It is well-documented that autistic people are over-represented in gender clinic referrals. This guest blog looks at the research that is currently going on to understand this, and what future research needs to be done. It was written for us by Katie Alcock, DPhil, CPsychol, Senior Lecturer, Department of Psychology, Lancaster University.
Why are autistic people more likely to have gender dysphoria? What science has taught us so far, and next steps.
Katie Alcock
Some people are very unhappy with the sex of their body and the way society views their sex according to stereotypes. If this gives them enough distress, then they may be diagnosed with gender dysphoria. People diagnosed with gender dysphoria have some desire to be, or to be treated as, another sex or gender to their birth sex1. It’s not the same, though, as just questioning your gender, or not fitting stereotypes – neither of those necessarily cause distress.
We know that autistic people are more likely to have mental health problems, such as anxiety. Autistic children and adults are also at least four times as likely to have gender dysphoria as the general population2,3.
We already know that for children, social transition (dressing as, and calling yourself a name of, the opposite sex) isn’t all that helpful4. For children and adults medical transition (taking medication or having surgery to change your body) doesn’t help mental or physical health either5,6. Indeed, social and medical transition may increase psychiatric illness7.
We need other solutions but they must be solutions that work for autistic people – so first, we need to know why more autistic people have gender dysphoria. There are quite a few clues about why this is, but so far they haven’t been put together.
Autistic people are diagnosed by showing differences to neurotypical people in three types of thinking, two that are quite similar: social communication and social interaction, and a third that is a bit different: restricted or repetitive behaviour. All autistic people are different – social communication can be anything from working out someone is talking to you, through to complex metaphor and idiom. Restricted or repetitive behaviour can mean hand flapping, lining up toys, or detailed catalogues of a collection.
To find out what is different about autistic people that makes them more likely to have gender dysphoria, researchers have looked at the types of thinking that are related to both conditions, because they might explain this overlap. Some of the research looked at people with a diagnosis of autism, or of gender dysphoria, or both. Other studies asked people about their traits – we are all different to each other in how likely we are to say we can work out what people are thinking or in how comfortable we are with our sexed bodies, and differences between people without any diagnosis can also tell us about autism and gender dysphoria.
For some of these differences, the only clue we have is that they are more common in one or the other group of people: autistic people think more in black and white – something can be one way, or another, but not both. A really intriguing study8 found that autistic children struggle to understand that a toy can, for example, look like chocolate but really be made of plastic. These children tended to say that if something changes its appearance, it changes its underlying reality.
Neurotypical children, and older children with learning disabilities who weren’t autistic, didn’t make as many mistakes. This ability – appearance/reality – is extremely closely related to sex/gender constancy – the ability to understand that dress and toy preferences don’t determine sex. Both of these abilities develop around the same age, and children who understand one usually understand the other.
To illustrate the link, in the 1960s, a very patient cat called Maynard put on a dog mask 9. Children under about 6 thought he had really turned into a dog. He has dog bones, and a dog tummy, they said. Children of this age also think that if a boy puts on a dress he has turned into a girl10. After this age they can see that clothing and toys don’t make a boy into a girl.
Children who have gender dysphoria, however, are later to understand this11. We don’t yet know what autistic children might think about this type of scenario, but this is definitely a clue.
For other clues, researchers have used a type of analysis called mediation. In this kind of analysis, we might know that both autistic people and those with gender dysphoria think in a certain way. If that thinking skill mediates (or alters) the link between autism and gender dysphoria in a statistical sense, it could help us know why people with one diagnosis are more likely to have the other condition.
One of the abilities that mediates the link between the conditions is called mentalising12. This is an everyday type of mindreading. We can tell what someone is thinking by the way they behave and look. Autistic people find this harder, and it probably leads to some of the social communication and social interaction difficulties they have. This ability could then be a clue to the extra risk of gender dysphoria in autistic children and adults.
One of the abilities that autistic people find easier is systemising ability13– it’s even been suggested as a reason autism might have appeared as a helpful trait through evolution. Systemising is the ability and desire to predict outcomes in the world, and to make the world an ordered place. Both this and need for cognitive closure14 are higher in autistic people. Need for cognitive closure is very similar to systemising and relates to a wish to know what the answer is to a question, and it’s also related to stereotyping15.
So far researchers have found that systemising is also a mediating factor16 between autism and gender dysphoria. Higher systemising ability links higher scores on an autism questionnaire to higher scores on a gender dysphoria questionnaire. If this also means more stereotyping in general, not fitting those stereotypes could be hard for autistic people. This is another clue in our quest to find out just why gender dysphoria is more common in autistic people.
Our next step is to investigate all these differences in thinking – appearance/reality and sex/gender constancy, mentalising, systemising, need for cognitive closure and stereotyping. We will try and work out what is different about autistic people compared to neurotypical people that makes them more likely to suffer distress over their sexed body and society’s expectations of them.
I’ve mainly been talking about differences in thinking styles – cognitive differences. There have been suggestions that the differences between autistic and non-autistic people that are relevant to gender dysphoria are, rather, social differences. For example, could autistic people be more or less comfortable with gender non-conforming behaviour – boys who like dresses and girls who like trucks? Some research says autistic children conform more to gender stereotypes17 but among young adults, those with more characteristics of autism seem to be less conforming to stereotypes18.
There are also some differences in the effects of puberty. While there’s no systematic difference in the physical effects or timing of puberty in autistic adolescents, sensory processing differences can make girls, in particular, more upset about having their periods, and parents and children worry about romantic and sexual relationships for their teenagers19.
What’s next? Well, one thing that we need to know is whether the differences we see in autistic people’s thoughts and reasoning are causing or being caused by other differences. We see people in short sleeved tops when the weather is warm, and we also see them eating ice cream. But ice cream eating doesn’t cause warm weather – we need to know which comes first.
To do this we will look at differences between autistic and non-autistic children or adults at the beginning and end of a time period. Things that are happening at the beginning of the time we study can affect things at the end – but it’s unlikely to be the other way round.
So, it might be that differences in telling what other people are thinking affects feelings around sex and gender. By looking at these differences over a longer time period we can see if differences in thinking at the outset affect feelings at the end of the time period. If this is what we find we would be more confident in knowing what exactly is causing autistic young people to have more gender distress. Knowing this would give us a better chance of working out how to best help these children and young adults.
1 American Psychiatric Association. in Diagnostic and Statistical Manual of Mental Disorders (2013).
2 Kallitsounaki, A. & Williams, D. M. Autism Spectrum Disorder and Gender Dysphoria/Incongruence. A systematic Literature Review and Meta-Analysis. J. Autism Dev. Disorders 53, 3103-3117 (2023). https://doi.org/10.1007/s10803-022-05517-y
3 Hisle-Gorman, E. et al. Gender Dysphoria in Children with Autism Spectrum Disorder. LGBT Health 6, 95-100 (2019). https://doi.org/10.1089/lgbt.2018.0252
4 Hall, R. et al. Impact of social transition in relation to gender for children and adolescents: a systematic review. Arch. Dis. Child., archdischild-2023-326112 (2024). https://doi.org/10.1136/archdischild-2023-326112
5 Cass, H. Independent review of gender identity services for children and young people. (2024).
6 Health, U. D. o. & Services, H. Treatment for pediatric gender dysphoria: Review of evidence and best practices. May 1, 2025-2005 (2025).
7 Ruuska, S.-M., Tuisku, K., Holttinen, T. & Kaltiala, R. Psychiatric Morbidity Among Adolescents and Young Adults Who Contacted Specialised Gender Identity Services in Finland in 1996–2019: A Register Study. Acta Paediatrica n/a https://doi.org/https://doi.org/10.1111/apa.70533
8 Baron-Cohen, S. Are autistic children “behaviorists”? An examination of their mental-physical and appearance-reality distinctions. J. Autism Dev. Disorders 19, 579-600 (1989).
9 De Vries, R. Constancy of generic identity in the years three to six. Mono. Soc. Res. Child Dev. 34, iii-67 (1969).
10 Alcock, K. Do school and equality education characteristics influence young children’s understanding of sex/gender constancy? J. Exp. Child Psychol. 241 (2024). https://doi.org/https://doi.org/10.1016/j.jecp.2024.105879
11 Zucker, K. J. et al. Gender Constancy Judgments in Children with Gender Identity Disorder: Evidence for a Developmental Lag. Arch. Sexual Beh. 28, 475-502 (1999). https://doi.org/10.1023/A:1018713115866
12 Kallitsounaki, A., Williams, D. M. & Lind, S. E. Links Between Autistic Traits, Feelings of Gender Dysphoria, and Mentalising Ability: Replication and Extension of Previous Findings from the General Population. J. Autism Dev. Disorders 51, 1458-1465 (2021). https://doi.org/10.1007/s10803-020-04626-w
13 Baron-Cohen, S. Two new theories of autism: hyper-systemising and assortative mating. Arch. Dis. Child. 91, 2-5 (2006). https://doi.org/10.1136/adc.2005.075846
14 Fujino, J. et al. Need for closure and cognitive flexibility in individuals with autism spectrum disorder: A preliminary study. Psychiatry Research 271, 247-252 (2019). https://doi.org/https://doi.org/10.1016/j.psychres.2018.11.057
15 Baldner, C. & Pierro, A. The Trials of Women Leaders in the Workforce: How a Need for Cognitive Closure can Influence Acceptance of Harmful Gender Stereotypes. Sex Roles 80, 565-577 (2019). https://doi.org/10.1007/s11199-018-0953-1
16 Hendriks, O., Wei, Y., Warrier, V. & Richards, G. Autistic Traits, Empathizing–Systemizing, and Gender Diversity. Arch. Sexual Beh. 51, 2077-2089 (2022). https://doi.org/10.1007/s10508-021-02251-x
17 Simcoe, S. M. et al. Are there gender-based variations in the presentation of Autism amongst female and male children? J. Autism Dev. Disorders 53, 3627-3635 (2023). https://doi.org/10.1007/s10803-022-05552-9
18 Schiltz, H. K., McVey, A. J., van Dyk, I. S., Adler, E. J. & Van Hecke, A. V. Brief Report: Links Between Nonconformity to Gender Norms, Autistic Features, and Internalizing Symptoms in a Non-clinical College Sample. J. Autism Dev. Disorders 53, 1717-1725 (2023). https://doi.org/10.1007/s10803-021-05033-5
Thank you. This is very interesting. I’m a retired CAMHS clinician and between 1994 and 2014, my team only saw one child with gender dysphoria. There was domestic abuse in the family and culturally girls were much less valued than boys. At the end of the 90s, a child and adolescent child psychotherapist from the Tavistock Children’s GIDS reported at a local event, that 9 out of 10 children and young people who presented in those days (in very small numbers), after high quality therapeutic support, turned out to be same-sex attracted. We didn’t know much about neurodiversity in those days.
I feel like something obvious is being missed here. I was diagnosed autistic aged 50. I hated my body growing up. I felt disgusting in clothes, hated looking in the mirror and thought people were always looking at me and finding me unacceptable. Had the internet and social media existed at the time I feel strongly that I would have been susceptible to gender ideology. But this does not mean that I had or have gender dysphoria. More likely, I feel, I may have succumbed because if I had been told at that age (when I was misdiagnosed worth depression), that the answer to how I feel was because I was actually a boy, I feel I most likely would have perused this as I would have given anything to not feel the way I did. I quite possibly would have believed this would fix my problems. But I would have been wrong. I now understand where that discomfort came from. It was (and still is) because I am autistic. That is all. Not gender dysphoric. But kids now are being given this as an option and are incredibly vulnerable to the ideology because they want to remove the discomfort. The social transitioning doesn’t work because the discomfort cannot be ‘cured’ by changing their name or their outward appearance or by asking others to perceive them differently. The suffering is because of the autistic brain which causes sensory difficulties and depersonalisation. And in many, perhaps the majority of cases, I understand that such young people turn out to be gay and gender non-conforming. I think gender ideology is the greatest crime ever committed against young people.
I agree. My teen daughter has been suffering with intense gender dysphoria for several years. She has also been diagnosed more recently with autism. She did express in elementary school that she preferred playing ball (badly) with the boys at recess because she could not participate well or did not enjoy the girls’ focus on talk/gossip. And from a young age, she expressed hating her body in many ways–she always felt ugly (she isn’t) and never liked to look at photos of herself. In puberty she began to feel fat (she wasn’t) and expressed hating her body and face even more, enough so that a diagnosis of body dysmorphia was probably warranted.
Idealizing the anorexic body and beginning to identify as male occurred simultaneously. She received tremendous support for her “born in wrong body” ideation from the same medical and mental professionals who refused to endorse her anorexic thinking. She has recovered from the anorexia but not from the gender dysphoria. I and her father refused to help her access medical transition services because we don’t believe she could tolerate the discomforts of cross-sex hormones, much less the pain of surgeries, and we believe she would be just as unhappy with her body post-transition, with the added health problems of a reconstructed urinary/sexual function. But her gender fixation is fierce and persistent, with idealized images put there by the marketing of gender ideologues. We are all stuck in this nightmare scenario of our daughter believing she needs radical medical intervention to live a normal life and we believing that such treatment would ruin any chance she has for a “normal” life. We believe the fixation and belief that transformation is possible is blocking her from progressing in basic life skills, but there seems to be no treatment for gender dysphoria apart from the brutal medicalization path. As you say, a great crime is being committed against young people.
Because they tend to see things as either/or, black or white. If they don’t fit in the “box” of stereotypical behavior and feelings associated with their body’s sex, then they must really be the opposite sex.