Title: Markers of Autism and Gender Incongruence in Children (MAGIC): Cognition in Autistic and Non-autistic Gender-incongruent Children and Their Families
Funder: Economic and Social Research Council

Abstract: This project aims to explore why autism spectrum disorder (ASD) and gender incongruence (when gender and biological sex do not align) appear to overlap at such a striking rate amongst young people and, if this is so, what the source of any overlap may be. Across six studies, the team from the University of Kent and the Tavistock and Portman NHS Foundation Trust will test competing theories about the nature of gender incongruence in autistic and non-autistic children, as well as their family members, with the aim of identifying 'cognitive markers' of gender incongruence. These markers have the potential to revolutionise our understanding and support of gender-incongruent children, and inform theories of both gender development and ASD. Following the very recent high court judicial review (Bell v Tavistock, December 2020), another direct aim of the project is to create the evidence base required to inform future clinical judgements and best practice, as well as questions about consent, that will guide support of this marginalised population. In order to meet this overall aim, the project has six academic objectives, to understand whether: 1. ASD has the same presentation and cognitive markers in cisgender and gender-incongruent children 2. Gender incongruence has a different foundation in autistic and non-autistic children 3. Gender identity develops differently in neurodivergent and neurotypical children across the dimensions of gender flexibility, gender typicality, gender expression and gender dysphoria 4. Theory of mind, cognitive flexibility, and/or alexithymia relate to the development of atypical forms of gender identity 5. Expressions and strength of gender, as well as cognitive markers of gender incongruence, run in the families of autistic and non-autistic, cisgender and gender-incongruent children In terms of outcomes, the project aims to allow for more accurate assessments of children referred to gender identity development services and aid the advancement of more effective personalised support. An intended outcome is also to inform the current debate regarding the understanding that clinic-referred children have about gender. In terms of dissemination and impact, the project has three further objectives: 1. To inform current debates and theories about the nature and underpinnings of gender incongruence, as well as its link to ASD. Through open-access, peer-reviewed publications in academic journals, presentations at conferences, and organisation of workshops, we will reach the relevant academic beneficiaries and, thus, support the development of the field. 2. Measures tested in this project that prove effective could be developed for use in gender identity services. The team will work with key stakeholders including Child and Adolescent Mental Health Services (CAMHS), Special Educational Needs Co-ordinators, support services for autistic people (e.g., National Autistic Society, Autistica), and gender identity development services for children 3. To produce a set of guidelines for GIDS, CAMHS, and parents and teachers on how best to support gender-incongruent youth.

Lay abstract: This project is a collaboration between the University of Kent and the Tavistock and Portman NHS Foundation Trust, which hosts Europe's largest gender identity development service (GIDS). Our aim is to understand gender incongruence (when birth-assigned sex does not align with experienced gender) and its striking link with autism spectrum disorder (ASD), which is diagnosed in gender-incongruent children at almost 10 times the population rate. The nature and underpinnings of this co-occurrence have not yet been researched systematically. Hence, clinicians, educators, and parents are trying to support a marginalised and vulnerable population of children with insufficient understanding of gender incongruence, or why it co-occurs with ASD at such a striking rate. The importance of investigating this co-occurrence was highlighted by a recent judicial review (Bell v Tavistock, Dec 2020) and there is consensus that services need to be tailored and adapted for gender-incongruent autistic children and their families. Therefore, this project is timely, and will address a major gap in current research. The investigators are leading child psychologists and psychiatrists, with substantial experience of working with the proposed populations and researching gender identity. Over three years, the team proposes to examine how gender incongruence may overlap with ASD in a series of studies, involving 200, 7- to 14-year-old, children/young people and their families who fall into one of the following four groups: 1) cisgender neurotypical children (i.e. children whose gender identity corresponds to their birth-assigned sex and who do not have ASD) 2) cisgender children with ASD 3) gender-incongruent neurotypical children 4) gender-incongruent children with ASD The series of studies will be conducted remotely by the research team and will use a wide range of implicit and explicit measures of various aspects of gender identity, as well as potential cognitive markers of these aspects, to understand whether: - ASD is associated with different cognitions in cisgender and gender-incongruent children - Gender incongruence is associated with different cognitions in autistic and non-autistic children - Gender identity develops differently in neurodivergent and neurotypical children across the dimensions of gender flexibility, gender typicality, gender expression, and gender dysphoria - Theory of mind, cognitive flexibility, and/or alexithymia relate to the development of atypical forms of gender identity - Expressions and strength of gender, as well as cognitive markers of gender incongruence, run in the families of autistic and non-autistic, cisgender and gender-incongruent children Answering these questions will identify possible 'cognitive markers' of gender incongruence that have the potential to revolutionise our understanding and support of gender-incongruent children, and inform theories of gender development and ASD. Cognitive markers represent intermediate levels between genes and behaviour that can be tapped using psychological measures, and which overcome problems associated with identifying children only on the basis of (often highly diverse) behavioural presentations and self-reports. This research will undoubtedly allow for enhanced assessments of children referred to GIDS and aid the development of more personalised support. We will engage stakeholders throughout, including parents and young people, specialist NHS Gender Services for children, CAMHS, schools, and support services for autistic people (e.g., National Autistic Society, Autistica). We will also produce a website, will publish our findings open access, and will provide a free workshop for parents, teachers, and clinicians. The uniqueness of this study means that it will generate findings of international significance likely to have an impact on theory building, clinical and educational practice, and societal understanding in the UK and beyond.

Research activity codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS
Health categories: MENTAL HEALTH