Autism and Gender Dysphoria

The link between autism and gender dysphoria is explored in this guest post by Millie (a pseudonym), an Autistic solo mum, researcher and advocate.

Millie was diagnosed with autism late in her life, at 38. As a child she played with stereotypically male toys, desired to be a boy and was mistaken for one often. Post puberty she struggled to fit in with her female peers and was abused and bullied. This led to self harm & self medicating. Subsequently, she was introduced to psychological health services. This was the beginning of years of misdiagnosis and powerful medications, often with negative impacts. After soul searching, self exploration and healing, she found wellness – embracing her gender non conformity, bisexuality, and especially being a mother.

Millie sees how Autistic sensory sensitivities, hyper focus, masking/camouflaging, communication differences, and social issues (including past abuse and pressure to conform) feeds discomfort in our bodies. She loves the push against social conformity many autistic people have, and worries about the impact of psychiatric medications and physical interventions on developing minds and bodies.

Millie has a professional background in clinical work in areas of neuro-psycho-social issues, focusing on addiction, mental health, disability and autism. She hopes the future will bring a more person-centred, holistic approach to care. We are grateful to Millie for writing this article on the link between autism and gender dysphoria, from her personal and professional perspective.

 

Autism and Gender Dysphoria

Disclaimer: I thought about what type of content warning might be fitting for this essay. I realised the only warning that seems necessary to give, was to myself. I am at risk for expressing these views, that although many share my concern, few feel able to speak.

Why do I care? Why would I bother taking the risk of being attacked, and ostracized?

I grew up as an undiagnosed autistic girl, who wanted, more than anything, to be a boy, for as long as I can recall. I didn’t find out that I am autistic until later in life. I just knew that I was different, weird, and didn’t fit, anywhere. Even if I had known, the severe lack of knowledge and support then, and still now, means that having an autism diagnosis was, and is not, a protective factor in any situation, let alone the one I am writing about here.

Scared to Speak, Afraid to Remain Silent

I have been wanting to write this for some time. I have concerns for autistic kids, and how they fit into this gender questioning phenomenon. They are naturally non stereotypical, in terms of gender expression. I am scared about what this means, in terms of medications and surgical interventions. I feel scared, angry and more than once I have cried. I reflect on my own life and the difficulties I had with my identity, and how my mental health and body confusion led me to many years of psychiatric interventions. I wonder how I would fare in the climate of today. I have a pretty good idea of what that would have looked like, and it scares the life out of me.

I have thought about what repercussions writing this may have for me. The main reason it has taken me this long is fear, fear of how people will respond to my concerns. Contrary to what some may think, I wouldn’t be lauded as a champion for children’s rights and wellbeing for talking about this. More likely I will be labelled a bigot, and if you knew me, you know this couldn’t be further from the truth.

So if I will not be seen as a champion for children’s rights, what will I be seen as for writing this? In a word, a witch.

Would you believe writing this could well have serious repercussions such as online abuse, physical assault, or even death threats? I could well be angrily told I am transphobic – a “terf”1 to be exact. The ‘accepted by current climate’ outcomes are loss of friendships, loss of employment and targeted misogynistic abuse. Why is it acceptable to threaten, or action, physical assault against people who critique, question and propose reviewing the situation? I am concerned that some of our most vulnerable kids are being supported to hate themselves, and their bodies.

Gender Dysphoria (GD) – is used to describe a condition where a person experiences discomfort or distress because they feel there is a mismatch between their biological sex and gender identity. GD, somewhat controversially, more recently, is not formally considered to be a mental illness.2 Don’t take from my essay that I don’t believe GD is a true state of being. I would debate that true GD is as typical as the numbers we are seeing. 70-90% of children who question their body/mind match end up accepting of their body, without any surgical or medical alterations.3 They develop into content, often gay or bisexual, adults. I do not intend to diminish anyone’s individual experience. I have many times in my life been very distraught having a female sexed body, living in a world of social expectations and stereotyping. I have, and do experience how disturbing and overwhelming that can be.

However, I do feel strongly that we must red flag how easily we are sending our kids down a serious and life-long medical pathway, often without thorough investigation. The activity to move GD away from being a psychiatric illness, has meant psych assessment or intervention is often not part of the intake process to so called, gender affirmation treatment.

A 2018 Guardian article4 discusses an issue at the Tavistock, the UK’s NHS gender clinic. A report was submitted to the board by senior staff, as well as parents of young people who attend said clinic. The report allegedly outlines concern at the speed of and brevity of their intake and assessment process. They suggest young people are not getting thoroughly screened before entering into a lifelong medical pathway. Furthermore, the desire to change your birth sex is not seen as a mental health issue, ergo reducing psychiatric intervention prior to inclusion.  I will use this as a basis to reflect on my thoughts, and concerns about this phenomenon.

This is an excerpt of the report from The Guardian article: “We have specific concerns about the situation of those with gender dysphoria in the age group 17 to 25 who are referred to the [adult] GIC [gender identity clinic], where they do not receive the complex psychosocial assessment offered at GIDS: for these young adults there is little exploration of the family or cultural context of their still developing gender identity.”

The report questions whether the clinic should do more to consider young people’s personal histories, notably by examining whether they are on the autistic spectrum, have experienced trauma or are being influenced by social pressures, before helping them on the path to transition.

Reading this last sentence prompted me to write this essay, which has been burning inside of me for a while. A minority of outspoken concerned parents, people with gender dysphoria and detransitioners are starting to speak out. This isn’t a minority per se, far from it. However, it is a minority that feel safe enough to talk. It may sound like I am being dramatic when I say ‘safe’. It’s 2020, we have social media platforms where people can express their opinion, right? It’s 2020, a time where things are out in the open, you can access accurate information to make well informed decisions, right? It’s 2020, no one would be promoting inaccurate, dangerous misinformation, especially when it comes to children, right? Wrong.

If a child is confused because they don’t fit into restrictive gender roles – often we are referring to clothes, beauty styles and hobbies – do we suggest medically/surgically altering very sensitive parts of their body ? It seems so.

Language, Sex and Gender

Children are being encouraged to question, from a very young age, whether they were born ‘wrong’ or not. Our kids, including ones with learning disabilities, and differences in social literacy, are being introduced to concepts like ‘The Genderbread Person’. This is an ideology that is based on stereotypical male/female attitudes and ‘typically expected roles.’

The Genderbread Person5 is described as a “teaching tool for breaking down gender into bite-sized digestible pieces”. The goal is to distinguish between L, G, B, Q and the T and between sex, gender identity, gender expression, and attraction. “Gender identity, gender expression, biological sex, and sexual orientation exist independent of one another.” A part of this thinking is, not all males have a penis, and not all females have a vagina. That is, your brain may not match your ‘pink bits’.

‘Maleness’ and ‘femaleness’ are socially constructed and biased. A stereotypical framework of men and women – with all of the biased lashings of pink v blue, trucks v dolls and the many other archaic boxes we have been fighting to escape for decades. Historically, there always have been feminine men and masculine females. Very few, if any people are purely masculine or feminine. That’s perfectly fine, in fact I think we need to celebrate that.

I find the genderbread person concept confusing. The intention may be good – if the intention is to show children they don’t have to conform to society’s gender stereotypes. However it seems to me that is exactly what is lost in delivery. For me, this says, I may have the wrong body, because I don’t do female things. My body is female sexed, but my brain seems to be severely lacking this ‘female essence’.

autism and gender dysphoria, image of Genderbread Person

This promotes the thinking of having a girl’s body, but liking ‘male’ things, means you are a boy born into a girl’s body. A mistake, a glitch. What impact is this having on body/mind connection? How does this impact their developing identity? This is confusion marketing. And it is aimed at our children at a time they are already confused and vulnerable. What happened to ‘growing to be happy in your body’? Isn’t the goal ‘loving the skin you are in’, to nurture a healthy self-identity? Self-loving, over self-loathing.

For autistic kids, feeling ‘from a different planet’, ‘wrong’ and like we don’t belong here, isn’t anything foreign. Tragically this group are 10x more likely to die by suicide.6 This form of death (and a myriad of psychological and physical issues connected to being neurodiverse) happens so frequently that an autistic person’s life expectancy is 58 years. That is 16 years less than the life expectancy of a non-autistic person. Perhaps more startling, autistic people who also have cognitive disabilities have an average life expectancy of just under 40 years.7

Ideas such as “I don’t belong” and “I am wrong”, are nuclearised, to “I am wrong, and also, I was born in the wrong body”.

Gender ideology has catapulted these seriously negative thoughts so far, that kids are willing to alter areas of their perfectly well functioning body, and begin to take powerful medications – medications that will be necessary for the rest of their lives. Medications to halt, or block puberty8, physiologically stopping the child’s puberty, hindering their psychosexual development, until cross sex hormones9 can be administered. Medications that will render them infertile (remember eugenics of autistic people, anyone10,11?) These medications also severely reduce their ability to have full sexual experiences and feelings as adults. Without psychosexual maturing, how do we know what our wants and desires are? Furthermore, these lifelong medications can leave people with painful and debilitating physical disorders.12

Given that autism also affects a person physically – allergies, seizure activity, sleep disorders, GI, autoimmune, thyroid and endocrine system issues, connective tissue disorders – just what are we doing administering medications with no long-term outcome studies?

Sex and gender are often conflated. This confuses people, and consequently convolutes discussions. Many words used in these conversations have been altered to fit an agenda, with new words being invented in order to further the cause. Yes, language evolves and develops over time. ‘Over time’ being the key here. Usually it is a slow change that becomes accepted and used by many, not inserted and forced upon us like many of these ‘new gender terms’.

Language is powerful in the autism community. Many autistic people describe English as a second language, in that it needs to be ‘rote learned’. This means not picking up on nuances, and ‘new’ uses of words. This can leave people confused, and unable to follow what’s really going on. Especially people like me, who have learning disabilities. Autistic people are more susceptible to suggestion, or manipulation, because of the differences in how they process language.  

Misunderstandings with words can have serious consequences for autistic people – being ‘taken the wrong way’ can mean we end up in physical altercations, or agree to something that we are against. It can mean we hurt someone we love, scarring our spirit, and our precious relationships. It can also mean we end up in situations that we expressly do not want to be in. These are all common outcomes for autistic people.

Sex pertains to biological dimorphism. Humans are either male or female. A person’s sex depends on the presence of either a male or female reproductive system, and the ability to produce big or small gametes, whether or not that system is functional.

The word Gender was originally used only in language, not in medical terminology. For example, German language has grammatical gender. All German nouns are classified into one of three genders – masculine, feminine and neuter. What we know as gender today is the social construct of what society has designed to be considered masculine and feminine, with a large focus on appearance and social behaviour. Ergo, ‘the socially-imposed division of the sexes’ as stated by Gayle Rubin.

Gender Roles, Stereotypes and Identity

Conformity is Not in Our Genes

Conforming to socially contrived gender expectations, so far as surgically changing physical appearance to match our ‘brain sex’, sounds regressive. Why can’t we be more open, accepting, and enjoy deviating from the norm?

The intersection of being both autistic and transgender is more common than you might think. Since 2010, there have been at least 9 studies on the potential link between ASD and gender dysphoria. Across all of these studies, almost without exception, rates of ASD or autism traits range from 5% to 54% among those with gender dysphoria, significantly higher than among the general population.13

This, from an International Society for Autism Research conference presentation, Willem Burger Hal, 2018: “The over-representation of ASD among individuals clinically referred for Gender Dysphoria (GD) has been observed across multiple sites internationally; up to 25% of youth gender referrals present with significant autism symptoms.” Many females presenting at clinics have what has been termed as ‘autistic traits’, and most people are aware of sex discrimination around autism assessments14. This would mean there is a good chance the rates of autism in this group are much higher than presently understood.

Even though people are aware of the notable co-occurrence between autism and GD, it is difficult to find autism specific gender dysphoria information. Given the strong co-occurrence of autism and gender variance, why is this? And why are these young people not being thoroughly screened for autism during the initial assessment process?

Keep in mind, even with a formal autism diagnosis, these kids are being funneled into gender services. Once they are service users the ‘autistic’ part of their identity is all but ignored, the focus becomes solely about their feelings of gender. This concerns me greatly.

A major part of an autism diagnosis is differences in social language, understanding and behaviour, basically we are not born with pre-existing social software. Our interpretation of hierarchy, roles in social structures and gender, is quite unique to our group. Masculinity and femininity are socially constructed, autistic people do not tend to fit at all neatly into either of these boxes.15 They are also more likely to be atypical with their sexuality.16

I love this about our group. I have always loved this part of who I am. I can wear my checked shirts, jeans and boots, and be rather convincingly male in appearance. Equally, I can don a flowery dress, make my hair into a ponytail and be ‘seen as’ a rather feminine entity. As a child my hair was short, mostly because my hobbies involved sports, making bush huts, and who had the time to tend to long hair? Not me. I kicked around with boys and did ‘gendered boy things’. I found guys easier to communicate with and understand. This came down to basic sentence structure for me, less words, less nuance, less confusing emotions underpinning each paragraph and often, not always, more honesty.

Furthermore, many, if not most, autistic adults also have childhood trauma17. I believe this is a combination of our natural physiological predisposition to anxiety (enlarged amygdala, hyper sensitive adrenal axis, sensory processing differences) as well as our challenges in communication with the humans around us. How does one have their needs met when our language doesn’t match our experience? What if we can’t find the words to describe it? Also, autism puts you at a much greater risk of bullying and sexual abuse.18

So, we have a group of naturally less stereotypical people who have difficulty in communicating their needs, who are often socially isolated and traumatised. This group are more likely than most to be confused about how they fit into the world, have problems with their sense of identity, and be less likely to have rigidity around being attracted to certain ‘sex’. They are more likely to have been survivors of bullying, and sexual abuse.

One thing I haven’t even touched on is that autism is considered a developmental delay. Autistic children can be very intellectually smart and socially naive. I haven’t even mentioned the impact of sensory processing disorders and ‘comfort in our bodies’, or interoception (the sense that lets us know what is happening internally) – that is an essay in its own right.

Autistic Stigma, Treatment and Cure Speak

Autism is extremely stigmatized. Many still see it as a deficit in human functioning. Autistic people are judged harshly by their ‘odd’ behaviours, and there is much pressure to ‘act normal’. The accepted therapy for children is Applied Behaviour Analysis or ABA. ABA is aimed at reducing autistic behaviours. The idea is to make us appear less autistic, so that we ‘fit in’ better, and be less noticeable, or disruptive. It is often compared to gay conversion therapy.19 The aim to normalize, or camouflage autisticness has serious psychological repercussions for the autistic person.20

Even without having ABA therapy, autistic people learn very young, to pretend, mimic and behave like other people to compensate. This is exhausting, and damaging to a person’s sense of identity. I have no doubt this contributes to the tragic mental health stats we have, especially self-harm, and suicide.21 For all of history, people have tried to medicate, therapize, and scare the autism out of us. Adult autistic people have usually experienced some form of traumatic ‘treatment’, whether via behaviour modification, serious psychopharmacological interventions, bullying or physical and emotional abuse. Many autistic adults are strong in their beliefs around not subjecting ‘cures’ or modifiers on autistic kids. They are often proponents of the ‘neurodiversity’ model which is underpinned by self-acceptance and pride.

Why does this ‘accept us as who we are’ attitude change when gender enters the conversation? I don’t understand that people can be against interventions to take the autism away, (an impossible goal btw), but then embrace medical and behavioural conversion, via medications and surgery to alter physical appearance and being. Furthermore, some have suggested autism traits decline after gender therapy, so what? Altering one’s gender is some kind of ‘cure’ for autism now?22 My theory would be that the upsurge in attention, support and acceptance one gets as a ‘trans’ kid, compared to an autistic kid, is what gives the appearance of less social anxiety. Increased connection is well known as a way to increase wellbeing. Do we need to go to the extreme of medically altering kids to accept them? Can we just not work harder at accepting and supporting these kids as they are: unique, valuable autistic humans.

The Ethics of Fertility

Autistic people, especially our young ones, are at risk, with gender hyper focus.  Major risks include sexual vulnerability23, confusion of identity and high chance of being coerced and influenced into making decisions, without proper informed consent.

And what about autism eugenics – our group has historically been, and still are, forcibly sterilised. Compulsory birth control or sterilization is not uncommon. I find it difficult to fathom how self-imposed sterilization is being accepted. What teenager is excited about having children? How is it possible to make such a decision at 13 years old? Consider the ‘social naivety’ I mentioned earlier. I’d suggest that autistic children are less likely to have formed a definite decision around having their own kids, especially when they still feel very much like a child themselves. If you had asked me at 13, ‘do you want your own kids?’ I would have been horrified. Ask me now if I would have been ok with having been allowed to make that choice at that age, even more horrified.

I have struggled since I remember with my mental health. I have faced my own death many times, whether that be due to risky behaviour with real death potential, or suicidal ideation. I have come close. The strongest protective factor in these times for me has been my children. Before them, I guess I was just lucky. The thought of how lost I would have been, in this world, without my children scares me. I really feel I would not have made it this far without them. I know that’s a lot to place on the heads of children; it is true though. I have fought for my life because of the worth and love I feel from being a mum.This, of course, may not be everyone’s experience, but how can you know well enough, to take that potential away when they are just a child?

I mourn what could have been, if I was that child, today. That child who craved to be a boy.

I am not alone in my concern about gender and autistic children.24 Autism and hyper focus can become problematic, no matter the chosen topic.25 Senior clinicians within the Tavistock, the UK’s biggest gender clinic, have concerns. I have no doubt there are clinicians everywhere who are scared silent. There has been a 4000% rise in children being referred to Tavistock clinic, and others like it, over the last 10 years.26 An increase this rapid in referrals, for any medical, social or psychological therapy, strongly indicates the need for close scrutiny. Especially in this case, when we are talking about medically and surgically sterilising children. Taking away their ability to mature naturally into a sexual being, permanently altering their physical sex organs. Add to that the lack of data on the physical effects the medications may have. There are indications for potential permanent damage, and disability. We owe it to these children and their families to assess risks and benefits and ultimately to ensure we ‘do no harm’.

Final Thoughts

I am scared for my community. I get upset thinking about people having physical scars from altering healthy body parts. I cry at the regret some people already have for being sterilized in their early teenage years.27 Regret that their healthy breasts have been removed, their voices left permanently deep, and their male pattern baldness. I get so very angry at the rhetoric from people who are meant to help fellow humans to live their best life. I see more agenda than compassion. I get angry about the fear, confusion and untruths that often underpin discussion. Parents are led to believe they have to follow the steps to transition their kids, or their kids will die by their own hand. This has become mainstream. And the autistic community has much more skin in the game than anyone seems to want to acknowledge.

Remember, the things I have written here make some people consider me evil, heretic, nasty and deserving of a punch in the face, or worse. You may not agree with what I say. However, I hope you can at least agree that these kids and their families deserve the right to have all of the options given to them. They deserve the truth, dignity and the ability to make the best choice for themselves and/or their loved one.

Now is an ideal time, and these kids are the ideal motivation for the different groups to come together. To formulate the most ethical and respectful way forward. It upsets me to see how brutal the divisions have become, and how much knowledge and wisdom, from all sides, is lost within the tension. I would hope that these different groups become open to finding ways to develop a gold standard of care. So much energy is being used on trying to prove each other wrong. The ones who have the most at stake here, the young people, become weapons and numbers for agendas. This does them no good whatsoever.

My hope would be that each person, who is referred to a gender clinic, would be screened for autism. And for this process to have a high level of professionalism and care. Self-understanding could allow them to better understand the diversity they naturally hold, in neurology as well as what we understand gender to be. This would also motivate medical professionals to develop autism specific therapeutic plans. Meaning individualised planning and support which would benefit these young people, and their families. They deserve to have the safety and space to figure out who they are, and how they process the world. Most importantly, give them a chance to explore their identity, before any one-directional medical interventions begin.


[1] The origins of the word TERF https://www.transadvocate.com/terf-what-it-means-and-where-it-came-from_n_13066.htm

[2] NHS Gender Dysphoria https://www.nhs.uk/conditions/gender-dysphoria/

[3] Ethical issues raised by the treatment of gender-variant prepubescent children. https://www.ncbi.nlm.nih.gov/pubmed/25231780

[4] https://www.theguardian.com/society/2018/nov/03/tavistock-centre-gender-identity-clinic-accused-fast-tracking-young-adults

[5] The Genderbread Person v4.0 https://www.genderbread.org/resource/genderbread-person-v4-0

[6] One 2015 study that mined Sweden’s large National Patient Registry found that they are 10 times as likely to die by suicide https://www.spectrumnews.org/features/deep-dive/hidden-danger-suicide-autism/

[7] Why people with autism die at a younger age. https://www.healthline.com/health-news/why-people-with-autism-die-at-younger-age#2

[8] Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents https://www.sciencedirect.com/science/article/pii/S2444866417301101

[9] Lupron lawsuits https://www.lupronvictimshub.com/lawsuits.html

[10] Hans Asperger and the Nazi Eugenics Program https://www.spectrumnews.org/news/new-evidence-ties-hans-asperger-nazi-eugenics-program/

[11] https://somegirlwithabraid.wordpress.com/2017/11/29/autistic-moments-autistics-should-be-sterilized/

[12] Court case on serious aftermath of Lupron https://www.ajc.com/lifestyles/health/body-fire-woman-blames-drug-for-pain-sues-maker/SXiOzDSFL694I7LcT4Ra0O/

[13] Growing Evidence for a Link Between GD and ASD https://www.forbes.com/sites/zhanavrangalova/2017/11/15/growing-evidence-for-a-link-between-gender-dysphoria-and-autism-spectrum-disorders/#7ec63e55153e

[14] The Extreme Male Brain in autism theory which subsequently excluded many females from gaining accurate diagnosis. https://www.cell.com/trends/cognitive-sciences/fulltext/S1364-6613(02)01904-6

[15] Sexuality and gender role in autism spectrum disorder: a case control study. https://www.ncbi.nlm.nih.gov/pubmed/24498228

[16] Dual Spectrums https://www.heraldextra.com/news/local/central/provo/dual-spectrums-more-people-with-autism-identify-as-lgbtq-than/article_58f4c198-84e8-504e-911d-db721da53a95.html

[17] At the Intersection of Autism and Trauma https://www.spectrumnews.org/features/deep-dive/intersection-autism-trauma/

[18] Girls with autism at high risk of sexual abuse, large study says https://www.spectrumnews.org/news/girls-autism-high-risk-sexual-abuse-large-study-says/

[19] Autistic Conversion Therapy https://awnnetwork.org/autistic-conversion-therapy/

[20] Evidence of increased PTSD symptoms in autistics exposed to applied behavior analysis https://www.emeraldinsight.com/doi/abs/10.1108/AIA-08-2017-0016

[21] The Costs of Compensation Autism https://www.spectrumnews.org/features/deep-dive/costs-camouflaging-autism/

[22] The Good Schools Guide https://www.goodschoolsguide.co.uk/special-educational-needs/family/gender-dysphoria

[23] Sexual Abuse of Children with Autism: Factors that Increase Risk and Interfere with Recognition of Abuse http://dsq-sds.org/article/view/1058/1228

[24] Whistleblower Teacher Makes Shocking Claim https://www.dailymail.co.uk/news/article-6401593/Whistleblower-teacher-makes-shocking-claim-autistic.html

[25] It is true that most people on the spectrum have a tendency to get very, very interested in their particular subjects. https://www.ambitiousaboutautism.org.uk/understanding-autism/behaviour/obsessions-and-special-interests

[26] Official figures show the number of girls being given gender treatment has risen from 40 in 2009-10 to 1,806 in 2017-18. https://www.thetimes.co.uk/article/inquiry-into-surge-in-gender-treatment-ordered-by-penny-mordaunt-b2ftz9hfn

[27] When a Child Says They Are Trans https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749/

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