"I had this fear that as an autistic person, they would take me less seriously": Trans autistic experiences of epistemic (in)justice in gender-affirming care.

Background: A disproportionate number of transgender and nonbinary people are autistic, and research suggests that trans autistic people experience significant barriers and challenges to accessing gender-affirming care. Much of the existing research in this area focuses on determining why trans people are more likely to be autistic, and less research has attended to trans autistic people's lived experiences of accessing gender-affirming care. Methods: To better understand these barriers and their impacts, I conducted qualitative interviews with 12 trans autistic people who had recently accessed gender-affirming medical care in the province of Ontario, Canada. Interviews were analyzed using reflexive thematic analysis. Results: Participants reported being frequently not believed, listened to, or taken seriously by healthcare providers, which I conceptualize as instances of epistemic injustice. I identify how medical discourses, ideologies, and clinical guidelines create conditions for gender-affirming care in which trans autistic people experience pervasive epistemic injustice. For example, participants felt pressure to conform to a transnormative and neuronormative narrative in order to be taken seriously by gender-affirming care providers. Some providers misinterpreted autistic communication styles and unfairly discredited their client's knowledge, eroding their trust in health care. While participants used creative self-advocacy strategies to access care, some providers felt threatened by this challenge to their epistemic power and medical authority. Conversely, participants also had positive experiences of epistemic justice when providers took their knowledge and lived experience seriously. Conclusion: I argue that gender-affirming care providers must practice epistemic humility by listening deeply and acknowledging the limits of their knowledge to deliver patient-centered care for trans autistic people. Systemic changes to the healthcare system and disrupting transnormativity and neuronormativity are necessary to improve trans autistic people's experiences of gender-affirming care and enable epistemic justice.