabbijohn, A. N., & VanderLaan, D. P. (2020). Self-harm and suicidality in gender-nonconforming children: A Canadian community-based parent-report study. Psychology of Sexual Orientation and Gender Diversity, 7, 76–90.

• MacMullin, L. N., Bokeloh, L. M., Nabbijohn, A. N., van der Miesen, A. I. R., Peragine, D. E., & VanderLaan, D. P. (2021). Examining the relation between gender nonconformity and psychological well-being in children: The roles of parents and peers. Archives of Sexual Behaviour, 50, 823–841.

• Martin, C. L., Andrews, N. C., England, D. E., Zosuls, K., & Ruble, D. N. (2017). A dual identity approach for conceptualizing and measuring children’s gender identity. Child Development, 88(1), 167–182.

• Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38–56.

• Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697.

• Santarossa, A., Nabbijohn, A. N., van der Miesen, A. I. R., Peragine, D. E., & VanderLaan, D. P. (2019). Separation anxiety and gender variance in a community sample of children. European Child and Adolescent Psychiatry, 28(12), 1629–1643.

• Spivey, L. A., Huebner, D. M., & Diamond, L. M. (2018). Parent responses to childhood gender nonconformity: Effects of parent and child characteristics. Psychology of Sexual Orientation and Gender Diversity, 5(3), 360–370.

• Steensma, T. D., Zucker, K. J., Kreukels, B. P. C., VanderLaan, D. P., Wood, H., Fuentes, A., & Cohen-Kettenis, P. T. (2014). Behavioral and emotional problems on the Teacher’s Report Form: A cross-national, cross-clinic comparative analysis of gender dysphoric children and adolescents. Journal of Abnormal Child Psychology, 42(4), 635–647.

• Sullivan, J., Moss-Racusin, C., Lopez, M., Williams, K. (2018). Backlash against gender stereotype-violating preschool children. PLoS ONE, 13(4), e0195503. doi: 10.1371/journal.pone.0195503

• Turban, J. L., & Ehrensaft, D. (2018). Research review: Gender identity in youth: Treatment paradigms and controversies. Journal of Child Psychology and Psychiatry, 59(12), 1228–1243.

• van Beijsterveldt, C. E. M., Hudziak, J. J., & Boomsma, D. I. (2006). Genetic and environmental influences on cross-gender behavior and relation to behavior problems: A study of Dutch twins at ages 7 and 10 years. Archives of Sexual Behavior, 35(6), 647–658.

• van der Miesen, A. I. R., Nabbijohn, A. N., Santarossa, A., & VanderLaan, D. P. (2018). Behavioral and emotional problems in gender-nonconforming children: A Canadian community-based study. Journal of the American Academy of Child and Adolescent Psychiatry, 57(7), 491–499.

• Wallien, M. S. C., Veentra, R., Kreukels, B. P. C., & Cohen-Kettenis, P. T. (2010). Peer group status of gender dysphoric children: A sociometric study. Archives of Sexual Behavior, 39, 553–560.

• Wong, W. I., van der Miesen, A. I. R., Li, T. G. F., MacMullin, L. N., & VanderLaan, D. P. (2019). Childhood social gender transition and psychosocial well-being: A comparison to cisgender gender-variant children. Clinical Practice in Pediatric Psychology, 7(3), 241–253.

• Yunger, J. L., Carver, P. R., & Perry, D. G. (2004). Does gender identity influence children’s psychological well-being? Developmental Psychology, 40(4), 572–582.

Spotlight Feature: Gender and Sexual Diversity in Autism

• Anna I. R. van der Miesen 

1. Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands

   Anna I. R. van der Miesen

As described in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), autism spectrum disorder (ASD) is defined as persistent deficits in social communication and interaction along with restricted, repetitive patterns of behavior, interests, or activities (APA, 2013). ASD is often considered a heterogeneous neurodevelopmental condition with a great variety of manifestations depending on developmental level and severity. The prevalence of ASD in youth is estimated at around 1% with a higher prevalence in youth assigned male at birth as compared to those assigned female at birth (Elsabbagh et al., 2012; Lai et al., 2014; Raina et al., 2017).

The views on gender identity and sexuality in autism have drastically changed over the past decades along with an increasing amount of research, media, and clinical attention to gender identity and sexuality in autistic¹ people (e.g., Dewinter et al., 2013; van der Miesen et al., 2016). While it was at one time questioned whether autistic children could develop a sense of their own gender identity (Abelson, 1981), and sexuality was considerably ignored as a healthy part of autistic people’s lives (e.g., Torisky & Torisky, 1985), nowadays sexuality development and sexual health are considered natural aspects of all individuals and human rights (World Health Organization, 2006). Related, attention to gender identity and sexuality has become more and more part of, for example, education programs for autistic youth (Pugliese et al., 2020) and autism research (Dewinter et al., 2020). This change in views and research attention has resulted in increased knowledge with the main consistent findings of increased gender nonconformity/gender diversity (an umbrella term to capture broad ranges of gender identity variations; Adelson, 2012) and sexual diversity in autistic people as compared to allistic (i.e., non-autistic) individuals (e.g., Byers et al., 2013; Dewinter et al., 2017; van der Miesen et al., 2016).

Research on the apparent co-occurrence of autism and gender diversity in youth has been highlighted in a series of studies, with the start of the literature going back to the 1990s with case descriptions (e.g., Landen & Rasmussen, 1997) of autistic people expressing gender nonconformity or identifying as transgender (an umbrella term for individuals who identify with a gender identity that diverges from their birth-assigned gender). The first systematic study was published in 2010 and found a prevalence of an ASD diagnosis of 7.8% using a diagnostic interview in transgender children and adolescents referred to a gender identity specialty service, which is considerably higher as compared to the estimated general population prevalence rate of ASD (de Vries et al., 2010). More recent studies found even higher prevalence rates of ASD diagnoses in transgender youth, with the most recent systematic study reporting a prevalence rate of 22.5% (Strauss et al., 2017). Other studies employed autism screening questionnaires in transgender youth (e.g., Leef et al., 2019) and found percentages of 13.1–68% using cut-off scores indicative of clinical-range autistic characteristics (for an overview of these studies, see Øien et al., 2018; van der Miesen et al., 2016). Conversely, studies focusing on gender diversity in autistic youth found increased parent-reported and self-reported gender diversity as compared to general population rates (e.g., Strang et al., 2014; van der Miesen et al., 2018a). In addition, one study found a link between gender nonconformity and autistic characteristics in a sample of children from the community (Nabbijohn et al., 2019), which confirmed the previous findings in clinic-based samples. Until now, most studies have focused solely on prevalence rates of the co-occurrence of gender diversity and autism and, therefore, it is unclear why this elevated co-occurrence might exist.

With regard to sexual diversity, most studies on lesbian, gay, and bisexual (LGB) orientations in autistic people have been performed in adults (e.g., George & Stokes, 2018) with a considerable body of research citing a higher prevalence of non-heterosexual or LGB orientations in autistic people as compared to general population rates (for an overview, see Pecora et al., 2020). The studies performed in autistic youth are limited but the first study in autistic adolescents confirmed the findings in autistic adults of LGB orientations being more frequently reported as compared to the general population (Hellemans et al., 2007). Other studies found comparable results with autistic adolescents reporting higher rates of non-heterosexual attractions (May et al., 2017). Similar to the apparent co-occurrence of autism and gender diversity, it is unclear why this increase in sexual diversity is found in autistic people.

The findings of increased gender nonconformity/gender diversity and sexual diversity in autistic people have clinical implications (e.g., Strang et al., 2018). Clinicians who work in gender specialty services should screen for autism and/or autistic characteristics, and those clinicians working with autistic youth should be aware of gender and sexual diversity and should have open conversations about these topics (Strang et al., 2018). It is also important to recognize that gender diversity and sexual diversity might each be disproportionately associated with higher rates of mental health challenges (e.g., Marshal et al., 2011; van der Miesen et al., 2018b). Further, initial findings suggest that being both autistic and gender or sexually diverse might be associated with elevated vulnerability for mental health challenges (e.g., van der Miesen et al., 2018b). Clinicians working with autistic gender and sexually diverse youth should, therefore, be attuned to mental health challenges and the health care needs of the individuals within these layered minority groups.

Spotlight references

• Abelson, A. G. (1981). The development of gender identity in the autistic child. Child: Care Health and Development, 7(6), 347–356.

• Adelson, S. L. (2012). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 51(9), 957–947.

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

• Byers, E. S., Nichols, S., & Voyer, S. D. (2013). Challenging stereotypes: Sexual functioning of single adults with high functioning autism spectrum disorder. Journal of Autism and Developmental Disorders, 43(11), 2617–2627.

• de Vries, A. L. C., Noens, I. L. J., Cohen-Kettenis, P. T., van Berckelaer-Onnes, I. A., & Doreleijers, T. A. H. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disorders, 40(8), 930–936.

• 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.

• Dewinter, J., van der Miesen, A. I. R., & Holmes, L. G. (2020). INSAR Special Interest Group Report: Stakeholder perspectives on priorities for future research on autism, sexuality, and intimate relationships. Autism Research, 13(8), 1248–1257.

• Dewinter, J., Vermeiren, R., Vanwesenbeeck, I., & van Nieuwenhuizen, C. (2013). Autism and normative sexual development: A narrative review. Journal of Clinical Nursing, 22(23–24), 3467–3483.

• Elsabbagh, M., Divan, G., Koh, Y. J., Kim, Y. S., Kauchali, S., Marcin, C., … Fombonne, E. (2012). Global prevalence of autism and other pervasive developmental disorders. Autism Research, 5(3), 160–179.

• George, R., & Stokes, M. A. (2018). Sexual orientation in autism spectrum disorder. Autism Research, 11(1), 133–141.

• Hellemans, H., Colson, K., Verbraeken, C., Vermeiren, R., & Deboutte, D. (2007). Sexual behavior in high-functioning male adolescents and young adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 37(2), 260–269.

• Kenny, L., Hattersley, C., Molins, B., Buckley, C., Povey, C., & Pellicano, E. (2016). Which terms should be used to describe autism? Perspectives from the UK autism community. Autism, 20(4), 442–462.

• Lai, M.-C., Lombardo, M. V., & Baron-Cohen, S. (2014). Autism. Lancet, 383(9920), 896–910.

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

• 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, 7(4), 383–395.

• Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., … Brent, D. A. (2011). Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-analytic review. Journal of Adolescent Health, 49(2), 115–123.

• May, T., Pang, K. C., & Williams, K. (2017). Sexual attraction and relationships in adolescents with autism. Journal of Autism and Developmental Disorders, 47(6), 1910–1916.

• Nabbijohn, A. N., van der Miesen, A. I. R., Santarossa, A., Peragine, D., de Vries, A. L. C., Popma, A., … VanderLaan, D. P. (2019). Gender variance and the autism spectrum: An examination of children ages 6–12 years. Journal of Autism and Developmental Disorders, 49(4), 1570–1585.

• Øien, R. A., Cicchetti, D. V., & Nordahl-Hansen, A. (2018). Gender dysphoria, sexuality and autism spectrum disorders: A systematic map review. Journal of Autism and Developmental Disorders, 48(12), 4028–4037.

• Pecora, L. A., Hooley, M., Sperry, L., Mesibov, G. B., & Stokes, M. A. (2020). Sexuality and gender issues in individuals with autism spectrum disorder. Child and Adolescent Psychiatric Clinics of North America, 29(3), 543–556.

• Pugliese, C. E., Ratto, A. B., Granader, Y., Dudley, K. M., Bowen, A., Baker, C., & Anthony, L. G. (2020). Feasibility and preliminary efficacy of a parent-mediated sexual education curriculum for youth with autism spectrum disorders. Autism, 24(1), 64–79.

• Raina, S. K., Chander, V., Bhardwaj, A. K., Kumar, D., Sharma, S., Kashyap, V., … Bhardwaj, A. (2017). Prevalence of autism spectrum disorder among rural, urban, and tribal children (1–10 years of age). Journal of Neurosciences in Rural Practice, 8(3), 368–374.

• 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.

• 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. Journal of Clinical Child and Adolescent Psychology, 53, 47(1), 105–115.

• Strauss, P., Cook, A., Winter, S., Watson, V., Wright Toussaint, D., & Lin, A. (2017). Trans pathways: The mental health experiences and care pathways of trans young people. Summary of results. Perth, Australia: Telethon Kids Institute.

• Torisky, D. & Torisky, C. (1985). Sex education and sexual awareness building for autistic children and youth: Some viewpoints and considerations. Journal of Autism and Developmental Disorders, 15(2), 213–227.

• van der Miesen, A. I. R., Hurley, H., Bal, A. M., & de Vries, A. L. C. (2018a). 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.

• van der Miesen, A. I. R., Hurley, H., & de Vries, A. L. C. (2016). Gender dysphoria and autism spectrum disorder: A narrative review. International Review of Psychiatry, 28(1), 70–80.

• van der Miesen, A. I. R., Nabbijohn, A. N., Santarossa, A., & VanderLaan, D. P. (2018b). Behavioral and emotional problems in gender-nonconforming children: A Canadian community-based study. Journal of the American Academy of Child and Adolescent Psychiatry, 57(7), 491–499.

• World Health Organization. (2006). Defining sexual health: Report of a technical consultation on sexual health, 28–31 January 2002, Geneva. Geneva, Switzerland: Author.