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

  • Emily Thrower
  • Ingrid Bretherton
  • Ken C. Pang
  • Jeffrey D. Zajac
  • Ada S. CheungEmail author
Original Paper


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


Transgender persons Gender dysphoria Attention-deficit hyperactivity disorder Autism disorders 



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

Author Contributions

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

Compliance with Ethical Standards

Conflict of interest

The authors have nothing to declare.


  1. Akgul, G. Y., Ayaz, A. B., Yildirim, B., & Perdahli Fis, N. (2018). Autistic traits and executive functions in children and adolescents with gender dysphoria. Journal of Sex and Marital Therapy,44, 619.CrossRefGoogle Scholar
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.CrossRefGoogle Scholar
  3. Booth, T., Murray, A. L., McKenzie, K., Kuenssberg, R., O’Donnell, M., & Burnett, H. (2013). Brief report: An evaluation of the AQ-10 as a brief screening instrument for ASD in adults. Journal of Autism and Developmental Disorders,43(12), 2997–3000. Scholar
  4. Cheung, A. S., Ooi, O., Leemaqz, S., Cundill, P., Silberstein, N., Bretherton, I., et al. (2018). Sociodemographic and clinical characteristics of transgender adults in Australia. Transgender Health,3(1), 229–238.CrossRefGoogle Scholar
  5. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., et al. (2012). Standards of care for the health of trans-sexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism,13, 165–232.CrossRefGoogle Scholar
  6. Dawson, A. E., Wymbs, B. T., Gidycz, C. A., Pride, M., & Figueroa, W. (2017). Exploring rates of transgender individuals and mental health concerns in an online sample. International Journal of Transgenderism,18(3), 295–304.CrossRefGoogle Scholar
  7. de Vries, A. L., Noens, I. L., Cohen-Kettenis, P. T., van Berckelaer-Onnes, I. A., & Doreleijers, T. A. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disorders,40(8), 930–936.CrossRefGoogle Scholar
  8. Delahunt, J. W., Denison, H. J., Sim, D. A., Bullock, J. J., & Krebs, J. D. (2018). Increasing rates of people identifying as transgender presenting to endocrine services in the Wellington region. New Zealand Medical Journal,131(1468), 33–42.PubMedGoogle Scholar
  9. Dewinter, J., De Graaf, H., & Begeer, S. (2017). Sexual orientation, gender identity, and romantic relationships in adolescents and adults with autism spectrum disorder. Journal of Autism and Developmental Disorders,47(9), 2927–2934. Scholar
  10. Dickerson Mayes, S., Calhoun, S. L., Mayes, R. D., & Molitoris, S. (2012). Autism and ADHD: Overlapping and discriminating symptoms. Research in Autism Spectrum Disorders,6(1), 277–285.CrossRefGoogle Scholar
  11. Ebejer, J. L., Medland, S. E., van der Werf, J., Gondro, C., Henders, A. K., Lynskey, M., et al. (2012). Attention deficit hyperactivity disorder in australian adults: Prevalence, persistence, conduct problems and disadvantage. PLoS ONE,7(10), e47404. Scholar
  12. Fielding, J., & Bass, C. (2018). Individuals seeking gender reassignment: Marked increase in demand for services. Bjpsych Bulletin,42(5), 206–210.CrossRefGoogle Scholar
  13. George, R., & Stokes, M. A. (2017). Gender identity and sexual orientation in autism spectrum disorder. Autism. Scholar
  14. Heylens, G., Aspeslagh, L., Dierickx, J., Baetens, K., Van Hoorde, B., De Cuypere, G., et al. (2018). The co-occurrence of gender dysphoria and autism spectrum disorder in adults: An analysis of cross-sectional and clinical chart data. Journal of Autism and Developmental Disorders,48, 2217–2223.CrossRefGoogle Scholar
  15. Heylens, G., Elaut, E., Kreukels, B. P., Paap, M. C., Cerwenka, S., Richter-Appelt, H., et al. (2014). Psychiatric characteristics in transsexual individuals: Multicentre study in four European countries. British Journal of Psychiatry,204(2), 151–156.CrossRefGoogle Scholar
  16. Hisle-Gorman, E., Landis, C. A., Susi, A., Schvey, N. A., Gorman, G. H., Nylund, C. M., et al. (2019). Gender dysphoria in children with autism spectrum disorder. LGBT Health,6(3), 95–100.CrossRefGoogle Scholar
  17. Holt, V., Skagerberg, E., & Dunsford, M. (2016). Young people with features of gender dysphoria: Demographics and associated difficulties. Clinical Child Psychology and Psychiatry,21(1), 108–118. Scholar
  18. Janssen, A., Huang, H., & Duncan, C. (2016). Gender variance among youth with autism spectrum disorders: A retrospective chart review. Transgender Health,1(1), 63–68.CrossRefGoogle Scholar
  19. Jones, R. M., Wheelwright, S., Farrell, K., Martin, E., Green, R., Di Ceglie, D., et al. (2012). Brief report: Female-to-male transsexual people and autistic traits. Journal of Autism and Developmental Disorders,42(2), 301–306.CrossRefGoogle Scholar
  20. Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health,9, 9. Scholar
  21. Kraemer, B., Delsignore, A., Gundelfinger, R., Schnyder, U., & Hepp, U. (2005). Comorbidity of Asperger syndrome and gender identity disorder. European Child and Adolescent Psychiatry,14(5), 292–296. Scholar
  22. Kristensen, Z. E., & Broome, M. R. (2015). Autistic traits in an internet sample of gender variant UK Adults. International Journal of Transgenderism,16(4), 234–245. Scholar
  23. Landen, M., & Rasmussen, P. (1997). Gender identity disorder in a girl with autism: A case report. European Child and Adolescent Psychiatry,6(3), 170–173.CrossRefGoogle Scholar
  24. Leef, J. H., Brian, J., VanderLaan, D. P., Wood, H., Scott, K., Lai, M.-C.,… Zucker, K. J. (2019). Traits of autism spectrum disorder in school-aged children with gender dysphoria: A comparison to clinical controls. Clinical Practice in Pediatric Psychology, No Pagination SpecifiedGoogle Scholar
  25. Lemaire, M., Thomazeau, B., & Bonnet-Brilhault, F. (2014). Gender identity disorder and autism spectrum disorder in a 23-year-old female. Archives of Sexual Behavior,43(2), 395–398. Scholar
  26. Leung, R. C., Vogan, V. M., Powell, T. L., Anagnostou, E., & Taylor, M. J. (2016). The role of executive functions in social impairment in autism spectrum disorder. Child Neuropsychology,22(3), 336–344. Scholar
  27. Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A.,… Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: Explanation and elaboration. BMJ (Clinical research ed.), 339, b2700-b2700. CrossRefGoogle Scholar
  28. May, T., Pang, K., & Williams, K. J. (2017). Gender variance in children and adolescents with autism spectrum disorder from the National Database for Autism Research. International Journal of Transgenderism,18(1), 7–15.CrossRefGoogle Scholar
  29. Moul, C., Cauchi, A., Hawes, D. J., Brennan, J., & Dadds, M. R. (2015). Differentiating autism spectrum disorder and overlapping psychopathology with a brief version of the social responsiveness scale. Child Psychiatry and Human Development,46(1), 108–117. Scholar
  30. Nahata, L., Quinn, G. P., Caltabellotta, N. M., & Tishelman, A. C. (2017). Mental health concerns and insurance denials among transgender adolescents. LGBT Health,4(3), 188–193. Scholar
  31. Nobili, A., Glazebrook, C., Bouman, W. P., Glidden, D., Baron-Cohen, S., Allison, C.,… Arcelus, J. (2018). Autistic traits in treatment-seeking transgender adults. Journal of Autism and Developmental Disorders, 48(12), 3984-3994CrossRefGoogle Scholar
  32. Parkinson, J. (2016). Gender dysphoria and autism spectrum disorders: A note of caution. LGBT Health,3(2), 175.CrossRefGoogle Scholar
  33. Pasterski, V., Gilligan, L., & Curtis, R. (2014). Traits of autism spectrum disorders in adults with gender dysphoria. Archives of Sexual Behavior,43(2), 387–393.CrossRefGoogle Scholar
  34. Pine, D. S., Guyer, A. E., Goldwin, M., Towbin, K. A., & Leibenluft, E. (2008). Autism spectrum disorder scale scores in pediatric mood and anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry,47(6), 652–661. Scholar
  35. Reisner, S. L., Biello, K. B., White Hughto, J. M., Kuhns, L., Mayer, K. H., Garofalo, R., et al. (2016). Psychiatric diagnoses and comorbidities in a diverse, multicity cohort of young transgender women: Baseline findings from project lifeskills. JAMA Pediatrics,170(5), 481–486.CrossRefGoogle Scholar
  36. Reisner, S. L., Vetters, R., Leclerc, M., Zaslow, S., Wolfrum, S., Shumer, D., et al. (2015). Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. Journal of Adolescent Health,56(3), 274–279.CrossRefGoogle Scholar
  37. Russell, G., Rodgers, L. R., Ukoumunne, O. C., & Ford, T. (2014). Prevalence of parent-reported ASD and ADHD in the UK: Findings from the Millennium Cohort Study. Journal of Autism and Developmental Disorders,44(1), 31–40. Scholar
  38. Shumer, D. E., Reisner, S. L., Edwards-Leeper, L., & Tishelman, A. (2016). Evaluation of asperger syndrome in youth presenting to a gender dysphoria clinic. LGBT Health,3(5), 387–390.CrossRefGoogle Scholar
  39. Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child and Adolescent Psychiatry,47(8), 921–929.CrossRefGoogle Scholar
  40. Skagerberg, E., Di Ceglie, D., & Carmichael, P. (2015). Brief report: Autistic features in children and adolescents with gender dysphoria. Journal of Autism and Developmental Disorders,45(8), 2628–2632.CrossRefGoogle Scholar
  41. Stagg, S. D., & Vincent, J. (2019). Autistic traits in individuals self-defining as transgender or nonbinary. European Psychiatry: The Journal of the Association of European Psychiatrists,61, 17–22.CrossRefGoogle Scholar
  42. Strang, J. F., Janssen, A., Tishelman, A., Leibowitz, S. F., Kenworthy, L., McGuire, J. K.,… Anthony, L. G. (2018). Revisiting the link: Evidence of the rates of autism in studies of gender diverse individuals. J Am Acad Child Adolesc Psychiatry, 57(11), 885-887. CrossRefGoogle Scholar
  43. Strang, J. F., Kenworthy, L., Dominska, A., Sokoloff, J., Kenealy, L. E., Berl, M.,… Wallace, G. L. (2014). Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Archives of Sexual Behavior, 43(8), 1525-1533.CrossRefGoogle Scholar
  44. Strang, J. F., Meagher, H., Kenworthy, L., de Vries, A. L. C., Menvielle, E., Leibowitz, S.,… Anthony, L. G. (2018). Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents. J Clin Child Adolesc Psychol, 47(1), 105-115. CrossRefGoogle Scholar
  45. Tateno, M., Tateno, Y., & Saito, T. (2008). Comorbid childhood gender identity disorder in a boy with Asperger syndrome. Psychiatry and Clinical Neurosciences,62(2), 238. Scholar
  46. Tateno, M., Teo, A. R., & Tateno, Y. (2015). Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood. Psychiatry and Clinical Neurosciences,69(10), 658. Scholar
  47. Taylor, L. J., Eapen, V., Maybery, M. T., Midford, S., Paynter, J., Quarmby, L.,… Whitehouse, A. J. O. (2016). Diagnostic evaluation for autism spectrum disorder: A survey of health professionals in Australia. BMJ Open, 6(9), e012517. CrossRefGoogle Scholar
  48. Turban, J. L. (2018). Potentially reversible social deficits among transgender youth. Journal of Autism and Developmental Disorders,48(12), 4007–4009. Scholar
  49. Turban, J. L., & van Schalkwyk, G. I. (2018a). Drs. Turban and van Schalkwyk reply. Journal of the American Academy of Child and Adolescent Psychiatry,57(11), 887–889. Scholar
  50. Turban, J. L., & van Schalkwyk, G. I. (2018b). “Gender dysphoria” and autism spectrum disorder: Is the link real? Journal of the American Academy of Child and Adolescent Psychiatry,57(1), 8–9.e2. Scholar
  51. van der Miesen, A. I. R., Cohen-Kettenis, P. T., & de Vries, A. L. C. (2018a). Is there a link between gender dysphoria and autism spectrum disorder? Journal of the American Academy of Child and Adolescent Psychiatry,57(11), 884–885. Scholar
  52. van der Miesen, A. I. R., de Vries, A. L. C., Steensma, T. D., & Hartman, C. A. (2017). Autistic symptoms in children and adolescents with gender dysphoria. Journal of Autism and Developmental Disorders. Scholar
  53. van der Miesen, A. I. R., Hurley, H., Bal, A. M., & de Vries, A. L. C. (2018b). Prevalence of the wish to be of the opposite gender in adolescents and adults with autism spectrum disorder. Archives of Sexual Behavior,47(8), 2307–2317.CrossRefGoogle Scholar
  54. VanderLaan, D. P., Leef, J. H., Wood, H., Hughes, S., & Zucker, K. J. (2015a). Autism spectrum disorder risk factors and autistic traits in gender dysphoric children. Journal of Autism and Developmental Disorders,45(6), 1742–1750.CrossRefGoogle Scholar
  55. VanderLaan, D. P., Postema, L., Wood, H., Singh, D., Fantus, S., Hyun, J.,… Zucker, K. J. (2015). Do children with gender dysphoria have intense/obsessional interests? Journal of Sex Research, 52(2), 213-219.CrossRefGoogle Scholar
  56. Vermaat, L. E. W., van der Miesen, A. I. R., de Vries, A. L. C., Steensma, T. D., Popma, A., Cohen-Kettenis, P. T., et al. (2018). Self-reported autism spectrum disorder symptoms among adults referred to a gender identity clinic. LGBT Health,5(4), 226–233.CrossRefGoogle Scholar
  57. Walsh, R. J., Krabbendam, L., Dewinter, J., & Begeer, S. (2018). Brief report: Gender identity differences in autistic adults: Associations with perceptual and socio-cognitive profiles. Journal of Autism and Developmental Disorders,48(12), 4070–4078.CrossRefGoogle Scholar
  58. Williams, P. G., Allard, A. M., & Sears, L. (1996). Case study: Cross-gender preoccupations with two male children with autism. Journal of Autism and Developmental Disorders,26(6), 635–642.CrossRefGoogle Scholar
  59. Woodbury-Smith, M. R., Robinson, J., Wheelwright, S., & Baron-Cohen, S. (2005). Screening adults for Asperger Syndrome using the AQ: A preliminary study of its diagnostic validity in clinical practice. Journal of Autism and Developmental Disorders,35(3), 331–335.CrossRefGoogle Scholar
  60. Zucker, K. J., Nabbijohn, A., Santarossa, A., Wood, H., Bradley, S. J., Matthews, J., et al. (2017). Intense/obsessional interests in children with gender dysphoria: A cross-validation study using the Teacher’s Report Form. Child and Adolescent Psychiatry and Mental Health,11(1), 51.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Medicine (Austin Health)The University of MelbourneHeidelbergAustralia
  2. 2.Department of Adolescent MedicineRoyal Children’s HospitalParkvilleAustralia
  3. 3.Murdoch Children’s Research InstituteParkvilleAustralia
  4. 4.Department of PaediatricsThe University of MelbourneParkvilleAustralia

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