This blog is based on my chapter Double Empathy and the Double Rainbow: Healthcare Inequities for Gender Diverse Autistic Adults in the Double Empathy reader. These slides were created and shared for the second PARC Double Empathy series in 2025 available to watch here.

The Double Empathy Problem (Milton, 2012) appreciates that miscommunication – and the blame which can come with it – happens between people of different neurotypes (Milton, 2012). What does this mean for Autistic people who are also trans and/or gender diverse?

The double rainbow

• Autistic people are twice as likely to be transgender or gender diverse (Bush, 2016;
• The “double rainbow” celebrates overlap between queer and neurodivergent identities (Morgan, 2019)
• Overlap often misinterpreted as pathology: “gender confusion,” “social deficits”, “gender failure”
• Stigma = reduced access to equitable healthcare

The barriers to healthcare

• Autistic people are twice as likely to be transgender or gender diverse (Bush, 2016;
• The “double rainbow” celebrates overlap between queer and neurodivergent identities (Morgan, 2019)
• Overlap often misinterpreted as pathology: “gender confusion,” “social deficits”, “gender failure”
• Stigma = reduced access to equitable healthcare

“We must choose which part of our bodymind to keep the safest – our physical or mental health.”

 – Munday, 2022

Power dynamics in healthcare

• Healthcare systems privilege cisgender, neurotypical norms
• Mismatch between Autistic, TGD, and neurotypical cis professionals
• Intersectionality: misogyny, transphobia, ableism, classism → “patient blame” culture

Complexifying the trans/gender diverse Autistic patients

• Complex” cases are often people who don’t fit normative expectations and are therefore “difficult” to care for
• Lack of training on Autism and gender diversity can lead to misjudgment 
• Shift of blame from systemic issues to individual non-compliance
• Transmedicalism and neuro-normativity exclude many TGD Autistic experiences

Transmedicalism

• Implies that all transgender people experience gender dysphoria – intense unease due to the mismatch of our assigned sex and gender (NHS, 2022).
• Relies on conformity to a medical model of transition.
• TGD people are held to sociocultural standards which police the way we talk, dress, behave, and express ourselves.
• Creates a hierarchy of legitimacy that demands a medical transition to “prove” trans identity (Conell, 2010; Johnson, 2016).

The exhaustion of self-advocacy

• Constant self-advocacy required to access safe care is exhausting
• Autistic/TGD practitioners also face epistemic injustice
• “Lived experience” valued only when convenient to power structures!
• Many must hide parts of their identity to stay safe in healthcare

“I do not bring my whole self into an examination room… some of my healthcare needs go unmet.”

– Munday, 2022

The role of healthcare environments

• Sensory overload, bureaucracy, and rigid communication norms = barriers
• The problem of Double Empathy begins before communication starts
• Bright lights → “too sensitive”
• Unclear forms → “didn’t understand simple instructions”
• “Disengaged from services”
• Many carry trauma from systemic discrimination

Recommendations from practitioners

✅ Check your biases & privileges – cis, non-Autistic and otherwise

✅ Follow inclusive guidelines ( e.g. AASPIRE, 2019)

✅ Use correct name/pronouns – ask & confirm, as things can change

✅ Communicate clearly and accessibly

✅ Ask about access needs and then support them!

✅ Give autonomy during procedures, including offering choice of practitioner 

✅ Seek education from TGD Autistic voices

✅ Collaborate across disciplines; build networks of allies

✅ Stay curious, get comfortable feeling uncomfortable as you learn more and do better

Conclusions

• Shift needed from fixing communication to sharing understanding
• Value lived experience as expertise
• Cultivate empathy that is mutual, informed, and intersectional
• Healthcare equity depends on systemic and attitudinal change
• Commit to unlearning bias and co-creating inclusive care

Double Empathy is a health issue, not just a social one

References and resources

AASPIRE Healthcare toolkit: https://autismandhealth.org.

Adams, N., & Liang, B. (2020). Trans and autistic. Jessica Kingsley Publishers.

Autistic Women & Nonbinary Network (2022). Trans autistic healthcare guide. Autistic Women & Nonbinary Network. https://awnnetwork.org/wp-content/uploads/2022/11/Final-Version-Before-You-Go-Know-Your-Rights-Booklet.pdf

Bev & Community at Square 8. (2009). Checklist of Neurotypical Privilege: New Draft. http://www.8square8.com/2009/08/checklist-of-neurotypical-privilege-new.html

Brown, L.X. Z. (2016, June 22). Gendervague: At the intersection of autistic and trans experiences. Asperger/Autism Network. https://www.aane.org/gendervague-intersection-Autistic-trans-experiences/.

Dale, L.K. (2019). Uncomfortable labels: My life as a gay autistic trans woman. Jessica Kingsley Publishers.

Kourti, M. (2021). Working with autistic transgender and non-binary people: Research, practice and experience. Jessica Kingsley Publishers.

Lawson, W. (2020). The autism spectrum and gender dysphoria. Build Something Positive. https://www.buildsomethingpositive.com/wenn/gender.html

Killermann, S. (2011). 30+ Examples of Cisgender Privileges. https://www.itspronouncedmetrosexual.com/2011/11/list-of-cisgender-privileges/

Sparrow, M. (2020). Spectrums: Autistic transgender people in their own words. Jessica Kingsley Publishers.

Walker, N. (2021). Neuroqueer heresies: Notes on the neurodiversity paradigm, Autistic empowerment, and postnormal possibilities. Autonomous press.

Bertilsdotter-Rosqvist, H., Brownlow, C., & O’Dell, L. (2013). Mapping the social geographies of autism – online and off-line narratives of neuro-shared and separate spaces. Disability and Sociology, 28 (3), 367-379.

Bruce, H., Munday, K., & Kapp, S.K. (2023). Exploring the Experiences of Autistic Transgender and Non-Binary Adults in Seeking Gender Identity Health Care. Autism and Adulthood, 5 (2), 191-203. http://doi.org/10.1089/aut.2023.0003

Deutsch, M.B. (2016, June 17). Creating a safe and welcoming clinic environment. University of California Transgender Care. https://transcare.ucsf.edu/guidelines/clinic-environment

Fisher, J. (2023). Epistemic injustice: The silenced voices. Mental Health Nursing. https://doi.org/10.1111/inm.13163

Gratton, F.V. (2019). Supporting transgender Autistic youth and adults: A guide for professionals and families. Jessica Kingsley Publishers.

Jackson-Perry, D. (2020). The Autistic Art of Failure? Unknowing Imperfect Systems of Sexuality and Gender. Scandinavian Journal of Disability Research, 22 (1), 221–229. http://doi.org/10.16993/sjdr.634

Kourti, M., & Griffin, E. (2022). Developing a good relationship with an autistic transgender or non-binary person as a professional. In M.Kourti (Ed), Working with autistic transgender and non-binary people: Research, practice and experience (pp.125-140). Jessica Kingsley Publishers.

Lawson, W. (2022). Reflection on the spectra of autism and gender identity: consideration for professionals supporting autistic transgender and non-binary people. In M.Kourti (Ed), Working with autistic transgender and non-binary people: Research, practice and experience (pp.107-124). Jessica Kingsley Publishers.

Milton, D.E.M. (2012). On the ontological status of autism: the ‘double empathy problem’. Disability and Society, 27 (6), 883–887.

Milton, D.E.M. (2021). ‘Here comes trouble’: Autism and gender performance. In M.Kourti’s (ed), Working with autistic transgender and non-binary people: Research, practice and experience (pp.25-32). Jessica Kinglsey Publishers.

Munday, K. (2022). Stories from under the “double rainbow”: trans and non-binary autistic narratives [unpublished master’s thesis]. 10.13140/RG.2.2.34886.75843

Nicolaidis, C., Raymaker, D., Kapp, S.K., Baggs, A., Ashkenazy, E., McDonald, K., & Joyce, A., (2019). The AASPIRE practice-based guidelines for the inclusion of autistic adults in research as co-researcher and study participants. Autism: An International Journal of Research and Practice, 23, 2007-2019.

Shaw, C.K.S., Carravallah, L., Jonhson, M., O’Sullivan, J., Chown, N., Neilson, S., & Doherty, M. (2023). Barriers to healthcare and a ‘triple empathy problem’ may lead to adverse outcomes for autistic adults: A qualitative study. Autism, 0 (00), 1-12. https://doi.org/10.1177/13623613231205629

Strang, J., Klomp, S.E., Caplan, R., Griffin, A.D., Anthony, L.G., Harris, M.C., Graham, E.K., Knauss, M., & van der Miesen, A.I.R. (2019). Community-based participatory design for research that impacts the lives of transgender and/or gender-diverse Autistic and/or neurodiverse people. Clinical Practice in Paediatric Psychology, 7 (4), 396-404.