Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-018-3469-1

ORIGINAL PAPER

A Quantitative Analysis of Mental Health Among Sexual and Gender

Minority Groups in ASD
Rita George1 · Mark A. Stokes1

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
There is increased mental-health adversity among individuals with autism spectrum disorder. At the same time, sexual and
gender minority groups experience poorer mental-health when compared to heteronormative populations. Recent research
suggests that autistic individuals report increased non-heterosexuality and gender-dysphoric traits. The current study aimed
to investigate whether as membership of minority grouping becomes increasingly narrowed, mental health worsened. The
present study compared the rates of depression, anxiety, and stress using the DASS-21 and Personal Well-Being using the
personal well-being index between 261 typically-developing individuals and 309 autistic individuals. As membership to a
minority group became more restrictive, mental health symptoms worsened (p < .01), suggesting stressors added. Specialized
care is recommended for this vulnerable cohort.

Keywords  Autism spectrum disorder · Sexuality · Sexual orientation · Gender · Well-being

Introduction
Autism spectrum disorder (ASD) is a lifelong neurodevel-
opmental condition that affects, among other things, the way
an individual relates to their environment and their interac-
tion with other people. While some individuals with ASD
have meaningful relationships and lead fulfilling lives, the
quality of life among many with ASD is lower compared to
their typically-developing (TD) peers (van Heijst and Geurts
2014; Billstedt et al. 2010). Individuals with ASD face a
range of difficulties owing to challenges from social com-
munication, social comprehension and imagination, which
adversely impact their adaptation to a neurotypical world.
Accordingly, accumulating evidence from clinical practice
and epidemiological research confirms that the rates of psy-
chiatric comorbidity are higher among individuals with ASD
than the general population (Bolton et al. 1998; Mannion and
Leader 2013; Piven and Palmer 1999). The prevalence of
mood disorders in ASD is between 53 and 70% (Lugnegård
et al. 2011; Hofvander et al. 2009) compared to much lower
prevalence rates in the general population, ranging from
* Mark A. Stokes
mark.stokes@deakin.edu.au
1
Faculty of Health, Deakin University, 221 Burwood
Highway, Burwood, VIC 3030, Australia
between 5 and 17% (Bijl et al. 1998; Jacobi et al. 2004).
Similarly, when comparing the prevalence rates of anxi-
ety in ASD which is between 50 and 56% (Hofvander et al.
2009; Lugnegård et al. 2011), these rates are much higher
compared to reports in the general population, which range
between 3 and 12% (Bijl et al. 1998; Jacobi et al. 2004).
At the same time, minority groups such as non-hetero-
sexual individuals (Sandfort et al. 2001) and individuals
with gender-dysphoria (Hepp et al. 2005; Toomey et al.
2010) suffer from a greater burden of depressive and anxi-
ety disorders, report poorer life-satisfaction (Powdthavee
and Wooden 2015; Davey et al. 2014), and a higher rate of
suicide attempts (Haas et al. 2014) compared to heterosexual
individuals and individuals without gender-dysphoria. Gen-
der-dysphoria is a clinical condition where individuals expe-
rience a persistent discontent over the incongruence between
their experienced and assigned gender, leading to significant
distress, challenges in social or occupational functioning,
and a desire to live a cross-gender life (American Psychiatric
Association 2013).
Research suggests that individuals with ASD report
higher rates of non-heterosexuality than their TD peers
(Hellemans et al. 2007, 2010; Gilmour et al. 2012; George
and Stokes 2017; George 2016). Additionally, empirical
reports suggest an association between ASD and gender-
dysphoric traits (GDT; George and Stokes 2016; DeVries

13
Vol.:(0123456789)
 Journal of Autism and Developmental Disorders

et al. 2010; Jones et al. 2012; Pasterski et al. 2013). Given Furthermore, it was hypothesized that all non-heterosexual
increased mental health adversity in the ASD population, individuals (sexual minority group) would have higher rates
and similar outcomes among non-heterosexual individuals, of Depression, Anxiety and Stress and reduced levels of Per-
and individuals with GDT, concerns may be additive for sonal Wellbeing than all heterosexual individuals, and there-
autistic individuals from a sexual and/or gender minority fore, reduced mental health. Lastly, it was hypothesized that
group, relative to their autistic peers who are heterosexual all individuals from a gender minority group (having GDT)
and without GDT. For the purposes of this study, sexual would have higher rates of Depression, Anxiety and Stress
minority group refers to individuals with a non-heterosex- and lower levels of Personal Wellbeing than all individu-
ual orientation, while gender minority group refers to indi- als without GDT, and therefore, reduced mental health. We
viduals with GDT. Moreover, an individual can belong to predict that as of minority grouping membership becomes
more than one minority group, i.e. an individual may be increasingly narrowed (i.e.: an individual is a member of
both non-heterosexual and have GDT. A conceptual model an increasing number of minority groups), so will the rates
is presented in Fig. 1 displaying one minority group within of Depression, Anxiety and Stress increase, while levels of
another minority group, and how stressors of one group Personal Wellbeing will decrease. That is, mental health
could add to that of another group. will worsen as minority group membership becomes more
While there is considerable evidence that individuals restrictive.
from sexual minority groups (Meyer 2003) and gender
minority groups (Toomey et al. 2010) experience poor psy-
chiatric health relative to their heterosexual peers and those Method
without GDT, there is a lack of research investigating the
mental health of individuals who are diagnosed with an ASD Participants
from a sexual and gender minority group. This study aimed
to address this gap using validated psychometric measures The present study compared 261 TD individuals (Mage
in an international sample of individuals with ASD. Mental = 30.20, SD = 11.92; 103 males and 158 females) with
health was evaluated for each participant based upon their 309 individuals with a diagnosis of ASD (Mage = 31.01,
rates of Depression, Anxiety, Stress and Personal well-being. SD = 11.37; 90 males, 219 females). Ethnic background is
This study aimed to assess (a) whether belonging to a sexual reported in Table 1. Additionally, the sample was largely
minority group further reduced the mental health of some- highly educated (see Table 1). There were no significant
one with ASD and (b) whether belonging to a gender minor-
ity group further reduced the mental health of someone with
ASD. Accordingly, it was hypothesized that all individuals Table 1  Demographic characteristics of the study sample
with ASD would have higher rates of Depression, Anxi- ASD (N = 310) TD (N = 261)
ety and Stress and lower levels of Personal Wellbeing than
Race/ethnicity %
all TD individuals, and therefore, reduced mental health.
Caucasian 81.6 71.4
African-American 0.6 1.1
Hispanic 1.0 2.2
Latino 0.3 0.5
Middle-Eastern 0.0 3.8
Asian 1.9 8.1
Pacific Islander 0.0 0.0
Indigenous or Australian Aboriginal 0.3 0.0
Multiracial 8.1 7.0
Other/rather not say 6.2 6.0
Education level %
Primary school 2.7 1.3
High school 17.7 24.2
Trade/Vocational school 7.4 5.8
Some University 29.7 25.5
Bachelor’s degree 23.2 25.8
Master’s degree 10.3 11.9
Fig. 1  Conceptual model of a ‘minority within a minority’. Each level Doctoral degree 3.5 2.9
rests upon the foundation of the prior level and includes all stressors Other/not sure 5.5 2.6
of the prior level. As levels increase, the amount of stress increases

13
Journal of Autism and Developmental Disorders
differences between the individuals with and without an
ASD on ethnicity or their levels of education.
Demographic Trends
Chi square tests were conducted to examine cohabitation
rates among different minority groups. Individuals with an
ASD were less likely to report cohabiting with a romantic/
sexual partner than were TD individuals, (χ2(571) = 49.81,
p < .001, φ = 0.29), Relative to their heterosexual peers, non-
heterosexual individuals were less likely to report cohabiting
with a romantic or sexual partner, (χ2(571) = 45.81, p < .001,
φ = 0.28). Relative to individuals without GDT, individu-
als with GDT were less likely to report cohabiting with a
romantic/sexual partner, (χ2(571) = 44.16, p < .001, φ = 0.28).
Chi square tests were also conducted to assess for group
differences on presence of a comorbid psychiatric diagno-
sis. Individuals with an ASD were more likely to report a
comorbid psychiatric diagnosis than were TD individuals,
(χ2(571) = 76.59, p < .001, φ = 0.37). Relative to their hetero-
sexual peers, non-heterosexual individuals were more likely
to have a comorbid psychiatric diagnosis, (χ2(571) = 67.42,
p < .001, φ = 0.34). Relative to individuals without GDT,
individuals with GDT were more likely to report a comor-
bid psychiatric diagnosis, (χ2(571) = 63.72, p < .001, φ = 0.34,
see Fig. 2).
Procedure and Measures
Upon receiving ethical approval for the research [Blinded],
national and international autism organizations were con-
tacted, including autism forums. TD participants were
recruited by word of mouth and through social media such
as Facebook. The study was solely conducted in electronic
format. Participants first completed a series of demographic
questions related to their age, country of residence, race,
and level of education, birth-sex, gender-identity, diagnos-
tic status, comorbid medical/psychiatric conditions, and
Non-Heterosexual
Heterosexual
GDT
No-GDT
ASD
TD
0 20 40 60 80
Co-morbid Psychiatric Diagnoses by Group %
Fig. 2  Comparison of comorbid psychiatric diagnoses between
minority groups (Black) versus control groups (Striped). Psychiatric
diagnoses included depression, bipolar manic depression, stress, anxi-
ety, post-traumatic stress disorder, and generalized anxiety disorder
cohabitation status. This was followed by administration of
the different psychometric measures.
Sell Scale of Sexual Orientation
The Sell Scale of Sexual Orientation (Gonsiorek et al. 1995)
is a comprehensive measure of Sexual Orientation. It is a
well-validated instrument which demonstrates construct
validity in its strong correlation with the Kinsey scale of
sexual orientation (r = 0.85), while test–retest reliability is
demonstrated in correlations ranging upward from 0.93 (for
further details please refer to George 2016 unpublished doc-
toral thesis).
Gender‑Identity/Gender‑Dysphoria Questionnaire
for Adolescents and Adults (GIDYQ‑AA)
The GIDYQ-AA (Deogracias et al. 2007) is a standardized
27-item instrument, which assesses cross-gender behavior
and different aspects of GD among adolescents and adults,
with the past 12 months as the time frame. The response
options are coded along a five-point scale as 1(always), 2
(often), 3(sometimes), 4(rarely), or 5(never). A cut-off mean
score of 3.00 is recommended by the authors to discrimi-
nate between individuals with and without GD, which has
a sensitivity of 90.4% for clients with GD and a specificity
of 99.7% for controls (Deogracias et al. 2007). Gender-dys-
phoric status (No-GDT versus GDT) referred to whether an
individual expressed GDT or not. No-GDT (never or rarely
experienced gender-dysphoric feelings) versus GDT (some-
times or always experienced gender-dysphoric feelings).
Depression, Anxiety, and Stress Scale‑21 (DASS‑21)
The DASS-21 is a short form of Lovibond and Lovibond’s
(1995) 42-item self-report measure of depression, anxiety
and stress. The DASS- 21 has several advantages over the
full-length version, in being shorter, without sacrificing on
reliability and having a cleaner latent structure (Henry and
Crawford 2005). Higher scores on each of the three scales
indicate greater severity of the distress. Because the DASS-
21 is a shortened version of the DASS, the final score was
doubled. The DASS had excellent psychometric properties
with reported internal reliabilities of 0.91, 0.84, and 0.90
for Depression, Anxiety and Stress, respectively (Lovibond
and Lovibond 1995). In the present study, strong Cronbach
alphas of 0.92, 0.87, and 0.89 were obtained for Depression,
Anxiety and Stress respectively. It also has excellent conver-
gent validity with other scales designed to measure Depres-
sion (Beck Depression Inventory: r = .74) and Anxiety (Beck
Anxiety Inventory: r = .81; Lovibond and Lovibond 1995).
13

Personal Wellbeing Index (PWI)
The Personal Wellbeing of participants was assessed using
the Personal Wellbeing Index scale (Davern et al. 2007).
The PWI contains seven items measuring satisfaction cor-
responding to a quality of life domain as: standard of living,
personal health, achieving in life, personal relationships,
safety, community-connectedness, and future security. These
domains are summed up to yield an average score. For the
purposes of the analysis, an individual’s PWI score was
scored following Davern, Cummins and Stokes (2007), and
then was recoded using the formula:
(100 − x)
Score = C ∗ (1)
100
where C is the constant, set to 42, required to convert par-
ticipant scores to the same metric as the DASS, and the
negation reverses the direction of the scores. This is a sim-
ple linear transformation of the data for the purposes of the
analysis only. By reversing and placing the PWI into the
same metric as the DASS for the analysis, the PWI scores
did not cross the DASS scores simply due to differences in
their underlying metrics, which would have given rise to
a spurious interaction between measures of mental health
(e.g.: DASS & PWI) in the profile analysis. (Note for all
tables raw PWI scores are reported; though for figures trans-
formed PWI data are presented.)
After transformation, higher scores on the PWI repre-
sented lower Personal Wellbeing. This enabled the PWI and
the DASS scales to be interpreted in a linear manner, where
higher scores on all scales represented greater mental dis-
tress. The PWI scale has sound psychometric properties.
Cronbach’s alpha is reported to be 0.85. The index has also
demonstrated good test–retest reliability across a 1–2-week
interval with a correlation coefficient of 0.84 (Lau et al.
2005). Construct validity is demonstrated through a corre-
lation of 0.78 with the Satisfaction with Life scale (Diener
et al. 1985).
Data Screening
Data were screened for missing values, outliers, and nor-
mality. Less than 5% of data was found to be missing on
the variables of interest, and cases with missing data were
excluded from analyses employing pairwise deletion where
necessary. No univariate or multivariate outliers were found.
No issues were identified with normality of the data.
Data Analytic Plan
In order to address the hypotheses that those within the
ASD group, non-heterosexual group, or gender minor-
ity group (having GDT) would have higher rates of
13
Journal of Autism and Developmental Disorders
depression, anxiety and stress and lower levels of well-
being as indicated by the Personal Wellbeing Index (PWI)
and therefore, reduced mental health, and that with more
restricted minority group membership (i.e.: having both
GDT and being an individual with ASD, etc.) would be
associated with even worse mental health, we undertook
a repeated measures MANOVA. We assessed diagnosis
(TD, ASD), sexual orientation (heterosexual, non-heter-
osexual), and GDT-Status (No-GDT, GDT) over mental
health. Mental health was assessed as a repeated meas-
urement, based on scores for depression, anxiety, stress,
and PWI. When dealing with multiple IVs (diagnosis,
GDT-status, sexual orientation) and a repeated measures
variable as the DV (PWI, depression, anxiety, stress) in
a repeated measures analysis, the repeated measurement
interacts with the IVs or predictors. The shape or profile
of each groups’ responses in the DVs becomes another
analytic IV, and this complication allows for differences
in profile or shape of the DVs to be considered (see
Tabachnick and Fidell 2001).
Initially, a single MANOVA was planned, using a single
4-way interaction (mental health by diagnosis by GDT-status
by sexual orientation). This would give rise to four 3-way
interactions, six 2-way interactions, and 4 main effects tests,
for a total of 15 planned tests. Following the initial analysis,
the single 4-way design was not found significant. Subse-
quently, we undertook two 3-way analyses (mental health by
diagnosis by sexual orientation; and mental health by diag-
nosis by GDT-status) resulting in a further 7 tests each: one
3-way interaction, three 2-way interactions, and three main
effects tests. Thereafter, nine tests of simple main effect were
undertaken involving 30 additional tests. In total, therefore,
there were 15 planned tests and 44 unplanned follow-up tests
used. Additionally, a single Spearman’s Rho correlation was
planned relating mental health status to minority status.
Consequently, we used a MANOVA Protection approach
with Sidak correction (Frane 2015) to adjust the type I error
rate, requiring that we obtain results more significant than
p < .001 to maintain an experimentwise error rate of p < .05.
Where Mauchly’s test of sphericity was violated, this was
corrected for using a Huyhh-Feldt corrections (Barcikowski
and Robey 1984; Girden 1992; Huynh and Feldt 1976).
Results
The means (Table 2) revealed all minority groups (ASD,
non-heterosexual, and those with GDT) reported reduced
mental health (depression, anxiety, stress, and personal
wellbeing) compared to their non-minority group peers.
The hypothesis that with increasingly narrow minority group
membership (i.e.: having both GDT and being an individ-
ual with ASD, etc.) mental health would further deteriorate
Journal of Autism and Developmental Disorders

Table 2  Mental health scores by Group Mental health profile indicators

group membership
Depression Anxiety Stress PWI
M SD M SD M SD M SD

Diagnosis***
ASD 19.14 11.82 15.23 10.67 22.45 10.35 49.79 20.15
TD 10.84 10.37 7.62 7.95 13.86 9.56 69.66 21.21
Sexual orientation***
Non-Heterosexual 18.97 11.75 15.26 10.41 21.93 10.26 49.89 20.34
Heterosexual 11.48 10.86 8.04 8.66 14.94 10.35 68.35 21.61
GDT-status***
GDT group 20.02 11.34 15.26 10.36 22.36 9.73 49.34 20.31
No-GDT group 9.00 9.51 6.97 7.87 13.31 10.15 71.84 19.60

***p < .001

non-heterosexuality), those with two or more minority group

Fig. 3  Mean mental health score by group membership. Scores
include the reversed and re-coded PWI, and the DASS scores. Data is
sorted by membership of increasingly restrictive minorities
suggests that membership of each minority would add or
increase mental health burden. To evaluate this, we corre-
lated minority status with mental health score. To derive
minority status, individuals were classified on the number
of minorities they belonged to. For instance, an individual
who did not identify with any minority group was classified
as having no minority status (x = 0), while individuals who
classified themselves as non-heterosexual, ASD, or reported
GDT, was classified as having one minority representation
(x = 1), individuals who had two such group memberships
were assigned a value of two (x = 2), and so on. The cor-
relation was significant (Spearman’s r = 0.60, p < .001 two
tailed). Thus, as minority status increased, mental health
symptoms worsened (see Fig. 3).
As we found that mental heath burden increased with
membership of increasingly restrictive minority groups, it
was necessary to establish if group membership was addi-
tive or if these interacted with each other. If group mem-
berships interact, this would mean that compared to those
with a single minority group membership (i.e.: ASD, GDT,
memberships (i.e.: ASD & GDT, ASD & non-heterosexual-
ity, etc.) could have a considerably increased or even reduced
mental health burden rather than a burden that was the sim-
ple addition of mental health burden inherited from each
group membership. If this impost on mental health is addi-
tive, there should either be no interaction between groups
with more restrictive minorities, or an ordinal interaction,
where the effect of additional group membership only
increases or reduces the total effect. To test this, we under-
took a repeated measures MANOVA assessing the 4-way
interaction between diagnosis, sexual orientation, GDT-sta-
tus and mental health, and all lesser interactions and effects.
The 4-way interaction was not significant, and its effect
size accounted for very little variance (F(2.66, 1465.88) = 0.53,
p = ns, η2 < 0.001). All lower order 3-way and 2-way inter-
action effects were also not significant (η2 < 0.008). Thus,
mental health burden did not increase due to an interaction
of group membership. This suggests that any increases in
mental health burden due to increasingly restricted group
membership were additive to each other (see Fig. 4).
Given the lack of significance from all interactions, we
examined the main effects, all of which were significant:
diagnosis (F(1, 551) = 28.76, p < .001, ƞ2 = .050); sexuality
orientation (F(1, 551) = 11.14, p < .001, ƞ2 = .020); and GDT-
status (F(1, 551) = 43.51, p < .001, ƞ2 = .070). Thus, mental
health depended on group membership, and did not change
at different levels of the other IVs (diagnosis, sexual orien-
tation, and GDT-status). Individuals with an ASD reported
poorer mental health than TD individuals, while individuals
who were non-heterosexual reported poorer mental health
than heterosexual individuals, and individuals with GDT
reported poorer mental health than individuals without GDT.
It was possible that a 4-way interaction failed because of
reduced power. Some design cells (i.e.: TD, non-heterosex-
ual individuals without GDT) had as few as 16 participants,

13

Fig. 4  Profile of mental health for each of groups evaluated. While
the PWI was rescored for the analysis by reversing and rescaling to
42, ensuring all variables were directionally and scale equivalent,
and preventing spurious interactions arising in the analysis, for ease
of interpretation, here the data is presented unadjusted. Thus, here
low PWI indicates a poorer outcome, as do higher scores for stress,
depression, and anxiety. a Mental health profiles based on diagnostic
status b mental health profiles based on sexual orientation c mental
health profiles based on GDT status
and others had only 40 (i.e.: non-heterosexuals without GDT
who had a diagnosis of ASD). As simpler analyses would be
more sensitive, we undertook two separate 3-way repeated
measures MANOVA analyses to assess for (a) sexual orien-
tation on diagnosis in mental health, and (b) GDT-status on
diagnosis in mental health.
The 3-way interaction using a repeated measures
MANOVA of diagnosis by sexual orientation by mental
health profile was not significant for diagnosis by sexual
13
Journal of Autism and Developmental Disorders
orientation by mental health (η2 = 0.003), for diagnosis by
mental health (η2 = 0.001), or sexual orientation by men-
tal health (η2 = 0.001; see Table 3). Mental health burden
was not changed by diagnosis and was not changed by
sexual orientation (see Fig. 5). Nonetheless, the interaction
between diagnosis and sexual orientation was significant
(F(1, 555) = 20.65, p < .001, ƞ2 = .036), accounting for 3.6%
of variance. Overall, mental health score depended upon an
individual’s sexual orientation as well as their diagnosis. In
order to explore this interaction further, simple main effects
were undertaken. Initially, sexual orientation separating over
diagnostic status was explored (see Table 4). For TD individ-
uals, those with different sexual orientations (heterosexual
versus non-heterosexual) had a significantly different mental
health burden (F(1, 256) = 92.95, p < .001, ƞ2 = .27), but this
was not found for individuals with ASD (ƞ2 = .012). Being
non-heterosexual added to the mental health burden of TD
individuals (M = 17.14, SD = 6.44) with non-heterosexual
TD individuals having worse mental health than heterosex-
ual TD individuals (M = 8.69, SD = 6.44). Thereafter, we
examined the simple main effect of diagnosis separating over
sexual orientation. For those with heterosexual orientation
there was a significant simple main effect over diagnosis
(F(1, 272) = 115.90, p < .001, ƞ2 = .299), but not those with a
non-heterosexual orientation (ƞ2 = .025). Overall, as may be
seen in Table 4, among heterosexual individuals, a diagnosis
of ASD worsened mental health, while among those with
non-heterosexual sexual orientation, a diagnosis of ASD did
not worsen mental health. In summary, being in one minor-
ity group resulted in increased mental health burden, but this
was not significantly increased by being in two minorities
(ASD and non-heterosexual).
A further 3-way repeated measures MANOVA was under-
taken to assess for the effect of diagnosis and GDT-status
on mental health. The 3-way interaction between diagno-
sis, GDT-status and mental health profile was not signifi-
cant (ƞ2 = .003; see Table 5), suggesting that individuals
with and without an ASD did not have a different profile of
mental health based on their GDT-status. The 2way interac-
tion between diagnosis and mental health profile was also
not significant (ƞ2 = .001; see Table 5), suggesting that the
mental health profile ratings did not differ for those with
and without ASD. The 2way interaction between GDT-
status and mental health profile was also not significant
(ƞ2 = .008; see Fig. 4). However, the interaction between
diagnosis and GDT-status was significant (F(1, 555) = 13.65,
p < .001, ƞ2 = .024; see Table 5), accounting for 2.4% of
the variance in mental health and suggests that the mental
health profiles of individuals with and without ASD dif-
fered according to GDTStatus. Simple main effects analysis
was undertaken examining diagnosis while separating GDT-
status. Among those without GDT a significant simple main
effect was found for diagnosis (F(1, 237) = 78.99, p < .001,
Journal of Autism and Developmental Disorders

Table 3  Multivariate profile analysis examining effects of diagnosis and sexual orientation on mental health
F Eta-squared
df = (2.65, 1484.26)

Within-subject effects
Mental health 110.30*** 0.170
Mental health × diagnosis 0.74 0.001
Mental health × sexual orientation 0.49 0.001
Mental health × diagnosis × sexual-orientation 1.87 0.003
df = (1, 550)

Between-subject effects
Diagnosis 78.73*** 0.124
Sexual orientation 55.14*** 0.091
Diagnosis × sexual orientation 21.02*** 0.037

Table 4  Simple effects comparing mental health for diagnostic

groups by sexual orientation

Non-Heterosexual Heterosexual
M SD M SD d

ASD
Depression 19.58 12.20 18.11 10.99 0.13
Anxiety 16.20 10.85 13.10 10.01 0.30
Stress 22.86 10.39 21.65 10.28 0.12
PWI 48.56 19.81 53.02 20.22 0.23
TD
Depression 17.32 10.32 8.10 9.11 0.95*
Anxiety 12.72 8.67 5.46 6.53 0.95*
Stress 19.40 9.52 11.52 8.58 0.87*
PWI 54.04 20.69 76.48 17.56 1.17*
Depression d 0.17 0.98†
Anxiety d 0.30 0.92†
Stress d 0.30 1.05†
PWI d 0.26 1.21†

*p < .001 over Sexual Orientation within Diagnosis; †p < .001 over

diagnosis within sexuality

those with GDT, additionally having a diagnosis of ASD did

Fig. 5  Mental Health profile for ASD versus TD by sexual orienta-
tion and for ASD versus TD for GDT-status. While the PWI was res-
cored for the analysis by reversing and rescaling to 42, ensuring all
variables were directionally and scale equivalent, preventing spurious
interactions arising in the analysis, for ease of interpretation, here the
data is presented unadjusted. Thus, low PWI indicates a poorer out-
come, as do higher scores for stress, depression and anxiety. a Profile
analysis of diagnosis by sexual orientation. b Profile analysis of diag-
nosis by gender dysphoric trait status
ƞ2 = .250), having a diagnosis of ASD worsened mental
health (M = 16.17, SD = 6.48) compared to TD individuals
(M = 8.00, SD = 6.48). This effect was not evident among
not significantly affect mental health (M = 20.52, SD = 8.03)
compared to the TD group (M = 17.50, SD = 8.03).
Simple main effects analysis was then undertaken on
GDT-status separating on diagnosis. For those with ASD,
there was a significant effect of GDT (F(1, 299) = 14.15,
p < .001, ƞ2 = .045). Those who had both ASD and GDT
(i.e.: members of increasingly restricted minority groups)
had worse mental health (M = 20.52, SD = 8.44) than those
who only had ASD and no GDT (M = 16.17, SD = 8.43).
Specifically, this group had worse stress levels and PWI
levels (see Table 6). However, things were more complex
for TD individuals. The addition of a minority status to

13
 Journal of Autism and Developmental Disorders

Table 5  Multivariate analysis examining effects of diagnosis and GDT-status on mental health

F Eta-squared
df = (2.65, 1470.86)

Within-subject effects
Mental health 97.46* 0.149
Mental health × diagnosis 0.72 0.001
Mental health × GDT-status 4.62 0.008
Mental health × diagnosis × GDT-status 1.60 0.003
df = (1, 555)

Between-subject effects
Diagnosis 63.88* 0.103
GDT-status 97.57* 0.150
Diagnosis × GDT-status 13.65* 0.024

Table 6  Simple effects comparing mental health for diagnostic p < .001, ƞ2 = .248), and worsened stress (F(1, 258) = 62.31,
groups by GDT-status p < .001, ƞ2 = .195). Thus, for TD individuals adding GDT
GDT No-GDT worsened mental health.
Finally, an examination of main effects was under-
M SD M SD d
taken. The main effect for GDT-status was significant for
ASD TD individuals (F (1, 256) = 147.08, p < .001, ƞ 2 =.365),
Depression 20.33 11.45 15.16 12.26 0.43 and individuals with ASD (F (1, 299) = 14.15, p < .001, ƞ2
Anxiety 16.09 10.41 12.34 11.07 0.35 =.045). While main effects may be interpreted in the pres-
Stress 23.38 9.48 19.37 12.42 0.37 ence of a significant interaction, they must be interpreted
PWI 47.33 19.62 58.98 18.69 0.61* cautiously, recognising that these effects reflect the aver-
TD age GDT trend (Keppel 1991; Kirk, 1995). Those with
Depression 19.19 11.06 6.47 6.65 1.39* GDT (M = 17.50 SD = 8.33) had worse mental health than
Anxiety 13.08 9.97 4.76 4.55 1.07* those without GDT (M = 7.96 SD = 7.39). A significant
Stress 19.68 9.91 10.81 7.81 0.99* main effect for diagnosis was also found accounting for
PWI 55.33 20.55 77.00 17.52 1.13* 10.3% of the variance in mental health (see Table 5). Indi-
Depression d 0.09 1.01† viduals with an ASD reported poorer mental health than
Anxiety d 0.29 1.07† their TD peers (see Table 6). There was also a significant
Stress d 0.39† 0.92† main effect for GDT-status, which accounted for 15.1% of
PWI d 0.40† 1.01† the variance in mental health (see Table 5). Individuals in
the GDT group reported poorer mental health than their
*p < .001 over GDT status within diagnosis
† peers without GDT.
 p < .001 over diagnosis within GDT-status
To summarise, single minority group membership
worsened mental health, adding a second minority group
this group worsened mental health. For TD individuals a membership if it was non-heterosexuality did not worsen
significant interaction of mental health by GDT-status was mental health, but adding a second minority group mem-
found (F(2.42, 619.41) = 6.96, p < .001, ƞ2 = .026). This was bership if it was GDT did worsen mental health. However,
not the case for those with ASD (ƞ2 = .002). Consequently, when compared to a single minority status of GDT, no
this interaction was also followed by further assessments additional minority membership worsened mental health.
of simple main effects, first controlling for GDT-status These results suggest a hierarchy of threats to mental
within TD individuals. Mental health scores differed for health through minority group membership. While ASD
TD individuals with GDT (F(2.19, 371.50) = 49.45, p < .001, diagnosis and non-heterosexuality do not additively
ƞ2 = .226) and without GDT (F(2.46, 213.60) = 19.26, p < .001, worsen mental health (see Table 4), when GDT was added
ƞ2 = .186). Among TD individuals the presence of GDT to ASD diagnosis, the effect was to worsen mental health.
significantly worsened PWI (F(1, 258) = 76.12, p < .001, ƞ2 It would appear the effect of GDT is more extreme than
= .228; see Table 6), worsened depression (F(1, 258) = 132., any other minority membership.
p < .001, ƞ2 = .341), worsened anxiety (F(1, 258) = 84.66,

13
Journal of Autism and Developmental Disorders
Discussion
The current study assessed whether either sexual minority
group membership or gender minority group membership
reduced the mental health of someone with ASD. Indi-
viduals who either had ASD, a non-heterosexual orien-
tation, or GDT reported poorer mental health than their
peers. These results suggest GDT adds to the poor mental
health associated with an ASD diagnosis. However, non-
heterosexual orientation did not add to their mental health
burden of those with ASD.
Participants in any of the three single group minori-
ties (ASD, non-heterosexuality, having GDT) reported
lower personal wellbeing compared to controls. Scores
on the PWI were about 50 out of 100, and well below
the that found for TD populations, which usually aver-
age about 74–77 points out of 100 (Cummins et al. 2014;
see Table  2). The range for an individual’s subjective
well-being is usually small, with 1 SD being about 5
points. Cummins et al. (2014) point out subjective well-
being appears to be tightly regulated by a well-defended
homeostatic mechanism. Levels that fall much below 75
(i.e.: more than—2 SD) are only seen in very unusual
circumstances, as supported by many assessments over
many thousands of participants (Cummins et al. 2014).
Prolonged challenges to subjective well-being have been
found to seriously impact upon it, and it is likely that the
chronic challenges associated with belonging to a minor-
ity group may considerably reduce subjective well-being
(Cummins et al. 2014), while the presence of a co-morbid
diagnosis may further exacerbate this. The most frequently
reported co-morbid conditions were depression, social
anxiety, generalized anxiety disorder (GAD) and obses-
sive–compulsive disorder (OCD). Affective disorders have
been linked to reduced well-being (Burns et al. 2011; Gar-
giulo and Stokes 2008).
Previous literature indicates higher levels of mental dis-
tress among sexual minorities (Sandfort et al. 2001) and
gender minority groups (Hepp et al. 2005). The increased
rates of mental health problems in these minority popula-
tions are often a consequence of the stigma and marginali-
zation attached to living outside mainstream sociocultural
norms (Meyer 2003). This stigma can lead to what Meyer
(2003) refers to as ‘minority stress’. This stress could
come from external adverse events, which among other
forms of victimization could include verbal abuse, acts of
violence, sexual assault by a known or unknown person,
reduced opportunities for employment and medical care,
and harassment from persons in positions of authority
(Sandfort et al. 2007). Minority stress levels are further
perpetuated by internal stresses, such as the anticipation of
adverse events, the vigilance this anticipation requires, the
internalization of negative social attitudes (Herek 2015),
efforts to conceal one’s sexual orientation and gender-
identity, and pressure to conform to societal expectations.
Additivity of Minority Stress: A Minority Within
a Minority
The three minority groups in the current study (ASD, sex-
ual minority group, gender minority group) reported poorer
mental health outcomes than their respective control groups,
possibly due to additivity of minority group-specific stress-
ors from different conditions. This cohort of individuals can
be conceptualized as a ‘minority within a minority’ and the
mental distress experienced within this cohort may be quan-
titatively and indeed qualitatively different from belonging
to one or the other minority populations alone.
Interestingly, results suggested that a minority sexual ori-
entation did not significantly worsen mental health among
individuals with ASD. However, the additive effects of GDT
to a diagnosis of ASD significantly worsened mental health
for this group when compared to non-GDT individuals
with ASD. A non-heterosexual orientation is understood as
a ‘concealable stigma’ unlike GDT (Herek and Capitanio
1996). By not disclosing our sexual orientation, some level
of stigmatization can be avoided. Moreover, non-heterosex-
uality is increasingly becoming more acceptable (Kuyper
et al. 2013). Our gender, however, unlike our sexual orienta-
tion, permeates every aspect of our lives, and affects how we
relate to the world and the world relates to us. Gender non-
conformity is more salient compared to sexual orientation,
and might thus induce a stronger negative reaction both from
confrontational external events and internalization of nega-
tive social attitudes, phobia and guilt due to cognitive disso-
nance related to the individual’s personal desires and expec-
tations versus sociocultural expectations. This dissonance
in addition to the socio-communicative and interpersonal
challenges characteristic of ASD, could understandably con-
tribute to considerable psychological stress. Victimization
and ostracization by peers of one’s own gender group during
early developmental stages when gender segregation is at its
peak, can increase the likelihood of experiencing significant
affective, cognitive and behavioural consequences for gen-
der non-conforming individuals in adulthood (Zucker 2005).
Results from the current study suggested that having GDT
had the most extreme adverse effect on mental health. Thus,
adverse mental health consequences may be more severe for
autistic individuals from a gender minority group when com-
pared to autistic individuals from a sexual minority group,
and results from the current study suggested that having
GDT had the most extreme adverse effect on mental health.
However, membership to minority sexual orientation
among TD individuals worsened mental health symptoms.
In addition to reasons previously mentioned, this difference
13

in adverse mental health effects of non-heterosexuality
between ASD and TD groups may be in part due to the rela-
tive insensitivity of autistic individuals to social reputation,
affording this population some insulation from any ensuing
stigmatization (Izuma et al. 2011). Alternatively, perhaps
individuals with ASD simply do not face the same level of
hostility related to sexuality differences as TD individuals
do. TD individuals typically have larger social networks rela-
tive to individuals with ASD, thus facilitating more exposure
to any stigmatization. Many individuals with ASD prefer
computer chat-rooms, where most obstacles related to social
cues, body-language and eye-contact are removed. Further-
more, family and friends of individuals with ASD report
more accepting and liberated attitudes toward sexuality, in
anticipation of reducing any additional stress that could be
caused by disagreement. If a particular disposition and a
supportive environment provides some level of protection
from any minority stigmatization among individuals with
ASD, the protection appears to only reduce the effects of
stigma, but not negate it, as indicated by overall poorer men-
tal health among autistic individuals.
Limitations
The demographic profile of the current sample may have
influenced these results. Individuals on the high-functioning
end of ASD may be particularly vulnerable to psychological
distress due to a deeper insight into their social challenges
(Settipani et al. 2012; Strang et al. 2012). The cognitive
capacity to recognize any social deficits may increase vul-
nerability to stress, provoke anxiety, and feelings of help-
lessness and depression. As the current sample had a large
proportion of participants with college education, it is likely
these individuals were more aware of their social difficulties.
This is supported by the elevated scores on the depression,
anxiety and stress scales reported by individuals with ASD.
Consequently, it would be useful to see if these results are
replicated in another study utilising a sample more typical
of the population.
The composition of the control group was not typical of
the wider population, with a higher number of sexually and
gender-diverse individuals who participated. This in fact
would make the findings in this study even more remark-
able and group differences may have been underestimated.
The cross-sectional design of the study however, did not
assess for psychological functioning through approaches less
susceptible to self-report biases, such as through measures
of daily functioning such as occupational status, job satisfac-
tion, and relationship success, and it is recommended that
future research examine these areas.
Most ASD studies demonstrate the usual male bias and
report fewer female participants. The current study did
not find this. This might be due to the online format of the
13
Journal of Autism and Developmental Disorders
study, where females are more likely than males to rely on
the internet for interaction and self-help (Addis and Mahalik
2003; Santor et al. 2007). As such, the study provided an
opportunity to study females with an ASD. Socio-cultural
gendered norms might also contribute to this trend (Kite and
Whitley 1996). Society is less tolerant towards males with
GDT than females with GDT (George 2016).
Conclusions
The present study yielded some important findings. The
results tend to suggest that relative to a non-heterosexual
orientation, having GDT presents with significant mental
health adversity among individuals with ASD (see Fig. 3).
Findings must be interpreted considering the strengths and
limitations of the study. This was the first study to quantita-
tively investigate the effects of non-heterosexuality and GDT
together, on mental health among individuals with an ASD.
Given ASD-characteristic cognitive and behavioural
styles, it is likely that the stresses experienced by sexual
and gender minorities who are on the spectrum are perceived
differently from neurotypical sexual and gender minority
groups. Further investigations would be useful to undertake,
particularly a qualitative investigation into the mental health
outcomes of individuals who belong to sexual and gender
minority groups within the ASD population. This study
would suggest that the design of specialized psycho-sexual
programs for gender-related challenges, tailored to birth-sex,
are necessary.
Acknowledgments  No funding was received for this research. This
work is original research and forms part of the doctoral dissertation
of the author.
Author Contributions  Both authors contributed to the analytic methods
and written work presented in this paper. RG and MAS conceived,
and participated in the design of the study. RG conducted all system-
atic search and meta-analysis procedures, and drafted the original
manuscript. MAS provided expertise regarding the study, critically
evaluated all key sections of the review, and assisted in drafting the
manuscript. MAS oversaw all analyses, participated in the interpreta-
tion of data, reviewed, and was involved in the write up of all drafts.
Both authors were involved in the final revisions and approval of the
published manuscript.
References
Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the con-
texts of help seeking. American Psychologist, 58(1), 5.
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (4th edn.). Washington, DC: Ameri-
can Psychiatric Association.
Barcikowski, R. S., & Robey, R. R. (1984). Decisions in single group
repeated measures analysis: Statistical tests and three computer
packages. The American Statistician, 38(2), 148–150.
Journal of Autism and Developmental Disorders
Bijl, R. V., Ravelli, A., & Van Zessen, G. (1998). Prevalence of
psychiatric disorder in the general population: results of The
Netherlands Mental Health Survey and Incidence Study (NEM-
ESIS). Social Psychiatry & Psychiatric Epidemiology, 33(12),
587–595.
Billstedt, E., Gillberg, I. C., & Gillberg, C. (2010). Aspects of
quality of life in adults diagnosed with autism in child-
hood: A population-based study. Autism. https://doi.
org/10.1177/1362361309346066.
Bolton, P. F., Pickles, A., Murphy, M., & Rutter, M. (1998). Autism,
affective and other psychiatric disorders: patterns of familial
aggregation. Psychological Medicine, 28(02), 385–395.
Brown, S. L. (2000). The effect of union type on psychological well-
being: Depression among cohabitors versus marrieds. Journal of
Health & Social Behavior, 4, 241–255.
Burns, R. A., Anstey, K. J., & Windsor, T. D. (2011). Subjective well-
being mediates the effects of resilience and mastery on depression
and anxiety in a large community sample of young and middle-
aged adults. Australian & New Zealand Journal of Psychiatry,
45(3), 240–248.
Carroll, L., Gilroy, P. J., & Ryan, J. (2002). Counseling transgendered,
transsexual, and gender-variant clients. Journal of Counseling &
Development: JCD, 80(2), 131.
Cummins, R. A., Li, N., Wooden, M., & Stokes, M. (2014). A demon-
stration of set-points for subjective wellbeing. Journal of Happi-
ness Studies, 15(1), 183–206.
Davern, M. T., Cummins, R. A., & Stokes, M. A. (2007). Subjective
wellbeing as an affective-cognitive construct. Journal of Happi-
ness Studies, 8(4), 429–449.
Davey, A., Bouman, W. P., Arcelus, J., & Meyer, C. (2014). Social sup-
port and psychological well-being in gender dysphoria: A com-
parison of patients with matched controls. The Journal of Sexual
Medicine, 11(12), 2976–2985.
Deogracias, J. J., Johnson, L. L., Meyer-Bahlburg, H. F. L., Kessler,
S. J., Schober, J. M., & Zucker, K. J. (2007). The gender identity/
gender dysphoria questionnaire for adolescents and adults. Jour-
nal of Sex Research, 44, 370–379.
DeVries, A. L. C., Noens, I. L. J., Cohen-Kettenis, P. T., van Berck-
elaer-Onnes, I. A., & Doreleijers, T. (2010). Autism spectrum
disorders in gender dysphoric children and adolescents. Journal
of Autism & Developmental Disorders, 40(8), 930–936.
Diener, E. D., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The
satisfaction with life scale. Journal of Personality Assessment,
49(1), 71–75.
Frane, A. V. (2015). Power and type I error control for univariate com-
parisons in multivariate two-group designs. Multivariate Behav-
ioral Research, 50(2), 233–247. https://doi.org/10.1080/002731
71.2014.968836.
Gargiulo, R. A., & Stokes, M. A. (2009). Subjective well-being as
an indicator for clinical depression. Social Indicators Research,
92(3), 517–527.
George, R. (2016). Sexual Orientation and Gender Identity in High-
Functioning Individuals with Autism Spectrum Disorder. (Unpub-
lished doctoral dissertation). Deakin University, Melbourne,
Australia.
George, R., & Stokes, M. (2016). “Gender is not on my Agenda!”:
Gender dysphoria and autism spectrum disorder. In Psychiat-
ric symptoms and comorbidities in autism spectrum disorder
(pp. 139–150). Berlin: Springer International Publishing.
George, R., & Stokes, M. A. (2017). Gender identity and sexual
orientation in autism spectrum disorder. Autism. https://doi.
org/10.1177/1362361317714587.
Gilmour, L., Schalomon, P. M., & Smith, V. (2012). Sexuality in a
community based sample of adults with autism spectrum disorder.
Research in Autism Spectrum Disorders, 6, 313–318.
Girden, E. R. (1992). ANOVA: Repeated measures (No. 84). Sage.
Gonsiorek, J. C., Sell, R. L., & Weinrich, J. D. (1995). Definition and
measurement of sexual orientation. Suicide and Life-Threaten-
ing Behavior, 25(1), 40–51.
Haas, A. P., Rodgers, P. L., & Herman, J. L. (2014). Suicide attempts
among transgender and gender non-conforming adults. Work,
50, 59.
Hellemans, H., Colson, K., Verbraeken, C., Vermeiren, R., &
Deboutte, D. (2007). Sexual behavior in high-functioning male
adolescents and young adults with autism spectrum disorder.
Journal of Autism & Developmental Disorders, 37(2), 260–269.
https://doi.org/10.1007/s10803-006-0159-1.
Hellemans, H., Roeyers, H., Leplae, W., Dewaele, T., & Deboutte, D.
(2010). Sexual behavior in male adolescents and young adults
with autism spectrum disorder and borderline/mild mental retar-
dation. Sexuality and Disability, 28(2), 93–104.
Henry, J. D., & Crawford, J. R. (2005). The short-form version of the
Depression Anxiety Stress Scales (DASS-21): Construct valid-
ity and normative data in a large non-clinical sample. British
journal of clinical psychology, 44(2), 227–239.
Hepp, U., Kraemer, B., Schnyder, U., Miller, N., & Delsignore, A.
(2005). Psychiatric comorbidity in gender identity disorder.
Journal of Psychosomatic Research, 58(3), 259–261.
Herek, G. M. (2015). Beyond “homophobia”: Thinking more clearly
about stigma, prejudice, and sexual orientation. American Jour-
nal of Orthopsychiatry, 85(5S), S29.
Herek, G. M., & Capitanio, J. P. (1996). " Some of my best friends”:
Intergroup contact, concealable stigma, and heterosexuals’
attitudes toward gay men and lesbians. Personality & Social
Psychology Bulletin, 22, 412–424.
Hofvander, B., Delorme, R., Chaste, P., Nydén, A., Wentz, E.,
Ståhlberg, O. et al. (2009). Psychiatric and psychosocial prob-
lems in adults with normal-intelligence autism spectrum disor-
ders. BMC Psychiatry, 9(1), 35.
Holtmann, M., Bölte, S., & Poustka, F. (2007). Autism spectrum
disorders: Sex differences in autistic behaviour domains and
coexisting psychopathology. Developmental Medicine & Child
Neurology, 49(5), 361–366.
Huynh, H., & Feldt, L. S. (1976). Estimation of the Box correction
for degrees of freedom from sample data in randomized block
and split-plot designs. Journal of Educational and Behavioral
Statistics, 1(1), 69–82.
Izuma, K., Matsumoto, K., Camerer, C. F., & Adolphs, R. (2011).
Insensitivity to social reputation in autism. Proceedings of the
National Academy of Sciences, 108(42), 17302–17307.
Jacobi, F., Wittchen, H. U., Hölting, C., Höfler, M., Pfister, H., Mül-
ler, N., & Lieb, R. (2004). Prevalence, co-morbidity and corre-
lates of mental disorders in the general population: results from
the German Health Interview and Examination Survey (GHS).
Psychological Medicine, 34(04), 597–611.
Jones, R. M., Wheelwright, S., Farrell, K., Martin, E., Green, R., Di
Ceglie, D., & Baron-Cohen, S. (2012). Brief report: Female-to-
male transsexual people and autistic traits. Journal of Autism &
Developmental Disorders, 42(2), 301–306.
Keppel, G. (1991). Design and analysis: A researcher’s handbook
(3rd edn.). Upper Saddle River, NJ: Prentice-Hall, Inc.
Kirk, R. E. (1991). Experimental design: Procedures for the behav-
ioral sciences (3rd edn.). Pacific Grove, CA: Brooks/Cole Pub-
lishing Company.
Kite, M. E., & Whitley Jr, B. E. (1996). Sex differences in atti-
tudes toward homosexual persons, behaviors, and civil rights
a meta-analysis. Personality and Social Psychology Bulletin,
22(4), 336–353.
Kuyper, L., Iedema, J., & Keuzenkamp, S. (2013). Towards toler-
ance. Exploring changes and explaining differences in atti-
tudes towards homosexuality in Europe. Sociaal en Cultureel
Planbureau.
13

Lau, A. L., Cummins, R. A., & McPherson, W. (2005). An investiga-
tion into the cross-cultural equivalence of the Personal Wellbeing
Index. Social Indicators Research, 72(3), 403–430.
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative
emotional states: Comparison of the depression anxiety stress
scales (DASS) with the Beck Depression and Anxiety Inventories.
Behaviour Research & Therapy, 33(3), 335–343.
Lugnegård, T., Hallerbäck, M. U., & Gillberg, C. (2011). Psychiatric
comorbidity in young adults with a clinical diagnosis of Asper-
ger syndrome. Research in Developmental Disabilities, 32(5),
1910–1917.
Mannion, A., & Leader, G. (2013). Comorbidity in autism spectrum
disorder: A literature review. Research in Autism Spectrum Dis-
orders, 7(12), 1595–1616.
Meyer, I. H. (2003). Prejudice, social stress and mental health in
lesbian, gay and bisexual populations: Conceptual issues and
research evidence. Psychological Bulletin, 129(5), 674–697.
https://doi.org/10.1037/0033-2909.129.5.674.
Pasterski, V., Gilligan, L., & Curtis, R. (2013). Traits of autism
spectrum disorders in adults with gender dysphoria. Archives
of Sexual Behaviour, 43(2), 387–393. https://doi.org/10.1007/
s10508-013-0154-5.
Piven, J., & Palmer, P. (1999). Psychiatric disorder and the broad
autism phenotype: evidence from a family study of multiple-inci-
dence autism families. American Journal of Psychiatry, 156(4),
557–563.
Powdthavee, N., & Wooden, M. (2015). Life satisfaction and sexual
minorities: Evidence from Australia and the United Kingdom.
Journal of Economic Behavior & Organization, 116, 107–126.
Sandfort, T. G., de Graaf, R., Bijl, R. V., & Schnabel, P. (2001). Same-
sex sexual behavior and psychiatric disorders: Findings from the
13
Journal of Autism and Developmental Disorders
Netherlands Mental Health Survey and Incidence Study (NEM-
ESIS). Archives of General Psychiatry, 58(1), 85–91.
Sandfort, T. G., Melendez, R. M., & Diaz, R. M. (2007). Gender non-
conformity, homophobia, and mental distress in Latino gay and
bisexual men. Journal of Sex Research, 44(2), 181–189.
Santor, D. A., Poulin, C., LeBLANC, J. C., & Kusumakar, V. (2007).
Online health promotion, early identification of difficulties, and
help seeking in young people. Journal of the American Academy
of Child & Adolescent Psychiatry, 46(1), 50–59.
Settipani, C. A., Puleo, C. M., Conner, B. T., & Kendall, P. C. (2012).
Characteristics and anxiety symptom presentation associated with
autism spectrum traits in youth with anxiety disorders. Journal of
Anxiety Disorders, 26(3), 459–467.
Strang, J. F., Kenworthy, L., Daniolos, P., Case, L., Wills, M. C., Mar-
tin, A., & Wallace, G. L. (2012). Depression and anxiety symp-
toms in children and adolescents with autism spectrum disorders
without intellectual disability. Research in Autism Spectrum Dis-
orders, 6(1), 406–412.
Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate analysis.
New York: Boston University: Harper Collins College Publishers.
Toomey, R. B., Ryan, C., Diaz, R. M., Card, N. A., & Russell, S.
T. (2010). Gender-nonconforming lesbian, gay, bisexual, and
transgender youth: school victimization and young adult psycho-
social adjustment. Developmental Psychology, 46(6), 1580.
van Heijst, B. F., & Geurts, H. M. (2014). Quality of life in autism
across the lifespan: A meta-analysis. Autism, 19(2), 158–167.
Zimmermann, A. C., & Easterlin, R. A. (2006). Happily ever after?
Cohabitation, marriage, divorce, and happiness in Germany.
Population & Development Review, 32(3), 511–528.
Zucker, K. J. (2005). Gender identity disorder in children and adoles-
cents. Annual Review of Clinical Psychology, 1, 467–492.