Date of Award

January 2023

Document Type

Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Ashley Hagaman

Abstract

Introduction The co-occurrence of gender diversity and neurodiversity has received increased attention in recent years. Clinical statistics suggest that transgender and gender diverse (TGD) individuals are more likely to be diagnosed with autism spectrum disorder than their cisgender counterparts, and that transgender and gender diverse neurodivergent (TGD-ND) individuals, particularly autistic individuals or those with ADHD, are at elevated risk of poor mental health outcomes compared to their neurotypical or cisgender counterparts. Thus, the TGD-ND population is both a notable proportion of the TGD population and a contingent of the population facing significant health disparities. A minority stress model is useful for understanding mental health risk factors for both gender minorities and neurological minorities. Under the respective minority stress models for gender and neurological minorities, healthcare plays a two-sided role in the mental health of both gender minorities and neurological minorities, posing as both a distal stressor (as a locus of interpersonal and structural stigma) and as a means to alleviate minority stress through gender affirming care and mental healthcare. To date, however, few studies have examined how ND-TGD individuals with ADHD and those on the autism spectrum experience stressors related to their dual minority status in the US healthcare system. Aims This study sought to understand how ND-TGD autistic youth and young adults as well as ND-TGD youth and young adults with ADHD who are enrolled in a gender-affirming care clinic in the state of Connecticut experience stigmatization and support in general healthcare, mental healthcare, and gender-affirming healthcare. Materials and Methods We conducted semi-structured qualitative interviews of 15 transgender and gender diverse patients in a pediatric gender clinic ages 14-25 who had diagnoses of either ADHD or autism. Purposive sampling was used to ensure representation across three demographic axes: age group (adolescent or young adult), diagnosis (ADHD, autism, or both), and gender identity. The interview guide’s major domains included 1) ND-TGD participants’ concept of their identities; 2) participants’ experiences of gender-related or neurotype-related stigma in healthcare; 3) participants’ perceptions of provider competence in gender diversity and neurodiversity; and 4) participants’ recommendations for improvement in intersectionally- affirming care. Interviews were recorded by audio and then transcribed verbatim. Results A thematic analysis illuminated three main themes. 1) Participants reported interwoven internal experiences of neurodivergence and gender Identity; 2) Participants reported decision making about engaging or disengaging neurodivergence and gender in healthcare encounters according to their perceptions of the stigmatization of both identities in each clinical context 3) Participants reported failure by their care providers to appropriately respond to their intersecting dual identities Conclusions Improving best practices for treating TGD-ND individuals in gender-affirming care and other care settings is an important step in developing care systems to support TGD populations in the United States. This study provides information on experiences of TGD-ND patients in healthcare settings that can inform the development of best practice protocols for treating individuals at this intersection.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 12/14/2025

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