Autistic Traits in Treatment-Seeking Transgender Adults
Journal of Autism and Developmental Disorders
Autistic Traits in Treatment-Seeking Transgender Adults
Anna Nobili 0 1 2 4
Cris Glazebrook 0 1 2 4
Walter Pierre Bouman 0 1 2 4
Derek Glidden 0 1 2 4
Simon Baron‑Cohen 0 1 2 4
Carrie Allison 0 1 2 4
Paula Smith 0 1 2 4
Jon Arcelus 0 1 2 4
0 Nottingham City Asperger Service, Highbury Hospital , Nottingham , UK
1 Institute of Mental Health, University of Nottingham , Room B12, B Floor, Innovation Park, Triumph Road, Nottingham NG7 2TU , UK
2 Nottingham National Centre for Transgender Health , Nottingham , UK
3 Cris Glazebrook
4 Autism Research Centre, Department of Psychiatry, University of Cambridge , Cambridge , UK
The present study aimed to compare prevalence of autistic traits measured by the self-reported autism spectrum quotientshort (AQ-short) in a transgender clinical population (n = 656) matched by age and sex assigned at birth to a cisgender community sample. Results showed that transgender and cisgender people reported similar levels of possible autistic caseness. Transgender people assigned female were more likely to have clinically significant autistic traits compared to any other group. No difference was found between those assigned male. High AQ scores may not be indicative of the presence of an autism spectrum condition as the difference between groups mainly related to social behaviours; such scores may be a reflection of transgender people's high social anxiety levels due to negative past experiences. Transgender is an umbrella term used to describe individuals whose gender identity does not match their sex assigned at birth based on sexual characteristics. This includes people who do not identify within the binary gender of male and female (non-binary people) (Beek et al. 2015; Richards et al. 2017). Transgender women are those assigned male at birth but who identify as female whilst transgender men are individuals assigned female at birth, who identify as male (Bouman et al. 2017a). Some transgender people access transgender health services as they have a wish to Vol.:(011233456789)
Autism spectrum conditions; Autistic traits; Transgender; Autism spectrum quotient (AQ); Social issues; Social anxiety
The present research was presented as oral presentation at the
EPATH (European Professional Association for Transgender
Health in April 2017; Belgrade, Serbia). The present study is part
of the doctoral dissertation of researcher Anna Nobili.
transition medically to their experienced gender. These
services include cross-sex hormone treatment (CHT) and
referral for gender affirming surgeries, among other supports
(Coleman et al. 2012)
Transgender people attending transgender health services
experience high levels of mental health problems,
including anxiety, depression and self-harm
(Arcelus et al. 2016;
Bouman et al. 2017b; Claes et al. 2015; Davey et al. 2016;
Dhejne et al. 2016; Heylens et al. 2014; Millet et al. 2017)
In addition, recent reports have hypothesised high levels of
autistic traits amongst transgender people attending gender
(Glidden et al. 2016)
. However, the populations
selected and the lack of appropriate comparison groups
of cisgender participants (individuals whose experienced
gender matches their sex assigned at birth) limit the results
of many of these studies
(Glidden et al. 2016; Strang et al.
2014; Shumer et al. 2015; Jacobs et al. 2014)
Literature on the prevalence of autistic traits showed that
a large number of individuals displaying non-autistic
psychopathology scored in the clinical range of ASC screening
instruments without dealing with true ASC
(Pine et al. 2008;
Tonge et al. 2016; White et al. 2012)
. Despite these
findings, there are strong clinical impressions suggesting a high
prevalence of autistic traits in clinical transgender
populations are supported by a number of published case studies
looking at both children and adults and by a few quantitative
(Kraemer et al. 2005; Lànden and Rasmussen 1997;
Lemaire et al. 2014; Mukkades 2002; Parkinson 2014;
Robinow 2009; Tateno et al. 2008; Vanderlaan et al. 2015)
recent systematic review exploring the frequency of autism
spectrum disorder (ASD) or autism spectrum conditions
(ASC) in transgender people suggested the presence of a
relationship between being transgender and presenting with
autistic traits in children and young people (Glidden et al.
2016). However, evidence to support the assumption of an
excess of autistic traits in adult populations is still lackin
(Jones et al. 2012
; Pasterski et al. 2014).
Three adult studies assessed rates of autistic traits in the
transgender populations. All three studies used versions of
the autistic spectrum quotient (AQ)
(Baron-Cohen et al.
. The AQ is a self-report instrument used to quantify
autistic traits in adults of average or above average
(Baron-Cohen et al. 2001)
. As the AQ-short is not
a diagnostic tool, the definition of caseness might be
misinterpreted as a diagnosis of this condition; thus caution is
needed when interpreting the results
(Hoekstra et al. 2008,
2011; Wheelwright et al. 2010)
AQ items are summed to give a total score, with
suggested cut-offs for potentially clinically significant ASC. The
scale measures two main higher order factors that related to
represent areas describing either difficulties or core traits
that are typically present in people with ASC; hence
difficulties in social behaviours and a fascination with number and
patterns. The first factor is further divided into subdomains
relating to social skills and communication, attention
switching and to detail, routine behaviours, and imagination.
Although there is no evidence that adult transgender
populations as a whole have higher AQ scores compare to
cisgender populations, the findings from all three studies
suggest that transgender populations assigned female sex at
birth may have elevated levels of autistic traits compared to
gender females (Jones et al. 2012
; Kristensen and Broome
2016; Pasterski et al. 2014).
Jones et al. (2012) compared autistic traits in a clinical,
adult transgender sample with 61 transgender men (mean
age 34 years) and 198 transgender women (mean age
45 years) to a cisgender (where the person’s gender matches
the sex they were assigned at birth) control group (mean
age 37 years) drawn from the general population (76
cisgender males, 98 cisgender females). Higher AQ scores in the
transgender group were accounted for by a highly significant
interaction between sex assigned at birth and transgender
status. Transgender men (also referred to as female to male
transgender people) had higher AQ scores compared to
typical cisgender females with a large effect size (d= 1.0), but
there was no difference between transgender women (also
referred to as male to female transgender people) and typical
cisgender males. Nearly 30% of transgender men had scores
above 28 on the AQ putting them more than two standard
deviations above a typical population mean and suggesting
they fell within the autistic phenotype compared to only 2%
of cisgender females. For transgender women the
comparable rate was 5% and for cisgender males it was 6.6%.
Pasterski et al. (2014) compared 91 transgender
individuals (63 transgender women and 28 transgender men; mean
age 36.5 years) attending a transgender health service to a
community control group. The study found no difference in
total AQ scores between cisgender and transgender groups
regardless of sex assigned at birth, but transgender males
scored significantly higher in the social skills (d = 0.44)
and attention switching (d = 0.68) sub-domains compared
to cisgender females. These differences were not observed
in transgender women using a validated cut-off of 32+
(Woodbury-Smith et al. 2005)
. Seven point one percent of
transgender men had AQ scores that might indicate the
presence of a clinical diagnosis of ASC compared to only 1% in
cisgender women, although this difference was not
significant. For transgender females and cisgender males the rate
was 4.7 and 3.9% respectively.
Finally, an online survey through social media of 446
adults, who self-identified as transgender
found that respondents assigned female sex
at birth had significantly higher AQ scores as assessed by the
(Allison et al. 2012)
compared to transgender
respondents assigned male sex at birth. This study found
high rates of ASC, but did not include a cisgender
comparison group. Nearly 40% of the sample scored above the
AQ-10 cut-off, indicating risk for possible clinical ASC
and 14% self-reported a clinical diagnosis of ASC (17%
for assigned females at birth and 10% for assigned males at
birth). These values are considerably higher than the
prevalence of ASC in the general population, which is estimated
at 1.5% for men and 0.2% for women
(Brugha et al. 2011)
Therefore, the existing evidence suggests that the high
rates of autistic traits found in studies including adult
transgender people appears to apply to those assigned a
female sex at birth
(Jones et al. 2012)
. This may be explained
by the extreme male brain theory (EMB)
, which suggests that a higher number of autistic traits
is associated with exposure to higher levels of foetal
(Auyeung et al. 2009; Baron-Cohen et al. 2015)
Affected individuals may therefore have more traits
associated with a ‘male brain’ such as an increased drive to
systemize and lower levels of empathy (Baron-Cohen 2003).
Only one study has used the AQ to investigate which
specific autistic traits are particularly prominent in
(Pasterski et al. 2014)
. This study did not
exclude participants who had received cross-sex hormone
therapy before their first assessment at the transgender health
service. As cross-sex hormone therapy reduces anxiety this
may have a direct effect on social skills (e.g. increase in
social confidence and social functioning, experiencing fewer
problems with socialisation and less social distress), one of
elevated autistic traits
(Bouman et al. 2016a, 2017b;
GómezGil et al. 2012)
. Other limitations in the small existing
literature are lack of an adequate cisgender comparison group
and small, poorly matched samples.
In view of the above limitations and in order to investigate
whether there is any validity to clinicians’ impressions of
higher autistic traits among the adult transgender
population attending transgender health services, this study aims
to compare the frequency of autistic traits in a large
representative sample of patients attending a transgender health
service to a large cisgender community population matched
by age and sex assigned at birth. Additionally, the study
aims to compare the profile of autistic traits between the two
samples stratified by sex assigned at birth. Based on
(Jones et al. 2012; Pasterski et al. 2014)
, it is
hypothesised that transgender participants assigned female
at birth will have higher total scores on a measure of autistic
traits compared to cisgender females.
Transgender group: All patients (n = 1020) invited to attend
an initial assessment at a national adult transgender
healthcare service in the UK between November 2012 and July
2016 were invited to participate in the study. Of these, 1002
(98.2%) consented. People on cross-sex hormone previous
to assessment were excluded (n = 293) and data were
missing from 48 people. Therefore a total of 661 (69.6%) were
included in the study and eligible for matching.
Cisgender group: The control group consisting of
cisgender individuals was drawn from a community sample
recruited through the Cambridge Psychology (http://www.
cambridgepsychology.com) website. This is a general
psychology research website for adults, which aims at recruiting
individuals in the general population who wish to take part
in research studies. People become aware of this website
by word of mouth and online searches. Participants who
self-identified as transgender were excluded from the control
group. Thus, a total sample consisting of 4070 cisgender
people was considered for matching.
Transgender participants were recruited from the
Nottingham Centre for Transgender Health in the UK. This is a
nationally commissioned service for people living in
England and Wales. The centre is one of the largest transgender
health clinics in Europe, receiving more than 1000 referrals
annually of people over the age of 17 years. The transgender
health clinic’s treatment programmes incorporate
assessment for treatment suitability, psychological support (if
needed), cross-sex hormone therapy and provides patients
with referrals for gender affirming surgeries.
A case–control design was used for this study. Transgender
participants were matched with cisgender participants 1:1
for age and sex assigned at birth by a researcher (AN) blind
to AQ score. Of 661 eligible participants in the
transgender group it was possible to find 656 sex assigned and age
matched controls from the cisgender sample. Participants
were matched by sex assigned at birth in order to not exclude
non-binary identities, when matching to the cisgender group.
Main Outcome Measures
Autism Spectrum Quotient Short Version—AQ-Short
(Hoekstra et al. 2011)
The AQ-short is a self-administered 28-items scale designed
to measure autistic traits in individuals with normal
intelligence and thus to give an indication of where a person lies
on the continuum of the spectrum, ranging from healthy to
(Woodbury-Smith et al. 2005)
. The AQ-short is a
shortened form of the well-validated AQ-50
et al. 2001)
and was developed by selecting the 28 most
relevant items with the aid of factor analysis. It comprises
two higher order factors related to autistic traits, including
numbers and patterns, which assesses the extent to which
people are fascinated by numbers, dates, patterns and
categories, and social behaviours. The social behaviours factor
represents skills related to social functioning and it
comprises four subscales: (1) social skills, which assesses
abilities and struggles in social interactions, (2) routine, which
assesses the extent to which people use routine to manage
new situations, (3) switching, which assesses how easily
people can move from one demand to another as well as
attention switching difficulties, and (4) imagination, which
assesses the extent to which people can understand others’
perspectives, intentions as well as to create mental pictures
(also known as empathic imagination). The latter subscale is
also related to theory of mind (ToM)
Hence, the AQ-short captures difficulties or core traits
typically found in people with autism, such as adapting to
change, developing less rigid mental and behavioural
flexibility as well as social skills
(Hoekstra et al. 2008)
. Like the
AQ-50, the AQ-short utilises a 4-point Likert scale ranging
from “definitely agree” to “definitely disagree”. Item scores
were reversed as appropriate so that higher values equated to
more autistic traits. Total scores range between 28 and 112.
Although not intended to be diagnostic tool, a cut-off of ≥70
was found to have a sensitivity of 0.94 and specificity of 0.91
to discriminate between an autism sample and a community
sample. Cronbach’s alphas ranged between 0.77 and 0.86
(Hoekstra et al. 2011)
Transgender participants were invited to complete a series
of questionnaires as part of a longitudinal study prior to
the first assessment appointment. The questionnaire
package included socio-demographic information and the
AQshort. Information regarding cross-sex hormone treatment
was also collected. Cisgender participants completed an
online version of the AQ-50 and provided
socio-demographic information. AQ-short items were extracted from
the AQ-50 for the cisgender group
(Hoekstra et al. 2011)
and total AQ-short scores, factor scores and subscale
scores were calculated for each participant. Participants
in the transgender group meeting inclusion and exclusion
criteria were matched blind 1:1 by age and sex assigned
at birth with participants in the control group (see Fig. 1).
Ethical approval was received for the study from the
NHS Ethics Committee (14/EM/0092) and by the Research
and Development Department of the Nottinghamshire
Healthcare NHS Foundation Trust in line with the Health
Research Authority guidance
No match found N=5
Sample 4070 people 656 pairs matched
Sample 1020 people
Available for matching
18 No consent
48 Missing values
Data analyses were performed using the Statistical
Software Package SPSS 23
. First, frequencies and
descriptive statistics were applied to the samples. As the
variables were normally distributed, parametric analyses
were performed. Chi square analysis was used to compare
possible ASC caseness (AQ-short ≥ 70) between the groups
and odds ratios calculated to express the likelihood of
possible ASC caseness occurring in one group compared to
. Paired t-tests were used to compare
AQ-short scores between groups. Independent t-tests were
used to ascertain differences in groups between assigned
females and assigned males at birth. An analysis of variance
(ANOVA) with age as a covariate was carried out to explore
potential interactions between group and sex assigned at
birth. Finally, Cronbach’s alphas were executed to determine
if the AQ-short is a reliable measure for use with transgender
populations attending clinical services. The level of
significance used for the statistical analyses was p < 0.05.
Socio‑demographic Characteristics of the Matched
A total of 1312 people participated in the study (656
transgender and 656 cisgender). The mean age for each
group was 28.28 years (SD = 12.25, range 16–74 years). A
total of 260 people (39.6%) in each group were assigned
female at birth whilst 396 (60.4%) were assigned male.
There was a significant difference in employment status
between the groups (χ2 = 144.85, df = 3, p < 0.001) with
more unemployed participants in the transgender group and
more students in the cisgender group (Table 1).
Differences in Clinical Caseness Between Groups
Within the cisgender group 218 people (33.2%) were found
to have scores at or above 70, indicating possible ASC
caseness, compared to 238 (36.3%) in the transgender group
(Table 2). The difference between the groups was not
statistically significant (χ2 = 1.344, df = 1, p = 0.271).
When comparing participants assigned female sex at
birth, a statistically significant difference was found between
groups with 45% of the transgender group scoring ≥ 70 in
total AQ scores, compared to 30% in the cisgender group
(30%) (χ2 = 13.102, df = 1, p < 0.001). This represents
nearly twice the risk of scoring above the screening cut-off
(OR = 1.939, 95% CI 1.35–2.78, p < 0.001) for the
transgender group. There was no difference between groups for
assigned males at birth (χ2 = 2.29, df = 1, p = 0.15).
Taking the group as a whole, the transgender group had
statistically significantly lower AQ-short total scores compared
to cisgender people [t(1188) = 1.96, p = 0.05, two tailed], but
the effect size was small (d= 0.11). The transgender group
had slightly, but statistically significantly higher scores for
the higher order factor of Social Behaviour (p = 0.004) and
lower scores for the higher order factor of numbers and
patterns (p < 0.000). Analyses of the Social Behaviour subscale
scores found that the transgender group had higher scores,
indicating more difficulties with the social skills, routine and
switching. However, they reported lower scores for
Imagination subscale and the higher order factor of numbers and
N = 656
patterns suggesting fewer problems with understanding the
perspective of others and less preoccupation and/or
fascination with logical sequences related to numbers and patterns
To test the hypothesis that higher levels of autistic traits
are found in transgender participants who were birth
assigned females compared to cisgender females, a two
way ANOVA was carried out with total AQ-short as the
dependent variable and sex assigned at birth (male/female)
and group (transgender/cisgender) as the independent
factors. Age was included as covariate. There were no main
effects of sex assigned at birth or group, but there was a
statistically significant interaction between the variables
[F(11307) = 22.006, p < 0.001] (Fig. 2). The covariate was
not significant [F(11307) = 0.195, p > 0.05] indicating that
age was unrelated to AQ-short total scores. Post hoc analyses
found that birth assigned females in the transgender group
had higher total scores (d = 0.2, p = 0.22) compared to the
cisgender group, whilst for birth assigned males the
cisgender group had higher scores (d = − 0.32, p < 0.001) (Table 4).
Analysing the factors separately suggested that higher
AQ-short scores for the transgender group within the birth
assigned females were due to substantially higher scores for
social behaviour. For assigned males there was no significant
Birth assigned females
(n = 520)
n = 260
n = 260
Birth assigned males
(n = 792)
Effect size Trans
Cohen’s d n = 396
n = 396
difference in social behaviour scores between the groups.
For numbers and patterns the cisgender group had higher
scores regardless of gender. In terms of subscales, there
was a significant group difference in social skills for birth
assigned females, but not birth assigned males. For other
subscales the pattern of differences was similar for birth
assigned males and birth assigned females, with higher
scores in the transgender group for Routine and Switching
and higher sores in the cisgender gender group for
Imagination and numbers and patterns (Table 4).
Finally, Cronbach’s alphas for internal consistency were
carried out to investigate if the AQ-short is a reliable
measure for use with transgender populations. The AQ-short
scale was found to have good internal consistency for the
transgender group (28 items; α = 0.845) and acceptable
internal consistency with the cisgender sample (28 items;
α = 0.674).
Clinical reports and previous studies have suggested the
existence of high levels of autistic traits among transgender
people attending clinical services seeking gender affirming
(Glidden et al. 2016)
previous studies have investigated levels of ASD in children
attending gender identity services
(de Vries et al. 2010)
very few have focused on the adult population. Those
studies recruiting adult transgender people, whether via
clinical services or online surveys, have reported high levels of
autistic traits and diagnoses
(Kristensen and Broome 2016;
Pasterski et al. 2014)
. However, those studies have failed to
compare their results with a matched controlled population
of cisgender people. The need for matching in this field is
particularly important as autistic traits are higher on
average amongst males
(Baron-Cohen et al. 2001; Baron-Cohen
. Therefore, with the aim of investigating the levels of
autistic traits in the transgender population attending
services and whether those traits were different to a matched
cisgender group, this study recruited a large population of
treatment-seeking transgender adults and compared them to
a large cisgender control group.
The study found that when comparing both groups there
were no significant differences in the number of people
who presented with scores suggesting a possible diagnosis
of ASC. In fact, the levels of possible caseness of ASC was
found to be high in both groups, with nearly a third of
participants in both the transgender (36.3%) and the cisgender
(33.2%) groups scoring above the clinical cut-off for
possible ASC caseness. The findings of this study suggest higher
prevalence rate of possible ASD cases among transgender
individuals than some studies
(Pasterski et al. 2014)
lower than others
(Jones et al. 2012; Kristensen and Broome
. The sampling techniques and different cut-offs used
by previous studies make direct comparisons difficult.
However, the general clinical impression of an
over-representation of people displaying autistic traits among transgender
clinical populations when compared to cisgender people
from the general population (Glidden et al. 2016) was not
confirmed by the findings of the present study.
This study confirmed previous findings from adult
studies that there is no evidence of increased rates of autism
in transgender populations as a whole. It should be noted
that the number of possible ASC caseness in both
cisgender and transgender people is significantly higher than the
prevalence of ASC which has been estimated at 1.1% in
the general population
(Brugha et al. 2011)
. Thus, the large
number of cisgender people with possible ASC may have
affected the results of the study. A possible explanation may
be that the AQ demonstrates a stronger negative predictive
value for ASC than a positive predictive value in the
samples. The AQ being a screening tool rather than a diagnostic
tool fits with this interpretation. Studies investigating levels
of ASD in the general population have found similar rates
of clinical ASD caseness
(Kristensen and Broome 2016)
Hoekstra et al. (2011) developed and validated the AQ-short
and found that both UK and Dutch control samples reported
average AQ-short total scores of approximately five points
lower than our cisgender sample.
It was when exploring the results according to gender
that the findings become more significant. Although no
differences were found between people assigned male at birth
(possible transgender female and/or non-binary people) and
cisgender males, a significant difference was found when
comparing people assigned female at birth. The study found
that within people assigned female at birth the transgender
group (possible transgender males and/or non-binary people)
was about twice as likely to have clinically significant levels
of autistic traits compared to cisgender females. This is in
keeping with the findings of previous research using
different versions of the same measure (AQ)
(Jones et al. 2012;
Kristensen and Broome 2016; Pasterski et al. 2014)
regard to the cisgender sample the findings of the present
study appear to support previous research suggesting the
presence of a male bias in the presentation of autistic traits
(i.e., EMB theory)
(Baron-Cohen et al. 2001; Baron-Cohen
2002; Hoekstra et al. 2008, 2011)
With regard to the transgender sample, the present results
suggesting that transgender assigned females at birth suffer
from higher overall autistic traits than transgender assigned
males at birth are partially in line with findings of previous
(Kristensen and Broome 2016; Jones et al. 2012)
A possible explanation for this might still be the
abovementioned EMB theory (Baron-Cohen et al. 2001), which
posits that assigned males at birth are more likely to and
have the tendency to suffer from higher levels of autism.
Consequently, transgender men might also face more social
difficulties and worries related to having to change
genderroles and thus gender-specific behaviours (e.g. not feeling
masculine enough, fear of being perceived as female), which
might lead to experiencing higher levels of social anxiety.
These results are in conflict with past literature suggesting
higher levels of social anxiety in transgender women due to
the reduced social acceptance of gender variant behaviours
amongst assigned males than assigned females (e.g. society
being more accepting of masculinity than femininity)
et al. 2017)
. Future research should try to properly
understand the different impact of autistic traits onto transgender
assigned females as well as on assigned males at birth.
There is a feeling amongst clinicians that current
screening and diagnostic tools may be biased towards identifying
and diagnosing assigned males. As a consequence, assigned
females have been under diagnosed by current clinical
(Gould and Ashton-Smith 2011; Lai et al. 2011; Brugha
et al. 2016)
The present study also examined AQ-short subscale
scores to understand differences in autistic traits between
groups. The study found that there were differences in the
autistic traits between groups. Transgender people
(particularly those assigned female at birth) were found to have
specific difficulties in relation to social behaviours,
including social skills, mental flexibility and problems switching
attention, the disruption of which could lead to increments
in anxiety levels
. These findings could be
associated with social anxiety, which is known to be highly
prevalent among the transgender population
(Millet et al.
. The transgender group, however, reported fewer
difficulties in relation to other autistic traits of poor imagination,
and fascination with numbers and patterns. Therefore, there
may be a confounding element where the transgender sample
scored higher on the AQ without the presence of ASC. This
may indicate that some transgender people do not really
present with ASC but the high levels of social difficulties due
to anxiety, depression and years of victimisation may affect
the way they interact with others, as suggested by
and van Schalkwyk (2018
). In fact interpersonal difficulties
among this population have already been described
et al. 2016)
. However, this would not explain higher scores
on attention switching or attention to detail.
Enhanced scores on the subscales for routine and
attention switching in the transgender population might be linked
to the elevated social anxiety symptomatology experienced
by this population. In fact, previous research has suggested
that autistic individuals report similar scores on the attention
switching subscale of the AQ-50 to people with a diagnosis
of social anxiety disorder
(Cath et al. 2008)
. They also stated
that socially anxious people have been found to display
higher scores than non-clinical controls
(Cath et al. 2008)
Thus, high scores on the routine subscale might reflect an
increase in social anxiety levels due to the social
difficulties related to changes in routine behaviours (e.g. switching
gender roles, which imply learning and practicing
different gender-specific behaviours), whilst high scores on the
attention switching subscale might indicate difficulties in
altering the focus of attention from negative and
anxietyproducing experiences (e.g. being looked at in the street
might lead to an increase in social anxiety levels due to the
transgender individual’s fear of being recognised as trans)
to more positive and adaptive coping behaviours (e.g. taking
into consideration that being looked at in the street might
be due to reasons other than the person being recognised as
transgender). Transgender people are known to face these
social challenges during the time of transition
and D’augelli 2006)
, which might result in them scoring
higher than cisgender people on the subscales related to such
As suggested by
individuals’ extreme marginalisation and vulnerability might lead
them to experience increased psychological, health and
especially social isolation, when compared to other social
groups. Consequently, some transgender people might
score particularly high on some AQ-short items and
subscales because of their dysphoria and related anxiety as
well as negative past experiences (e.g. transphobia,
(Skagerberg et al. 2015)
. Thus, certain scores on the
AQ-short might simply indicate increased social difficulties,
which would increase their AQ-short total scores reaching an
ASD caseness level, while not being driven by the presence
of ASC. This idea is supported by literature investigating
autistic traits in socially anxious populations with the use
of both AQ-50
(White et al. 2012)
et al. 2016)
. These studies suggested that the scores in the
subscales related to social functioning and behaviours might
be inflated by the difficulties experienced in social
interactions and that scores on the AQ subscales related to social
functioning need to be interpreted with caution when the
subjects display marked social difficulties
(Tonge et al. 2016;
White et al. 2012)
. Against this, studies recruiting those with
social anxiety may well be sampling individuals who have
higher levels of autistic traits. It will be important to try to
disentangle these in the future.
Notwithstanding the strengths of the present research
(e.g., large sample size, matched controls, and
homogeneity of sample in terms of treatment status), there are several
limitations. First, as a case–control study was adopted
participants should have been matched on additional variables
other than age and sex assigned at birth (e.g., IQ,
educational level) to properly eliminate the issue of confounding
and gaining appropriate efficiency. Second, as previously
discussed the AQ-short is a self-reported assessment tool
for autistic traits instead of a diagnostic tool. Third, the data
relative to the cisgender participants was gained through the
“Cambridge Psychology” website and snowballing sampling
and response bias might have biased the results as high
levels of autistic traits were found in this population. Fourth,
transgender and cisgender groups completed different
versions of the AQ, which might have had an impact on how
the participants approached and answered the items of the
scale, although the items collected from the AQ-50 were the
same as per the AQ-short.
Future studies may focus on analysing the role of gender
affirming treatment (cross-sex hormones) in autistic traits
as measured by the AQ. It has been noted clinically that
transgender people with a previous diagnosis of ASC express
fewer and less obvious autistic traits following medical
transition. This has raised questions about the diagnostic safety
of an ASC diagnosis made in transgender people. Studies
which include diagnostic tools such as a clinical interview
and/or formal diagnostic tools such as the Autism Diagnostic
(ADI-R—Lord et al. 1994)
Diagnostic Observation Schedule
(ADOS—Lord et al. 2002)
Diagnostic Interview for Social and Communication
(DISCO—Wing et al. 2002)
and which control for
transitional status and anxiety are needed to fully explore the
nature of elevated autistic traits in transgender populations.
Overall, this study found that autistic traits appear to be
more prevalent in transgender people assigned female at
birth, but not in those assigned male at birth. The autistic
traits found in both groups appear to be particularly
connected to social skills, which may be associated to the high
levels of anxiety and low self-esteem that this group often
(Claes et al. 2015; Bouman et al. 2016b, 2017b;
Millet et al. 2017)
. As transgender people displayed issues
with the social features of ASC whilst reduced difficulties
with autistic traits that may be less likely to be mimicked
by the experience of gender dysphoria, undergoing gender
affirming medical treatment might have a positive impact
by improving interpersonal skills and social interactions.
Longitudinal studies investigating the role of cross-sex
hormone treatment on autistic traits are therefore needed as they
may help reaching more robust evidence as to whether the
observed autistic traits equate to clinical ASC or not.
Author Contributions AN, CG & JA designed the study, analysed the
data and wrote the article; WPB and DG provided clinical advice on
the interpretation of the analyses and reviewed the article; SB, CA
and PS advised on the analysis of the cisgender dataset and reviewed
Funding Funding was provided by Leicester Partnership NHS Trust
(Grant No. ID0E2OBG7892).
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://creativeco
mmons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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