When it’s not “just autism”: ASD does not rule out gender dysphoria

As both transgender identities and autism have received increasing attention in recent years, a growing number of misconceptions have proliferated about the relation between these phenomena. News outlets run stories with questionably phrased headlines such as “Are autistic children more likely to believe they’re transgender?”, suggesting that trans people’s genders are simply a matter of a personal “belief” that could be either true or false. Other online publications claim trans people may be “suffering from a mental disorder which could have been treated in another way”, and that their apparent gender could instead be “an autistic obsession”. I’ve personally heard from several trans people whose progress in transitioning has been delayed or obstructed by therapists and doctors who believed it was possible that their gender was not genuine, but rather a result of being on the autism spectrum.

Such practices do not reflect what is currently known about individuals with both gender dysphoria and autism. The assumption that a trans person’s gender has emerged from aspects of their autism, rather than this straightforwardly being their gender as in allistic individuals, is largely unfounded. There is a kernel of fact at the center of this speculation: those with gender dysphoria have an elevated likelihood of being autistic or exhibiting autistic features, and autistic people are also more likely to be dysphoric or gender-variant (May, Pang, & Williams, 2017).

But the observation of “some of these people are on the autism spectrum” is distinctly different from the claim of “some of these people are on the autism spectrum and their autism is causing the false appearance of a transgender identity”. A significant proportion of trans people are autistic. This does not therefore mean they aren’t trans.

Contemporary scientific literature on co-occurring gender dysphoria and autism generally does not conclude that autistic people’s trans identities are any less authentic than those of allistic people. May et al. (2017) note that autistic traits can actually make this group less likely than allistic individuals to refrain from coming out or visibly manifesting a gender-variant identity:

Difficulties with mentalizing or theory of mind and empathy deficits may also facilitate individuals with ASD “coming out” as transgender without concern for societal prejudices. … These difficulties may also result in a person with ASD operating unaware of expectations of others, which could mold their internalized perception of gender.

Strang et al. (2014) recognize these factors as well, and state that autism should not be considered a barrier to recognizing and affirming a trans person’s gender:

In ASD, children and adolescents may be less aware of the social restrictions against expressions of gender variance and therefore less likely to avoid expressing these inclinations. It could also be theorized that excessively rigid or‘‘black and white’’ thinking in ASD could result in a child with ASD rigidly interpreting mild or moderate gender nonconforming inclinations as more intense or absolute. However, this second idea is in contrast to a report from de Vries et al. (2010) that, after extended psychiatric evaluation, a substantial proportion of adolescents with ASD and concurrent GID/gender dypshoria showed persistent gender variance and were appropriate for gender transitioning.

Kennedy (2013) also observes that trans and gender-variant youth are less likely to perceive or adhere to trans-hostile (cisgenderist) social norms that discourage expression of gender variance:

The restricted nature of social groupings in primary and most secondary schools, and the lack of alternative social groupings available to those excluded from the school or class group, means that social exclusion represents a very real threat to them if they fail to conform to group norms. As such the decision by the majority of trans children to conceal their gender non-­‐conformity represents a rational one given the information available to them at the time. The tendency of trans children to conceal or suppress their gender identities appears to arise, to a significant extent, from their perception of this tacitly expressed culture. However, there is one group of children for whom this tacit culture is either undetectable or unimportant: AS children. In most cases AS children would probably be unable to detect this tacit ideology; a process that results in most trans children concealing or suppressing their gender identities. Yet it is also probable that even if they did realise that it was socially unacceptable, most would be unlikely to be able to conceal it or to perceive the need to conceal. This presents us with an apparent paradox in which cultural cisgenderism is either not perceived or not perceived as important by AS children who are trans, whereas it affects non-­‐AS children who are trans to a far more significant extent.

This results in those trans children who are AS becoming apparent much more readily than non-­‐ AS children because of the differential effects of cultural processes and social relations, in this case caused by cisgenderism.

In other words, their autism has not summoned their transness into existence – it was already there. Instead, allistic individuals’ lack of autism is keeping their transness disproportionately repressed.

Researchers in this area do not contend that autism invalidates or undermines the reality of a person’s transness, but rather recognize that these individuals should be supported in their gender identity with additional help as needed for any struggles that may emerge from the interaction of their autism and gender dysphoria. Current guidelines on the treatment of this population, assembled by expert consensus, explicitly refute such attempts to dismiss their gender dysphoria as inauthentic (Strang et al., 2016):

The diagnosis of ASD should not exclude an adolescent from also receiving a GD diagnosis and, when indicated, appropriate GD-related treatment. However, clinicians and parents sometimes dismiss GD as a trait of ASD (e.g., as an overfocused or unusual interest). Although in some cases GD symptoms appear to stem from ASD symptoms, many adolescents have persistent GD independent of their ASD. …

There are some young people with ASD who do not embody a binary transgender presentation (e.g., they may not work to present as a different gender, they may not dress as a different gender, they may not be concerned with their name, etc.) These variations from more common GD presentations may raise issues of credibility for parents, medical/psychological professionals, and so on. However, many such youth appear to have persistent gender signs, feelings, or experiences of another gender and should not be excluded from consideration of GD diagnosis and appropriate related treatments, tailored to their individual needs. …

An ASD diagnosis should not exclude the potential for medical GD treatments, including puberty suppression and cross-sex hormone intervention.

Shumer, Reisner, Edwards-Leeper, & Tishelman (2016) echo this stance:

Our data support inclusion of ASD screening as part of any comprehensive gender assessment, especially as diagnosis of ASD has implications for management of gender dysphoria. For example, a patient with ASD and gender dysphoria may require specialized psychosocial interventions, focused on navigating unique social challenges encountered during hormonal and social transition from the natal sex to the affirmed gender. Youth have the right to appropriate assessment, diagnosis, and treatment of both ASD and gender dysphoria to ensure optimal clinical care.

These positions are not speculative or theoretical – they are based on extensive direct clinical experience with autistic and gender-dysphoric individuals. Medical professionals working closely with this group of patients do not regard autism as by any means a barrier to treating their gender dysphoria and recognizing their identities. The attribution of transness as a mere epiphenomenon of autism is not only baseless – it’s thoroughly contradicted by known medical realities. ■

References

• Kennedy, N. (2013). Cultural cisgenderism: consequences of the imperceptible. Psychology of Women Section Review, 15(2), 3–11.
• May, T., Pang, K., & Williams, K. J. (2017). Gender variance in children and adolescents with autism spectrum disorder from the National Database for Autism Research. International Journal of Transgenderism, 18(1), 7–15.
• Shumer, D. E., Reisner, S. L., Edwards-Leeper, L., & Tishelman, A. (2016). Evaluation of Asperger syndrome in youth presenting to a gender dysphoria clinic. LGBT Health, 3(5), 387–390.
• Strang, J. F., Kenworthy, L., Dominska, A., Sokoloff, J., Kenealy, L. E., Berl, M., . . . Wallace, G. L. (2014). Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Archives of Sexual Behavior, 43(8), 1525–1533.
• Strang, J. F., Meagher, H., Kenworthy, L., de Vries, A. L. C., Menvielle, E., Leibowitz, S., . . . Anthony, L. G. (2016). Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents. Journal of Clinical Child & Adolescent Psychology. Advance online publication. doi:10.1080/15374416.2016.1228462