Introduction
Gender diversity, gender dysphoria and gender incongruence definitions
Gender identity is the internal sense of the self as male, female, both, neither, or something else (American Psychological Association, 2015). Gender identity can be the same as sex assigned at birth or it can differ. It is a diverse experience, with all individuals experiencing their gender identity in a unique way, being in different places on spectra of masculinity and femininity. These experiences are not exclusive to people who self-define as transgender or gender diverse (American Psychological Association, 2015). In modern Northern European majority communities, people who identify a difference between their internal sense of gender and the sex that was assigned to them at birth are often identified as transgender or gender diverse (TGD). This TGD term is used inclusively in this paper to refer to people who are transgender, non-binary, agender, gender fluid and a wide range of other non-cis-gender experiences of gender identity.
Gender dysphoria occurs when people experience discomfort or distress, socially or in relation to their body, because there is a mismatch between their gender identity and their sex assigned at birth (this does not occur for all individuals who identify as TGD) (NHS, 2020). Gender diversity is not a mental illness and is a normal and natural part of human diversity. For some people (not all), its resolution requires medical interventions, and, for this purpose, the International Classification of Diseases (ICD-11) defines gender incongruence as: ‘a marked and persistent incongruence between an individual’s experienced gender and the assigned sex, which often leads to a desire to “transition”, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual’s body align, as much as desired and to the extent possible, with the experienced gender’ (ICD-11 HA60).
Neurodiversity definition
There has been a recent shift from the deficit-based medical model of autism as defined by the DSM-V (2013), to understanding autism as part of the neurodiversity paradigm. Neurodiversity coined by Singer (Reference Singer2017), is described as the natural variation in human brain development, which refers to the differing experiences of individuals interacting with the world (Pellicano and den Houting, Reference Pellicano and den Houting2022). Neurodivergence is inclusive of a range of neurodevelopmental differences such as autism, attention deficit hyperactivity disorder (ADHD), Tourette’s syndrome and dyslexia, amongst others. This paradigm considers the diversity and strengths and difficulties with which an individual may present. Within this paradigm, autism is understood as differences in social interaction and communication, the double empathy problem, differences in attention (monotropism), sensory differences and certain preferences for routine and structure. Farahar and Foster (Reference Farahar and Foster2019) propose a model of three-dimensional autistic space to consider how an individual’s specific circumstances (such as physical environment, family dynamics, mental and physical wellbeing) will influence how autism impacts upon them. It builds on the idea of the spectrum, whilst also incorporating fluctuations across the lifespan, in resources and coping.
In this paper, autism is the main focus under the neurodevelopmental paradigm, due the relatively high prevalence rates of autism and gender diversity. There are other conditions which highly co-occur for this group of individuals (such as attention deficit hyperactivity disorder, ADHD; Thrower et al., Reference Thrower, Bretherton, Pang, Zajac and Cheung2020; Warrier et al., Reference Warrier, Greenberg, Weir, Buckingham, Smith, Lai and Baron-Cohen2020), and this is considered within the limitations of this paper.
Prevalence rates
There is increasing evidence of a high prevalence of neurodivergent diagnoses, in particular autism, in the gender diverse population (Murphy et al., Reference Murphy, Prentice, Walsh, Catmur and Bird2020; Thrower et al., Reference Thrower, Bretherton, Pang, Zajac and Cheung2020). Warrier et al. (Reference Warrier, Greenberg, Weir, Buckingham, Smith, Lai and Baron-Cohen2020) found that individuals are 3–6 times more likely to identify as transgender if they are autistic. In the survey ‘Autistic Not Weird’ from Bonnello (Reference Bonnello2022) (n = 11,212), 92.32% of respondents identified as neurodivergent and of those respondents, 18.70% identified as transgender. In further research, the prevalence rates for autistic transgender individuals were found to be between 6 and 26% and few studies examined the rates for ADHD transgender individuals (Thrower et al., Reference Thrower, Bretherton, Pang, Zajac and Cheung2020). In addition, Strang et al. (Reference Strang, Meagher, Kenworthy, de Vries, Menvielle, Leibowitz and Anthony2018a) explored autistic traits in gender diverse individuals who defined ‘a wish to be the other gender’, which found that gender diversity was higher in children with a diagnosis of autism (5.4%) than children with ADHD (4.8%).
Bouzy et al. (Reference Bouzy, Brunelle, Cohen and Condat2023) discuss some of the theories which propose to explain this co-occurrence, such as differences in social norms within the autistic community, leading to less identification with gender norms and ‘less pressure to conform to these norms’, which, they suggest, may allow for greater gender diversity in autistic individuals. In reality, these are largely theories created about autistic TGD people and not by them and may be limited in not understanding the autistic TGD experience from the individuals themselves. Research from Özel et al. (Reference Özel, White, Clark, Indremo, Zejlon, Rüegg and Papadopoulos2025) showed the high co-occurrence of autism and gender dysphoria, but showed no difference in gender incongruence rates between autistic and non-autistic people who are gender dysphoric. There is no accepted causal theory for the intersection between autism and TGD supported by evidence (Gratton et al., 2023), but after decades of research in the field from gender and autistic pathologising and non-pathologising research groups, this is likely to be because no such causal explanation exists. The authors postulate that it is a basic error of scientific thinking to discover a correlation and assume causation. Furthermore, the potential impacts of perpetuating this error in modern healthcare practice could have significant negative impacts on the lives of autistic TGD people, by experiencing barriers to accessing gender affirming care, and difficulties from clinicians and service users in understanding each other (Cooper et al., Reference Cooper, Mandy, Butler and Russell2023).
Gratton et al. (2023) explored the intersection between autistic and TGD experiences and the expert panel concluded some findings; notably, the importance of respecting TGD autistic people’s wellness and resilience whilst also acknowledging the difficulties, discrimination and stigmatisation they may face: that autistic gender-diverse people are experts in their own identity and should be involved in all aspects of research and clinical care. Furthermore, neurodivergent affirming strategies were considered imperative to reduce barriers and improve access to necessary support, whilst also improving communication between healthcare professionals and service users. Botha and Gillespie-Lynch (Reference Botha and Gillespie-Lynch2022) discuss autistic identity development and the importance of understanding intersectionality in the context of someone’s autism, exploring racial-ethnic minorities and gender and sexual minorities. They posit that using an intersectional lens, clinicians can become more flexible in their understanding of positive autistic identity development and strategies to promote it. There is also emphasis on the importance of autistic community and collectivism. Further research from Cooper et al. (Reference Cooper, Mandy, Butler and Russell2023) demonstrated how autistic TGD adults felt it was important to understand their autism as part of their identity and how it intersects with other parts of themselves. Another consideration is research looking at length of time since diagnosis of autism, and that over time, individuals assimilate their diagnosis into their understanding of themselves, whilst those with a relatively recent diagnosis, may find it more challenging to integrate how autism is understood and relates to themselves (Oredipe et al., Reference Oredipe, Kofner, Riccio, Cage, Vincent, Kapp, Dwyer and Gillespie-Lynch2022).
Pearson and Rose (Reference Pearson and Rose2021) highlight the higher vulnerability of discrimination and harassment due to being in a minoritised group and the consequent importance of raising awareness of the correlation between gender diversity and autism for healthcare professionals in assessing risk. Research from Hellström (Reference Hellström2019) emphasised the prevalence of TGD autistic people discussing distress in therapy, the role of their embodied experience in their life narrative, and the impact that this has on their mental health cannot be overstated. Many people learn to live with relatively elevated levels of distress as ‘background noise’ and may not offer it as a cause of distress despite the impact that it has on them. This can be because of a combination of cutting off from the distress and lower levels of emotional and body awareness. This area was also under-researched and there has been a call for further research to explore cyber bullying, frequency and intensity of victimisation and the health outcomes associated with experiences of polyvictimisation (Tan et al., Reference Tan, Treharne, Ellis, Schmidt and Veale2020; Testa et al., Reference Testa, Habarth, Peta, Balsam and Bockting2015).
A common concern for neurodivergent individuals in discussing their autism diagnosis in a gender clinic is that they may be denied care, not be taken as seriously, or that the treatment intervention might be delayed further (Gratton et al., 2023). Strang et al. (2018) and Cooper et al. (Reference Cooper, Mandy, Butler and Russell2023) proposed some initial clinical guidance for assessing gender dysphoria for autistic adolescents which stated the importance of an extended diagnostic period, in order to understand additional complexities such as clinical and psychosocial challenges, social functioning and risk of victimisation or safety.
It has been observed that in adult gender clinics in the UK, for the majority of autistic and TGD people presenting to adult services, an extended assessment is not required, as information gathering falls comfortably within the expected time remit of the holistic biopsychosocial assessment undertaken in the clinics. However, TGD and autistic people present to all parts of the healthcare system and so it is incumbent upon healthcare professionals to learn how best to work therapeutically with and support them.
Current guidance for therapeutic intervention/cognitive behaviour therapy
Gender clinics in the UK provide individuals experiencing gender dysphoria with different interventions which may include hormone therapy and/or surgical transition in order for individuals to feel that their body is more aligned with their gender identity. Not all individuals who are TGD experience gender-related distress or gender dysphoria, and thus, these individuals may not access support from a gender clinic, as the interventions offered do not align with their desired goals. The majority of individuals who access gender clinics do not require psychological intervention or therapy (NHS England, 2019). However, individuals who do experience significant mental health difficulties, such as anxiety, depression or experiences of trauma (often related to experiences of stigma and discrimination) may benefit from sensitive and supportive psychological intervention (British Psychological Society, 2017; British Psychological Society, 2024a). Strang et al. (Reference Strang, Knauss, van der Miesen, McGuire, Kenworthy, Caplan and Anthony2021) found that autistic-TGD adolescents experience significant mental health difficulties and identified that autism diagnosis, autism characteristics and executive functioning-related gender barriers were potential risk factors for poorer mental health outcomes. In addition to this, the stigma of being neurodiverse and TGD was associated with poorer mental health outcomes. Autism is described as integral to identity, but also a source of stigmatisation, discrimination and feeling marginalised (Botha et al., Reference Botha, Dibb and Frost2022).
Petty et al. (Reference Petty, Hamilton, Heasman and Fiberesima2023) highlight important social contexts for psychological therapists working with neurodivergent clients and how clinicians must adopt the neurodiversity framework and be neuro-affirming in their approach. These researchers also discuss the importance of staff confidence in providing a neuro-affirming approach. In addition, there is emphasis on clinicians’ understanding of historical context and current, ever-changing understanding of neurodiversity. It is therefore important for therapists to remain curious and understanding of personal narratives of difference. Finally, they discuss the impact of the cumulative toll of marginalisation and how this may shape an individual’s experience.
Within gender clinics in the UK, there are a small number of psychological therapists who provide therapeutic interventions such as psychosexual, humanist and queer informed counselling, narrative and systemic therapies, cognitive analytic therapy (CAT) and cognitive behaviour therapy (CBT). There has been longstanding guidance, updated more recently, supporting therapists in all fields to provide sensitive therapy that is respectful of the needs of gender, sexually and relationally diverse (GSRD) service users (British Psychological Society, 2024b). Additionally, adapting CBT for autistic people has received some research attention. In particular, ensuring that therapists provide appropriate reasonable adjustments to promote access and engagement to therapy is key (NAS Good Practice Guide: National Autistic Society, 2024; BPS recommendations for working with autistic people). Stark et al. (Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a) provide a guide offering a curious approach to making adaptations for psychological therapy with autistic adults. These researchers are seven autistic adults from different professional backgrounds who consider the therapeutic environment, style of therapy and coping skills to consider a neuro-affirming lens and approach when working therapeutically with autistic individuals.
BPS guidance for psychologists and research from Howlin et al. (Reference Howlin, Back, Bates, Conallen, Crabtree, Daves-Hales and O’Dell2021) states there is no ‘one size fits all’ approach to autism and there is no single therapeutic intervention which will be appropriate; instead therapists should focus on finding the right approach for each individual. The guidance goes on to state that adaptations to therapy are likely to be required for autistic individuals. This might include practical adaptations such as ensuring the sensory environment of the clinic is not aversive for the individual (e.g. switching off or dimming lights), ensuring the same room is used to create predictability and allowing additional time for processing speed difficulties, for example. There is also attention to incorporating autistic experience into the therapeutic understanding of an individual and formulation, in order to provide the right support. Further guidance from the BPS in 2024 (British Psychological Society, 2024a), in their article ‘Five ways staff can humanise mental health care for autistic people’ emphasises the importance of understanding accumulation of micro-trauma, the careful use of language, understanding the individual’s autistic experience, adapting communication needs and understanding their unique sensory profile. Therapists must then incorporate these five areas into adaptations in the therapeutic intervention and psychological formulation of the individual’s needs and strengths. Further guidance from McGreevy et al. (Reference McGreevy, Quinn, Law, Botha, Evans, Rose, Moyse, Boyens, Matejko and Pavlopoulou2024) (see Appendix 1 in the Supplementary material) promotes the use of the ‘experience-sensitive framework’, which is a neuroinclusive approach considering eight different dimensions of wellbeing, and through incorporating these dimensions within practice, providing neurodivergence affirming support. In addition, therapists should understand the double empathy problem (Milton, Reference Milton2012a), to consider how this may be experienced in the therapeutic context. The double empathy problem from Milton (Reference Milton2012a) considered the ‘gap’ that occurs when an allistic individual relates to and communicates with a neurodivergent individual and vice versa. Breakdowns or misunderstanding in communication is our mutual responsibility, and, as such, careful attention should be paid to provide adaptations where required and address any misunderstandings due to differing social and communication styles.
There are best practice principles when implementing psychological intervention with autistic individuals, which include ensuring the views and perspective of the individual are understood and should focus on individuals’ strengths as well as limitations (Barthélémy et al., Reference Barthélémy, Fuentes, Howlin and Van Der Gaag2019). Current therapeutic guidance suggests providing an affirmative therapeutic space and ensuring appropriate gender literacy (Spencer et al., Reference Spencer, Berg, Bradford, Vencill, Tellawi and Rider2021) is key, alongside being aware of the wider socio-political landscape and the impact of this on the individuals we are working with and incorporating awareness of culture and systemic factors into our formulations (Ellis and Reilly-Dixon, Reference Ellis and Reilly-Dixon2023).
Cooper et al. (Reference Cooper, Loades and Russell2018) identified a ‘need for training and ongoing supervision to increase therapist confidence in and ability to make appropriate adaptations to CBT treatment protocols for autistic people’. Bernardin et al. (Reference Bernardin, Lewis, Bell and Kanne2021) cautioned that any attempts to make autistic people appear less or not autistic can be deeply harmful, and Pavlopoulou et al. (Reference Pavlopoulou, Crane, Hurn and Milton2024) highlight the need for autism acceptance, recognising the neurodiversity paradigm and that autism and other neurodevelopmental differences are part of the natural variation of human development. It is therefore important for clinicians and therapists to be aware of masking and camouflaging behaviours, which is an important initial focus within the therapeutic setting to inform formulation and treatment (Pearson and Rose, Reference Pearson and Rose2021). Furthermore, research from Brede et al. (Reference Brede, Cage, Trott, Palmer, Smith, Serpell and Russell2022) found that mental health services are not currently providing appropriate or adequate support for autistic individuals and there are concerns about iatrogenic harm. This research highlighted the importance of mental healthcare professionals and cognitive behaviour therapists understanding how being autistic affects an individual’s mental health difficulties, being curious, building trusting relationships and supporting individuals to advocate for their needs. Similarly, research from Paynter et al. (Reference Paynter, Sommer and Cook2025) found that the most crucial factor in psychological therapy for autistic individuals was a neuro-affirming approach.
The following framework was borne out of this research with the aim of incorporating intersecting experiences of autism and gender diversity effectively in the therapeutic setting, and in turn, supporting staff and service users to understand their intersectionality.
Aims
This paper has been written by two clinical psychologists working in the Northern Region Gender Dysphoria Service (NRGDS) providing psychological therapy and cognitive behaviour therapy (CBT) with TGD neurodivergent adults.
Our aim is to provide a framework of understanding the overlap between being autistic and being transgender and gender diverse, where these two constructs intersect and where they are disparate. Our second aim is to provide suggestions on how cognitive behavioural therapists, psychological therapists and psychologists may use this framework within psychological therapy to support neurodivergent TGD adults.
Co-creation of framework and application
The framework (Fig. 1) has been co-created by the two authors of this paper and adult service users (n = 4) accessing psychological therapy within the NRGDS. The framework has been refined based on feedback from service users. It was also presented to the multi-disciplinary team within the NRGDS clinic for further suggestions and amendments. This is aligned to guidance which outlined ‘nothing about us without us’ (Hoekstra et al., Reference Hoekstra, Girma, Tekola and Yenus2018), which ensures that service user involvement is key to ensure the individuals accessing this framework have contributed to its production. Whilst the creation of this framework was with adult service users, many of its principles and ideas could be applied to work with autistic TGD children and young people. However, it is important to note that there will be additional considerations for this group in thinking about developmental age, wider systemic and family context and access to services and treatment for gender dysphoria, if this is pertinent.
Framework – a cognitive approach to understanding therapeutic work with autistic transgender or gender diverse individuals.
Figure 1. Long description
A Venn diagram illustrating the impact of living in a neuro-normative, cis-hetero-normative society on autistic and transgender or gender-diverse individuals. The diagram consists of three overlapping circles. The left circle represents ‘Being autistic’ and includes traits such as valuing predictability, monotropism, stimming, interaction preferences, alexithymia, and sensory differences. The right circle represents ‘Being transgender or gender diverse’ and includes challenges such as body dysphoria, difficulty during puberty, and pursuing social or medical transition. The overlapping center circle represents ‘Being autistic and transgender,’ highlighting issues like masking, sensory challenges, sex and relationship challenges, stigmatization, and the impact on sense of identity and place in society. The diagram emphasizes the unique and intersecting experiences of individuals who are both autistic and transgender or gender diverse.
Understanding the framework and how to use it in the therapy context
The framework will be described in more detail below, alongside suggestions of areas for exploration in the therapeutic context. These have been split into framework headings and the evidence base, alongside clinical observations and the authors’ recommendations for the use of the framework. It is designed to be used and adapted on an individual basis, combining the clinical expertise of the therapist and the life experiences of the service user. Ensuring co-production of the framework will lead to the best outcome and most meaningful approach for staff and the service user. This will in turn guide the therapeutic intervention and support the formulation and understanding of the individual’s needs.
Being autistic
Valuing predictability and difficulty managing change
Evidence base
Intolerance of uncertainty and valuing predictability can be due to cognitive, sensory, and emotional factors; sudden changes in environment, routines, or sensory input can be overwhelming, causing discomfort or anxiety for autistic individuals (Jenkinson et al., Reference Jenkinson, Milne and Thompson2020; Joyce et al., Reference Joyce, Honey, Leekam, Barrett and Rodgers2017). For example, new textures or a change in routine can trigger sensory overload, making it challenging to adapt to change (Stark et al., Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a). Conversely, predictable routines can provide a sense of security and reduce anxiety; for example, being given information in advance of an appointment on the location, staff member and types of questions likely to be asked to ensure predictability and set up expectations (Collis et al., Reference Collis, Dark, Russell and Brosnan2024; Cooper et al., Reference Cooper, Loades and Russell2018; Cooper et al., Reference Cooper, Mandy, Butler and Russell2023). This is in line with reasonable adjustments (Equality Act, 2010).
Monotropism (Murray et al., Reference Murray, Lesser and Lawson2005; described below) may partly explain why autistic people may struggle with change. Rapid changes can overwhelm processing capacities and take time to process, leading to temporary confusion and difficulty making sense of the new circumstance, while the processing is occurring. The uncertainty of change can trigger anxiety in autistic individuals. Fear of the unknown, alongside challenges in understanding neurotypical social cues and ambiguous situations, can lead to heightened stress and worry (Jenkinson et al., Reference Jenkinson, Milne and Thompson2020).
Recommendations
Exploring how change impacts on the service user may inform how their capacity can become overwhelmed, leading to distress or cumulatively leading to burnout. Discussing factors that are challenging for individuals to manage may identify specific triggers to someone’s levels of distress. As therapists, more predictability can be provided to support this, such as ensuring procedure of CBT appointments is predictable, use of agenda setting, reflections, use of summaries and contracting endings from the beginnings, as well as the use of neuro-affirmative therapeutic goals (Best Practice Guidelines, British Psychological Society, 2021; Stark et al., Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a). The Good Practice Guide (National Autistic Society, 2024) suggests, where possible, using the same room, and same day and same time for appointments.
Monotropism and autistic joy
Evidence base
Murray (Reference Murray2018) and Murray et al. (Reference Murray, Lesser and Lawson2005) describe monotropism as a ‘pull’, explaining that attention is directed by our interests. These researchers define monotropism as the ability of autistic people to have an intense, singular focus providing a rich and involving experience which often has great value. It suggests that the mind and attention is based on an ‘interest system’, where we are all interested in many things, and our interests help direct our attention. In a monotropic mind, fewer interests are active at the same time and attention falls onto these with greater intensity. These interests also use more processing resources, making it less likely that people will be aware of things outside their focus. This can have a significant impact on how autistic people approach daily activities and manage their focus. For people with a monotropic mind, it can be challenging to switch between tasks or maintain attention on multiple things at once. Autistic individuals often have unique and intense interests that play a significant role in their lives. These interests can range from careers, hobbies and passions to hyper-fixations, repetitive interests, or what have often been referred to as special interests. Research from Cooper et al. (Reference Cooper, Mandy, Butler and Russell2023) highlight the importance of discussing interests to promote engagement and the therapeutic relationship.
Pellicano and den Houting (Reference Pellicano and den Houting2022) discuss the gap in the literature around positive experiences of autism due to the pathologising medical model. Wassell (Reference Wassell2025) explored autistic joy in a qualitative study and identified four main themes: autistic sensorium as a source of joy, the importance of special interests, things must be right (referring to environment), and other people need to change (referring to acceptance of autism from others). Within this study, 94% of participants (n = 86) agreed that they actively enjoy aspects of being autistic and that this differs from joy experienced by those that are not autistic.
Recommendations
Within therapy, this may mean being aware of differing attention styles (such as monotropism and flow-states) and making adjustments in line with this. This could involve ensuring the session focus is a topic of interest or allowing additional time to discuss topics when someone may get into a flow state. This could be collaboratively agreed within the agenda setting. It is important that therapists are cognisant of these differing attention styles and provide an accepting space for this. It is also key to encompass joyful and positive aspects of someone’s autistic identity and how these impact on their wellbeing.
Stimming
Evidence base
Stimming and the use of sensory regulation is not unique to autistic people but is not widely thought about or recognised in non-autistic populations. Stimming can relate to seeking out sensory feedback and this can have a self-soothing, regulating impact for autistic individuals (Kapp et al., Reference Kapp, Steward, Crane, Elliott, Elphick, Pellicano and Russell2019). Stimming has value as a method of self-soothing and emotional processing as well as bringing joy. Stimming takes different forms for different people and could involve physical movements (such as rocking, pacing, running), vocal stims (such as repeating certain noises, sounds or phrases), as well as other sensory behaviours such as knitting and stroking pets (Stark et al., Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a). These authors advise encouraging stimming through provision of sensory toys and verbally giving permission for clients to stim will allow for building on self-soothing strategies within the therapy room. Kapp et al. (Reference Kapp, Steward, Crane, Elliott, Elphick, Pellicano and Russell2019) found that autistic individuals report stimming to be an important mechanism for self-regulation and/or communication of emotions. Stimming behaviours may also be used as a way of managing anxiety and intolerance of uncertainty in attempts to self-soothe and reduce anxiety levels (Joyce et al., Reference Joyce, Honey, Leekam, Barrett and Rodgers2017).
Recommendations
Whilst further research is needed in this area, particularly in considering how supporting stimming in therapy may impact on wellbeing, it is important CBT practitioners explore this on an individual level. Within the clinical therapeutic context, it may therefore be important to ensure access to fidget toys or physical movement during the appointment for people to engage in self-soothing and regulatory behaviours or to feel more at ease. In addition, stimming behaviour that supports someone to self-soothe and regulate, should be incorporated into our CBT formulation and strategies for managing distress and overwhelm.
Interaction preferences
Evidence base
The differences in communication styles between autistic and non-autistic individuals are now better understood from the proposal of the double empathy problem. Dr Damian Milton (Reference Milton2012a) defined the double empathy problem as the breakdown in mutual understanding in interactions, and thus non-autistic individuals have difficulty in understanding and relating to the emotions of autistic people and vice versa. Essentially, when people with very different experiences of the world interact with one another, they will struggle to empathise with each other. This theory considers all people involved in a social interaction and why communication may breakdown.
Autistic people often make adjustments for the neurotypical communication style (through masking behaviours), often spending hours learning how to understand and mimic neurotypical communication (Stark et al., Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a). Furthermore, research from Crompton et al. (Reference Crompton, Ropar, Evans-Williams, Flynn and Fletcher-Watson2020) demonstrated that communication between autistic people is highly effective, and communication breakdown occurs between groups of autistic and non-autistic individuals. Many autistic people have been misunderstood and given negative feedback, creating anxiety around communication, which can reinforce feelings of anxiety or emotional overwhelm in relation to social interactions, and in turn, lead to feeling misunderstood and marginalised (Camus et al., Reference Camus, Macmillan, Rajendran and Stewart2022).
Recommendations
Most often, non-autistic people have not made the same efforts to adjust to meet the needs of autistic people. Therefore, it will be of benefit to adapt therapy and communication in a way that suits the needs of the individual. This could take various different forms, such as providing a written summary of the session, allowing audio recording of the session, using drawing, music or using the chat function in online appointments, adapting communication to preferred communication styles (not solely relying on verbal communication) (Schaeffer et al., Reference Schaeffer, Abd El-Raziq, Castroviejo, Durrleman, Ferré, Grama and Tuller2023). The Good Practice Guide (National Autistic Society, 2024) recommends considering communication adaptations such as using simple, plain language, allowing for additional processing time and discussion around what adaptations and adjustments can be provided. Furthermore, research from Cooper et al. (Reference Cooper, Mandy, Butler and Russell2023) stated communication adaptations (full list within paper) should include checking understanding of questions, using special interests to increase engagement, using forced-choice questions or open-ended questions with prompts and presenting information in manageable chunks. This is not an exhaustive list, and it will be imperative to explore communication preferences with the individual to ensure therapy is meaningful and accessible to them. These recommendations may require adaptations to CBT approaches such as adapting the use of Socratic questioning, increasing the use of summaries and asking for feedback based on the individuals’ interaction preferences. It will also be key to ensure that the individual feels comfortable and at ease in the communication, if we are expecting them to discuss their vulnerabilities and difficulties with their mental health to inform our therapeutic intervention. In addition, further conversations around non-verbal communication may be supportive also. For example, we can explore whether eye contact is uncomfortable for the individual, alongside other communication adaptations within the therapy setting (Cooper et al., Reference Cooper, Mandy, Butler and Russell2023). We then may consider the physical environment of the therapy room, having chairs side-by-side for example, rather than facing each other (Stark et al., Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a). As therapists, we are likely to gain a richer understanding of an individual’s presenting difficulties if we allow for adaptations in communication to explore this (Stark et al., Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a).
Alexithymia
Evidence base
Kinnaird et al. (Reference Kinnaird, Stewart and Tchanturia2019) found higher prevalence rates of alexithymia (difficulty recognising or describing emotions) for autistic individuals compared with non-autistic individuals. Rates of alexithymia were approximately 49% for autistic individuals, which suggests potential increased vulnerability to mental health problems. This is a key area of exploration in the therapeutic context to explore and develop emotional literacy for individuals who are alexithymic and support further understanding of how overwhelm, stress and distress may build for them and identifying coping strategies for managing this (Stark et al., Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a). Stark et al. (Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a) further consider potential interoceptive difficulties (ability to cue into bodily sensations) and naming these experiences. Further research from Lim (Reference Lim2020) and Reyes et al. (Reference Reyes, Pickard and Reaven2019) are supportive of emotional regulation strategies as part of therapeutic intervention to support autistic individuals with alexithymia.
Recommendations
The therapeutic intervention may begin by supporting an individual in identifying a language for their feelings, aligning with the CBT principle of eliciting emotional expression. Autistic individuals who are alexithymic often can identify when they are feeling okay and not okay, but the small nuances in between these changes may be trickier to identify if alexithymia and interoceptive difficulties are present. Therefore, an individualised scale which represents exactly what that individual notices can be supportive to develop understanding (Stark et al., Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a). This may be in relation to anxiety, distress, overwhelm, or all of the above. Using the service users’ idiosyncratic descriptions/drawings/images/colours/communication (Schaeffer et al., Reference Schaeffer, Abd El-Raziq, Castroviejo, Durrleman, Ferré, Grama and Tuller2023) of their experiences will be the most authentic way of exploring their understanding of their distress and how this feeling is experienced for them.
Sensory experiences
Evidence base
Sensory perceptions are the neurological pathways through which we experience the world and so an exploration of the sensory world of a neurodivergent person is an important starting place in any therapy relationship (Bogdashina, Reference Bogdashina2016). Making sense of how an individual experiences the world at a sensory level as too little, too much, bringing joy or pain, is key in formulating the way that they are affected by everything from the environment to relationships and themselves (Stark et al., Reference Stark, Ali, Ayre, Schneider, Parveen, Marais, Holmes and Pender2021a). These authors discuss the importance of exploring an individual’s hyper- and hypo-sensitivities. This can, in turn, help inform self-soothing supportive strategies to manage anxiety or depression, as well as considering additional aversive sensory environments that may add to feelings of sensory overwhelm or distress.
Recommendations
Understanding an individual’s sensory profile is a key underpinning in any formulation process as it allows a sensitive, collaborative and person-centred formulation to be free from neuro-typical values, goals and expectations that would otherwise be counterproductive. For example, many autistic people who dislike crowded places with lots of noise (MacLennan et al., Reference MacLennan, Woolley, Andsensory, Heasman, Starns, George and Manning2023) have had an experience of meeting with a therapist and being told that they should try to habituate to these environments, to go out more. A sensitive and collaborative neuro-informed formulation would instead understand why this was difficult at a sensory level (e.g. noise, people, crowds, being touched) and work with the person to decide if their goals included being outside and modifying these experiences (e.g. headphones, quieter times of day, face mask, hood up) or just finding alternatives to going out that reduce stress in their life (e.g. online shopping, permission not to do those things). A robust understanding of someone’s sensory profile within the CBT formulation will give further understanding and awareness of factors that can support levels of distress and overwhelm and contributors to this within different environments.
Being transgender/gender diverse
Body dysphoria
Evidence base
Body dysphoria, a specific aspect of gender dysphoria, is discomfort or distress arising from incongruence between a person’s physical body and their gender identity. Not everyone who is gender diverse experiences body dysphoria, and some people continue to experience body dysphoria even after all of the physical changes from medical transition have been completed. This distress may contribute to other negative emotions and challenges in emotional regulation. Many people cope with the distress that their body causes them by ‘cutting off’ or disconnecting from their bodily experience. Pulice-Farrow et al. (Reference Pulice-Farrow, Cusack and Galupo2020) explored how trans individuals describe their experience of dysphoria, finding that a feeling of disconnection from their body was separate to their distress and that gender dysphoria could change over time; 69.8% of individuals who participated, reported disconnection from their body, and described this as feeling ‘jarring’, ‘uncomfortable’ and ‘off’. Participants also talked about specific body-part disconnections, such as primary or secondary sex characteristics or aspects of their physical body which can be gendered by society (for example, voice and height).
This presents difficulties in lots of areas of life but particularly in sexual relationships. Martin and Coolhart (Reference Martin and Coolhart2022) explored the influence of body dysphoria on intimate relationships and sexual experiences for trans-masculine individuals and found they had to manage their bodies using strategies of mental, physical and relational negotiation. The study highlighted the need for clinicians to be aware and understand the connection between body dysphoria and sexual experiences. This may therefore be explored in therapy.
Recommendations
If an individual experiences significant body dysphoria, whereby they feel disconnected from their body or specific body parts (Pulice-Farrow et al., Reference Pulice-Farrow, Cusack and Galupo2020), strategies such as body scans or progressive muscle relaxation, or mindfulness could be aversive and harmful for them (Fender, Reference Fender2025). Exploration of an individual’s body dysphoria may help identify goals for their transition or what would enable an individual to feel more affirmed and aligned with their body. Other strategies (such as mindfulness, breathing techniques or other relaxation strategies) can be used in this instance, so as not to encourage avoidance, but also to ensure a strategy which could be aversive is not suggested.
Body dysphoria and gender dysphoria can be a complex relationship, and many people report heightened anxiety about coping with a changing body even when the changes are wanted. Not all individuals will pursue medical transition in relation to body dysphoria, as they may pursue social transition (changing things such as their name, pronouns, appearance and gender expression), which still does involve significant change. Many people cope well with the change brought about by medical transition and this leads to improved quality of life (What We Know Project, Cornell University, 2018), but for those who find it more challenging this can be caused by a range of problems. Some people report that they are having new and overwhelming experiences as their body becomes more congruent and as a consequence, they are more present in it more of the time. Within clinical observation, it has been noted that this ‘cut off’ experience can be misconstrued as dissociation but is more usually a refocusing of attention to another more manageable part of the experience in line with a monotropic attentional style. It is therefore imperative that this experience is robustly understood by the therapist, in order to understand whether this is an area to consider in therapy; to support with further strategies or to incorporate into our formulation and conceptual integration of how this impacts on the individuals’ emotions and wellbeing.
Difficulty during puberty
Evidence base
Puberty is a particularly vulnerable time if the changes being experienced are not congruent with internal gender identity (Schardein and Hotaling, Reference Schardein and Hotaling2022). Historically, for young people at a Tanner developmental stage of 2 and above, GnRH analogues, also known as puberty blockers, could be prescribed in order to mitigate the distress and offer a reflective period of a few years in which to think about gender identity without the pressures of puberty. Horton (Reference Horton2024) found that parents noticed their TGD child’s distress increasing when they noticed elder siblings or peers starting puberty. The major themes discussed around pre-pubertal anxiety were difficulties accessing hormone blockers and for a minority of individuals who were prescribed blockers, experiences of relief and frustration. Vrouenraets et al. (Reference Vrouenraets, de Vries, Hein, Arnoldussen, Hannema and de Vries2022) discuss the impact of puberty on wellbeing and this being a critical time for TGD individuals considering puberty blockers as a first step in gender affirming care. These researchers found that puberty blockers reduced distress for adolescents and their parents and provided relief in the inhibition of further development of secondary sex characteristics. In 2024, the UK government permanently banned the use of puberty blockers in young people under the age of 16 years except in the context of a medical trial which has yet to be designed. This decision has impacted a generation of young TGD people to a youth of potential increased distress and permanent pubertal changes, which increase the potential for serious impacts on their mental wellbeing in the long term (Horton, Reference Horton2024; Horton and Pearce, Reference Horton and Pearce2024).
Recommendations
For TGD autistic adults discussing distress in therapy, the role of their embodied experience in their life narrative and the impact that this has on their mental health cannot be overstated. Many people learn to live with relatively high levels of distress as ‘background noise’ and may not offer it as a cause of distress despite the impact that it has on them (Pulice-Farrow et al., Reference Pulice-Farrow, Cusack and Galupo2020). This can be because of a combination of cutting off from the distress and lower levels of emotional and body awareness. These can combine to create a vulnerability to high levels of embodied distress that can be experienced as both chronic and acute with different triggers and might underpin significant mental health crises and yet remain largely out of awareness or too difficult to voice, even in a therapeutic setting (Pulice-Farrow et al., Reference Pulice-Farrow, Cusack and Galupo2020). It is for the therapist to hold this potential in mind and sensitively include embodied experiences in enquiries about precursors to distress and general wellbeing when formulating (considering eliciting key cognitions related to this). Puberty may be a key area of someone’s life to explore in more detail within therapy and to ensure this experience is considered in terms of impact on wellbeing and dysphoric feelings to their body.
Pursuing social and/or medical transition and managing this change
Evidence base
The processes of social and medical transition are profound times of personal change, sometimes compared with a ‘second puberty’ as a way of drawing a comparison to the enormity of the challenge faced by a person undertaking these processes (Luquet et al., Reference Luquet, Redcay, Counselman-Carpenter and Gunn2025).
During a social transition, individuals may disclose their gender identity to family, friends and colleagues. They may also begin to demonstrate their gender identity through their gender expression, such as in their appearance, clothes, voice, hair or interests/hobbies. Some of these expressions may be visible, whereas others may not. As described previously, acceptance from others in relation to this expression promotes more positive psychological wellbeing (Testa et al., Reference Testa, Habarth, Peta, Balsam and Bockting2015; Tinlin-Dixon et al., Reference Tinlin-Dixon, Bechlem, Stevenson-Young, Hunter and Falcon-Legaz2025; Wright, Reference Wright2020). A systematic review of the literature from Hall et al. (Reference Hall, Taylor, Hewitt, Heathcote, Jarvis, Langton and Fraser2024) concluded the lack of robust research in the area of assessing the long-term impact of social transition for children and adolescents. On the other hand, research from Olson et al. (Reference Olson, Durwood, Horton, Gallagher and Devor2022) found that youth who socially transitioned at an early age (changing child’s pronouns, first name, hairstyle, and clothing) continued to identify in that way (5-year follow-up study) and that retransitions were infrequent (7.3%). Horton (Reference Horton2023) explored the impact of pre-pubertal social transition and found childhood affirmation of their gender identity was critical for their happiness and wellbeing. While these studies explore youth experiences of social transition, it emphasises the relevance of time of social transition and potential impact on overall wellbeing and feelings of affirmation and acceptance from others.
During a medical transition, individuals may undergo hormonal treatments or surgeries, which can bring about physical changes. These changes, such as the development of new secondary sexual characteristics and the alleviation of dysphoria, can influence how an individual perceives and experiences their own body and can lead to improved quality of life and relationship satisfaction (What We Know Project, Cornell University, 2018). Research from Luquet et al. (Reference Luquet, Redcay, Counselman-Carpenter and Gunn2025) identifies the positive impact on wellbeing medical transition can have and highlights the importance of improving access to gender-affirming care for individuals wishing to medically transition.
Recommendations
As a therapist, it is vital to be cognisant of the impact of both social and medical transition experiences and explore within the formulation the impact on the individual’s emotional wellbeing (alongside eliciting key cognitions and behaviours), adjustment to body changes and social role, as well as the overall impact on feelings and cognitions of dysphoria, self-esteem and confidence (APA Guidelines, American Psychological Association, 2015). Many people expect to experience feelings of euphoria when the changes noted are more aligned to their true identity, but this is not the case for all, and therefore providing a safe, containing space to explore the multi-faceted experience of this transition is likely to be valuable for the individual. It may be key to consider psychological theories around assimilation and accommodation of change and adjustment that is so intrinsic to someone’s sense of self and personhood. It may also be supportive to explore the situational or context-dependent emotional response during certain aspects of an individual’s experience of social and/or medical transition.
Being autistic and transgender
Masking
Evidence base
Autistic masking or camouflaging (terms tend to be used interchangeably) is made up of three different phenomena: masking, compensation and assimilation (Pearson and Rose, Reference Pearson and Rose2021). It is a strategy used by some autistic people to try to appear neurotypical (not autistic) and this can happen both consciously and unconsciously. This can involve deliberately trying to suppress autistic traits and behaviours. It can also include developing compensatory behaviours in certain social interactions (Hull et al., Reference Hull, Petrides and Mandy2020).
The demands of continuously self-monitoring and adapting behaviour to ‘do what is expected’ require a huge amount of personal resource. Pearson and Rose (Reference Pearson and Rose2021) consider social identity theory in relation to autistic masking and as a rationale for why individuals may mask or camouflage themselves. They highlight the importance of understanding how stigma and marginalisation impact on masking behaviours, intersectionality and caution about stereotyping a ‘female autism phenotype’. Their research identifies that camouflaging can have significant consequences leading to increased emotional distress and potential burnout. Furthermore, autistic camouflaging is found to be a predictor of suicidal behaviour (Cassidy et al., Reference Cassidy, Gould, Townsend, Pelton, Robertson and Rodgers2020). Research from Bernardin et al. (Reference Bernardin, Lewis, Bell and Kanne2021) found that autistic masking predicted depression, anxiety, stress and suicidality.
Research from Osmetti et al. (Reference Osmetti, Allen and Kozlowski2024) explored gender identity concealment and how this may have a combination of protective and distressing effects on an individual’s psychological wellbeing, while assigned sex concealment appears to be associated with mostly positive impacts on someone’s psychological wellbeing. These authors also explored the impact of involuntary disclosure of trans identity and the detrimental impact this can have for an individual. They highlight the need for further research to explore how ‘outness’ impacts on mental health. Further research from Carvalho et al. (Reference Carvalho, Carvalho, Fonseca, Santos and Castilho2022) explored the relationship between centrality of shame, self-concealment and fear of receiving compassion from others and how this could impact on psychological suffering. Results showed that fear of receiving compassion from others was associated sequentially to experiences of shame and then associated with self-concealment. This further identified a need for further research in this area.
Price (Reference Price2022) explored the concept of masking in a ‘female presentation’, discussing that there may be additional social pressures girls and women face because of more restrictive social standards and expectations, and not conforming to these ideals appears to have a greater cost. Although this focuses only on binary and not diverse gender presentations, the research explains women and girls are more likely to be masking than males but also acknowledges that this is not a phenomenon exclusive to females as previously thought.
Research shows the increased prevalence of mental health difficulties in the LGBTQIA+ population and the micro-aggressions and overt cultural and structural stigma that people can face on a daily basis (Kurup, Reference Kurup2023; Meyer, Reference Meyer2014). Pavlopoulou et al. (Reference Pavlopoulou, Crane, Hurn and Milton2024) consider the impact of double marginalisation, examining our own biases and expectations and being proactive about addressing masking in the therapy room. Some patients may potentially be masking their trans identity and some TGD people want understandably to be received without question (to ‘pass’) as cis-gender as it reduces the stigma and aggression that they may face. This consequence of the stigma experienced with a lack of acceptance of TGD individuals in society is a key area of exploration within therapy. It may be helpful to discuss their motives for wanting to ‘pass’ and why this is important, to unpick whether there is intrinsic or extrinsic motivation for this. Within gender clinics, speech and language therapy (SALT) intervention is offered that can explore strategies to masculinise or feminise voice. Gender diverse individuals have reported that their voice is often something that ‘gives them away’ (i.e. revealing trans identity). For some individuals, their preference may be to appear stealth and keep their trans identity hidden. Again, this may be an area for exploration in therapy to determine the reasoning behind this importance for the individual. This area is a complex mixture of internalised stigma related to viewing TGD people as less valuable than cis-gender people (internalised transphobia) and a real need to keep themselves safe and reduce the threat posed by the people around them (Ellis and Reilly-Dixon, Reference Ellis and Reilly-Dixon2023).
Recommendations
With all this in mind, it is imperative that we create a safe space within the therapy room to discuss masking and the impact of this on wellbeing, energy levels and feelings of acceptance by others. We also need to demonstrate our allyship in creating this sense of safety, as an individual’s personal experience of being vulnerable is likely to have been met with previous negative experiences of stigmatisation and discrimination; this is likely to strengthen our interpersonal effectiveness within the therapeutic relationship.
‘Not fitting in’
Evidence base
As previously discussed, members of a minority group can feel as though they do not fit in with the majority. This can lead to feeling othered, an outsider, or not fitting in.
Being neurodivergent can mean that a person’s preferred methods of communicating diverge from the majority; for example, writing information down, using gestures or communicating through methods which have reduced social factors, for example, communicating online, through text or social media. Autistic languaging can be diverse in nature (Schaeffer et al., Reference Schaeffer, Abd El-Raziq, Castroviejo, Durrleman, Ferré, Grama and Tuller2023).
Being TGD can also mean that people are not accepted as part of the majority group. TGD individuals often report feeling as though they do not fit in to the gender they were assigned at birth, the binary norms of being male and female or the societal gender norms and socialisation of being a particular gender (Gratton et al., Reference Gratton, Strang, Song, Cooper, Kallitsounaki, Lai, Lawson, van der Miesen and Wimms2023). Research from Tinlin-Dixon et al. (Reference Tinlin-Dixon, Bechlem, Stevenson-Young, Hunter and Falcon-Legaz2025) highlighted the importance of community supportive spaces (such as Pride) and the impact of individuals being their authentic self publicly and how this, in turn, enabled individuals to move to a place of acceptance.
Recommendations
Unfortunately, when an individual is not seen to be part of the majority group, they can receive unwanted attention, harassment or become ostracised. The minority stress model from Testa et al. (Reference Testa, Habarth, Peta, Balsam and Bockting2015) demonstrates how distal stressors of discrimination, victimisation and rejection can lead to proximal stressors of internalised transphobia, concealment and negative expectations. In therapy, it will be key to explore someone’s experiences of not fitting in and how this may have shaped their core beliefs about themselves, others and the world. This may have involved bullying and exploitation amongst other potential traumatic experiences. A sense of community and fitting in can be hugely valuable, and for some people this may be found in LGBTQ+ groups or through other shared interests and groups which enable safe, authentic and genuine connections with others (Laws, Reference Laws2019; Tinlin-Dixon et al., Reference Tinlin-Dixon, Bechlem, Stevenson-Young, Hunter and Falcon-Legaz2025). Bernardin et al. (Reference Bernardin, Lewis, Bell and Kanne2021) and Paynter et al. (Reference Paynter, Sommer and Cook2025) therefore discuss the importance of treatment which focuses on self-esteem and self-acceptance for the individual and also the importance of increasing autism-acceptance among healthcare staff working with the individual. It will be important to discuss the interplay between an individual’s sense of belonging or not fitting in with any masking behaviours in the conceptual integration of our formulation.
Sensory challenges
Evidence base
The need to understand the sensory experience of the individual in formulating is also important in managing the sensory needs in relation to transition (Warrier et al., Reference Warrier, Greenberg, Weir, Buckingham, Smith, Lai and Baron-Cohen2020). Sensory perception of body parts may have been a change that an autistic person has struggled to accommodate to during puberty and the combined distress of unwanted changes because of the sensory experiences and because of their gendered connotations can be extraordinarily complex to unpick (Oliver et al., Reference Oliver, Poysden, Crowe, Parkin, Mair, Hendry, Macey and Gillespie-Smith2025). For example, breasts may be both distressing because they are a visible marker that may cause others to gender the owner as female, and also because their movement may cause sensory distress. A person may not want to wear a bra because it is both uncomfortable at a sensory level and usually seen as a feminine article but wearing a chest binder may be too uncomfortable to tolerate, or their chest may be too large and so they may compromise with a sports bra (Cooper et al., Reference Cooper, Mandy, Butler and Russell2023). This compromise may still be a source of significant distress which is often managed with a combination of ignoring or cutting off awareness (Laws, Reference Laws2019). Where people have more cognitive resources, they commonly reframe dysphoric experiences into something less gendered for example, ‘lots of guys are overweight and have a bit of a chest, so I call these my “moobs” and it helps me to cope’.
For autistic TGD people, who often have heightened sensory sensitivities, physical changes brought about by medical transition can trigger a range of emotional responses and impact their sexual identity. Cooper et al. (Reference Cooper, Mandy, Butler and Russell2023) discussed the interaction between sensory sensitivities and gender dysphoria for autistic TGD individuals, finding that sensory sensitivities may reduce, increase or remain the same during physical bodily changes. Individuals might find their feelings magnified during this period, such as through emotional fluctuations, self-acceptance, and adjusting, which can affect self-esteem and confidence.
Recommendations
The need to manage sensory perceptual experiences can affect what someone is able to tolerate in how they present themselves in their affirmed gender (Cooper et al., Reference Cooper, Mandy, Butler and Russell2023). Some people may feel that their need for comfortable clothing or a manageable hairstyle, to avoid sensory distress, may limit how strongly gendered they appear to others and can face a difficult compromise in affirming their gender and managing overwhelming sensory experiences, such as hair on their body or face, tight-fitting or restrictive clothing or tucking genitals to make them less noticeable. It is important that people are supported to find affirming and comfortable ways to adapt or retain their appearance in a way that is right for them and that therapists reflect on their personal values about appearance and gender and do not attempt to impose these on the individual, providing a safe and trusting space for exploration of what feels authentic for that individual.
Sex and relationship challenges
Evidence base
For autistic TGD people, transitioning can be a deeply personal and exciting experience, impacting various aspects of their lives, including their sex life and libido (a person’s desire to engage in sexual activity). Transitioning involves a complex interaction between physical, emotional, and social changes, and its effects on one’s sexuality and sexual desires can be significant and varied (Martin and Coolhart, Reference Martin and Coolhart2022). Self-defined sexuality may be something that people begin to explore during this time as changes in the external presentation of gender may lead to new ways of defining sexual attractions and partners (Galupo et al., Reference Galupo, Henise and Mercer2016). For example, someone who has a male gender identity, has always been attracted to men and is now perceived by others as male, may move towards labelling their sexuality with others as ‘a gay man’ which can lead to new group membership and social roles.
Individuals may undergo hormonal treatments or surgeries, which can bring about physical changes. These changes, such as the development of new secondary sexual characteristics and the alleviation of dysphoria, can influence how an individual perceives and experiences their own body. For autistic TGD people, who often have heightened sensory sensitivities, these physical changes can trigger a range of emotional responses and impact their sexual identity (American Psychological Association, 2015). They might find their feelings magnified during this period – emotional fluctuations, self-acceptance, and adjusting can affect self-esteem and confidence. For many people, a more affirming body opens the potential for comfort in engaging in sexual encounters for the first time and this, whilst being a cause of celebration, can also lead to increased vulnerability and a period of adjustment (Ward et al., Reference Ward, Pipkin, Frary and Kempinska2024).
Recommendations
This therefore may be relevant to explore and be aware of within therapy, in navigating safe relationships with others. Martin and Coolhart (Reference Martin and Coolhart2022) emphasise that it is critical for therapists and clinicians to understand the connection between body dysphoria and sexual experiences and the potential impact on wellbeing in relation to this. In noted clinical observations, if an autistic person struggles with making sense of abstract concepts and/or imagining things that they haven’t seen before (aphantasia) then it can be hard for them to begin to imagine how they might tolerate, or struggle with a different body habitus, or use that body in new future situations (such as a pre-surgical physical examination, or a sexual encounter). If a person’s only or most frequently used strategy is to ‘cut off’ from their body, emotional regulation while in an embodied state may be a new skill for them to learn. As a therapist, it may then be key to provide the space for this discussion and support to connect to potential application of change methods and how this may be tolerated.
Stigmatisation
Evidence base
The impact of living in a cis-hetero-neuro-normative society can lead to stigmatisation (Gratton et al., 2023; Meyer, Reference Meyer2003; Tan et al., Reference Tan, Treharne, Ellis, Schmidt and Veale2020; Testa et al., Reference Testa, Habarth, Peta, Balsam and Bockting2015). This may mean an individual who is autistic and TGD may be emotionally, socially, physically and sexually vulnerable with others, in the sense that difference can be exploited.
Growing up in a culture that places primary value on cis-hetero-neuro-normativity means that it is impossible not to internalise these values (Worthen, Reference Worthen2016). Everyone throughout society experiences and expresses them explicitly or implicitly, whether we are aware of holding these values or not. It is not until we seek out our values and challenge them, as an ongoing process, that we truly become aware of what ‘normal’ is in our minds and how that affects us day to day. It may therefore be important for therapists to explore our own values and assumptions within clinical supervision to consider how this may impact on the therapeutic relationship.
For people who are members of groups who are held to have lower value in this culture, that lack of value becomes internalised too. This can lead to a range of responses, from self-deprecation to low self-esteem and active acts of harm and oppression against the self (Marzetti et al., Reference Marzetti, McDaid and O’Connor2022; Wright, Reference Wright2020). These are not theoretical values; people living as openly different from accepted ‘norms’ can often face harassment and harm from members of society believing themselves justified in acting against them (Ellis et al., Reference Ellis, Bailey and McNeil2016). This then reinforces the core beliefs about worthlessness and shame (Laws, Reference Laws2019; Tinlin, Reference Tinlin2023).
Recommendations
As previously discussed in the sections on masking and not fitting in, experiences of double (or multiple) marginalisation being autistic and TGD can have significant consequences on someone’s sense of themselves and their self-worth. Within a formulation of someone’s mental health experiences, it will be key to acknowledge and incorporate their experiences of stigma, and potential coping strategies to support them when feeling de-valued by other groups. Validation of someone’s negative experiences and potential trauma is key in understanding how these feelings may then become internalised. Exploration of where and when an individual feels safe to be their authentic self and more connected to their identity can be useful to consider factors which enable feelings of safety and authenticity.
Neither (autism nor gender diversity) are mental health conditions but they can significantly impact wellbeing
Evidence base
As outlined, due to multiple factors, autistic TGD individuals are much more likely to experience significant mental health difficulties such as anxiety, depression, burnout, as well as vulnerability to traumatic experiences (Strang et al., Reference Strang, Anthony, Song, Lai, Knauss, Sadikova and Kenworthy2023) and increased vulnerability to suicidality (Cassidy et al., Reference Cassidy, Gould, Townsend, Pelton, Robertson and Rodgers2020). Therefore, the impact of being an autistic, TGD individual in a cis-hetero-neuro-normative world has its impact. It is important as clinicians that we do not conflate these experiences, as being autistic and TGD are not mental health conditions and it is in fact, imperative that this is not pathologised in order to provide a space of acceptance, safety and exploration. As outlined by Botha et al. (Reference Botha, Dibb and Frost2022), being autistic was described as being integral to identity but the impact of this on mental wellbeing due to the socio-cultural outlook is vital to consider. Likewise, being part of the LGBTQIA+ community can be an instrumental aspect of someone’s identity and personhood and therefore exploring this in understanding the context of someone’s mental health difficulties is essential in our formulation and plans for therapeutic intervention.
Recommendations
Allyship and genuine therapeutic rapport will be key in the therapy space and in order to collectively explore support for an individuals’ mental health difficulties. Developing further understanding within the therapeutic relationship of how these intersecting parts of an individuals’ identity (being autistic and TGD) impacts on their wellbeing and mental health and vice versa in how their mental health may impact on their identity and sense of themselves.
Sense of identity and place in society
Evidence base
An individual’s experiences of coming out are unique and personal. It is often a time of worry about how loved ones, such as family and friends, might react and respond. Affirmation, including family support, use of preferred name and pronoun, and support for social transition are all associated with positive mental health and low levels of depression or anxiety (Glynn et al., Reference Glynn, Gamarel, Kahler, Iwamoto, Operario and Nemoto2016; Pollitt et al., Reference Pollitt, Ioverno, Russell, Li and Grossman2021; Russell, Reference Russell and Kapp2020). Unfortunately, some individuals’ experience may be rejecting or shaming, which can lead to a negative impact on mental health (Worthen, Reference Worthen2016). This may in turn contribute to experiences of stigma, discrimination and victimisation (Marzetti et al., Reference Marzetti, McDaid and O’Connor2022). Masking may in turn ‘blur’ someone’s sense of their identity and this may be an area for exploration in therapy. It may be conducive to explore someone’s values to give direction of shared therapeutic goals and living a life aligned with someone’s values and factors which hold importance for them.
In exploring someone’s sense of identity and place in society, it may be helpful to consider the minority stress models (Meyer, Reference Meyer2003; Testa et al., Reference Testa, Habarth, Peta, Balsam and Bockting2015; see Appendix 2 in the Supplementary material) to incorporate the impact of stigmatisation and discrimination in the context of someone’s current difficulties. The primary aim of the minority stress model is to help explain disparities in mental and physical health between majority and stigmatised minority groups (Meyer, Reference Meyer2014). Frost and Meyer (Reference Frost and Meyer2023) discuss how minority or marginalisation stress theory identifies both proximal and distal stressors. Hendricks and Testa (Reference Hendricks and Testa2012) and Testa et al., (Reference Testa, Habarth, Peta, Balsam and Bockting2015) expanded on the minority stress model and considered the specific experiences gender diverse and gender non-conforming individuals may have and how this may impact on wellbeing, such as experiences of victimisation or rejection and internalised transphobia. Specifically, as it relates to marginalised gender identities and sexual orientations, proximal stressors include internal or individual-related experiences such as expectations of rejection, concealment of one’s identity, and internalised stigma, and distal stressors include external or community/society-level experiences such as discrimination, violence, and rejection related to sexual orientation or gender identity (Meyer, Reference Meyer2014). Social stress theory hinges on the idea that social disadvantage can translate into health disparities (Schwartz and Meyer, Reference Schwartz and Meyer2010). It is also important to consider the impact of this on internalised transphobia and how this may be a perpetuating factor to explore in your therapeutic approach in order to move towards a place of acceptance or neutrality (Ellis and Reilly-Dixon, Reference Ellis and Reilly-Dixon2023).
Recommendations
In this exploration of someone’s sense of identity, it will be important to adopt an experience sensitive approach (McGreevy et al., Reference McGreevy, Quinn, Law, Botha, Evans, Rose, Moyse, Boyens, Matejko and Pavlopoulou2024; see Appendix 1 in the Supplementary material). This ensures we as clinicians are providing a neuro-affirming and identity affirming approach within therapy. Appendix 3 (Supplementary material) shows the factors for consideration of a neuro-affirming approach as discussed in the book from Pavlopoulou et al. (Reference Pavlopoulou, Crane, Hurn and Milton2024). These factors are importance for us to hold in mind as therapists and map onto the framework and much of what has been discussed within this paper. Recommendations from research (American Psychological Association, 2015; Brede et al., Reference Brede, Cage, Trott, Palmer, Smith, Serpell and Russell2022; British Psychological Society, 2021; British Psychological Society, 2024a; Cooper et al., Reference Cooper, Loades and Russell2018; Cooper et al., Reference Cooper, Mandy, Butler and Russell2023) demonstrate the importance of therapists understanding autistic culture and LGBTQIA+ culture to enable conversations around specific experiences that may be relevant to understanding impact on wellbeing or core beliefs central to understanding someone’s mental health difficulties. For example, this may be knowledge around autistic burnout, or what it means to be stealth and having the understanding and language to provide authentic discussion around the impact of this for the individual. These concepts may be key to include and integrate within our formulation.
Summary
Our initial aim was to provide a framework of understanding the overlap between being autistic and being transgender and gender diverse, where these two constructs intersect and where they are disparate. We believe the above framework can serve as a method for learning and understanding this collaboratively with an individual to support their and our professional understanding of the context of their identity. Our second aim was to provide suggestions on how psychological therapists, cognitive behavioural therapists and psychologists may use this framework within cognitive behaviour therapy to support autistic transgender and gender diverse individuals. We feel the above descriptions, and ensuring that this is a framework which is co-produced with the service user, will support psychological therapists and psychologists to have a structure around understanding the intersectionality of neurodivergence and gender diversity. This could further support ongoing decisions about a service user’s care and treatment, in a way that is neuro-affirming and gender-affirming.
This framework was utilised in therapy with four clients and was reported to be useful in understanding the intersection of someone’s neurodivergence and gender diversity. The framework was also presented to the Northern Region Gender Dysphoria Service (NRGDS) multi-disciplinary team, and further recommendations were made by professionals in attendance to refine this.
Limitations
This framework has not been robustly empirically tested, it has been produced through an iterative process of learning and working therapeutically with autistic gender diverse individuals, as well as exploring the current research literature and evidence base. It is imperative that this framework should continue to be reviewed and evaluated by autistic TGD individuals and clinicians to assess its utility and accessibility. It is also important to acknowledge that this is a rapidly developing field of research, and at the time of writing, the language and terminology used, is that which is accepted and understood best by the current evidence base. This framework addresses two potential aspects of someone’s intersectionality (autism and TGD) due to the high prevalence rates of this co-occurrence. However, there may be other aspects of intersectionality or personhood that will be necessary to incorporate into formulation, particularly if these are also protected characteristics (for example, BAME) (Tan et al., Reference Tan, Treharne, Ellis, Schmidt and Veale2020). In addition, there is evidence which shows individuals who are autistic and gender diverse, may also be more likely to have an attention deficit hyperactivity disorder (ADHD) diagnosis (Del Río et al., Reference Del Río, Cuellar-Flores, de Lara, Castañeda-Vozmediano, González, Pérez, Rodriguez and Ron2025; Thrower et al., Reference Thrower, Bretherton, Pang, Zajac and Cheung2020), and as outlined in the introduction, are at increased risk of mental health difficulties (Strang et al., Reference Strang, Knauss, van der Miesen, McGuire, Kenworthy, Caplan and Anthony2021). This is likely to add another layer of complexity and utilising models such as the minority stress models (Meyer, Reference Meyer2003; Testa et al., Reference Testa, Habarth, Peta, Balsam and Bockting2015) may be key in supporting our understanding and formulations. There will be aspects of autistic and TGD experience not explicitly discussed in this paper, therefore it is instrumental for clinicians to use this framework as a base for further exploration and curiosity of how these intersecting identities impact on the individual and how this relates to their mental health difficulties.
Clinical implications
The clinical implications of this framework are to be used in psychological therapy by qualified psychological therapists, cognitive behavioural therapists, and psychologists. For utility in a therapeutic context, this framework could also be used by wider multi-disciplinary teams to inform formulation of an individual’s strengths and needs to inform their ongoing care and support from the appropriate mental healthcare team. The framework adopts a neuro-affirming and gender-identity affirming approach which should be led with curiosity, acceptance and a non-judgemental approach.
The intention of the framework is to support therapists and service users to move to a place during therapy where the service user is more accepting, non-judgemental and satisfied with their identity and who they are. Through having these safe, exploratory conversations in therapy, this may lead to feelings of empowerment for the service user. If this is not possible, a place of neutrality and less self-criticism, would also be a viable therapeutic goal. The idea of embracing a narrative and core belief of ‘This is who I am and that is okay’. As with the introduction of any framework for formulation, it will be key for therapists to gain feedback from service users on the utility of using this and whether this is a helpful method of exploration.
Key messages
The key messages from the current literature in this area, the proposal of this framework and its use with the authors and service users, are as follows:
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• It is imperative that therapists have a robust understanding of autism and what it means to be transgender and gender diverse. Further development of this knowledge can be sought through clinical supervision, continued professional development, specific training and integration in community groups.
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• In order to be most effective in our work with autistic TGD individuals in therapy, reasonable adjustments, our approach and our areas of exploration must be individualised and adhere to the specific needs of the service user we are working with. There is no ‘one size fits all’ and there is huge heterogeneity in the autistic TGD population. Therefore, as therapists we must remain curious and spend time getting to know the individual in order to be able to tailor the therapeutic approach accordingly.
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• True collaboration in this process is integral. We must be cautious of our own biases, expectations and perspectives which have been shaped by our own socio-cultural background. It is therefore vital to not impose our own beliefs or expectations on the service user and ensure therapeutic goals are collaboratively agreed and are aligned to the values of the service user.
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• Creation of a safe and accepting space within therapy is not to be under-estimated. The multiple layers of stigmatisation and victimisation in this population are extensive and therefore provision of a safe place to explore someone’s authentic identity could be the first opportunity an individual has had to have this conversation.
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• The purpose of this framework and therapy with autistic TGD individuals is to develop a compassionate self-narrative which incorporates intersecting aspects of their identity and promotes self-advocacy and resilience.
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• Connection to a safe community where the service user is safe to be their authentic selves will be a valued and important outlet.
Conclusion
Research is still in its initial stages in this area; however, the proposed framework may lend a starting point or initial formulation to support cognitive behavioural therapists and individuals in understanding their autistic identity and transgender or gender diverse identity, whilst also conceptualising the overlap. The hope is that understanding an individual’s presentation in this way, will empower the individual and enhance their knowledge and understanding of themselves, thus enabling them to be a self-advocate and have a robust understanding of their needs. The purpose of therapy is to equip the individual with better understanding and strategies to manage their own wellbeing when challenges arise, and the hope is that this framework may serve as a starting point for therapists and service users.
Key practice points
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(1) Seek out additional continued professional development and training in neurodivergence and gender diversity.
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(2) Seek appropriate supervision when working therapeutically with neurodivergent, gender diverse individuals.
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(3) Incorporate the individual’s experience of these intersecting aspects of their identity into their therapeutic formulation where appropriate.
Further reading
Further reading can be sought through the papers referenced in the main body of this article and within the references. It would be encouraged specifically to read literature written by neurodivergent gender diverse individuals and neuro-affirmative therapy.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1754470X26100762
Data availability statement
Not applicable to this article.
Acknowledgements
We would like to thank the service users from NRGDS for their input into the framework and the wider MDT for their discussion and contributions to this framework.
Author contributions
Renske Herrema: Conceptualization (lead), Investigation (equal), Validation (equal), Writing - original draft (lead), Writing - review & editing (equal); Anna Laws: Supervision (lead), Validation (equal), Writing - review & editing (equal).
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare none.
Ethical standards
Authors of this paper have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS. No ethical approval was obtained, as no personally identifiable or clinically sensitive information has been used, and the framework has been derived and used as part of standard practice.
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