Minority Stress,Camouflaging,and Mental Health Outcomes in Transgender and/or Non-binary Autistic Adults

Abstract

Background:

This study sought to examine the role of autistic and gender minority stress, resilience, and camouflaging in predicting mental health outcomes in transgender and/or non-binary autistic adults in the United Kingdom.

Methods:

In total, 412 transgender and/or non-binary autistic participants completed an online survey. This survey consisted of the Gender Minority Stress and Resilience Scales, Autistic Minority Stress and Resilience Scales, the Camouflaging Autistic Traits Questionnaire, the Depression, Anxiety and Stress Scale, and the Posttraumatic Stress Disorder Checklist.

Results:

The final models in hierarchical regression predicted depression (R² = 0.24), anxiety (R² = 0.26), stress (R² = 0.21), and posttraumatic stress (R² = 0.32). Camouflaging remained a significant unique predictor of anxiety and stress. Internalized anti-autistic prejudice remained a significant unique predictor of each model. Everyday anti-autistic discrimination uniquely predicted anxiety and posttraumatic stress. Gender minority negative expectations uniquely predicted depression and posttraumatic stress.

Conclusion:

These findings suggest that gender and autistic minority stress and camouflaging significantly predict a proportion of variance in depression, anxiety, stress, and posttraumatic stress experienced by transgender and/or non-binary autistic adults.

Community Brief

Why is this an important issue?

Transgender and/or non-binary (TNB) adults and autistic adults may have worse mental health compared with the general population. Little research has looked at the mental health of those who are both TNB and autistic.

What was the purpose of this study?

This study looked at mental health outcomes in TNB autistic adults in the United Kingdom. It investigated factors associated with better or worse mental health, including depression, anxiety, stress, and posttraumatic stress. The factors we looked at were: 1.

being physically disabled and/or being non-binary.

minority stress (the extra stress faced by people who belong to a discriminated-against minority group).

resilience (strategies to cope with stress).

camouflaging (minimizing the visibility of autistic traits).

What did the researchers do?

We surveyed 412 TNB autistic adults in the United Kingdom. We asked questions about demographics, autistic minority stress, gender minority stress, resilience, camouflaging, and mental health outcomes. Then we did statistical analyses on the results.

What were the results of the study?

Participants generally scored highly on depression, anxiety, stress, and posttraumatic stress scales. Participants reported frequent experiences of transphobic and anti-autistic discrimination. As experiences of minority stress and camouflaging increased, so did mental health outcome scores. A statistical analysis called a regression was done. This showed that demographics, minority stress, and camouflaging significantly predicted between 21% and 32% of the change in depression, anxiety, stress, and posttraumatic stress.

What do these findings add to what was already known?

This was one of the first studies to show that a sample of TNB autistic adults in the United Kingdom report poor mental health and high rates of discrimination and victimization. Our findings showed, for the first time to our knowledge, that autistic minority stress is associated with anxiety, depression, and posttraumatic stress and that camouflaging is associated with posttraumatic stress and autistic pride with reduced depression. We showed that gender minority negative expectations, autistic internalized prejudice, anti-autistic everyday discrimination, and camouflaging may be particularly important factors in predicting the change in mental health outcomes.

What are potential weaknesses in the study?

Online recruitment may have excluded some autistic adults with higher support needs. Measuring discrimination and distress at the same point in time means that the results cannot prove that past discrimination causes distress later on. There also may have been important variables that we didn’t include that would have influenced the results. The scales we used also probably did not capture the complexity of experiences of TNB autistic adults.

How will these findings help autistic adults now or in the future?

Our findings could help highlight to health care providers and policymakers the urgency of reducing anti-autistic and transphobic discrimination and supporting the mental health of TNB autistic adults.

Introduction

“Transgender” is an umbrella term used for individuals whose gender differs from the gender socially attributed to their assigned sex at birth.¹ This term originated in Western Europe and North America. In these cultures, gender is classified as two mutually exclusive (binary) categories, which are assigned at birth based on observable biological sex traits. Transgender people are either a binary gender (man or woman) or they are not (non-binary person). “Transgender and/or non-binary” (TNB) are now commonly used terms globally, although humans have naturally differed in their relationships to their socially assigned gender and their gendered bodies throughout history and across cultures, and local or traditional cultural identities may not fit accurately under the above definitions.^2–4 Western European and North American cultures remain cisnormative, in that being cisgender (not TNB) is considered and treated as default.¹ These cultures are also neuronormative, in that there is an assumption that there is one normal way for human minds to function.⁵ “Neurodivergent” is the umbrella term for those whose minds function in ways that vary significantly from that standard, and neurodiversity describes this variation.⁵ Autistic describes neurodivergent individuals who share a pattern of differences in thinking, moving, sensing, and communicating.⁵ Neurodiversity and gender diversity overlap and intersect, with many individuals being TNB and autistic.⁶ While terminology constantly evolves, the above definitions represent a shift from a “pathology paradigm” approach to a depathologized diversity approach.

The pathology paradigm is the dominant scientific assumption that there is one healthy range for human minds and bodies to belong to and those who diverge significantly from this standard are disordered or deficient.^5,7 The International Classification of Diseases (ICD) classifies autistic individuals as having “autism spectrum disorder” (ASD), so too does the Diagnostic and Statistical Manual for Mental Disorders (DSM-5).^8,9 TNB individuals were similarly framed as having “transsexualism” or “gender identity disorder” until 2019, although the current version of the ICD has amended this whereby “gender incongruence” is now listed under “conditions related to sexual health.”⁸ The current version of the DSM-5 moved from inclusion of “gender identity disorder” as a mental disorder to listing “gender dysphoria” in 2013.⁹ The pathology paradigm has been used to marginalize, oppress, and sometimes attempt to eliminate minorities who vary significantly from what is considered “normal,” including sexuality, gender, and neurodivergent and disabled minorities.¹⁰ Depathologization approaches can promote powerful changes; for example, the removal of homosexuality from the ICD in 1990 marked a critical turning point in the improvement of human rights, legal protection, and social acceptance of sexual minorities.⁷ Depathologization of TNB and autistic individuals may reduce the discrimination they experience and the acceptability of conversion therapy and eugenic efforts.^11,12 Depathologization approaches need not deny the medical needs of disabled or pathologized communities but rather destigmatize requiring medical support such that those with support needs are not framed as “deficient” or “abnormal.”¹³

TNB and autistic minorities experience high rates of depression, anxiety, and suicidality.^14,15 A small but growing number of studies have shown high rates of adverse mental health outcomes in adults who are both TNB and autistic.¹⁶ A component of psychological distress in some TNB individuals is gender dysphoria, or severe distress caused by gender incongruence.⁹ These individuals can find relief through gender-affirming health care (GAHC) interventions such as hormone therapy or surgery.^17,18 However, it is crucial that not all psychological distress in TNB autistic adults is located as internal to the individual.^2,19 A depathologization approach lends itself to an ecological framework approach, where distress is understood as related not only to individual factors but also to the interpersonal, systemic, and structural context.^1,2,11 To explore the drivers of poor mental health in TNB autistic adults, this study will examine the role of dual minority stress and camouflaging in predicting depression, anxiety, stress, and posttraumatic stress in TNB autistic adults in the United Kingdom.

Minority stress

Minority stress theory (MST) posits that minority populations experience additional stressors that lead to higher rates of adverse mental health outcomes.^20–22 Distal, observable minority stressors include structural oppression in legal and health care systems and direct experiences of discriminatory violence and abuse. The internal experience and reaction to these stressors lead to more proximal stressors: expectations of rejection or discrimination, concealment of identity, and internalized prejudice.²¹ MST was initially conceptualized to understand the mental health of sexual minorities but has since been extended for TNB minorities and autistic minorities.^23,24 Using these measures, gender minority stress (GMS) can predict 20%–43% of the variance in depression, anxiety, and suicidal ideation in TNB adults, with the effect sizes larger and more consistently found for proximal than distal stressors.^15,25–27 Autistic minority stress (AMS) can predict 72% of the variance in psychological distress in autistic adults.²⁴

Minority resilience

Resiliency is a multidimensional phenomenon describing the resources that an individual has available to deal with stressful situations.²⁸ Qualitative literature describes multiple components that could play a role in resilience in TNB and autistic populations, including building knowledge around gender and neurodiversity, gender euphoria, finding positive media representation, involvement in activism, understanding one’s autistic strengths, authenticity, self-acceptance, and agency.^4,29–33 Minority stress measures commonly include measures of individual resilience, such as feelings of intra-community connectedness, which have been shown to buffer the impact of minority stress on mental health outcomes in the TNB community and autistic community.^23,30,34 A meta-analysis of the use of the Gender Minority Stress and Resilience Measure (GMSR) found that pride and community connectedness significantly negatively correlated with depression and anxiety symptoms, r = −0.07 to r = −0.16.²⁷ Without an equal focus on resilience and well-being, minority stress literature risks positioning TNB and autistic individuals as victims of their social environments. Therefore, this study includes scales of gender minority and autistic minority community connectedness and pride, alongside the GMS and AMS scales.

Camouflaging

Autistic camouflaging involves conscious and unconscious strategies used by autistic individuals to mask or compensate for their autistic traits as an attempt to fit in and cope under neurotypical social norms.³⁵ Higher camouflaging scores across measures consistently correlate with increased psychological distress and suicidality.^36,37 Camouflaging researchers acknowledge that the whole population employs camouflaging to different degrees depending on various factors.³⁵ However, autistic camouflaging may be particularly important to study due to the centrality of differences in navigating social situations within the autistic experience. Camouflaging measures have not yet been used in transgender autistic samples. Non-binary autistic people score particularly highly on the Camouflaging Autistic Traits Questionnaire (CATQ), although this research had small nonbinary samples.^38,39 This study explores whether autistic camouflaging continues to predict adverse mental health outcomes in TNB autistic adults when accounting for GMS and AMS.

Mental health outcomes

The few quantitative studies to examine mental health outcomes in TNB autistic individuals indicate higher levels of anxiety, depression, and posttraumatic stress disorder (PTSD) compared with autistic cisgender, cisgender non-autistic, and TNB non-autistic comparison groups.¹⁶ This literature relies on small and heterogeneously defined TNB autistic samples (n = 1–35) and focuses on children and adolescents. The single study with a larger sample of TNB autistic individuals (n = 193) is a survey of Australian youth.⁴⁰ In this sample, 68.9% scored in the severe range for depression, 37.7% in the severe range for anxiety, 57.0% had a previous PTSD diagnosis, and 57.2% had attempted suicide. Additionally, Kung and colleagues measured autistic traits in a sample of TNB adults and found that autistic traits and gender minority stress correlated with poorer mental health outcomes.⁴¹ In the qualitative literature, TNB autistic adults link their distress to the stress of managing dual identities and heightened feelings of “difference” and “otherness,” dual marginalization in social and health care settings, sensory sensitivity heightening body dysphoria, and the stress of “double masking” as cisgender and non-autistic.^32,42–47 Many TNB autistic adults are also lesbian, gay, bisexual, or queer; therefore, there is also likely to be an additional burden of sexual minority stress.^48,49

In the UK context, the TNB community report high rates of depression, anxiety, self-harm, and suicidal ideation, with 27% of those aged 16–25 rating that it was “likely” they would die by suicide.^50,51 Autistic adults also report high rates of depression, anxiety, and suicidal ideation, with 35% attempting suicide at least once.^52,53 Both TNB and autistic communities link a proportion of their distress to discrimination. TNB adults relate their depression, anxiety, suicidal ideation, and chronic stress-related physical illness to discrimination and violence experiences, limited and inequitable access to GAHC, rising transphobic media rhetoric, barriers to all forms of health care, and rejection by partners and family members.^50,54,55 Autistic adults report various forms of discrimination, and 91% feel society does not accept them.^24,56 Those labeled as having a learning disability are particularly vulnerable to hate crime, forced institutionalization, being viewed as unintelligent or incapable, and feeling unsafe in public.⁵⁷ TNB autistic adults in the United Kingdom are therefore likely to experience high rates of mental health problems, as well as high levels of anti-autistic and transphobic discrimination, victimization, and rejection. They also experience specific intersectional stressors, such as infantilization and denial of care in GAHC settings.^42,54

Aims and hypotheses

This study aims to quantitatively explore mental health outcomes in a large sample of TNB autistic adults in the United Kingdom, in line with recommendations into how research into multiply marginalized groups can take an intersectional perspective, and specific recommendations from TNB and autistic experts.^6,58–60 The independent variables are GMS and resilience, AMS and resilience, and camouflaging. The outcome variables are depression, anxiety, stress, and posttraumatic stress. Dichotomously scored discrimination and victimization scale outcomes are reported descriptively. Hypothesis 1:

Demographics, namely being non-binary and physically disabled, will be related to higher depression, anxiety, stress, and posttraumatic stress scores.

Hypothesis 2:

High GMS scales, AMS scales, and camouflaging scale scores will be related to high depression, anxiety, stress, and posttraumatic stress scores.

Hypothesis 3:

High resilience scale scores will be related to low depression, anxiety, stress, and posttraumatic stress scores.

Hypothesis 4:

Disability, being non-binary, camouflaging, GMS, AMS, and resilience, will significantly predict the variance in depression, anxiety, stress, and posttraumatic stress.

Methods

Inclusion/exclusion criteria

Participants were eligible to take part in the study if they were TNB, aged 18 years and above, proficient in English, and able to provide their own consent. Participants were eligible whether they were self-identified as autistic or had a clinical diagnosis. Including self-identified autistic adults is critical to a depathologization approach; furthermore, clinical diagnosis is not easily accessible or preferable for a significant proportion of autistic adults.⁶¹

Participants

Originally 765 responses were recorded on the online survey; however, 158 participants did not go beyond the information screen, 52 participants did not provide consent, 7 did not meet the inclusion criteria, and 61 did not complete the outcome measures. Cases suspected to be automatic survey-takers (bots) were further removed (n = 78) following recommended screening methods.⁶² These included incorrectly answering the bot-check question (“Please select the answer that rhymes with bat”), giving nonsensical answers in free-text responses, or when multiple cases were started within one minute of each other and gave identical answers to the first set of demographic questions. The final sample included 412 cases.

An a priori power calculation computed a minimum adequate sample size of 128; however, the final analytic strategy required a reanalysis due to the increase in number of maximum predictor variables entered. The second power calculation using a G*Power calculator computed a minimum adequate sample size of 256 with the maximum 29 predictor variables. This calculation used the statistical test: linear multiple regression: fixed model, R² increase. The calculation used a statistical power of 0.95, a significance level of 0.05, and an effect size of 0.15. The effect size was based on a medium effect size as proposed by Cohen.⁶³

Table 1 presents a summary of the sample characteristics. In this sample of TNB autistic adults, 79.37% of participants were aged 18–34; the maximum age was 66. Non-binary individuals comprised 73.30% of the sample, and those who used White British/Irish as one of their race/ethnicity descriptors comprised 80.34%. Polysexual orientations were the most commonly described: 33.74% used bisexual, 19.66% used pansexual, and 54.13% used queer. Disabilities were very common; 83.50% reported any disability (not including being autistic), 65.29% had a mental health condition, 31.07% had a physical disability, and 54.13% were multiply neurodivergent. All scale variables demonstrated good internal consistency (see Supplementary Data S1). Approximately half (52.18%) reported having a clinical autistic diagnosis. Mean scores on the outcome variables were not significantly different between those who reported a clinical autistic diagnosis and those who did not (depression U = 19556.50, p = 0.18; anxiety U = 21328.00, p = 0.90; stress U = 19249.50, p = 0.11; posttraumatic stress U = 20246.50, p = 0.44). The mean camouflaging score was 130.56, higher than previously reported mean scores for autistic and non-autistic cisgender adults.⁶⁴ The mean scores for anxiety (mean [M] = 9.52, standard deviation [SD] = 4.45) and depression (M = 10.95, SD = 5.24) fell into the severe range. The mean score for posttraumatic stress (M = 40.34, SD = 17.97) was above 33. The score of 33 is described by the PTSD Checklist for DSM-5 (PCL-5) authors as the clinical cutoff for a diagnosis of PTSD when the score is used in combination with a clinical interview; however, it is important to note that scoring 33 and above on this scale alone is insufficient to assume a PTSD diagnosis in the present sample.⁶⁵

Table 1.

Demographics and Scale Variables (N = 412)

Characteristic	n	%
Age in years (5 missing)
18–24	166	40.29
25–34	161	39.08
35–44	55	13.35
45–54	15	3.64
55–64	9	2.18
65+	1	0.02
Gender^a
Woman/trans woman	59	14.32
Man/trans man	125	30.34
Non-binary/agender/genderqueer	302	73.30
Traditional or Indigenous gender	3	0.73
Questioning/unsure/unlabeled	23	5.58
Autistic diagnosis
Has diagnosis	215	52.18
Does not have diagnosis	188	45.63
Unsure	9	2.18
Race/ethnicity^a
White (British, Irish)	331	80.34
White (Gypsy, Roma, Traveler)	10	2.43
White (Other)	48	11.65
Black (British, Irish)	2	0.49
Black (Caribbean, African)	6	1.46
Black (Other)	1	0.24
Asian (British, Irish)	6	1.46
Asian (Indian, Pakistani, Bangladeshi, Chinese)	16	3.88
Asian (Other)	8	1.94
Arab (British, Irish)	1	0.24
Arab (Other)	0	0.00
Mixed or other, please state^b	29	7.04
Sexual orientation^a
Gay	52	12.62
Lesbian	57	13.83
Bisexual	139	33.74
Pansexual	81	19.66
Queer	223	54.13
Straight	13	3.16
Aromantic	42	10.19
Asexual	89	21.60
Demisexual	54	13.11
Other, please state^b	32	7.77
Disability^a
Any disability (other than autistic)	344	83.50
ADHD or other neurodivergence^b	223	54.13
Physical disability^b	128	31.07
Mental health condition^b	269	65.29
Sensory difference (e.g., Blind, d/Deaf)^b	26	6.31
Other^b	23	5.58

	M (SD)	alpha
Scale variables
Gender minority non-affirmation	18.06 (5.11)	0.86
Gender minority internalized prejudice	11.73 (8.12)	0.90
Gender minority negative expectations	23.18 (6.23)	0.86
Gender minority non-disclosure	10.56 (5.71)	0.88
Gender minority community connectedness	12.69 (4.67)	0.84
Gender minority pride	19.71 (6.56)	0.84
Autistic minority everyday discrimination	9.79 (7.88)	0.89
Autistic minority expectations of rejection	14.88 (5.58)	0.84
Autistic minority internalized prejudice	10.24 (6.30)	0.87
Autistic minority behavioral concealment	17.46 (5.24)	0.83
Autistic minority community connectedness	31.48 (9.07)	0.88
Autistic minority pride	15.14 (4.98)	0.70
Autistic minority outness	10.42 (3.14)	0.72
Camouflaging	130.56 (21.54)	0.90
Depression	10.95 (5.24)	0.90
Anxiety	9.52 (4.45)	0.83
Stress	12.43 (4.21)	0.82
Posttraumatic stress	40.34 (17.97)	0.94

Multiple options could be selected.

Optional free text box provided.

ADHD, attention-deficit/hyperactivity disorder; alpha, Cronbach’s alpha; %, percentage of total sample; M, mean; n, number; SD, standard deviation.

Ethics

Ethical approval was granted by the University of Edinburgh Health in Social Science Ethics Committee and the University of Edinburgh was the sponsor.

Procedure

The lead researcher who carried out the study is TNB and autistic. Two TNB autistic community experts provided feedback on the design and accessibility of the project and were offered reimbursement at £50 per hour.

The lead researcher approached voluntary sector organizations and invited them to share the online survey with their community members. From March 1 to May 1, 2023, participating organizations shared the advertisement on their social media platforms. The research team also shared it on their personal and professional social media platforms.

Participants took part in the online survey that consisted of a series of online questionnaires that collected data anonymously using the Qualtrics platform. Participants were required to indicate they had read the information sheet, consent form, and eligibility criteria to progress to the survey, which was estimated to take 30–45 minutes and allowed for breaks. First, demographics were collected including questions regarding gender, autistic diagnosis, race/ethnicity, sexual orientation, disability, and age. These were presented in multiple-choice format with free-text options. The wording was co-designed by the lead researcher and community experts. The participants then completed the Gender Minority Stress and Resilience Scales, Autistic Minority Stress and Resilience scales, the CATQ, the Depression, Anxiety and Stress Scale (DASS-21), and the PCL-5. At the end of the survey, participants were able to submit their email addresses through a separate online form to participate in the prize draw. All participants were then directed to a debrief sheet. Prize draw winners were randomly selected; one prize of £100 and four prizes of £50 were distributed in July 2023.

Measures

Gender minority stress and resilience scales

The GMS scales consisted of nine scales measuring GMS constructs: discrimination (GMS-D), rejection (GMS-R), victimization (GMS-V), non-affirmation (GMS-NA), internalized prejudice (GMS-IP), negative expectations (GMS-NE), and non-disclosure (GMS-ND). Two additional scales measured resilience constructs of pride (GMS-P) and community connectedness (GMS-CC).³⁴ GMS-D, GMS-V, and GMS-R scales consisted of a total of 18 items about whether participants had experienced common types of discrimination, rejection, or victimization, and response options were “Yes,” “No,” or “Don’t Know.” GMS-NA, GMS-IP, GMS-NE, GMS-ND, GMS-P, and GMS-CC consisted of a total of 41 Likert-scale items, and response options ranged from strongly disagree to strongly agree. The GMS scales each demonstrate good internal consistency in TNB adults.³⁴

Autistic minority stress and resilience scales

The AMS scales consisted of eight scales measuring AMS constructs, victimization and discrimination (AMS-VD), everyday discrimination (AMS-ED), behavioral concealment (AMS-BC), expectation of rejection (AMS-ER), internalized prejudice (AMS-IP), community connectedness (AMS-CC), outness (AMS-O), and pride (AMS-P). AMS-VD, AMS-ED, AMS-BC, AMS-ER, AMS-IP, and AMS-O subscales have been previously validated and showed good internal consistency.²⁴ The AMS-CC subscale was added and has shown good composite reliability (n = 138, Composite Reliability = 0.92).³⁰ This study adapted the AMS-P subscale from the GMS measure at the request of the community experts by changing the word “trans/nonbinary” to “autistic.” One variable was deleted (“I am comfortable revealing to others that I am autistic,” AMS-P7) as this improved internal reliability from α = 0.45 to α = 0.70. There were 51 items in total. AMS-ER, AMS-CC, AMS-BC, and AMS-P were 5- to 6-point scales with response options ranging from strongly disagree to strongly agree. AMS-ED and AMS-IP were 4-point scales from never to often. AMS-O was a 4-point scale from none to all, and AMS-VD was binary with yes = 1, no = 0.

Camouflaging autistic traits questionnaire

The CATQ is a self-report questionnaire of 25 items answered on a 7-point scale from strongly disagree to strongly agree according to how much the participants camouflage their autistic traits.⁶⁶ The total scores for the CATQ range from 25–175, with higher scores indicating more frequently reported camouflaging behaviors. This scale has been validated in autistic and non-autistic adults and has demonstrated excellent internal consistency.⁶⁶

Mental health outcomes

Outcome scales included the DASS-21 and the PCL-5.^65,67 The DASS-21 includes items on experiences of depression, anxiety, and stress symptoms in the past month, with response options ranging from never to almost always. It provides nominal cutoffs for normal (general population score) to extremely severe.⁶⁷ The PCL-5 includes 20 5-point Likert-style items on symptoms of PTSD in the last month, with responses ranging from not at all to extremely. Scores of 33 and above are considered the clinical cutoff for likely PTSD by PCL-5 authors, subject to further clinical assessment.⁶⁵ Both scales demonstrate strong internal consistency.^68,69

Data analysis

A missing values analysis of the predictor and outcome variables showed 0.66% missing data, with no variables with 5% or more missing data. Little’s test was significant, χ²(25,013, n = 412) = 25518.14, p = 0.012, rejecting the null hypothesis that the cases were missing completely at random. A dummy variable was constructed as to whether cases had more than 5% missing values across the predictor and outcome variables. Chi-squared tests showed that cases with different demographics did not significantly differ in missingness, indicating that the values were likely missing at random (MAR). Removing cases with a large percentage of MAR data by listwise deletion can bias the analysis.⁷⁰ In a large dataset, where <5% of data points are missing, missing values have little impact on the analysis.⁷¹ Thus, all cases were retained without imputation.

Descriptive statistics were computed for the dichotomously scored GMS-V, GMS-R, GMS-D, and AMS-VD subscales.

A preliminary exploration was performed to determine if each other scale variable met the assumptions for parametric tests. Statistically significant Shapiro–Wilks values were yielded for several scale variables, indicating that they did not meet the assumption of normality (see Supplementary Data S1). The data were therefore subjected to bivariate Spearman’s rank correlations for non-parametric data. Variables included in the correlation analysis were the demographic variables of “physical disability” and “gender,” which were dummy coded. Participants were asked, “Do you have a physical disability?”; answers were coded no = 0, yes = 1. If only a binary gender was disclosed in response to the question “How would you describe your gender and/or relationship to gender?” this was coded as binary = 0, and if any non-binary identity was disclosed, this was coded as non-binary = 1. Also included were the seven AMS and resilience scales, six GMS and resilience scales, the camouflaging scale, and the four outcome variables. These 20 variables were included with a two-tailed significance cutoff of 0.05. A Bonferroni correction (0.05/80 = 0.0006) was made to reduce the likelihood of type I error.⁷¹

Multiple regressions are known to be robust to violation of assumptions such as normality, particularly with a large sample size; therefore, for regression analysis, this result was not overinterpreted.⁷¹ All predictor variables were entered into hierarchical multiple regression for each outcome. Disability and gender demographics were entered in Step 1. Camouflaging scores were entered in Step 2. This was based on the theoretical assumption that adopting camouflaging behaviors (e.g., forcing eye contact) may start in early childhood or infancy and predate exposure to many experiences of minority stress captured by these measures. There is a more substantial evidence base for the relationship between GMS and resilience and mental health outcomes than for AMS. Therefore, GMS and resilience variables were entered in Step 3, followed by AMS and resilience variables in Step 4.

Results

Descriptive statistics

Participants reported experiencing anti-autistic and transphobic victimization, rejection, and discrimination (see Table 2).

Table 2.

Frequency of Dichotomously Scored Minority Stressors

Dichotomously scored minority stressors	n	Yes %
Gender minority violence (ever)
Verbal harassment or teasing	410	69.76
Threatened with outing or blackmail	411	16.79
Personal property damaged	408	11.03
Threatened with physical harm	409	32.52
Physical violence	410	25.61
Sexual violence	411	18.00
Gender minority discrimination (ever)
Difficulty getting medical or mental health treatment	410	54.88
Difficulty finding a public bathroom	410	69.76
Difficulty getting identity documents	408	65.69
Difficulty finding or keeping housing	408	15.93
Difficulty finding or keeping employment	409	25.43
Gender minority rejection (ever)
Difficulty finding or keeping a relationship	411	47.20
Rejection by religious community	398	44.47
Rejection by ethnic/racial community	409	21.52
Rejection by friends	408	54.41
Rejection by school or workplace	408	45.83
Rejection by family	411	58.64
Anti-autistic discrimination and violence (in the last year)
Physical or sexual violence	406	16.26
Theft or destruction of property	407	10.57
Attempted violence or theft	409	9.29
Threatened with violence	410	22.44
Verbal harassment or abuse	409	49.14
Thrown an object at	409	13.45
Fired or denied employment	407	25.06
Denied housing	409	5.62

These labels have been shortened for readability. Each label corresponds to an individual item in the GMSR (Testa et al.²⁴). Each item originally is formatted as Because I am (autistic, trans/non-binary), I (e.g., was treated with less courtesy).

AMS, autistic minority stress; GMSR, Gender Minority Stress and Resilience Measure.

Table 3.

Spearman’s Rank Correlations Between Predictor Variables and Outcome Variables

	DIS	GEN	CATQ	GMS-NA	GMS-IP	GMS-NE	GMS-ND	GMS-P	GMS-CC	AMS-ED	AMS-ER	AMS-IP	AMS-BC	AMS-O	AMS-P	AMS-CC	DEP	ANX	STR	PTS
DIS	—
GEN	0.03	—
CATQ	0.10	−0.02	—
GMS-NA	0.05	0.24^**		—
GMS-IP	0.00	−0.35^**	0.25^**	0.07	—
GMS-NE	0.23^**	−0.06	0.36^**	0.29^**	0.31^**	—
GMS-ND	0.06	−0.33^**	0.35^**	0.13^*	0.52^**	0.36^**	—
GMS-P	−0.01	0.22^**	−0.06	0.18^**	−0.45^**	−0.04	−0.31^**	—
GMS-CC	0.09	0.01	−0.09	0.08	−0.26^**	0.01	−0.12	0.44^**	—
AMS-ED	0.12	−0.04	0.28^**	0.21^**	0.23^**	0.39^**	0.28^**	−0.01	−0.02	—
AMS-ER	0.17^**	−0.06	0.36^**	0.28	0.15^*	0.49^**	0.23^**	−0.07	−0.07	0.44^**	—
AMS-IP	−0.05	−0.19^**	0.29^**	0.09	0.52^**	0.18^*	0.31^**	−0.25^**	−0.29^**	0.16^*	0.13	—
AMS-BC	0.02	−0.09	0.44^**	0.16^*	0.33^**	0.30^**	0.38^**	−0.23^**	−0.24^**	0.29^**	0.26^**	0.50^**	—
AMS-O	0.04	−0.06	−0.16^*	−0.11	−0.12	−0.08	−0.11	0.05	0.17	0.12	0.00^*	−0.25^**	−0.33^**	—
AMS-P	−0.03	−0.08	−0.12	0.05	−0.28^**	−0.07	−0.17	0.42^**	0.21^**	0.28^**	0.02	−0.49^**	−0.37^**	0.33^**	—
AMS-CC	0.13	0.13	0.13	0.20^**	−0.17^*	0.10	−0.05	0.16^*	0.27^**	0.04	0.22^**	−0.34^**	−0.18^*	0.38^**	0.46^**	—
DEP	0.03	−0.17^*	0.26^**	0.21^**	0.35^**	0.33^**	0.20^**	−0.10	−0.16^*	0.21^**	0.23^**	0.37^**	0.19^**	−0.08	−0.19^**	−0.02	—
ANX	0.16	−0.10	0.35^**	0.23^**	0.26^**	0.34^**	0.24^**	−0.05	0.01	0.36^**	0.24^**	0.29^**	0.17^**	−0.02	−0.07	0.15^*	0.48^**	—
STR	0.12	−0.06	0.40^**	0.22^**	0.25^**	0.32^**	0.19^**	0.01	−0.03	0.24^**	0.26^**	0.30^**	0.20^**	−0.05	−0.07	0.07	0.60^**	0.65^**	—
PTS	0.16^*	−0.12	0.32^**	0.24^**	0.29^**	0.41^**	0.28^**	−0.02	−0.07	0.45^**	0.35^**	0.33^**	0.23^**	−0.03	−0.11	0.09	0.64^**	0.65^**	0.63^**	—

p < 0.05 (two-tailed).

p < 0.0006 (two-tailed).

DIS: Physical Disability Declared = 1, No Physical Disability = 0. GEN: Any Nonbinary Identity Declared = 1, Binary Only = 0.

AMS, autistic minority stress; AMS-BC, AMS-behavioral concealment; AMS-CC, AMS-community connectedness; AMS-ED, AMS-everyday discrimination; AMS-ER, AMS-expectation of rejection; AMS-IP, AMS-internalized prejudice; AMS-O, AMS-outness; AMS-P, AMS-pride; ANX, Anxiety; DEP, depression; DIS, disability; GEN, gender; PTS, posttraumatic stress; STR, stress; CATQ, Camouflaging Autistic Traits Questionnaire; GMS, gender minority stress; GMS-CC, GMS-community connectedness; GMS-IP, GMS-internalized prejudice; GMS-NA, GMS-non-affirmation; GMS-ND, GMS-non-disclosure; GMS-NE, GMS-negative expectations; GMS-P, GMS-pride.

Correlational analyses

Spearman’s rank correlations were carried out (see Table 3) and showed that being disabled was significantly correlated with increased scores in posttraumatic stress. Being non-binary was correlated with decreased depression scores. Neither correlation retained significance following adjustment for multiple correlations.

Correlation strength was determined using Cohen’s 1992 criteria.⁷² Camouflaging was weakly positively correlated with depression and moderately positively correlated with anxiety, stress, and posttraumatic stress. Gender minority non-affirmation, non-disclosure, and internalized prejudice were weakly positively correlated with mental health outcomes, apart from a moderate positive correlation between internalized prejudice and depression. Gender minority negative expectations were moderately positively correlated with all mental health outcomes. Gender minority community connectedness was weakly negatively correlated with depression; this did not retain significance following adjustment for multiple comparisons, and no significant correlation was found between gender minority pride and mental health outcomes. Anti-autistic everyday discrimination was weakly positively correlated with depression and stress and moderately correlated with anxiety and posttraumatic stress. Autistic minority expectations of rejection and behavioral concealment showed significant weak positive correlations with depression, anxiety, stress, and posttraumatic stress, except a moderate positive correlation between expectations of rejection and posttraumatic stress. Autistic minority internalized prejudice was moderately positively correlated with depression, stress, and posttraumatic stress and weakly positively correlated with anxiety. Autistic outness showed no significant correlations with mental health outcomes. Autistic pride was weakly negatively correlated with depression. Autistic community connectedness was weakly positively correlated with anxiety; this lost significance post Bonferroni adjustment.

Regression analyses

Table 4 shows the results of the hierarchical multiple regressions. The regressions assessed the predictive power of physical disability and gender, camouflaging (CATQ score total), GMS scales, and AMS scales to predict variations in mental health outcomes. Cook’s distances were between 0.00–0.06. The assumptions of linearity, normality, and homoscedasticity were not violated (see Supplementary Data S1). Although the beta coefficients showed some indication of multicollinearity, Variable Inflation Factor values were between 1 and 2.18, tolerance values were 0.43 or higher, and Spearman’s rank correlations were all <0.70.

Table 4.

Hierarchical Regression for Camouflaging and Minority Stress Predicting Depression, Anxiety, Stress, and Posttraumatic Stress

	Depression				Anxiety				Stress				Posttraumatic stress
Variable	B	SE	β	t	B	SE	β	t	B	SE	β	t	B	SE	β	t
Step 1
(Constant)	12.31	0.57		21.78^**	9.90	0.48		20.61^**	12.57	0.46		27.51^**	42.43	1.93		21.98^**
DIS	0.42	0.59	0.04	0.71	1.39	0.50	0.14	2.77^*	1.13	0.48	0.12	2.38	5.92	2.01	0.15	2.95^*
GEN	−1.99	0.63	−0.17	−3.19^*	−1.08	0.53	−0.11	−2.03	−0.67	0.51	−0.07	−1.32	−5.27	2.14	−0.13	−2.47
Step 2
(Constant)	4.82	1.69		2.86^*	1.02	1.39		0.73	3.35	1.31		2.56	11.47	5.68		2.02
DIS	0.17	0.57	0.02	0.30	1.09	0.47	0.11	2.31	0.83	0.45	0.09	1.86	4.90	1.93	0.13	2.53
GEN	−2.00	0.61	−0.17	−3.30^*	−1.09	0.50	−0.11	−2.18	−0.68	0.47	−0.07	−1.45	−5.32	2.05	−0.13	−2.60
CATQ	0.06	0.01	0.24	4.70^**	0.07	0.01	0.33	6.76^**	0.07	0.01	0.37	7.46^**	0.24	0.04	0.29	5.77^**
Step 3
(Constant)	3.50	1.93		1.82	−1.77	1.65		−1.07	1.06	1.57		0.68	0.83	6.54		0.13
DIS	−0.04	0.55	0.00	−0.07	0.82	0.47	0.08	1.72	0.62	0.45	0.07	1.39	3.56	1.87	0.09	1.90
GEN	−1.75	0.68	−0.15	−2.58	−0.74	0.58	−0.07	−1.27	−0.49	0.55	−0.05	−0.90	−3.60	2.30	−0.09	−1.57
CATQ	0.02	0.01	0.08	1.54	0.04	0.01	0.22	3.97^**	0.05	0.01	0.27	4.91^**	0.10	0.04	0.12	2.24
GMS-NA	0.11	0.05	0.13	2.25	0.07	0.04	0.10	1.77	0.03	0.04	0.04	0.77	0.18	0.16	0.06	1.08
GMS-IP	0.15	0.04	0.23	3.66^**	0.09	0.04	0.16	2.44	0.08	0.03	0.15	2.30	0.30	0.14	0.13	2.13
GMS-NE	0.18	0.05	0.22	3.87^**	0.10	0.04	0.14	2.52	0.11	0.04	0.17	2.94^*	0.75	0.16	0.26	4.63^**
GMS-ND	−0.09	0.05	−0.09	−1.56	0.01	0.05	0.01	0.16	−0.02	0.04	−0.03	−0.51	0.20	0.19	0.06	1.05
GMS-P	0.04	0.05	0.05	0.84	0.01	0.04	0.02	0.33	0.06	0.04	0.10	1.61	0.34	0.16	0.13	2.11
GMS-CC	−0.17	0.06	−0.15	−2.71^*	0.04	0.05	0.04	0.73	−0.03	0.05	−0.04	−0.68	−0.42	0.21	−0.11	−2.02
Step 4
(Constant)	4.84	2.45		1.98	−0.49	2.05		−0.24	0.60	2.00		0.30	5.88	7.92		0.74
DIS	−0.17	0.54	−0.01	−0.31	0.66	0.45	0.07	1.44	0.58	0.44	0.06	1.32	2.67	1.76	0.07	1.52
GEN	−1.72	0.67	−0.14	−2.57	−0.81	0.56	−0.08	−1.44	−0.40	0.55	−0.04	−0.73	−3.23	2.17	−0.08	−1.49
CATQ	0.01	0.01	0.05	0.82	0.04	0.01	0.17	3.03^*	0.05	0.01	0.24	4.05^**	0.05	0.05	0.06	1.02
GMS-NA	0.10	0.05	0.11	2.06	0.07	0.04	0.09	1.67	0.03	0.04	0.04	0.72	0.14	0.16	0.05	0.88
GMS-IP	0.10	0.04	0.15	2.18	0.03	0.04	0.05	0.80	0.03	0.04	0.05	0.77	0.07	0.14	0.03	0.46
GMS-NE	0.18	0.05	0.22	3.60^**	0.09	0.04	0.12	2.03	0.10	0.04	0.15	2.52	0.50	0.16	0.17	3.08^*
GMS-ND	−0.07	0.05	−0.08	−1.32	0.00	0.05	0.00	−0.04	−0.03	0.04	−0.03	−0.57	0.11	0.18	0.03	0.61
GMS-P	0.06	0.05	0.08	1.22	−0.02	0.04	−0.03	−0.39	0.04	0.04	0.06	0.93	0.27	0.17	0.10	1.62
GMS-CC	−0.16	0.06	−0.14	−2.45	0.04	0.05	0.05	0.84	−0.01	0.05	−0.01	−0.19	−0.28	0.21	−0.07	−1.37
AMS-ED	0.02	0.04	0.03	0.49	0.13	0.03	0.23	4.04^**	0.05	0.03	0.09	1.53	0.64	0.12	0.28	5.26^**
AMS-ER	0.02	0.05	0.02	0.40	−0.04	0.05	−0.05	−0.94	0.00	0.04	0.00	−0.01	0.20	0.18	0.06	1.11
AMS-IP	0.19	0.06	0.23	3.33^**	0.19	0.05	0.26	3.94^**	0.17	0.05	0.26	3.76^**	0.69	0.18	0.24	3.79^**
AMS-BC	−0.12	0.06	−0.12	−1.98	−0.13	0.05	−0.15	−2.42	−0.07	0.05	−0.09	−1.42	−0.34	0.20	−0.10	−1.69
AMS-O	0.01	0.09	0.01	0.10	−0.05	0.08	−0.04	−0.67	0.02	0.07	0.02	0.33	0.04	0.30	0.01	0.14
AMS-CC	0.05	0.04	0.09	1.44	0.07	0.03	0.14	2.20	0.02	0.03	0.04	0.68	0.09	0.12	0.04	0.74
AMS-P	−0.14	0.07	−0.13	−1.95	−0.01	0.06	−0.01	−0.09	0.02	0.06	0.03	0.40	−0.12	0.23	−0.03	−0.55
Total variance	Adjusted R² = 0.24 F(16,344) = 7.95, p < 0.001				Adjusted R² = 0.26 F(16,344) = 8.94, p < 0.001				Adjusted R² = 0.21 F(16,344) = 7.06, p < 0.001				Adjusted R² = 0.32 F(16,344) = 11.61, p < 0.001

p < 0.01.

p < 0.001.

SE, standard error.

After controlling for demographics in Step 1, camouflaging explained a further 5.65% of the variance in depression, F(3357) = 11.07, p < 0.001. GMS variables were added in Step 3 and explained a further 13.40% of the variance in depression, F(9351) = 10.94, p < 0.001. The effect of camouflaging became insignificant. AMS variables were added in Step 4, accounting for a further 5.09% of the variance in depression. The final model was significant and explained 23.61% of the variance in depression, F(16,344) = 7.95, p < 0.001. Gender minority negative expectations and autistic minority internalized prejudice significantly uniquely contributed to the final model.

After controlling for demographics in Step 1, camouflaging explained a further 10.99% of the variance in anxiety, F(3357) = 29.51, p < 0.001. GMS variables were added in Step 3 and explained a further 6.30% of the variance in anxiety, F(9351) = 9.99, p < 0.001. AMS variables were added in Step 4, accounting for a further 8.99% of the variance in anxiety. The final model was significant and explained 26.09% of the variance in anxiety, F(16,344) = 8.94, p < 0.001. Camouflaging remained a significant unique predictor of anxiety in the final model, as did autistic minority everyday discrimination and autistic minority internalized prejudice.

After controlling for demographics in Step 1, camouflaging explained a further 13.23% of the variance in stress, F(3357) = 21.33, p < 0.001. GMS variables were added in Step 3 and explained a further 5.20% of the variance in stress, F(9351) = 9.99, p < 0.001. AMS variables were added in Step 4, accounting for a further 4.31% of the variance in stress. The final model was significant and explained 21.22% of the variance in stress, F(16,344) = 7.06, p < 0.001. Only camouflaging and autistic internalized prejudice provided significant unique contributions to the final model.

After controlling for demographics in Step 1, camouflaging explained a further 8.20% of the variance in posttraumatic stress, F(3357) = 16.29, p < 0.001. GMS variables were added in Step 3 and explained a further 11.58% of the variance in posttraumatic stress, F(9351) = 12.06, p < 0.001. The effect of camouflaging became insignificant. AMS variables were added in Step 4, accounting for 11.44% of the additional variance in posttraumatic stress. The final model was significant and explained 32.04% of the variance in posttraumatic stress, F(16,344) = 11.61, p < 0.001. Gender minority negative expectations, autistic minority everyday discrimination, and autistic minority internalized prejudice significantly contributed to the final model.

Discussion

This was among the first studies to explore the impact of camouflaging, minority stress, and resilience on mental health outcomes in TNB autistic adults. High rates of anti-autistic and transphobic discrimination, victimization, and rejection were reported. The first three hypotheses were based on correlations. The first hypothesis was largely unsupported, with a weak correlation between disability and posttraumatic stress and between being nonbinary and decreased depression. The second hypothesis was supported, with higher scores on GMS scales, AMS scales, and camouflaging measure being positively correlated with all mental health outcomes. The third hypothesis was largely unsupported, with only autistic pride and gender minority community connectedness showing a negative correlation with depression scores. Furthermore, autistic minority community connectedness was positively correlated with anxiety. The fourth hypothesis, based on regression analyses, was partially supported. When camouflaging and all scales of GMS and AMS were entered into hierarchical regression models, these predicted a significant proportion of the variance in depression, anxiety, stress, and posttraumatic stress. Camouflaging uniquely predicted anxiety and stress. Regarding AMS, internalized anti-autistic prejudice remained a significant unique predictor of each model. Everyday anti-autistic discrimination uniquely predicted anxiety and posttraumatic stress. Gender minority negative expectations uniquely predicted depression and posttraumatic stress. It should be noted that, while a small number of scales pertaining to AMS and GMS explained unique significance in the outcomes, it is likely that the high shared variance across the GMS and AMS scales contribute to improved model fit. Therefore, further examination of the potential mechanistic effects of AMS and GMS is warranted in future research.

The majority of the sample were non-binary and polysexual, supporting previous findings that autistic adults are particularly diverse in gender and sexuality.^32,48,73 It has been speculated that chronic illness is common in TNB autistic adults, which this study demonstrated for the first time.⁶ This study supports the understanding that in the United Kingdom, TNB autistic adults experience high rates of anxiety, depression, stress, and posttraumatic stress. Scores in the severe range as found in this study are higher than those last reported for TNB adults, autistic adults, or the general adult population, although various measures have been used across studies.^50,53,74 Rates were similar to those found in the only comparable sample of Australian youth.⁴⁰ This study was among the first to utilize the CATQ in a TNB autistic sample, and TNB autistic adults had a mean score above that of cisgender or nonbinary autistic adults, indicating an increased reported use of camouflaging behaviors.⁶⁴

Kung and colleagues found that autistic traits predict depression and anxiety over GMS in a TNB sample.⁴¹ Our findings suggest that this may be partly explained by the effect of AMS, particularly anti-autistic everyday discrimination and internalized prejudice. Studying the effect of AMS scales, instead of measuring autistic traits, aligns with a depathologization approach, in that it places the locus of causality into the sociocultural environment. Furthermore, comparing the mental health impact of different types of marginalization is likely unhelpful and may be harmful; therefore, we will not make comparisons between the relative weight of AMS scales and GMS scales.⁵⁸ Our study also extends previous research into AMS that found that AMS facets predict general psychological distress and reduced well-being.^24,39 Our findings additionally show that AMS internalized prejudice predicted depression, anxiety, stress, and posttraumatic stress, and everyday anti-autistic discrimination predicted anxiety and posttraumatic stress. As noted earlier, further replication of these effects is required to corroborate these facets as unique explanatory factors in mental distress.

Autistic pride and TNB community connectedness were correlated with reduced depression, indicating the utility of exploring these factors in future research. The lack of significant correlations between TNB pride or autistic community connectedness and improved mental health outcomes in this study does not support the findings of a recent meta-analysis of studies using the GMSR or previous research into autistic community connectedness.^27,30 However, the GMS and AMS measures used may not adequately capture the nuanced experience of community connectedness and pride and the diversity of resilience in TNB autistic adults.²⁷ Of note, autistic community connectedness was related to increased anxiety in this study. The qualitative literature suggests that TNB autistic adults can struggle to feel connected with either the TNB or the autistic community or even face exclusion. TNB communities have described experiencing energy drain and greater exposure to vicarious minority stress in relation to community connectedness, and autistic adults may experience high rates of social anxiety.^27,32,75 Whether TNB autistic community connectedness and pride are protective or not, or whether it varies widely between individuals, requires further exploration. So too does the impact of TNB autistic community connectedness with other TNB autistic people and pride in being both TNB and autistic. Multiple other components could play a role in resilience, including building knowledge around gender and neurodiversity, gender euphoria, finding positive media representation, involvement in activism, understanding one’s autistic strengths, authenticity, self-acceptance, and agency.^4,29–33

Camouflaging was correlated with all mental health outcomes in this sample, including posttraumatic stress. Autistic adults describe camouflaging as sometimes necessary for safety and success but emotionally exhausting and leading to a state of burnout.^76,77 It is a central tenet of MST that concealment (which includes camouflaging-style social strategies) and expectation of distal stressors develop as protective strategies, but this can lead to adverse mental health outcomes in the long term.²¹ This supports AMS as a model of understanding autistic mental health outcomes. Whether autistic camouflaging is theoretically distinct from other forms of minority concealment is a debated topic.^35,78 Camouflaging research has called for further analyses of camouflaging in autistic adults who experience other forms of marginalization, which this study aimed to do, namely, in TNB autistic adults.³⁸ In this study, camouflaging continued to uniquely predict anxiety and stress when AMS and GMS were entered into the regression. This could be evidence that autistic camouflaging is a distinct theoretical construct. Concealment, passing, and switching are also distinct theoretical constructs in the gender and sexual minority stress literature and in Black scholarship.^21,23,79,80 Applying an intersectionality lens to this issue supports the argument that autistic camouflaging is likely distinct but only insomuch as that every marginalized group has a distinct form of concealment. Furthermore, camouflaging two minority identities likely creates unique and specific camouflaging or concealment experiences. This may have contributed, in this study, to the high mean CATQ score in TNB autistic adults.

Strengths and limitations

This study recruited a large sample of a small and marginalized population in a relatively short time frame. This highlights the acceptability of exploring TNB autistic mental health using an intersectional minority stress framework and a depathologization approach. The author’s positioning as TNB autistic and the paid inclusion of community experts added experience and authenticity to the project and may have reduced the participant–researcher power imbalance and fostered community trust and respect in the research process.^60,81 The short time frame for this research project did not allow for purposive sampling of community members who could not use the internet, read English, or participate in the research process without additional support. This limits the generalizability of these results to a proportion of autistic community members.

While this study provided important insights into the experience of TNB autistic adults, any attempt to operationalize complex constructs such as marginalization, resilience, camouflaging, and mental health will necessarily be overly simplistic and reductive. Despite the utility of MST, minority stress measures do not incorporate all factors related to the wider sociopolitical environment around the individual, such as their relationship with all types of discrimination in media, policy, law, and law enforcement.⁸² Furthermore, they do not easily translate across cultural and ethnic contexts.⁷⁵ Neither do they incorporate resilience measures as comprehensively as stress measures despite qualitative literature often capturing multiple creative and extensive forms of resilience in minority populations.^31,32,83,84 The above limitations may elucidate our finding that AMS, GMS, camouflaging, and disability explain maximally 32% of the variance in mental health outcomes.

The methodology of this article included the use of multiple self-report questionnaires. Other potential approaches may include examining the interactive effect of two global measures or creating a new measure specifically for the intersectional minority stress experienced by TNB autistic people.⁵⁸ Shared variance in our model may have been explained by respondent bias clustering across measures or the presence of specific co-occurring differences. The cross-sectional nature means that direction and causality cannot be assumed from the results of the analysis.

Implications

Research

Conducting and disseminating research on the structural factors underlying minority mental health is a critical form of advocacy available to psychologists and other academics.⁸⁵ Our findings make an urgent case for reducing rates of discrimination, victimization, and rejection faced by TNB and autistic adults in the United Kingdom. The high rates of physical disability in this sample indicate that research into the link between minority stress, multisystemic “wear and tear,” and chronic pain and fatigue requires exploration in autistic populations.⁸⁶ Perhaps most urgently, TNB and autistic communities report high levels of suicidality in the United Kingdom.^50,53 Minority stress, depression, and posttraumatic stress are all predictors of suicidality.^87,88 The prevalence and correlates of suicidality in TNB individuals, autistic individuals, and TNB autistic individuals in the United Kingdom require urgent update and exploration. This must include an examination of protective factors and preventative interventions, such as improving the accessibility and responsiveness of health care and psychological interventions for TNB autistic adults. The links between camouflaging, minority stress, and posttraumatic stress require further exploration, particularly in autistic populations who belong to multiple marginalized groups. A more nuanced understanding of TNB autistic resilience is required and this should incorporate individual, intra-community, inter-community, and systems-level factors.² However, our findings also indicate that focusing research on resilience without focusing on reducing minority stress is unlikely to prevent the high rates of psychological distress in TNB autistic adults.

Clinical practice

Societal attitudes toward the TNB autistic community must change. Health care professionals, academics, policymakers, media producers and legislators, all have a key role in bringing about this change. In clinical practice, health care professionals working with TNB autistic adults can pay attention to autistic and TNB voices and incorporate depathologization approaches into their work. Key to a depathologization approach is understanding that neurodiversity and gender diversity are normal human variations, and that TNB and autistic individuals are not intrinsically mentally ill by varying from cisnormative and neuronormative standards. However, as this sample demonstrates, TNB autistic adults are at risk of severe distress. During formulation, experiences of transphobic and anti-autistic discrimination, and the impact of internalization of prejudice and camouflaging or concealment, should be explored.²⁷ Targeted psychological work in TNB autistic adults could focus on negative expectations and internalized prejudice. Support must acknowledge the stigma and conditions that necessitate camouflaging and create environments where autistic adults can safely camouflage less rather than merely placing the expectation of change onto the individual.⁸⁹ Practitioners, organizations, and systems can improve their accessibility through diversifying the ways in which they communicate, design spaces, and individualize support.

Conclusion

This study explored mental health outcomes in TNB autistic adults in the United Kingdom. GMS, AMS, and camouflaging were correlated with depression, anxiety, stress, and posttraumatic stress. Final hierarchical regression models yielded significant results and highlighted the unique contribution of anti-autistic everyday discrimination and internalized prejudice, camouflaging, and gender minority negative expectations. This study demonstrates an example of a depathologization approach to TNB autistic mental health research. There is a broad scope for future research, and clinical practitioners can actively support TNB autistic clients in their individual practice and in their workplace. Focusing on improving individual resilience is unlikely to be sufficient. In order to reduce and prevent severe psychological distress, urgent action must be taken to tackle anti-autistic and transphobic discrimination at interpersonal, community, societal, and structural levels.

Footnotes

Acknowledgments

The authors would like to thank the autistic TNB people who took part in this study and the individuals and charities that assisted with the dissemination of the online survey. It is brave to put your trust in academic researchers, and your input is highly valued and appreciated. The authors would also like to thank the two community experts who offered advice about the design and implementation of this study, whose insight and wisdom were indispensable.

Authorship Confirmation Statement

L.C.J.W.: Conceptualization, methodology, formal analysis, investigation, data curation, writing—original draft, and visualization. K.G.-S.: Validation, resources, writing—reviewing and editing, and supervision. K.V.I.: Conceptualization, methodology, and writing—reviewing and editing. Community Expert 2: Conceptualization and methodology. K.G.: Formal analysis. The article has been submitted solely to Autism in Adulthood.

Author Disclosure Statement

No competing financial interests exist. L.C.J.W. used their personal and professional networks to support with the survey dissemination and submitted the results of this study as part of their dissertation for their master’s qualification. The frequency data from this survey was distributed to the voluntary sector organizations who supported with dissemination and can be found online as a charity sector-style report.

Funding Information

No funding was received in relation to this research study.

Supplementary Material

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