Prevalence of Co-Occurring Mental Health Conditions Among Autistic Sexual and Gender Minority Adults Compared to Their Peers In the All of Us Research Program

Background and Purpose

Emerging research indicates that a considerable proportion of autistic adults identify as sexual and/or gender minorities (SGM), but the lack of population-based studies that assess autism, sexual orientation, and gender identity limits knowledge about this group. Historically, most research focused on the size and reason for the overlap between gender diversity and autism rather than focusing on the needs and health of these groups. What little that is known suggests that SGM autistic individuals experience increased adverse experiences and barriers to care. Two studies (n=20, n=56) found that SGM autistic adults reported greater unmet healthcare needs, insurance-related barriers to care, and refusals of care compared to non-SGM autistic adults, impacting their mental health.

The purpose of this study is to determine: the proportion of adults in the All of Us Research Program dataset who identify as SGM and autistic, and the prevalence of co-occurring mental health conditions among autistic SGM adults, as compared to their peers.

Methods

This study uses survey data from the All of Us Controlled Tier Dataset (version 8), a voluntary research program for adults in the U.S. including surveys and electronic health record linkage, containing data between May 1, 2019, and October 1, 2023. The final sample includes 598,401 respondents. Outcomes of interest included the following mental health diagnoses: post-traumatic stress disorder (PTSD), eating disorders, depression, bipolar disorder, and anxiety. Differences between four analytic groups (ASD+SGM [n=1,474], ASD-only [n=1,195], SGM only [n=61,210], and no ASD or SGM or “controls” [n=534,522]) across demographic variables were calculated. Logistic regressions were used to predict the likelihood of having each of the five mental health conditions by demographic variables.

Results

SGM autistic adults had the highest proportions of co-occurring mental health diagnoses. After adjusting for race, age group, sex, highest educational degree and health insurance, ASD+SGM individuals had 21.0 times the odds of PTSD compared to controls (95% CI 18.8-23.5). This was higher odds compared to ASD-only 10.5 (95% CI 9.3-12.0) and SGM-only 2.64 (95% CI 2.56) respectively. ASD+SGM individuals in this study also had significantly higher odds of depression (20.3 OR, 95% CI 17.8-23.1), anxiety (18.0 OR, 95% CI 15.9-20.4), and bipolar disorder (9.1 OR, 95% CI 7.9-10.4) than controls. Notably, the ASD+SGM group also had higher odds of these conditions as compared to the SGM-only group and the ASD-only group.

Conclusions and Implications

SGM autistic individuals face increased odds of co-occurring mental health diagnoses while also facing barriers to accessing affirming, quality care. Minority stress theory, social safety theory, and others have been used to understand why SGM people are at increased risk for mental health conditions. It is important to understand how these might apply to autistic SGM and how to address these mechanisms via intervention. To meet the needs of this underserved population, clinical mental health practices and equitable healthcare changes that are informed by and for community members should be implemented. The All of Us dataset is a promising avenue for examining health disparities at the intersection of multiple identities.