**6. Clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents**

The initial clinical guidelines for ASD-GD [59] in adolescents have been developed using Delphi method [60] and contain strong advocacy for adolescents with ASD to gain equal access to gender-related services and not be precluded from gender affirming care when diagnostic criteria of GD are met. The guidelines emphasise the need for carrying out gender assessments in tandem with an in-depth consideration and accommodation of ASD-related factors that may impact genderrelated exploration and identify broader needs of neuro-diverse adolescents [59]. Since the initial guidelines' have been publicised, more recent study by Strang et al. [61] reported on a proposed community-driven clinical model to attend to the broader care needs and preferences of adolescents with ASD/neurodiversity and GD. It is also important to engage young people with a lived experience of ASD/GD and their carers into a productive dialogue about further services and interventions as they hold unique insights into how services can best respond to the complex needs of affected individuals and promote many other related domains including education, employment, housing and family services. Certainly, there are reports that the education and community outreach programs as part of gender diversity services are very important to the service users and have grown exponentially in a way that was not initially anticipated [62].

Adolescents with ASD may not embody a binary transgender presentation, while some may conflate sexuality with gender and need affirming education. In the course of psychological therapy, one may wish to explore whether traits of ASD such as intense/obsessional interests or social communication deficits contribute to a child's gender schema (e.g. wishing to be a specific anime character) and, eventually

determine their gender-nonconforming identity. It is especially valuable to discriminate if ASD' influence is long-lasting with no alternative gender preferences, especially in light of reports that highlighted the desistence pattern of gender variance among young people with ASD [54, 63]. The results of these studies should be viewed with caution owing to the lack of robust evidence underpinning the conclusions.

Gender transition is a complex multi-stage procedure that could be difficult to achieve by individuals with neurodevelopmental disorders, including autism and ADHD, as their treatment decisions, planning and follow through may be compromised due to a deficit at a higher-level executive functioning. Typical ASD' cognitive profile also implies a certain level of inflexibility and a highly selective hyper-focus; these qualities are likely to reduce an individual's ability to set and complete goals [64] and may compete with their care needs and treatment priorities. Having a rigid cognitive set may make it hard for a young person with ASD to recognise gender fluidity and to see gender expression as a spectrum; rigid thinking may also lead some to assume that having gender incongruence means that they must seek affirming medical treatment. These more vulnerable individuals may need additional help in navigating the care system and deciding on appropriate service and management plan, its important to ensure that they understand that gender affirming treatment is optional.
