Sage Journals: Discover world-class research

Abstract

Gender-diverse youth report significantly poorer mental health outcomes than other youth populations. Neurodiverse youth also report poorer mental health outcomes than their neurotypical peers. Research shows that school experience impacts these outcomes. However, this research has yet to explore how belonging to both populations affects mental health, particularly in school. Thus, this study sought to explore people's experiences of being neuro- and gender diverse in school, and how these experiences impacted their mental health. This study also looked at what schools could do to support the mental health of this population. Interviews/focus groups were conducted with 12 people aged between 16 and 19 attending sixth forms, colleges, and universities across England. This age range was selected so that participants could reflect on their recent experiences of school. Reflexive thematic analysis developed four themes. Participants acknowledged that their school experiences were turbulent, because of the way others treated them, due to their identities. Participants did not feel understood and in turn, did not receive enough consistent and appropriate support, which negatively impacted mental health. However, participants also noted that understanding teachers, bespoke support, and representation all improved their mental health at school. Implications for educational professionals are also discussed.

Keywords

ADHD adolescents anxiety autism depression development diagnosis education environmental factors family functioning and support

Introduction

Mental health is a state of mental well-being characterised by resilience, and an ability to learn and work well in the face of stresses inherent to life on Earth (The World Health Organisation, 2022). We have accepted the importance of mental health in modern society (Kovess-Masfety et al., 2005; Theodosiou et al., 2020), viewing mental illness as understandable in such a context, with stigma around mental illness decreasing over time (Schomerus et al., 2022). Despite best efforts, though, the mental health of the UK youth population has been worsening in the long term and has continued to deteriorate since the COVID-19 pandemic (Thorpe & Gutman, 2022). In 2017, 12.1% of children and young people aged 7 to 16 had a ‘probable mental health disorder’, which raised to 20% in 2023. For those aged 17 to 19, the proportion increased from 12% in 2017 to 23% in 2023 (Baker & Wade, 2023). Young people are facing a ‘rising tide of mental ill-health’ (McGorry et al., 2022), with suicide now the leading cause of death among young people worldwide (McMahon et al., 2023).

One group for whom mental health difficulties are particularly prevalent are those who identify as lesbian, gay, bisexual, transgender, intersex, queer/questioning, and other sexual and gender-diverse identities (LGBTQIA+; Mental Health Foundation, 2022), with gender-diverse youth reporting the highest rates of poor mental health of any youth group (Strauss, 2020). ‘Gender diverse’ is a collective term used to describe any gender identities that differ from the gender a person was assigned at birth, including identities consistent with conceptualisations of gender as binary (female, male), those that thwart such binary constructs (non-binary, agender, bigender, genderfluid, genderqueer, etc.). ‘Cis-gender’ refers to those who identify as the gender they were assigned at birth. Gender-diverse youth experience significantly elevated rates of depression, anxiety, suicidal ideations, and eating disorders than their cis-gender peers (Gallagher & Axelrad, 2023; Newcomb et al., 2020).

Another group for whom mental health difficulties are particularly prevalent is neurodiverse young people. ‘Neurodiverse’ is a collective term used to identify anyone whose neurological or cognitive function differs from most of the population. Examples of neurodiverse identities include autism, attention-deficit hyperactivity disorder (ADHD), dyslexia, dyspraxia, and Tourette's syndrome. Neurodiverse young people are 10 times more likely to experience mental health difficulties than their neurotypical peers (Accardo et al., 2022), and experience an increased risk of self-harm and suicidality (Balazs & Kereszteny, 2017; O’Halloran et al., 2022).

Poor mental health outcomes among both neurodiverse and gender-diverse youth have been closely linked to their experiences at school. For gender-diverse young people, this may be due in part to schools operating within a cis-normative framework. Cis-normativity describes a set of rules, norms, and expectations that inherently privilege cis-gender identities and marginalise those who are gender diverse (McBride & Neary, 2021). Gender-diverse youth navigate a high level of hostility and victimisation at school, and face challenges navigating cis-normative institutions that are ill-prepared for the inclusion of these pupils. Experiences of marginalisation negatively impact the mental health of gender-diverse individuals (Day et al., 2018; Horton, 2023; Ullman, 2018).

While gender-diverse people must navigate cis-normative institutions, neurodiverse people must similarly navigate neurotypical environments. Neurodiverse people experience high levels of victimisation at school (Granieri et al., 2023), difficulties with sensory processing (Connolly et al., 2023), cognitive demand, and navigating social situations (Armstrong, 2012; Spaeth & Pearson, 2023). The school environment, build with neurotypicality in mind, can often be unpredictable and overstimulating, and highly anxiety-provoking for neurodiverse learners (Nielson & Bond, 2023). Neurodiverse people sometimes engage in masking, suppressing aspects of their identity or behaviour in order to conform to perceived social expectations. However, the toll of sustained masking can become overwhelming for some and can itself further exacerbate their mental health challenges (Khudiakova et al., 2024). Neurodiverse young people experience higher levels of emotional-based school non-attendance (EBSNA) than any other youth population and although the exact figure of neurodiverse youth experiencing EBSNA is not known, in one sample of children experiencing EBSNA, 92.1% were neurodiverse and 83.4% of these students were autistic (Connolly et al., 2022).

A substantial body of research has identified a strong link between neurodiversity and gender diversity. Neurodiverse individuals are three to six times more likely to identify as gender diverse than their neurotypical peers, with autistic individuals showing the highest association (Janssen et al., 2016; Warrier et al., 2020; Weir et al., 2021). Warrier et al. (2020) also found that gender-diverse participants had higher rates of various neurodiverse and psychiatric conditions, including ADHD, bipolar disorder, depression, learning disorders, Obsessive Compulsive Disorder, and schizophrenia, compared to cis-gender participants, with autism showing the strongest association

Currently, there is no definitive explanation as to why gender diversity and neurodiversity, particularly autism, are so strongly correlated; however, there are likely several contributing factors. Some researchers consider that neurological conditions impact brain functioning and the way a person perceives gender (Bölte et al., 2023). There may also be greater gender diversity within the neurodiverse population because these individuals may be less aware of, and less susceptible to, social pressures around gender norms (LGBTQIA+ Health Education Center, 2020). Walsh et al. (2018) found that gender-diverse people present with elevated traits of autism in comparison to their peers which suggests that autistic people may not identify with gender norms as strongly as those who are neurotypical and therefore may identify as gender diverse (Rivera, 2022; Strang et al., 2023). Kourti and MacLeod (2019) interviewed young gender-diverse people with autism, who explained that their identities were simply not gendered in the way that one might expect in neurotypical populations.

While the relationship between neurodiversity and gender diversity is gaining increasing attention, research into the lived experiences of individuals at this intersection remains limited. To date, only a small number of studies have explored the personal experiences of those who identify as both neurodiverse and gender diverse (Milne, 2021; Strang et al., 2018); yet these studies only look at the experiences of autistic people and have not yet explored the experiences of other neurodiverse people. The way society views autism and neurodiversity is changing (Leadbitter et al., 2021; Pellicano & Houting, 2022) and there is now an opportunity to consider in greater depth the experiences of neurodiverse young people more broadly.

At present, no studies have explored the lived experiences of neuro- and gender-diverse people in school and the impact of such on their mental health, despite the fact research has shown separately how detrimental school can be (Day et al., 2018; Granieri et al., 2023). Although Allen-Biddell (2021) examined how to make schools more inclusive for neuro- and gender-diverse youth through interviews with educational psychologists, they did not include the perspectives of the young people themselves.

There is a need to gain a better understanding of the school experiences of a larger sample of neuro- and gender-diverse young people and how these experiences impact mental health. Equally important is the inclusion of their voices to capture firsthand accounts of how school experiences have impacted their mental health and wellbeing. In response to this need, the following research question was developed:

How do the school experiences of gender-diverse and neurodiverse students impact their mental health?

Methodology

Participants

Participants were 12 students aged 16 to 19 (M = 16.67, SD = 1.07; see Table 1 for participants’ demographic data) from six colleges and two universities across England, recruited through snowball sampling. The inclusion criteria for this study were that participants were over 16, identified as both neurodiverse (see Table 1 for neurodiverse labels participants used) and gender diverse, and had attended a UK school at some stage in their lives. No individuals who came forward to participate were excluded. The researcher shared the recruitment poster (Appendix A) on her social media accounts (Instagram, X, and Facebook). An autism charity also shared it on their social media accounts but no potential participants were recruited through that post. The researcher also sent the poster to University LGBTQIA+ societies via Instagram and emailed it to all colleges across the UK. Interested individuals then emailed the researcher and if they met the inclusion criteria, they were invited to take part in either an online interview or a focus group. While participants of any age over 16 were encouraged to take part, only individuals between 16 and 19 showed interest in joining the study. A £20 Amazon voucher was given to all participants as remuneration for taking part.

Table 1.

Participants’ Demographic Data.

Participant	Neurodiversity identified	Gender identified	Age	Ethnicity	Current schooling	Focus group?
1	Autism and dyslexia	Trans male	18	White British	Sixth form	N
2	Autism and ADHD	Trans male	17	White British	College	N
3	ADHD	Non-binary	19	Black British	University	N
4	Autism	Non-binary	16	White British	Sixth form	N
5	Autism	Trans male	18	White British	University	N
6	Autism and ADHD	Unlabelled	16	Greek	College	N
7	Autism	Non-binary	16	White (Polish)	Sixth form	N
8	Autism	Non-binary	16	White British	College	N
9	ADHD	Trans male	16	White British	College	Y
10	Autism	Trans male	16	White British	College	Y
11	Autism	Trans male	16	White British	College	Y
12	Autism	Trans female	16	White British	College	N

Note: All identity labels are the exact wording of participants.

ADHD: attention-deficit hyperactivity disorder.

Design

This research adopted a qualitative approach and used nine unstructured interviews and one unstructured focus group to gather data. Nine participants chose to take part in online individual interviews, and three participants, all from the same college, requested an in-person focus group to be held at their college.

Ethical approval was obtained from the University of Southampton's Ethics and Research Governance Committee.

Procedure

All interviews were conducted via video call on Microsoft Teams. Three participants chose not to have their cameras on and all interviews lasted between 27 and 50 minutes. The in-person focus group was 48 minutes long. Interviews were video-recorded using Microsoft Teams and the focus group was voice-recorded using a Dictaphone. The focus group (of three participants) and individual interviews were transcribed, omitting personal information that could be used to identify individuals.

At the onset of all interviews, the researcher introduced herself, disclosed her own neurodiverse identity, and outlined the study's purpose to help participants feel at ease and recognise the value of their input. As interviews and the focus group were unstructured, conversations were participant led and did not follow a set format.

Member Checking

Following initial data analysis, participants were invited to look at and respond to an early summary of themes shared with them via email. Participants were able to reflect on themes generated from their own and other interviews and provide feedback. Nine participants responded.

Process of Analysis

Reflexive thematic analysis was used to analyse the data gathered, chosen because of its reflexive, flexible, and interpretive nature which allows a researcher to find patterns in data and bring participants’ experiences together to tell a collective story (Byrne, 2022). The epistemological approach and ontological stance taken in this research was interpretivist. Within interpretivism, interpretations, interactions, and collaboration create knowledge, that itself is constructed, reconstructed, and composed of the meaning humans give to specific contexts. The researcher then interprets these constructions and brings them together to form a larger wealth of knowledge (Hiller, 2016). The researcher plays a key role in this process, bringing their values, beliefs, and perceptions to the research (Potrac et al., 2014).

Regarding the analytical process, Braun and Clarke's (2021) phases of thematic analysis were used as a guide, the process started by reading and re-reading transcripts from the interviews and focus group, developing initial codes from both interview and focus group data in the same way. This was an iterative process in which codes were re-named and merged to ensure they were as representative of the data as possible. Following this, codes were organised into developing themes. After conversations with her thesis supervisors, the researcher structured these themes into analytical themes and subthemes and after feedback from participants, these themes were finalised.

Braun and Clarke's (2020) tool for evaluating thematic analysis was also used throughout this process as a guide to ensure quality and transparency of analysis.

Analysis

Through the analytical process, we actively developed four themes and 12 subthemes, as illustrated in Figure 1. While each theme is presented as conceptually distinct, we acknowledge areas of overlap, which are indicated by the connecting lines in the figure.

Figure 1.

Thematic Map.

Themes

Navigating Intersecting Identities

Speaking about both their neuro- and gender-diverse identities, all participants acknowledged that their identities were connected: ‘Being trans and autistic is so intertwined to me’ (P5). However, these two identities did not impact participants equally with every participant stating that their neurodiverse identity had a more profound impact on their school experience: ‘I think my neurodiversity has had a far bigger impact. It's been around for longer’ (P3). Additionally, some participants explained that neurodiversity impacted their mental health at school more:

Yeah, I think it [my neurodiversity] impacted my school journey, which then impacted my mental health because I was failing in school because I wasn't getting that support, and then me failing and was making me more upset like it was just like a cycle. (P1)

Neurodiversity impacted participants’ school experiences in many ways; some found lessons difficult: ‘like I didn't realize why I struggle so much in lessons is because of my autism’ (P1) and this impacted participants’ ability to focus and remain calm in lessons: ‘my attention span was awful’ (P2) and gain momentum to begin work: ‘I find it really hard to like start tasks’ (P3). One of the hardest parts of school for participants was socialising and making friends: ‘I couldn’t just make friends’ (P9) which often led to alienation and loneliness for participants: ‘well, I think the social aspect is undoubtedly the hardest part. Like it's been I find it nearly impossible getting along with people my own age’ (P4).

Participants were conscious that their diverse identities impacted them from a young age, but no participants started learning about or understanding either of their identities until significantly further into their academic journeys. Many participants felt that the COVID-19 pandemic was a key event in helping them understand themselves and their identities: ‘I realised I was trans and also that I was probably autistic over lockdown’ (P5).

Additionally, participants found that learning about one of their identities had a domino effect, in that it often led them to discover the presence of their other diverse identities. Several participants learned about their sexual and gender identities first and then their neurodiversity.

Well, I always knew I was special. (all laugh and agree) But I guess it started with gender for me and as I was learning about that I was like hold up I am also special in other ways. In the first few years of secondary it was learning about my sexuality and then my gender-diversity and more recently I have realised I am special in other ways and I am neurodiverse too. (P11)

A factor that helped participants’ identities evolve was interactions with friends and family. For some participants, being around other individuals with shared experiences was helpful: ‘I kinda just realised one day cause most of my friends at school were queer in some form’ (P3). For others, having open conversations with friends was illuminating: ‘it's more recently it's been my neurodiversity because they [my friends] will, like they were the ones who point out and they were like we think you have this. And I was like, do I?’ (P1). For other participants, colloquial comments from family members resonated and these helped them to connect their behaviours to their identities: ‘I would tell my parents I was having issues with my clothes and they would joke that it was because I was on the spectrum and about a month later I was like maybe you guys are correct’ (P9).

Many participants were aware of their gender identity before they felt comfortable to share it with others or present as such because identifying away from gender norms was understandably a difficult thing to come to terms with and accept for participants: ‘well, it was only the last year of secondary that I like fully came out as trans. Like I knew before, but I didn't really accept it. I didn't really want to be transgender’ (P1). Most participants chose to share their gender-diverse identity at school, with friends or trusted school staff before they told their families because they were worried about their family's reactions. Several participants felt they were living two separate lives:

It was really nice to an extent because I'd never been properly gendered and named by teachers before and adults around me before. But it would be like it was like, like genuinely ridiculous how I'd like I'd get. I'd get on my bike to go home, I'd take off my lanyard, has a pronoun pin and my name on it, and I'd roll it up and I'd shove it in like the bottom of my bag. And then I'd ride home. And then I'd be like, Hello family that I haven't told. And so it's like it's quite hard because it was genuinely it was like living a double life. (P5)

Participants shared that their neurodiverse identity has always been relatively consistent across different situations in contrast to their gender identity because the impact of their neurodiversity is not something they can always actively control. For some participants, their identity was still evolving; they were still figuring it out and did not feel that they had a fully established sense of self yet and are therefore not able to present authentically yet because they still do not know what that means to them: ‘it is still new to me and I am still figuring out what it all means to me’ (P10).

Normative Expectations are Abusive

When asked if they enjoyed school, no participant said yes, all participants generally perceived their school experience to be more negative than positive: ‘I say generally it's a mixed bag. It's tough at times, but then sometimes it goes OK’ (P12). Several participants spoke about how they enjoyed the primary years of their education, but when they got to secondary school, they found things more difficult:

Primary school was alright because mental stuff was not really affecting me yet. But when we got to secondary and I started figuring out things about myself I thought hold on this is going to impact things, because it's obviously a really important part of yourself and in school life, it can distract you. (P11)

Some attributed finding secondary school more difficult to the withdrawal of appropriate and helpful support in primary that did not continue into secondary school:

So I went and got diagnosed with that and I got support all through primary with it, like with extra lessons, overlays, and stuff like that. But then in secondary, it just stopped. It should just didn't happen. It all just stopped. (P1)

Fundamentally, all participants shared that school was difficult, not because they had diverse identities, but because of how those identities were perceived. The structure and systems within school did not support or facilitate the progress or mental health of learners who differed from the norm.

The cis-normative culture of school was mentioned several times as a factor that significantly impacted participants’ mental health: ‘I guess the sort of whole school system being so gendered, I think is the main thing that sort of impacts my mental health’ (P4). Several elements of school life reinforced gender norms such as sports days, gendered language from staff, and gendered toilets. Some participants who attended private schools shared that all lessons were taught in gendered classes, with the assumption that all pupils identified as cis-gender. Not fitting into this normative expectation left participants questioning their sense of self: ‘everything is very gendered at my school and when I realised, I was non-binary it was scary, I felt like an impostor’ (P4).

Systemic policies within schools also acted as a barrier to acknowledging and supporting participants, especially regarding gender identity. Some participants shared that their school was reluctant to change their dead name (the name they used prior to changing it) to their chosen name on their administrative systems, this made participants feel dismissed and unsupported: ‘It just made me feel like they weren't there for me, especially when they refused to change my name because they said it was too much admin’ (P2). Additionally, assumptions and perceptions of gender and neurodiversity were detrimental to the participants’ acceptance and understanding of their own needs: ‘I just found that very difficult because I'd only ever heard of boys having it, so I didn't know there was a possibility that you know, someone like me could have it’ (P8).

Participants also spoke about how the classroom environment and the curriculum did not feel suitable for neurodiverse learners: ‘I really struggled with comprehension in English because I really struggled to sort of understand what they were asking me and what they wanted to do and say’ (P4). In many cases, the classroom environment hindered participants’ learning and led participants to experience high levels of anxiety, to the point where some had to take medication and others engaged in self-harming behaviours: ‘yeah, I remember sitting on the edge for like 2 hours straight in some classes, like just sweating, and I used to do this thing where I used to hold my breath for long periods’ (P2).

Participants also spoke about how the pressure of exams significantly impacted their mental health:

It was so stressful and throughout mid-secondary school and GCSE it was really impacting my mental health and I was not in a good space. I felt like I was in a box as I just thought I was going to fail. (P11)

Participants felt that school and their teachers held them to normative expectations because many school staff did not know how to appropriately support neurodiverse pupils: ‘I would say that they weren't fully equipped in all the right places because a lot of the [neurodiverse] students weren't really getting the help they needed in a class all the time’ (P12) or gender-diverse pupils: ‘I think it comes from a place of not having experience around transgender pupils that made it so awkward because they didn't really know what to do with this information’ (P2).

Understandably the weight of expectations and lack of appropriate support negatively impacted participants’ mental health. However, when participants were brave enough to seek mental health support at school they were often dismissed because of the severity of their difficulties:

I told her [my counsellor] that my mental health was getting worse and she legit said to me we can't do anything because you're too bad right now. Mentally you are so unwell that we can't do anything and I was like, what? What?. (P1)

One Size Never Fits All: Either We Pretend It does, or We Break the Mould

When participants were offered support, particularly in relation to their neurodiverse needs, they often felt that the support strategies were generic and in some cases hindered and did not help: ‘and in year six, my teacher noticed that I was heavily struggling, so she dropped me down a set, and that ruined it even more ‘cause it demotivated me’ (P6). Offers of unhelpful general support were further endorsed by participant 11:

We had input about how to revise but it was not differentiated and there was nothing specific about how to do it if you are neurodiverse. It was generic stuff that did not help.

Participants felt the same way about the mental health support they were offered in school: ‘The school did not support, like they tried to but it was really bad’ (P1).

Regarding gender, participants shared that if they did not fit the expected norms, they were questioned about their identity, to the point of discomfort: ‘I did at one point try to tell teachers about my name change and stuff. They made me feel very awkward about it. It was just. Ohh I wanna go by this now and they'd be like – Why?’ (P2). This lack of acknowledgement and support made participants feel disregarded and rejected, thus they masked their neuro and gender diversity to be accepted at school. Some reflected how they thought they had masked subconsciously, but for most participants, masking was a conscious choice. Masking allowed participants to blend in with their peers and go under the radar; ultimately it provided a sense of safety: ‘I definitely tried to blend, I was so anxious about my teachers noticing I was different and telling me off for it. I just wanted to be normal’ (P2). While this served a purpose for a time, when participants started to realise the extent to which they were masking they sought support but often adults did not believe them because they were not seeing stereotypical behaviours they associated with specific conditions and as a result, refused to support participants:

I didn't tell my school that I was gender diverse. Anyway, I told my counsellor at some point, because it was strictly confidential and I realised that I was probably also autistic, but I didn't have any paperwork to prove it, so it would be like I'd go to the support team that is like I I feel like I need these things and they'd be like well you haven’t got any needs. Well, they didn't say this to me directly, but like it gave the the feeling of, well, you haven't been diagnosed since you were four. You've never been in learning support. You do pretty well academically, so you must be fine. And I and it was like, but no, I've been I've been heavily masking for years without realising it and that's one of the reasons it's taken such a toll on my mental health, but you don't see that because I'm getting good grades in my exams, so that's fine. (P5)

Participants more consciously masked their gender-diversity than their neurodiversity. This was predominantly because participants worried more about the hostility that has historically surrounded gender diversity: ‘well, in all honesty, I've mainly had to hide it in school because I I feel there's a lot of social pressure and stigma towards’ (P12). Some participants also felt it was easier to conceal their gender identity: ‘I can put on a dress and people will think I am a girl, I cannot do with my autism, it is harder to hide’ (P5). Participants who did choose to be their authentic selves at school felt that the way they were treated was impacted. Regarding neurodiversity, in some cases being honest about difficulties led to bespoke and helpful support:

For me, one of my best, one of my favourite teachers ever in terms of like accommodations was my GCSE geography teacher. He was absolutely amazing he heard that I typed my I'm end of year assessments and he said, you know, he made it really clear from the get go that I could type any tests in his course like most teachers, don't even like offer. (P4)

However, this support was typically sporadic and only implemented by specific teachers, who had experience of or were neurodiverse themselves: ‘my other teacher comes to mind was my chemistry teacher, and he was also neurodiverse. So he just, you know, he just understood’ (P7).

Unfortunately, not all participants had positive experiences when they shared their neurodiversity with school staff. Many participants felt that their needs were dismissed because they did not have a diagnosis: ‘Since I'm not diagnosed I can't fully, I like try to get help and they are like no. You need a diagnosis and I'm like ohh great’ (P1).

Some participants found that presenting in line with their gender-diverse identity was a positive experience, one participant described being referred to as ‘them’ as being: ‘like euphoria’ (P8). Some school staff were very acknowledging and made for a positive experience: ‘My creative writing teacher in first term was great. They were really supportive. They got it. I think they were also non-binary perhaps’ (P3). However, for most, it was not as positive an experience, with many participants feeling that not all staff cared about their authentic identity: ‘Some teachers did try with the pronouns really hard and I really appreciate that but some forgot or didn’t try’ (P11). Many chose not to share their authentic identity with all school staff because they assumed they would be treated negatively: ‘I told teachers I trusted not every single one, but ones that like I felt like wouldn't judge me or anything’ (P1). Participants chose to do this, not because they did not feel that staff wanted to help, but because they did not understand gender diversity: ‘I also didn’t tell certain teachers because I did not think they would be able to help because of limitations in their understanding’ (P11).

Most participants suffered judgement, prejudice, and rejection from their peers due to their gender identity: ‘I was made to feel very different and teenagers, being teenagers, I was chastised that a lot’ (P2). Some participants also had a similar experience when they were open about their neurodiversity: ‘Not out loud, but you can see that they look. They look disgusted. Oh, I have, like, a whole catalogue of things that people have said to me about my autism’ (P4).

Our Diversity Needs to be Nurtured not Dismissed

Participants felt that their diverse needs were predominantly dismissed at school, with many only receiving support when they advocated for themselves. Participants felt that they had to prove that they needed support:

A lot of my teachers understood my ADHD because I would at the beginning of the year, I'd be like I've got ADHD. I struggle to listen and if it looks like I'm not listening, I am listening, but some of the teachers were a little bit irritated by that like I have this one teacher in year 8, who just refused to acknowledge my needs. (P8)

However, even when they advocated for themselves, some participants did not receive any support: ‘I compiled a 31-page document on how to support my neurodiverse needs that I gave to my SENCo (Special Educational Needs Co-ordinator), but my SENCo disregarded it completely’ (P6).

In some incidents, because participants were forced to advocate for themselves, they felt that school staff expected participants to educate staff and peers and act as advocates for themselves and younger diverse pupils. Participants expressed great frustration about this: ‘It really does just feel like I'm doing all the work and. Yeah, it it shouldn't be like that’ (P4).

Participants all preferred college to school because they were not expected to have all the answers or solely advocate for themselves. While this is positive, participants felt saddened that they had to wait until college to receive consistent, appropriate support and they felt that their school experience could have been completely different if they had been supported the way they were at college earlier on in their academic journey: ‘It's been great. I like it [college]. I feel very, very nice about it and it's unfortunate that it's only two years ‘cause I spent five years in a very bad place’ (P6).

Additionally, representation of gender diversity and neurodiversity within the school community was important to participants and contributed largely to how nurtured and seen they felt at college. Participants spoke about how clubs, societies, openly diverse staff, and diverse awareness events made them feel supported: ‘I think it is great that in college we have our pronoun badge a pride group, and a gender group. That gives us a lot more visibility’ (P11).

Participants also discussed a range of further ways their diversity could have been supported at school. Three main suggestions emerged. The first, relating directly to neurodiversity, was that learning should be presented in a range of ways for neurodiverse learners because they learn in different ways to their neurotypical peers: ‘I would say sort of when it comes to like revision and studying, looking into stuff that. Or like looking into kind of teaching styles that like work better for neurodiverse pupils’ (P4). The second was that all staff should be upskilled in how to support neurodiverse and gender-diverse learners: ‘I would hope that they [school staff] get a better education on neurodiversity that they can understand it better’ (P6). Finally, all pupils should also be educated in diversity from as early as primary school. This would help challenge stereotypes and allow students to talk more openly about their needs:

Yeah, I feel like I feel like having topics on LGBTQ and neurodiversity. What to say what not to say, and like debunking stereotypes and just introducing terms to people because that I feel like those lessons could help someone figure out that. (P6)

It was important to participants that this information needs to come from diverse individuals with lived experience: ‘Yeah, like also as well people, the information needs to come from autistic people themselves’ (P4).

Discussion

This study describes four themes that captured gender-diverse and neurodiverse participants’ school experiences. Participants described a personal journey of discovering the centrality of their neurodiversity and gender diversity respectively and using that to forge an identity. Wider research has described the challenges young people who are both gender diverse and neurodiverse experience understanding who they are as overwhelming (Cooper et al., 2023); these participants described school as part of that overwhelming experience. The wider research also echoed our participants in identifying negative school experiences as affecting their understanding of themselves and their mental health (Allen-Biddell, 2021; Connolly et al., 2022; Ullman, 2018). Yet our participants did not consider their neurodiverse and gender-diverse identities to be equally central to their burgeoning identities at once. Extending preceding research (Oliver et al., 2025; Strang et al., 2018), participants described living authentically necessitating their transgressing neurotypical expectations earlier in their school experience in part because it was easier to hide their gender diversity than their neurodiversity.

One of the key challenges neurodiverse and gender-diverse young people face is the normative assumptions of mainstream school environments. Such environments privilege neurotypical and cis-gender experiences as both expected and desirable and inherently marginalise those who do not, or cannot, conform (McBride & Neary, 2021). While the effects of overt hostility and victimisation in such environments are well established (Day et al., 2018; Horton, 2023; Ullman, 2018), the present study indicates that the effects of such marginalisation begin earlier and more insidiously than the research might have indicated, especially with regards to neurotypicality. For neurodiverse and gender-diverse young people the standards set by the privileging of cis-gender and neurotypical expectations are unachievable. These young people, then, must choose whether to thwart expectations in pursuit of authenticity, or attempt to shape themselves to appear to meet these expectations.

While research has competently described neurodiverse efforts to change themselves to fit into a neurotypical world, an act known as ‘masking’ (Spaeth & Pearson, 2023), participants in the present study clarify the considerable effort young people who are both gender diverse and neurodiverse make when they try to fit into the normative expectations of both neurotypicality and cis-normativity. In school environments, therefore, our first effort to support the neuro- and gender diversity of students should be to expand our expectations, to make room for the possibility of gender diversity and neurodiversity in our students. These participants considered that being seen for their complete, authentic selves, and being listened to when things go wrong, were critical to their inclusion. Schools have an opportunity to fully include these young people with whole-school approaches that feature early intervention, that promote community and belonging, and that welcome the counter-normativity of these students. Despite facing many challenges, participants did acknowledge when given appropriate support, they felt their mental health, academic outcomes, and school experience improve.

Implications

Arguably, the most important implication of this research is that the way diverse identities are perceived and supported in educational provisions needs to change. Participants in the present study reflected that classrooms and school spaces did not feel diverse-friendly. Schools might find it helpful to invite gender- and neurodiverse students to join them on learning walks through the school and through a school day, listening to them where they describe any friction they experience between themselves and the school around them, the telltale abrasive discomfort that indicates a discordant interaction with a world not made with you in mind.

Normative expectations, one-size-fits-all teaching, and rigid zero-tolerance policies made participants in the present study feel isolated and like they needed to change or conceal their needs to fit in. In schools that are not built with them in mind, neurodiverse and gender-diverse students may transgress school rules to manage their wellbeing. Whether a need to move provokes a young person to fidget, an intolerance of uncertainty prompts a few interrupting requests for clarity, or whether a young person grows their hair longer than the school rules permit for a ‘boy’ to manage their dysphoria, we must remain understanding in our interpretation of their behaviours. Shannon (2020) urged that classrooms should change to meet the needs of all learners and generally school policies need to become more flexible (Budnyk et al., 2022), with reasonable adjustments implemented for those who need them.

Participants in the present study wanted their peers to understand their diverse identities and to know how to behave, and the right language to use. This could be done through having open conversations about diversity in a safe and controlled way at school as well as through more specific teaching around diversity, which could be embedded in the Relationships, Health, and Sex Education curriculum. Representation also matters, and staff feeling open to share their own gender diversity and neurodiversity inherently creates a school setting in which young people can see people like them in positions of responsibility. Participants shared that they did not feel that their mental health was consistently or appropriately safeguarded at school. Therefore, a further implication of this research is that schools need to create and enforce safeguarding policies in schools that specifically relate to supporting and protecting the mental health of gender- and neurodiverse students; alongside this, staff need to be trained in how to spot signs that someone in this population may be experiencing mental health difficulties. When a young person needs mental health support we should offer help responsively and we should ensure that our interventions are affirming. Affirmation can feature in any intervention by shaping it to validate the identities of the people participating (Expósito-Campos et al., 2023). Many people do not support people who are diverse appropriately, not because they are prejudiced, but because they do not feel skilled or confident and they are scared of getting it wrong (Erickson-Schroth & Jacobs, 2017). Improving staff's understanding of what mental health difficulties look like for those who are diverse will empower them to approach and support this population more appropriately.

Strengths and Limitations

A significant strength of this study is that it provides a much-needed insight into the mental health experiences of individuals who identify as both neuro- and gender diverse in school. Through its positive lens and focus on factors and support that protect and improve mental health the researcher has highlighted several clear actionable recommendations and next steps for educators. These suggestions will help school staff to support both the mental health and academic outcomes of neuro- and gender-diverse young people.

Approximately 0.5% of the English and Welsh population identify as gender diverse (Booth & Goodier, 2023), with the current figure for the entirety of the UK unknown. This population accounts for a minuscule percentage of UK residents. Thus, being able to recruit and gain the perspectives of 12 participants from six educational institutions across England is a strength of the study. However, despite this strength, its representativeness is nevertheless a limitation. The study aimed to recruit anyone who was 16+, identified as both neuro- and gender diverse, and had attended a UK school for any period, but all participants were between the ages of 16 and 19 and were currently attending an educational provision in England, the majority also identified as white British. Additionally, not as many different neurodiverse or gender-diverse identities were represented in the sample as the researcher had originally hoped which has meant that the sample was less representative of this population. One reason for this and a further limitation of this study is its recruitment method. The researcher attempted to recruit participants through charities and community groups but the majority that were contacted were unable to be involved with this research. One charity did support recruitment by posting the post on their Facebook, but no potential participants came forward through this. Consequently, all eventual participants were recruited through social media and by emailing educational provisions. Targeting potential participants through emailing educational provisions meant the study was more likely to gain the voices of younger members of this population, who were still in education.

Using both interviews and a focus group improved the richness of this study's data (Lambert & Loiselle, 2008). Conducting online interviews was beneficial in some ways as it allowed participants to be in their chosen environment which can make them more comfortable and open to sharing personal experiences (Gray et al., 2020) and it also meant that the researcher was able to include participants from across the country in the sample. Nonetheless, conducting interviews online can compromise the quality of data because interviewers may miss facial and physical cues from interviewees (Gray et al., 2020). Hence, conducting these interviews in person could have increased the quality of the research findings further.

Conclusions

This research has built upon current literature to provide important insights into the school experiences of neuro- and gender-diverse individuals and how these experiences impact their mental health. All participants reflected that both their neurodiverse and gender-diverse identities diverged from those of the neurotypical and cis-gender people for whom the system was built; young people who are gender diverse and neurodiverse report a predominantly negative school experience. Nevertheless, participants also shared many factors that were protective of their mental health at school. While this study provides readers with some understanding of the mental health experiences at schools of neuro- and gender-diverse people, it also shows that with responsive, affirming support, we can yet help these young people to find a home at school.

Footnotes

ORCID iD

Abigail Vines

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Appendix A. Participant Recruitment Poster

References

Accardo

A. L.

Pontes

N. M. H.

Pontes

M. C. F.

(2022). Heightened anxiety and depression among autistic adolescents with ADHD: Findings from the national survey of children’s health 2016–2019. Journal of Autism and Developmental Disorders, 3, 1–14. https://doi.org/10.1007/s10803-022-05803-9

Allen-Biddell

(2021). Facilitating inclusion in schools for gender-diverse children and young people including those at the intersection of neuro and gender diversity. The University of Manchester (UK).

Armstrong

(2012). Neurodiversity in the classroom: Strength-based strategies to help students with special needs succeed in school and life. ASCD. ISBN: 1416614834.

Baker

Wade

(2023). Mental health statistics: Prevalence, services, and funding in England. https://commonslibrary.parliament.uk/research-briefings/sn06988/

Balazs

Kereszteny

(2017). Attention-deficit/hyperactivity disorder and suicide: A systematic review. World Journal of Psychiatry, 7(1), 44. https://doi.org/10.5498/wjp.v7.i1.44

Bölte

Neufeld

Marschik

P. B.

Williams

Z. J.

Gallagher

Lai

M. C.

(2023). Sex and gender in neurodevelopmental conditions. Nature Reviews Neurology, 19(3), 136–159. https://doi.org/10.1038/s41582-023-00774-6

Booth

Goodier

(2023). England and Wales census counts trans and non-binary people for the first time. https://www.theguardian.com/uk-news/2023/jan/06/england-and-wales-census-counts-trans-and-non-binary-people-for-first-time#:∼:text=The%20number%20of%20people%20who,was%20not%20male%20or%20female

Braun

Clarke

(2020). One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology, https://doi.org/10.1080/14780887.2020.1769238

Braun

Clarke

(2021). Thematic analysis: A practical guide. Sage. ISBN: 1473953243.

10.

Budnyk

Rembierz

Arbeláez-Encarnación

T. F.

Rojas-Bahamón

M. J.

Arbeláez-Campillo

D. F.

Chinchoy

Matveieva

(2022). Formation of tolerance in the inclusive environment of an educational institution. Amazonia Investiga, 11(56), 305–319. https://doi.org/10.34069/AI/2022.56.08.29

11.

Byrne

(2022). A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Quality & Quantity, 56(3), 1391–1412. https://doi.org/10.1007/s11135-021-01182-y

12.

Connolly

S. E.

Constable

H. L.

Mullally

S. L.

(2023). School distress and the school attendance crisis: A story dominated by neurodiversity and unmet need. Frontiers in Psychiatry, 14, 1237052. https://doi.org/10.3389/fpsyt.2023.1237052

13.

Connolly

Patterson

Hockey

Mullally

S. L.

(2022). School distress in UK school children: Characteristics and consequences. https://doi.org/10.1101/2022.09.28.22280324

14.

Cooper

Butler

Russell

Mandy

(2023). The lived experience of gender dysphoria in autistic young people: A phenomenological study with young people and their parents. European Child & Adolescent Psychiatry, 32(9), 1655–1666. https://doi.org/10.1007/s00787-022-01979-8

15.

Corbett

B. A.

Muscatello

R. A.

Klemencic

M. E.

West

Kim

Strang

J. F.

(2023). Greater gender diversity among autistic children by self-report and parent-report. Autism, 27(1), 158–172. https://doi.org/10.1177/13623613221085337

16.

Day

J. K.

Perez-Brumer

Russell

S. T.

(2018). Safe schools? Transgender youth’s school experiences and perceptions of school climate. Journal of Youth and Adolescence, 47(8), 1731–1742. https://doi.org/10.1007/s10964-018-0866-x

17.

Erickson-Schroth

Jacobs

L. A.

(2017). ‘You're in the wrong bathroom!’: And 20 other myths and misconceptions about transgender and gender-nonconforming people. Beacon Press. ISBN: 10: 0807033898.

18.

Expósito-Campos

Pérez-Fernández

J. I.

Salaberria

(2023). Empirically supported affirmative psychological interventions for transgender and non-binary youth and adults: A systematic review. Clinical Psychology Review, 100, Article 102229. https://doi.org/10.1016/j.cpr.2022.102229

19.

Gallagher

K. A.

Axelrad

M. E.

(2023). Psychological disorders and positive mental health in gender-diverse youth. Bulletin of the Menninger Clinic, 87(2), 162–188. https://doi.org/10.1521/bumc.2023.87.2.162

20.

GOV.UK. (2019). All pupils will be about mental and physical wellbeing. https://www.gov.uk/government/news/all-pupils-will-be-taught-about-mental-and-physical-wellbeing

21.

Granieri

J. E.

Morton

H. E.

Romanczyk

R. G.

Gillis Mattson

J. M.

(2023). Profiles of school refusal among neurodiverse youth. European Education, 55(3-4), 186–201. https://doi.org/10.1080/10564934.2023.2251013

22.

Gray

L. M.

Wong-Wylie

Rempel

G. R.

Cook

(2020). Expanding qualitative research interviewing strategies: Zoom video communications. The Qualitative Report, 25(5), 1292–1301. https://doi.org/10.46743/2160-3715/2020.4212

23.

Harvey

(2015). Beyond member-checking: A dialogic approach to the research interview. International Journal of Research & Method in Education, 38(1), 23–38. https://doi.org/10.1080/1743727X.2014.914487

24.

Horton

(2023). Institutional cisnormativity and educational injustice: Trans children's experiences in primary and early secondary education in the UK. British Journal of Educational Psychology, 93(1), 73–90. https://doi.org/10.1111/bjep.12540

25.

Janssen

Huang

Duncan

(2016). Gender variance among youth with autism spectrum disorders: A retrospective chart review. Transgender Health, 1(1), 63–68. https://doi.org/10.1089/trgh.2015.0007

26.

Khudiakova

Russell

Sowden-Carvalho

Surtees

A. D. R.

(2024). A systematic review and meta-analysis of mental health outcomes associated with camouflaging in autistic people. Research in Autism Spectrum Disorders, 118, 102492. https://doi.org/10.1016/j.rasd.2024.102492

27.

Kim-Cohen

Caspi

Moffitt

T. E.

Harrington

Milne

B. J.

Poulton

(2003). Prior juvenile diagnoses in adults with mental disorder: Developmental follow-back of a prospective-longitudinal cohort. Archives of General Psychiatry, 60(7), 709–717. https://doi.org/10.1001/archpsyc.60.7.709

28.

Kourti

MacLeod

(2019). ‘I don't feel like a gender, I feel like myself’: Autistic individuals raised as girls exploring gender identity. Autism in Adulthood, 1(1), 52–59. https://doi.org/10.1089/aut.2018.0001

29.

Kovess-Masfety

Murray

Gureje

(2005). Evolution of our understanding of positive mental health. Promoting Mental Health .

30.

Lambert

S. D.

Loiselle

C. G.

(2008). Combining individual interviews and focus groups to enhance data richness. Journal of Advanced Nursing, 62(2), 228–237. https://doi.org/10.1111/j.1365-2648.2007.04559.x

31.

Leadbitter

Buckle

K. L.

Ellis

Dekker

(2021). Autistic self-advocacy and the neurodiversity movement: Implications for autism early intervention research and practice. Frontiers in Psychology, 12, 782. https://doi.org/10.3389/fpsyg.2021.635690

32.

LGBTQIA+ Health Education Center. (2020). Neurodiversity & gender-diverse youth: An affirming approach to care 2020.

33.

McBride

R. S.

Neary

(2021). Trans and gender diverse youth resisting cisnormativity in school. Gender and Education, 33(8), 1090–1107. https://doi.org/10.1080/09540253.2021.1884201

34.

McDougall

(2011). Mental health problems in childhood and adolescence. Nursing Standard (Through 2013), 26(14), 48. https://doi.org/10.7748/ns2011.12.26.14.48.c8857

35.

McGorry

P. D.

Mei

Chanen

Hodges

Alvarez-Jimenez

Killackey

(2022). Designing and scaling up integrated youth mental health care. World Psychiatry, 21(1), 61–76. https://doi.org/10.1002/wps.20938

36.

McMahon

E. M.

Hemming

Robinson

Griffin

(2023). Editorial: Suicide and self harm in young people. Frontiers in Psychiatry, 13, 1120396. https://doi.org/10.3389/fpsyt.2022.1120396

37.

Mental Health Foundation. (2022). LGBTIQ+ people: statistics. https://www.mentalhealth.org.uk/explore-mental-health/mental-health-statistics/lgbtiq-people-statistics

38.

Milne

(2021). The experiences of autistic transgender and gender-diverse young people. Prof Doc Thesis University of East London School of Psychology. https://doi.org/10.15123/uel.89w62

39.

Neilson

Bond

(2023). The experience of anxiety for autistic children and young people: A thematic synthesis review. Research in Autism Spectrum Disorders, 109, 102274. https://doi.org/10.1016/j.rasd.2023.102274

40.

Newcomb

M. E.

Hill

Buehler

Ryan

D. T.

Whitton

S. W.

Mustanski

(2020). High burden of mental health problems, substance use, violence, and related psychosocial factors in transgender, non-binary, and gender diverse youth and young adults. Archives of Sexual Behavior, 49, 645–659. https://doi.org/10.1007/s10508-019-01533-9

41.

O'halloran

Coey

Wilson

(2022). Suicidality in autistic youth: A systematic review and meta-analysis. Clinical Psychology Review, 93, 102144. https://doi.org/10.1016/j.cpr.2022.102144

42.

Oliver

Poysden

Crowe

Parkin

Mair

A. P. A.

Hendry

Gillespie-Smith

(2025). Just listen to me. Help me explore it. An Interpretative Phenomenological Analysis Exploring Experiences of Gender Dysphoria, Identity And Resilience in Autistic Adolescents Assigned Female at Birth. Journal of Autism and Developmental Disorders, 1–18. https://doi.org/10.1007/s10803-024-06688-6

43.

Otto

Reiss

Voss

Wüstner

Meyrose

A. K.

Hölling

Ravens-Sieberer

(2021). Mental health and well-being from childhood to adulthood: Design, methods, and results of the 11-year follow-up of the BELLA study. European Child & Adolescent Psychiatry, 30(10), 1559–1577. https://doi.org/10.1007/s00787-020-01630-4

44.

Pellicano

den Houting

(2022). Annual research review: Shifting from ‘normal science’ to neurodiversity in autism science. Journal of Child Psychology and Psychiatry, 63(4), 381–396. https://doi.org/10.1111/jcpp.13534

45.

Rivera

H. R.

(2022). The intersection of gender diversity and neurodiversity: How to support gender diverse youth and young adults on the autism spectrum in the educational setting (Doctoral dissertation, Alliant International University).

46.

Schlack

Peerenboom

Neuperdt

Junker

Beyer

A. K.

(2021). The effects of mental health problems in childhood and adolescence in young adults: Results of the KiGGS cohort. Journal of Health Monitoring, 6(4), 3. https://doi.org/10.25646/8863

47.

Schomerus

Schindler

Sander

Baumann

Angermeyer

M. C.

(2022). Changes in mental illness stigma over 30 years – Improvement, persistence, or deterioration? European Psychiatry, 65(1), e78. https://doi.org/10.1192/j.eurpsy.2022.2337

48.

Shannon

D. B.

(2020). Neuroqueer(ing) noise: Beyond ‘mere inclusion in a neurodiverse early childhood classroom. Canadian Journal of Disability Studies, 9(5), 489–514. https://doi.org/10.15353/cjds.v9i5.706

49.

Spaeth

Pearson

(2023). A reflective analysis on how to promote a positive learning experience for neurodiverse students. Journal of Perspectives in Applied Academic Practice, 11(2). https://doi.org/10.56433/jpaap.v11i2.517

50.

Strang

J. F.

Powers

M. D.

Knauss

Sibarium

Leibowitz

S. F.

Kenworthy

Anthony

L. G.

(2018). ‘They thought it was an obsession’: Trajectories and perspectives of autistic transgender and gender-diverse adolescents. Journal of Autism and Developmental Disorders, 48, 4039–4055. https://doi.org/10.1007/s10803-018-3723-6

51.

Strang

J. F.

van der Miesen

A. I.

Fischbach

A. L.

Wolff

Harris

M. C.

Klomp

S. E.

(2023). Common intersection of autism and gender diversity in youth: Clinical perspectives and practices. Child and Adolescent Psychiatric Clinics, 32(4), 747–760. https://doi.org/10.1016/j.chc.2023.06.001

52.

Strauss

Cook

Winter

Watson

Toussaint

D. W.

Lin

(2020). Associations between negative life experiences and the mental health of trans and gender diverse young people in Australia: Findings from trans pathways. Psychological Medicine, 50(5), 808–817. https://doi.org/10.1017/S0033291719000643

53.

Theodosiou

Knightsmith

Lavis

Bailey

D. S.

(2020). Children and young people's mental health. ISBN: 9781912755400.

54.

Thomas

Jenkins

Burch

Calamos Nasir

Fisher

Giotaki

Wright

(2016). Promoting mental health and preventing mental illness in general practice. London Journal of Primary Care, 8(1), 3–9. https://doi.org/10.1080/17571472.2015.1135659

55.

Thorpe

W. J. R.

Gutman

L. M.

(2022). The trajectory of mental health problems for UK emerging adults during COVID-19. Journal of Psychiatric Research, 156, 491–497. https://doi.org/10.1016/j.jpsychires.2022.10.068

56.

Ullman

(2018). Breaking out of the (anti)bullying ‘box’: NYC educators discuss trans/gender diversity-inclusive policies and curriculum. Sex Education, 18(5), 495–510. https://doi.org/10.1080/14681811.2018.1431881

57.

Walsh

R. J.

Krabbendam

Dewinter

Begeer

(2018). Brief report: Gender identity differences in autistic adults: Associations with perceptual and socio-cognitive profiles. Journal of Autism and Developmental Disorders, 48, 4070–4078. https://doi.org/10.1007/s10803-018-3702-y

58.

Warrier

Greenberg

D. M.

Weir

Buckingham

Smith

Lai

M. C.

Baron-Cohen

(2020). Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals. Nature Communications, 11(1), 3959. https://doi.org/10.1038/s41467-020-17794-1

59.

Weir

Allison

Baron-Cohen

(2021). The sexual health, orientation, and activity of autistic adolescents and adults. Autism Research, 14(11), 2342–2354. https://doi.org/10.1002/aur.2604

60.

World Health Organization. (2022). Mental health. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response

Voices Unheard: How School Shapes Mental Health for Gender and Neurodiverse Youth

Abstract

Keywords

Introduction

Methodology

Participants

Design

Procedure

Member Checking

Process of Analysis

Analysis

Themes

Navigating Intersecting Identities

Normative Expectations are Abusive

One Size Never Fits All: Either We Pretend It does, or We Break the Mould

Our Diversity Needs to be Nurtured not Dismissed

Discussion

Implications

Strengths and Limitations

Conclusions

Footnotes

ORCID iD

Funding

Declaration of Conflicting Interests

Appendix A. Participant Recruitment Poster

References