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Funder: Simons Foundation Autism Research Initiative; doi: http://dx.doi.org/10.13039/100014370, Funder: Templeton World Charity Foundation; doi: http://dx.doi.org/10.13039/501100011730, Funder: Medical Research Council; doi: http://dx.doi.org/10.13039/501100000265, Funder: NIHR Biomedical Research Centre, Funder: NIHR Collaboration for Leadership in Applied Health Research and Care - East of England, Funder: Queen Anne's Gate Foundation, Funder: Corbin Charitable Trust, BACKGROUND: Recent research suggests that autistic individuals have shorter lifespans and experience worse health (greater health burden) than non-autistic individuals. Small, qualitative studies suggest that autistic adults also experience poor self-reported healthcare quality. METHODS: An anonymized, cross-sectional, self-report questionnaire was administered to n = 4158 individuals. The study assessed prevalence of chronic health conditions, healthcare quality, differences in overall health inequality score, and effects of the coronavirus pandemic on healthcare quality. We used Fisher's exact tests, binomial logistic regression, and predictive machine learning tools, as appropriate. RESULTS: The final sample included n = 2649 participants (n = 1285 autistic) aged 16-96 years. Autistic adults reported lower quality healthcare than non-autistic adults across 50/51 items, including poorer access to healthcare and poorer communication, alongside increased anxiety, sensory sensitivity, system-level problems, shutdowns, and meltdowns. Differences between groups were stark: aggregated health inequality scores predicted autism diagnosis, even after stratifying by sex. Autistic adults were also more likely to have chronic health conditions than non-autistic adults. There were no significant differences in healthcare quality for autistic adults before and during the pandemic, although they received relatively poorer quality healthcare than non-autistic adults across both periods. LIMITATIONS: The study's sampling methods are not likely to capture the perspectives of all autistic individuals, especially those with intellectual disability. Both the autistic and control samples are biased towards UK residents, white individuals, those assigned female at birth, and those who completed an undergraduate degree or higher education. As such, these results may limit their generalizability to other groups. Finally, these results relate to self-reported differences in healthcare quality between autistic and non-autistic adults. The observed group differences may in part reflect differences in perception and communication rather than differences in actual healthcare quality. CONCLUSIONS: Autistic adults are more likely to have chronic health conditions alongside self-reported lower quality healthcare than others. Health inequalities between these groups are widespread and dramatic; unfortunately, they existed before and have persisted after the onset of the coronavirus pandemic.

UNSTRUCTURED The COVID-19 pandemic accelerated the uptake of digital health worldwide and highlighted many benefits of these innovations. However, it also stressed the magnitude of inequalities regarding accessing digital health. Using a scoping review, this article explores the potential benefits of digital technologies for the global population, with particular reference to people living with disabilities, using the autism community as a case study. We ultimately explore policies in Sweden, Australia, Canada, Estonia, the United Kingdom, and the United States to learn how policies can lay an inclusive foundation for digital health systems. We conclude that digital health ecosystems should be designed with health equity at the forefront to avoid deepening existing health inequalities. We call for a more sophisticated understanding of digital health literacy to better assess the readiness to adopt digital health innovations. Finally, people living with disabilities should be positioned at the center of digital health policy and innovations to ensure they are not left behind.

Funder: Applied Health Research and Care (ARC‐EoE); Id: http://dx.doi.org/10.13039/501100012358, Funder: Corbin Charitable Trust, Funder: Medical Research Council; Id: http://dx.doi.org/10.13039/501100000265, Funder: National Institute of Health Research (NIHR), Funder: Templeton World Charity Foundation; Id: http://dx.doi.org/10.13039/501100011730, Funder: University of Cambridge; Id: http://dx.doi.org/10.13039/501100000735, Funder: Department of Health; Id: http://dx.doi.org/10.13039/501100003921, Funder: Health Research; Id: http://dx.doi.org/10.13039/100005622, Funder: National Institute for Health Research; Id: http://dx.doi.org/10.13039/501100000272, Funder: Biomedical Research Centre; Id: http://dx.doi.org/10.13039/100014461, Funder: AUTISM SPEAKS; Id: http://dx.doi.org/10.13039/100000073, Funder: Horizon 2020; Id: http://dx.doi.org/10.13039/100010661, Funder: European Union; Id: http://dx.doi.org/10.13039/501100000780, Funder: Innovative Medicines Initiative; Id: http://dx.doi.org/10.13039/501100010767, Funder: Wellcome Trust; Id: http://dx.doi.org/10.13039/100010269, Small studies suggest significant differences between autistic and nonautistic individuals regarding sexual orientation and behavior. We administered an anonymized, online survey to n = 2386 adults (n = 1183 autistic) aged 16–90 years to describe sexual activity, risk of sexually transmitted infections (STIs), and sexual orientation. Autistic individuals are less likely to report sexually activity or heterosexuality compared to nonautistic individuals, but more likely to self‐report asexuality or an ‘other’ sexuality. Overall, autistic, and nonautistic groups did not differ in age of sexual activity onset or contraction of STIs. When evaluating sex differences, autistic males are uniquely more likely to be bisexual (compared to nonautistic males); conversely, autistic females are uniquely more likely to be homosexual (compared to nonautistic females). Thus, both autistic males and females may express a wider range of sexual orientations in different sex‐specific patterns than general population peers. When comparing autistic males and females directly, females are more likely to have diverse sexual orientations (except for homosexuality) and engage in sexual activity, are less likely to identify as heterosexual, and have a lower mean age at which they first begin engaging in sexual activity. This is the largest study of sexual orientation of autistic adults. Sexual education and sexual health screenings of all children, adolescents, and adults (including autistic individuals) must remain priorities; healthcare professionals should use language that affirms a diversity of sexual orientations and supports autistic individuals who may have increased risks (affecting mental health, physical health, and healthcare quality) due to stress and discrimination from this intersectionality.

Autistic individuals may be at risk of premature mortality, and physical health comorbidity increases this risk; however, most studies fail to include older autistic adults or consider lifestyle-related factors that affect health. We developed an anonymous, online physical health survey. The final sample included n = 2368 individuals (mean age = 41.42), and of these, n = 1156 were autistic individuals (mean age = 40.98). We utilized three sex-stratified statistical models to determine the prevalence of cancer, cardiovascular conditions, respiratory conditions, and diabetes. All three models indicate that autistic females are more likely to have cardiovascular conditions, respiratory conditions, asthma, low blood pressure, arrhythmias, and prediabetes than non-autistic females, and autistic males are more likely to have arrhythmias than non-autistic males; these results suggest that autistic individuals carry increased risks for these conditions when compared to the general population, even after controlling for age, ethnicity, education level, body mass index, smoking, and alcohol use. Further, these risks may differ depending on biological sex for autistic individuals. Autistic adults, and particularly autistic females, have greater and wider-ranging risks than previously thought, even after controlling for demographic and lifestyle-related factors. Although this is a large sample of autistic adults across the lifespan, future research should employ larger, population-based samples to confirm these findings. Lay abstract Previous research indicates autistic individuals die at a younger age than others and that this is possibly due in part to chronic physical health conditions. The present study used an anonymous, online survey to determine how common certain physical health conditions are among autistic adults, compared with non-autistic adults. We found autistic adults are more likely to develop heart conditions, lung conditions, and diabetes than non-autistic adults. Autistic females may be at higher risk of developing certain conditions (including respiratory conditions, asthma, and prediabetes) than autistic males. Finally, autistic individuals have increased health risks even when considering lifestyle factors (such as smoking, alcohol, and body mass index). This is still a relatively small study, and future research needs to confirm these findings and identify why these risks exist.

It is unclear whether transgender and gender-diverse individuals have elevated rates of autism diagnosis or traits related to autism compared to cisgender individuals in large non-clinic-based cohorts. To investigate this, we use five independently recruited cross-sectional datasets consisting of 641,860 individuals who completed information on gender, neurodevelopmental and psychiatric diagnoses including autism, and measures of traits related to autism (self-report measures of autistic traits, empathy, systemizing, and sensory sensitivity). Compared to cisgender individuals, transgender and gender-diverse individuals have, on average, higher rates of autism, other neurodevelopmental and psychiatric diagnoses. For both autistic and non-autistic individuals, transgender and gender-diverse individuals score, on average, higher on self-report measures of autistic traits, systemizing, and sensory sensitivity, and, on average, lower on self-report measures of empathy. The results may have clinical implications for improving access to mental health care and tailoring adequate support for transgender and gender-diverse individuals., It is unclear if rates of autism and other neurodevelopmental and psychiatric diagnoses are elevated in transgender and gender-diverse individuals compared to cisgender individuals. Here, the authors use data from five different large-scale datasets to identify elevated rates of autism diagnoses, diagnoses of other neurodevelopmental and psychiatric conditions, and elevated traits related to autism in transgender and gender-diverse individuals, compared to cisgender individuals.