Gender identity & sexuality in neurodevelopmental conditions

Gender, sexuality & neurodevelopmental conditions

Historical view - individuals with neurodevelopmental conditions as asexual or childlike

Led to a lack of research and clinical attention

Ethical concerns limited research

• Informed consent? Vulnerability? Exploitation?

Biases hindered early studies

• Example: focus on victimisation

Moving foward

Focus on sexual education, consent, and health relationships

Studies on the impact of neurodevelopmental conditions on sexual development and expression

Research on gender identity and sexual orientation within neurodivergent populations

Emphasis on the need for tailored support

Basics of sexuality

Sexual attraction: Refers to who a person is physically attracted to

• Can also involve romantic and emotional involvement

Sexual Identity: how a person identifies their sexual attraction and orientation

• heterosexual, homosexual (gay/lesbian), bisexual, asexual, and pansexual

Sexuality is diverse and can be fluid, meaning it may change over time

Cultural and societal norms play a significant role in shaping how sexuality is understood and expressed

Sexual development

Sexuality

Sexual orientation typically emrges between middle childhood and early adolescence

UK 2021 Census

89.4% of the general population identify as heterosexual

3.2% of the population aged 16 and over identified as lesbian, gay, bisexual, or another sexual orientation (LGBT+). 

• 1.5% identify as gay or lesbian

• 1.3% identify as bisexual

• 0.3% identify as another sexuality

Autism & sexuality

Weir et al., 2021

Anonymous, self-report survey

• 1,183 autistic and 1,203 non-autistic adolescents and adults (aged 16-90 years)

Eight times more likely to identify as asexual and ‘other’ sexuality than their non-autistic peers

Sex differences in sexual orientation:

• autistic men are 3.5 times more likely to identify as bisexual than non-autistic men

• autistic women are 3 times more likely to identify as homosexual than non-autistic women

ADHD & sexuality

Research suggests that women with ADHD are more likely to have had homosexual experiences (Young & Cocallis, 2023)

However, generally, individuals with ADHD do not differ from neurotypical peers in their self-reported sexual orientation

BUT the potential to show more hypersexual behaviours (Hertz et al., 2023; Soldati et al., 2021)

ADHD features and sexuality

Basics of gender

"sex" vs "gender"

"Sex" typically refers to biological attributes, such as chromosomes, hormones, and anatomy

"Gender" is largely understood as a social construct:

• Involves the norms and expectations that societies create around what it means to be a "man," "woman," or other gender identities

• These norms vary across cultures and change over time

Gender identity

An individuals internal sense of their own gender

Deepy personal experience that may or may not align with the sex they were assigned at birth

Gender identity exists on a spectrum and people may identify as male, female, non-binary, or other gender identities

Gender diversity = experiencing aspects of your gender as different from your assigned sex at birth

Gender diversity can result in gender incongruence where a person’s gender identity differs from their sex assigned at birth

Gender is a complex interplat of social, cultural and personal factors, distinct from the biological concept of sex

The general population

Survey-based research estimates that as many as 1% to 2% of adolescents identify as gender diverse (i.e. gender nonconforming or transgender; Rider et al., 2018)

In the 2021 UK Census 0.5% of the general population indicated that their gender identity differed to their sex registered at birth

Gender dysphoria

People may experience discomfort or distress when their assigned sex is different from the gender they identify with

This is known as gender dysphoria

In the UK, transgender people must be assessed for gender dysphoria before physical interventions such as gender affirming hormones and surgery can be accessed on the NHS

• NB. Not all trans people have dysphoria

While many trans individuals do experience gender dysphoria, it not universal experinece, and some trans poeple may not experience it at all

CIs people can also experience dysphoria

DSM-5-TR - children

A marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):

• A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)

• In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing

• A strong preference for cross-gender roles in make-believe play or fantasy play

• A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender

• A strong preference for playmates of the other gender

• In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities

• A strong dislike of one’s sexual anatomy

• A strong desire for the physical sex characteristics that match one’s experienced gender

DSM-5-TR - adolescents and adults

A marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)

• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)

• A strong desire for the primary and/or secondary sex characteristics of the other gender

• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

Gender diversity in autism

The first systematic study was led by de Vries et al

Investigate the incidence of autism in children and adolescents referred for gender diversity services

7.8% of the samle met strict diagnostic criteria for autosm - 10x higher than the prevelance of autism in the general population at the time

Strang et al

Identified studies of gender diverse and trangender youth that included only clincial autism disgnoses or autism diagnosed through comprehensive methods

In all 7 available studies rates of clincial diagnoses were significantly greater compared to the general population

Corbett et al - 2023

Gender diversity research with autistic children has typically relied on parent-report based on a single question

Used the Gender Diversity Screening Questionnaire (Self-Report and Parent-Report)

• Two domains: Binary Gender Diversity and Nonbinary Gender Diversity

244 children (140 autism and 104 neurotypical)

Self-report: Autistic children showed higher Gender Diversity (both binary and non-binary) than neurotypical children.

Parent-report: A significant difference in gender diversity between the groups on body incongruence

Underscores “the need to better understand and support the unique and complex needs of autistic children who experience gender diversity.”

Gender diversity & ADHD

Very limited, few studies specifically look at ADHD

• Warrier et al., 2020 – Transgender & Gender diverse individuals had elevated rates of ADHD

• Prevalence rate of 8.3% in children and adolescents referred for gender care (Holt et al., 2016)

• Prevalence rate of 4.3% in TGD adults (Cheung et al., 2018).

Ignatova et al., 2025:

10,277 ADHD & Transgender early adolescents (12-13 years)

Data taken from the longitudinal Adolescent Brain Cognitive Development (ABCD) study (based in the US)

Methods: “Are you transgender?” Yes (TG), no (CG) or maybe (GQ)

Gender diverse individuals showed higher levels of ADHD traits

Results reduced when controlling for stress

• Authors linked to current climate in the US

Lived experience - autistic and transgender

Cooper et al., 2022

21 autistic adults took part in semi-structured interviews

• All participants identified as transgender and/or non-binary

Main Findings:

• Distress due to their bodies not matching their gender identities, while managing complex intersecting needs

• Societal acceptance of gender and neurodiversity

• Barriers in accessing healthcare for their gender needs

• Tension between need to undergo a physical gender transition versus a need for sameness and routine

Positive experiences

“We see the world differently” (Participant 22), referring to the idea that being autistic allows one to step outside of societal norms and follow your own path

“I have never tried to fit in with people, or very rarely. So whilst now my gender presentation is very stereotypically male, there are some things that I do are intentionally more feminine, but I don't care” (Participant 12)

“Then after having a [autism] diagnosis a lot more of my experiences have come to light again and there's things that I do actually make me really uncomfortable or things that really don't suit me that I have edited to ignore a long time ago.” (Participant 17), found the diagnosis comforting and this allowed new coping strategies to be implemented

DSM-V-TR autism

“Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)”

Dysphoria & sensory sensitivities

Cooper et al., 2022:

Some participants described ‘sensory dysphoria’ - distress linked to sensory experiences

• Wearing uncomfortable fabrics and shapes associated with girls’ clothes

• Sensory challenges of puberty including periods, and growing facial hair

‘I was stuck between having really bad gender dysphoria not wearing a binder or feeling really uncomfortable sensory wise.’ 

Biological theories

Prenatal Hormone Exposure:

• Variations in prenatal hormone exposure could contribute to differences in how individuals perceive and experience gender

• not a simple cause-and-effect relationship

Brain Structure and Function:

• Differences in structure and function could influence how individuals process and internalise social constructs like gender

• Differences in brain regions involved in social cognition and self-perception might play a role

Increased self identification

Autistic individuals may be less influenced by societal norms and expectations surrounding gender & sexuality

Leading to a greater likelihood of expressing their authentic gender or sexual identities, even if it deviates from societal norms

In other words, they may be less likely to suppress or conform to traditional gender roles or sexual identities due to social pressures

Differences in social cognition & sensory processing

Systemising and Pattern Recognition:

• a more analytical approach to gender, breaking down its components and questioning traditional norms

Intense Focus and Special Interests:

• Increased depth, leading to a more profound understanding of their own identity & less influence from outside sources

Sensory sensitivities/sensation seeking:

• Certain clothing textures or social environments associated with specific genders might be intensely uncomfortable

• Preference for certain gendered presentations due to the sensory input it provides

Gender identity, sexuality & down syndrome

Limited to no studies investigating gender diversity in Down Syndrome

• Parent-report regarding more general views of sexuality in DS

• No studies directly speaking to individuals with DS

Instead, studies focus on the need for and improvement of sexual education for individuals with DS

Sex ed in down syndrome

The World Health Organization advocates for SE as a human right

• BUT adolescents and young adults with intellectual or developmental disabilities are frequently excluded

Often focuses on safety and abuse prevention rather than a holistic approach

• healthy relationships, consent, and sexual fulfilment

Need to work with these individuals to develop implement more accessible and effective SE programs

Schmidt et al - 2021

Improving the accessibility of sexuality education (SE) for individuals with intellectual or developmental disabilities.

Qualitative data collection through interviews and focus groups

• Individuals, parents, healthcare providers, and educators.  

Universal design for Learning (UDL)

UDL adapts education to fit diverse learner needs

The 3 UDL Principles

• Representation (the "what"): Offer information in varied formats (e.g., visual, auditory).  

• Action/Expression (the "how"): Provide different ways for learners to interact and express themselves.

• Engagement (the "why"): Increase motivation through choice, relevance, and collaboration.

UDL in Sexuality Education

UDL makes SE accessible and engaging for all