Autism & Gender Identity – Autism, Gender and Society

6.1 Schools Guidance

Stonewall are leading the vanguard of organisations providing training and guidance to schools, to fulfil the LGBT requirements of the new statutory RSE curriculum.^{^[1]} Other organisations include Educate & Celebrate, the Intercom Trust, the Allsorts Youth Project, ^{^[2]}and the Proud Trust. Notably, the schools guidance produced by these organisations doesn’t mention Autism or wider SEND issues, with the exception of The Allsorts Youth Project guidance and the relaunched Stonewall schools guidance.

To the untrained eye (and training for school staff about Autism is usually only a basic overview) it looks legitimate because some of it is – the information about Autism and SEND is accurate but unconnected to LGB orientations or Trans identities. Earlier versions of their guidance suggested that SEND pupils just need to have trans identities and issues around transition explained more accessibly. This remains as a core message, but is surrounded by more generalised SEND guidance.^{^[3]}

They are clearly addressing Autism but ignore the complexity and breadth of other SEND conditions. There is also nothing in their guidance aimed at supporting children with physical disabilities who may grow up and navigate LGB relationships or gender identity issues.

For children with gender dysphoria, there is little discussion of how they may be supported to approach and manage relationships. Teen and adult sexuality navigated through the locus of a trans identity are beyond the scope of schools guidance but are nonetheless an important aspect of transition that is often not discussed. For children who undergo a medical pathway, the reality of underdeveloped genitalia and remaining in a temporary state of arrested development while they watch their peers go through puberty, grow taller and more emotionally mature and then have to try and navigate a sexual relationship with a medically altered body will be exceptionally challenging but these complex realities must be raised. One of the difficulties with the notion of the ‘trans child’ (as opposed to a child with gender dysphoria who with support may desist) is that the realities of transition are too complex to explain appropriately to children and be understood, so they must be hugely simplified. In doing so however, children both autistic or not, will be given unrealistic expectations of transition.

What is notable by its absence is that many autistic and SEND pupils will have an Education and Healthcare Plan (EHCP). These are legally binding documents that outline the steps a local authority and school must put in place in order to meet the educational and health related needs of a child. They are detailed documents with a high degree of specificity about the support in place, how it is funded and who is responsible for the provision concerned. They are reviewed yearly and revisions can be made, but on the basis of provable need.

A child with a SEND profile who is socially transitioning or who has been prescribed puberty blockers should have this flagged up within the context of their SEN Support plan or EHCP; given that they can be in place until the age of 25. Further, how would the safeguarding duty of the various multi-disciplinary teams that support SEND children and/or the provision of EHCPs (the Early Intervention Team, Team around the Child, or an EHCP review panel) fit with mandating and managing support for a social or medical transition? The assortment of schools guides simply avoid the issue altogether.

There is no indication in their advice about how identity formation may differ in autistic children, or children with other disability-related needs and no correlation between Autism and the huge rise in referrals to The Tavistock GIDS. The answer to an exponential increase in referrals with 48% of all referrals from children with autistic traits, shouldn’t be an enlarged chapter in schools guidance; it should be an urgent enquiry into what might be happening with this particular, already marginalised cohort of children and young people.

One of the most obvious omissions is information or resources for young people who either desist or detransition. The only guidance that seems to be given by any of the organisations supporting trans young people, is ‘some people may desist or detransition, but it’s rare’. There is no signposting to support, or acknowledgement that having gone through the process of social transition, and possibly the start of medical transition, that a more robust mechanism for support will be necessary.

It is precisely this lack of resources that makes the schools guidance so incredibly concerning from a safeguarding point of view; the direction of travel is assumed to only be one way and so support is only given on one direction.

It is my opinion that hundreds of young people who wouldn’t have considered themselves trans in the past, are now adopting that identity because they are having entirely normal feelings portrayed to them as a trans identity. The schools guidance approaches the teaching of gender identity with a one-size-fits-all approach, tempered with an acknowledgement that an autistic child may need a clearer explanation. What isn’t addressed is that for autistic children, who can take longer than their neurotypical peers in terms of emotional development, teaching of RSE and LGBT issues needs to be carefully tailored to their emotional and cognitive understanding.

The national safeguarding framework Keeping children safe in education^{^[4]} is clear about the need to not place developmentally inappropriate expectations on a child as well as the need to be mindful of the diverse needs of the children in their care. The RSE curriculum is one area where this is particularly important, both for adjusting lessons to provide clear information that can be understood, but to check back and make sure that communication needs are being met. It is hard to imagine the potential confusion for autistic children reading the Gendered Intelligence trans youth sexual health booklet^{^[5]} (available via the Proud Trust resources page) with its statement ‘A woman is still a woman, even if she enjoys getting blow jobs. A man is still a man, even if he likes getting penetrated vaginally’.

An autistic child, depending on their profile, may not have an accurate concept of what a relationship is, or should look like. Alexythymia and low levels of interroception may leave them with no way to make sense of confusing feelings, emotions and sensations. They may have an entirely different concept of what sex and relationships involve than may be assumed, and this may leave them open to abuse or coercion.

Rather than trying to ‘bend’ an autistic child around neurotypical concepts, it is more appropriate to tailor an RSE curriculum, with safeguarding in mind, around the diverse needs of the child, taking into account the very different process of social and emotional understanding, therefore teaching the RSE syllabus in a way that plays to their strengths.

The Proud trust have a video on their website where three young transgender identified children are interviewed about how they knew they were trans and what they want from a supportive school environment.^{^[6]} Zach, who identifies as a boy, says ‘What I would have changed about my school is the teachers being more casual about it, because the teachers thought it was a huge deal’.

Charlie, identifying as non-binary, says of their realisation that they were trans/non-binary, ‘At primary school, we were divided up into boys and girls and I didn’t feel like it was fair’. Lastly Natalie, identifying as a girl, observed that ‘you just know’ when asked how they knew they were transgender, adding at the end ‘I’m just me, really’.

These young people have provided heartfelt testimony about why they chose their identities, but the reasons given are simplistic enough that autistic children watching this film are likely to see themselves in the young protagonists. However, I argue that what so many autistic young people are experiencing as gender dysphoria, are in fact common worries about how to navigate puberty. A review of research shows that between 60 and 90% of young people with gender dysphoria will desist^{^[7]} – suggesting that most autistic young people who are supported through puberty will not continue to identify as trans.

Autistic children and young people can often interpret information in unexpected ways. The assumption so far, is that as a growing number of autistic children are identifying away from their natal sex, so we should treat them all as though they are actually the opposite sex, or non-binary as appropriate.

Anecdotally, parents report that autistic girls are talking to each other about the possibility of using puberty blockers not as a way of changing identity, but as a convenient way of halting the development of their breasts and periods. To these children they are simply another option; a medicine that appears to be readily available if you follow the right script which is easily accessible on YouTube or Tumblr. This is reinforced by the number of young transmen posting videos about their transition and making it seem not just easy, but edgy and cool.

Stonewall’s guidance encourages teachers and school support staff to affirm a trans identity, on the basis that the child will know better than you who they are. However, identity formation in young people is a long and complex process during which they will try on many identities for size before reaching adulthood. The idea that a child can have a fixed identity at such a young age, with no possibility that they will change their minds, goes against everything that we know as a society about child psychological development. The idea that adults working with neurodiverse children can easily navigate these uncharted waters based on the scant guidance provided, is unrealistic in the extreme.

It is important to teach children, as part of LGBT education, that a very small number of people suffer from a mismatch between their sexed body and their sense of themselves as a male or female, and that they may choose to live differently. That this is not an excuse for unkindness, or cruelty, and those who are unkind, cruel or who hurt trans people are breaking the law, just as others who are Homophobic, Lesbophobic or Biphobic are breaking the law. That this sits alongside discrimination based on Race, Sex and Disability in the Equality Act, and breaching it is a criminal act.

It is important for educators to acknowledge that children may know people who are part of the LGBT Community, this may include their families and is part of what makes our society so rich and varied and valuable. That children may grow to realise that they themselves are part of the LGBT community and that they are protected. All this should be simple to do. But it should be done without telling children and young people that if they like things that we have arbitrarily designated for the opposite sex, or if they like a mixture of both, or if they don’t feel male or female, that they are Trans.

This is complicated by schools outsourcing this teaching to groups, many of whose educational focus is built around an activist agenda. The excellent Children’s Rights Impact Assessment of the Allsorts Youth Trust schools guidance by Helen Saxby^{^[8]} highlights a lack of attention to safeguarding within it, resulting in many local education authorities withdrawing it. However, it shouldn’t take these measures for local authorities to examine the toolkits their schools are using, and assess whether or not they breach not only safeguarding guidelines but also the Equality Act.

If teachers or schools staff come across information that they are unsure about yet don’t feel able to question within the school setting, this should ring alarm bells. There is nothing related to working with children, no theory related to education or the care of children, that should be beyond question. Schools are bound by legislation that governs child safeguarding, and with that in mind, there should be nothing that cannot be raised and no questions that are off limits when it comes to safeguarding concerns.

1. The National Autistic Society

As the leading advocacy organisation for autistic people in the UK, the National Autistic Society (NAS) is often the first port of call for autistic people and their families to find information that is accurate, up-to-date, and that they feel they can trust.

There is no doubt that the NAS wants to do the best it can for the autistic community and there is a wealth of well-researched information as well as links to academic centres of excellence such as The Tizard Centre at the University of Kent.

The NAS Gender Identity page^{^[9]} opens with this confusing statement: Gender Identity and sex are different things. People are usually assigned a gender at birth according to their genitalia – male or female

How someone feels about their gender is known as gender identity. Some people identify as the gender they were assigned with at birth, others don’t. Some people may be assigned male at birth, but identify as female. Some may be assigned female but identify as male, or people may identify as neither female nor male. Some people may feel both male and female at different times. We all express our gender in different ways, for example in how we dress and act.

From the start, they confuse biological sex and the concept of gender by using the words both interchangeably and to mean different things. It is this confusing wordplay that makes it so hard for people to navigate this subject. Given that the NAS exists to support people with a neurological difference in the areas of social communication and understanding, it is hard to understand why they would write about this subject in such a confusing fashion.

They do link to a number of articles and research papers, but these are not reassuring. While the NAS and their team supporting trans youth clearly want to support autistic children with gender dysphoria, the support links are to Mermaids, Stonewall and GIRES (the UK Gender Identity Research and Education Society). They also link to Young Minds, a mental health charity for children and young people, but qualify it by stating that they don’t tailor their information to autistic young people; in fact, none of the organisations listed cater for gender dysphoric autistic children – they are expected, as in so many other areas, to just fit in around information geared to a neurotypical audience. In fact, a quick look for Autism on the Stonewall website at the time of writing, brought back the message ‘sorry, no results found’.

The Mermaids website appears not to have a search function at all, but at the time of writing, there didn’t appear to be any reference to Autism. A search on the GIRES website brings up seven webpages about Autism, mostly discussing the link between Autism and gender identity.

The link that the NAS give on the same page for the clinical guidelines for Co-occurring Autism and Gender Dysphoria or incongruence^{^[10]} states in the abstract both that there is an overrepresentation of youth with co-occurring Autism but also acknowledges that there are no guidelines for clinical care when ASD and GD co-occur. But two of the contributors to the study, which incorporates what is described as best clinical practice of current experts are Dr Norman Spack and Diane Ehrensaft. Both Spack and Ehrensaft are proponents of the gender affirmative model for children. Crucially, the study acknowledges the complications inherent in diagnosing gender dysphoria in autistic children:

Diagnosing GD can be complex in adolescents with ASD due to ASD-related weaknesses in communication, self-awareness, and executive function. For example, ASD communication deficits can result in unclear, tangential communication, which can make it difficult to know how an adolescent truly feels about their gender. ASD-related executive function deficits may result in concrete thinking and struggle with ambiguity and future thinking, which can make assessing an adolescent’s understanding of the long-term implications of gender transition/treatment challenging. In addition, ASD-related flexibility difficulties can limit a young person’s ability to embrace the concept of a gender spectrum or that gender can be fluid; adolescents with ASD may present with more “black-and-white” thinking about gender.

NAS also link to a paper by van der Miesen et al, called ‘Is there a link between Gender Dysphoria and Autism Spectrum Disorder?’^{^[11]} The paper contains this measured acknowledgement:

Given the low-grade evidence in this field for most clinical recommendations, good-quality research is of great relevance. We support the debate on the GD-ASD literature and acknowledge that translations of the findings to the lay press such as “Do transgender children just have Autism?” are not helpful. Also, we agree with many of the limitations brought forward by the authors and acknowledge that, at present, sound underlying evidence for a GD-ASD link is lacking. However, we believe that some nuance in argumentation could help forward the debate of this clinically important topic.

Following the full High Court case which highlighted that the Tavistock GIDS have kept no statistics or records about the number of autistic children they have referred on to medical pathways^{^[12]} as well as the recent decision by the Karolinska Hospital in Sweden to stop prescribing puberty blockers and cross sex hormones to dysphoric children under 18,^{^[13]} we think that the NAS should be more cautious in their approach.

As the largest advocacy organisation in the UK for the autistic community, the NAS have a duty to act responsibly on the issue of gender dysphoria and autistic children and young people. In the light of the increase in media coverage and awareness of the last six years, it is no longer possible for any organisation, least of all the NAS, to state that they were unaware of the unprecedented increase in children with gender dysphoria and the link with Autism.

At the very least they should be reporting responsibly and in order to do that, they must review the evidence. The NICE review of the evidence base for treating children and adolescents with puberty blockers^{^[14]} and cross sex hormones^{^[15]}, both of which indicate a sparse evidence base, is echoed by international clinicians. In addition to Sweden, concerns have been voiced by clinicians in the Netherlands, as noted by Dr Thomas Steensma from the Centre for Expertise on Gender Dysphoria at Amsterdam UMC.^{^[16]}

Further, Michael K Laidlaw MD, an endocrinologist in California and member of the Society for Evidence Based Gender Medicine (SEGM), has written extensively about the potential harms of suppressing puberty^{^[17]} while SEGM has highlighted the huge rise in children globally presenting with gender dysphoria with autism and ADHD and noted that ‘the reasons for these changes are understudied and remain poorly understood’.^{^[18]}

Three of the professionals who have submitted research papers to the NAS’s Network Autism platform are Dr Wenn Lawson, Dr Sally Powis and Joe Butler, a SEND Consultant who provides training alongside Stonewall trainers, on supporting SEND LGBT children in school.^{^[19]}

Dr Wenn Lawson, a trans man who specialises in research on Autism in females, is, rightly, a hugely respected figure within the autistic community. Much of what they write in their paper Gender Dysphoria and Autism^{^[20]} is based on their own journey with dysphoria and transition. Dr Lawson is in fact, one of the few contributors who acknowledges the need to ‘appreciate the costs – emotionally, physically, socially, medically and financially’ of transitioning. They are also very clear that the ‘decision to transition must never be considered lightly and must always be closely monitored by a specialist physician (eg: endocrinologist). They also, in stating that sexuality and gender identity are not binary concepts, acknowledge that they may change at various points during one’s life. While these are both sensible points to bear in mind, what we know is that in the current climate, there simply aren’t enough resources to provide the level of psychotherapeutic work that is needed to potentially unpick the basis for a trans identity in an autistic young person, and assess properly whether any gender dysphoria is rooted in other factors, such as autistic difficulties with puberty, sensory issues or theory of mind, mental health diagnoses, sexual abuse or the rejection of – or confusion around – sex based stereotypes.

Dr Lawson is very clear that, for autistic people, a special interest, obsession or an attempt to mimic a peer can often be mistaken for gender dysphoria; what they describe as single-minded thinking. Dr Lawson ends their paper with the observation that ‘It’s not about us choosing this, but about ending the struggle of living with a disconnection from who we really are, in other words, it chooses us’. An observation that I suspect resonates with most autistic people who turn to the gender diverse community as a place where they will be welcomed, as opposed to many neurotypical communities where they struggle to find a place that they belong.

Dr Sally Powis, Consultant Clincial Psychologist at Kingswood Trust and Spectrum Specialists, in her 2017 paper Gender dysphoria and Autism: Challenges and support,^{^[21]} acknowledges that for many autistic children and young people, the desire to transition can be a reflection of confusion, a fetish or distress at growing up. She acknowledges that it can be difficult to help autistic people with reduced cognitive ability to understand their feelings, find a way to help them communicate them and decide on the best outcome for them.

This contrasts with the Stonewall, Mermaids and Gendered Intelligence approach of affirmation, and raises the possibility of young people embarking on medicalised pathways without the necessary cognitive understanding.

Dr Powis suggests that gender clinics will want to embark on work with a therapist to explore these feelings, but this approach been exposed as uneven at the Tavistock GIDS by Newsnight. The ‘extended psychiatric evaluation’ she mentions as part of the requirement for medical treatment was found to be variable in its application.^{^[22]}

Powis is very clear about the likelihood of autistic girls being gender non-conforming and finding difficulty tuning in to the social cues of peers, as well as a fear of changes to the body during puberty and she acknowledges the high rates of suicidal ideation in the autistic population. However her assertion that gender specialists are becoming more aware of Autism needs to be shored up by robust training of all gender clinic staff including the many and varied ways that Autism can present.

Joe Butler is a SEND Consultant who provides SEND LGBT training in conjunction with Stonewall, and has helped produce the Allsorts Youth trust schools guide. She has written a paper for the NAS Supporting trans and gender questioning autistic pupils. ^{^[23]}

She writes from the perspective that autistic pupils who identify as trans probably are trans and her advice is to ‘ensure that a pupil’s expression is not automatically attributed to Autism i.e. clothing preferences or hair length seen as a sensory need or behaviours explained as special interests.’

She suggests that staff should advocate for a pupil in the event of barriers to communication or misconceptions, such as the pupil lacking capacity. This is a valid observation, however, the majority of school staff working with autistic children on a day-to-day basis across the UK don’t have the depth of understanding of Autism as well as gender identity issues, to be able to manage this safely and confidently.

She talks about staff having an awareness that some girls with sensory issues may experience the emotional impact of not being able to manage wearing a binder, but neglects to add that many autistic girls may be attracted to wearing binders precisely because they need the extreme pressure as a way of self-soothing throughout the day. For some girls, they may become confused that this means they are trans as opposed to a girl who has specific sensory needs.

As well as signposting to Gendered Intelligence and Stonewall as support organisations, she also suggests that other pupils should be supported and educated when a peer transitions. This is followed by an observation that transition is easier in a school where a culture and curriculum have gender identity embedded in it; therefore adding an additional layer of difficulty and challenge to pupils with social communication difficulties who may find it very difficult to understand complex concepts like transitioning.

Schools are also encouraged to make gender neutral toilets available, be led by the wishes of the child, and to be explicit that the school proactively teaches about gender and trans awareness. All of this is prescribed without any mention of safeguarding, either of the gender dysphoric child or the other pupils in the school.

Part of the role of the NAS is to encourage an exploration of this ‘conceptual separation’; Given that the number of autistic young people identifying as trans is significant, and the lack of a robust evidence base for the affirmative model of treatment now recognised, the delay in addressing these issues is extremely concerning.

6.3 Parenting and Autism

Parenting an autistic child, as with any kind of additional needs, can be incredibly challenging. Much of the challenge arises as a result of the barriers faced by autistic children and adults when navigating a world that simply isn’t designed to match up with an autistic mode of processing. If we understand the brain as an operating system, then the autistic population are navigating the world using Apple’s iOS system, while the world has been designed for a population running on an Android system.

Add into this the fact that although the majority of people are now aware of autism, most don’t really understand autism. This is perhaps understandable given that most training and information provided about autism can only give an overview; every autistic person will have a different profile of social, emotional, communication and sensory needs that is unique to them so there can never be a one-size-fits-all set of tools for supporting autistic children. Funding across the country provided to local authorities for SEND support are not ringfenced by schools for use by individual pupils, nor are they required to report back to the government how the money is spent, so levels of support vary across local authorities.

It is also the case that autistic children often have at least one parent with autism or other neurodiversity but these are often undiagnosed. All these factors combine to mean that parents of autistic children, particularly if they are neurodiverse themselves, can be a constant uphill struggle. It can be absolutely exhausting to have to fight for every resource that your child needs, while local authorities who are chronically underfunded, are fighting to hold on to them. Adding gender dysphoria into this already fraught mix may feel like one issue too many, or at least one issue that many parents will feel ill equipped to manage. In these circumstances parents can’t be blamed for turning for advice to the organisations that they are signposted to by CAMHS and by schools; Mermaids, Gendered Intelligence and Stonewall. As these organisations are heavily skewed towards an affirmation approach, it is essential that autistic advocacy organisations, schools, youth organisations and statutory bodies like CAMHS and the NHS interrogate the resources they are using and ensure they are in line with the most up to date recommendations of the interim Cass report, NICE guidelines and Department for Education guidelines around using fact based and evidenced resources.

6.4 Parenting and Identity

Parenting in a digital age is exceptionally challenging. In the online social landscape children are increasingly competing for affirmation of their worth among strangers and competing for attention from a range of online influencers who have replaced pop stars and actors in the firmament of celebrity.

A possible contributor to the acceptance of identity politics among some parents has been the desire over the past few decades to tell our children that they are special. On the contrary, the vast majority of us are quite delightfully ordinary, and all the better for it. Most of us lead quite similar lives, surrounded by friends, family and colleagues, enjoying pleasures, joy and laughter, tempered by emotional pain, illness and loss.

It’s likely that what the majority of parents actually mean when they tell their children ‘you’re special’ is ‘you have value and you are loved’. Because it’s true; everyone does have value and is worthy of love. But the words we use to describe our children are inadvertently distorting that, along with a sense of their place in the world.

For recent generations of young people, the idea that they can achieve anything they want can, in many cases, set them up for disappointment when the reality of adult life is realised; the realities of the job market, a natural ability in one area not aligning with the ability needed to follow their dreams and financial insecurity all often provide a rude awakening. This is exacerbated by the proliferation of reality based television shows, promoting the idea that fame, glamour and happiness are there to be won, and that any of us are capable of winning them. It is no surprise then that for some autistic children, it is easier to live within this dream world where they are accepted, loved and valued in a way that day to day school life can rarely match.

For autistic children, the lure of instant acceptance is incredibly hard to resist and affirmation model allows children and their parents to be celebrated without qualification; the irony comes as we realise that in affirming a binary sense of cross-gender, we reinforce the very gendered stereotypes that we purport as a society to have been trying to dismantle.

It can be tremendously hard to look at your child and see them suffer. But we accept, as parents, that this is a part of their journey to adulthood. A necessary yet exquisitely painful process that they must pass through in order to develop a secure sense of self. Identity is something that all young people wrestle with, often trying on a variety of personas for size, before amalgamating their fractured adolescent selves into a rounded and secure adult.

There can also be an overwhelming urge to protect our children from pain, to continue to ‘kiss it better’, to solve their problems for them, despite our knowing that we cannot protect them forever. Indeed, for young people, developing the skills to face and then navigate their own emotional landscape, is an essential part of growing up and developing emotional intelligence and resilience.

For some parents, seeing their child’s pre-pubertal body gain strength and height and secondary sex characteristics may be difficult. Watching their child grow may cease to be a journey of wonder and cause feelings of panic and dislocation at the realisation of their own mortality or possible redundancy in their children’s future lives.

This shouldn’t necessarily be; healthy families have healthy relationships and a parent’s strong sense of self allows for a life after parenthood (which is potentially a life long journey anyway). As we age our relationship with our children deepens as they develop their own personalities and opinions and realising that we are no longer the centre of our children’s world can be a crushing but necessary realisation. The problems come when we refuse to let go.

It is also the case that many parents of autistic children are autistic or have ADHD or are otherwise neurodivergent. This is something that parents are becoming increasingly aware of, as they start to view their own traits through the filter of their autistic child. This has proven to be increasingly the case with women, many more of whom are now seeking diagnosis themselves following the diagnosis of their daughters.

Parenting as an autistic adult comes with it’s own unique challenges as there is no guarantee that an autistic parent will have a similar sensory, social or learning profile to their child; this can cause difficulties when there are competing emotional or sensory needs and can be a difficult situation to adapt to.

There are also incidents of autistic parents adopting a non-binary or trans identity after their child has developed gender dysphoria or a trans identity, which may not be unexpected if they are looking for resources to support their child. As a great deal of information for parents is based around the concept of gendered behaviours, which themselves are socially constructed sex based stereotypes, it is understandable that they may then recognise themselves in these descriptions, particularly as they are more likely than average to be gender non-conforming themselves.

The risk is that there may then develop a situation wherein either the parent and child become dependent on each other for validation of their identity, or where one may feel unable to change their mind for fear of invalidating or upsetting the other.

Finally, the stresses of parenting a child with disabilities shouldn’t be underestimated. A significant proportion of families with autistic or otherwise neurodivergent children are lone parent families. If they are able to work, this is likely to mean a lower paid job or a job with part time hours. Supporting children while navigating an often complex social care system, communicating with schools or colleges, managing hospital and CAMHS appointments and monitoring and supporting EHCP/SEN Support provision, can lead to periods where they become overloaded and need to decompress.

1. Suicidal Ideation

The autistic population already have a heightened level of suicidal ideation compared to their neurotypical peers, and in particular if they have the label of ADHD. ^{^[24]} The National Autistic Society website provides information outlining the reasons for this in the wider population while also listing additional factors that may affect the autistic community. it is vitally important therefore, that these levels of risk can be teased out and separated from the figures attributed to children and young people with gender dysphoria as they are likely to have entirely separate origins.^{^[25]}

In their podcast Gender – A wider lens,^{^[26]} Sasha Ayad and Stella O Malley (both therapists working with gender diverse young people) state that it’s very unlikely that young children will complete suicide, a fact that is echoed by the Tavistock’s own research, which estimates that the rate of suicidal ideation and self-harm is no higher than that of CAMHS users.^{^[27]}

In fact, the two usually quoted pieces of research in the UK regarding the rate of suicide attempts by trans identifying youth, are the 2014 PACE study with Brunel University and the 2017 Stonewall Schools Survey. The difficulty with both these is that they are based on online self-selecting respondents, with no controls for previously existing mental health problems.

The data showed that of the 2000 self-selecting LGBT respondents, there were only 27 trans identified young people under the age of 26. Thirteen of them reported attempting suicide although there was no further disaggregation to indicate when this was (either pre or post transition), if it coincided with incidence of co-morbid mental health difficulties, or whether it was related to sexual orientation (across the wider survey, Gay and Lesbian respondents all reported higher levels of suicidal ideation).This was confirmed in correspondence with the lead researcher, Dr Nuno Nodin of the University of London – Royal Holloway.^{^[28]}

Nevertheless, the PACE study result was misrepresented by the Guardian newspaper, who neglected to clarify the sample size of 27 in its assertion that 48% of trans youth have attempted suicide.

Of course, thirteen is still too many, but the greatly reduced cohort number suggests that the sample size may be too small to be conclusive and the suicidality may be attributed to other issues than simply being trans. Indeed, the Samaritan guidelines have always been abundantly clear that any reporting of suicide should never attribute suicide, or suicidal ideation to one single cause. In addition, body dysmorphia, eating disorders and emotionally unstable personality disorder are all common alongside autism, and all have comparatively high rates of suicidal ideation.

For clarity, longitudinal research collated in 2012 by Dhejne et al, indicates that post transition, the likelihood of death by suicide remains high.^{^[29]} Unfortunately having been misrepresented in the media, the figure of 48% has been continuously repeated, however without the additional contextual information.

Ayad and O Malley observed that adolescents in crisis situations often have passing suicidal thoughts, but these very often relate to wanting difficult feelings or situations to stop, rather than actually wanting to die. They also note that self-reported suicide attempts can vary significantly from a serious risk of death to taking four aspirins.

It is important to recognise the seriousness of young people experiencing mental health difficulties. Indeed, the landscape in which this is happening is fraught because of the paucity of funding for CAMHS and local charities and groups who support young people. However, it is fair to say that a significant factor in encouraging parents along an affirmation path is the ever-present spectre of the death of their child.

This is happening alongside young people online and in schools encountering the idea that if they are not allowed to transition, that they themselves will feel suicidal; in this way it risks becoming a self-fulfilling prophesy. In addition, as Ayad and O Malley observe, for young people, the possibility of suicide represents an option of control for them, at a time when they are navigating a raft of conflicting and important feelings.

Part of the narrative around the idea of transgender children is that while we are told that being trans isn’t a mental health condition, it nevertheless brings with it a higher than average risk of mental health problems. This is rationalised by placing the blame for the mental health difficulties outside the child, and locating it in the people around them; those who are not accepting their identity in the same way they see themselves.

Despite the ethical problems inherent in making the community responsible for a child’s ongoing good mental health, this claim is repeated widely. Transgender support charity Mermaids have recently extended this claim to the concept of misgendering. They commissioned a survey of 2000 UK adults conducted by Censuswide to gauge understanding of pronoun usage among the general population and carried out a self-selecting survey of young people via their Instagram page. On their website, under the heading ‘pronouns and prejudice’, they reported that 86% of British adults don’t understand that negative mental health is one of the most likely impacts of misgendering someone. In addition, only 6% of adults polled ask each new person they meet their preferred pronouns, with 45% stating that they don’t feel the need to ask and 22% assuming the pronouns they would use based on appearance. ^{^[30]}

These results are described by Mermaids CEO Susie Green as ‘A misgendering crisis, with the UK public not understanding the mental health impact that using the wrong pronouns can have on young minds.’ Instagram personality Ellesse Char goes on to claim in their video for Mermaids that misgendering someone ‘can cause so much harm’ but without offering any explanation of what this harm might be.

The well-publicised risk of suicide in young people with gender dysphoria recently led the Swedish Government to consider a bill that would allow 15 year olds to undergo sex reassignment surgery without their parents’ permission. This was based on a 2015 Public Health Agency report in which 40% of young people stated that they had attempted suicide. Despite this being referenced in five separate places in the report, there was no source provided.

Speaking in the Swedish documentary The Trans Train,^{^[31]} Angela Samfjord the Head of Child and Adolescent Psychiatry at the University of Gothenberg commented that ‘there is a very clear predominance of the female sex, up to 85% with high psychiatric morbidity and 90% with some psychiatric diagnosis. 80% have two or more psychiatric diagnoses. 45% are self- harming, 20% have an autism diagnosis but another 35% had so many symptoms that we wanted to refer them for a full evaluation.’ This statistic reflects a similar percentage of autistic children attending at the London Tavistock GIDS. She went on to describe how clinicians were expected to initiate affirming treatments; something she described as playing on her conscience and as being unprepared for.

Danita Wasserman, Professor in psychiatry and suicidology at the Karolinska Institute in Sweden, is extremely sceptical of the claimed 40% rate of suicide attempts in the 15 – 19 year old age group. Speaking in the documentary, she said, ‘In the scientific world we say that if you get surprising results, the first thing you do is verify they are really correct; that there’s no error in method, in interpretation or that the study population isn’t highly unusual. There are very many pitfalls to this kind of study.’ She was clear that she felt the study was unreliable and that she had serious doubts that the suicide attempt rate is as high as claimed.

The Swedish Public Health Agency also distanced itself from the statistic, advising that ‘it is important to apply caution when interpreting these results. As a cross -sectional and self- report study, it is not randomised or verifiable.’

When challenged, Britta Bjorkholm, Department Head at the PHA Sweden, changed tack and suggested that a large proportion of transgender youth are troubled by suicidal thoughts and many have attempted suicide. The legislation is based on ‘uncertain data’ leading the documentary makers to question whether the clinic even knew what constituted a beneficial approach for gender dysphoric youth. Whether sex reassignment surgery at 15 reduces the number of suicides wasn’t interrogated within the report, with Bjorkholm admitting that they didn’t ‘conduct any such analyses.’ Further, Lena Hallengren, Minister for Health and Social Affairs stated that the figures were ‘common knowledge; no-one questions that.’

This is similar to both the misrepresented PACE study and the Stonewall Schools Study, both of which were based on self-selecting online respondents with neither study controlling for pre-existing mental health conditions.^{^[32]} While the media, lobby groups and MPs repeat the assertion that 48% of gender dysphoric children and young people have attempted suicide, the data on which these claims are made is considered to be unreliable.

Wasserman points out that vulnerable people are discouraged from making life-changing decisions when they are depressed or grieving, so why would oppositional advice be given to this vulnerable group of children when it is known that many of them are depressed and anxious; to this end she recommends talking therapy throughout puberty. It remains inexplicable that despite the Swedish cohort of GIDS patients having an even higher rate of autistic referrals than the Tavistock GIDS (55% comprised those with a diagnosis of autistic traits compared to 48% for the Tavistock) that there remain no research studies investigating why this is the case. This is important given the increased risk of suicidal ideation already evident in the autistic population. In the meantime, Swedish Gender Identity clinics for adolescents have seen a 30% drop in referrals since the Trans Train documentary was broadcast.^{^[33]}

1. Detransitioners

Genspect is an organisation comprised of therapists, clinicians, academics and members of the trans community who are advocating for parents of gender-questioning children and young people. This year, it hosted the first DeTrans Awareness Day conference. It featured an array of young people speaking about their experiences of medical transition and their later realisation that the concept of being trans was masking other issues such as homophobia, an awareness that there wasn’t enough therapeutic intervention and that issues such as being Lesbian or autistic were either unacknowledged or masked by immersion into a transgender identity.

Twenty-two year old detransitioner Allie spoke eloquently about her transition at the age of nineteen and her detransition. Upon detransitioning, Allie was diagnosed autistic and recognised that living as undiagnosed autistic was a significant factor in her decision making process.

Ever since I grew up, I was a Tomboy, a very masculine child and I was raised in a very masculine environment…I always struggled to get along with girls.

There is a growing awareness, especially since the high profile judicial review led by detransitioner Keira Bell, that there is a sizeable and ever growing community of detransitioners; young people both male and female who transitioned as children or adolescents and have now begun the process of either detransition; reversing where possible the physical changes wrought on their bodies by hormones and surgery, or desisting: realising that they are not dysphoric or that the gender identity that they adopted is not an accurate reflection of who they are and that they are reconciled to their sexed bodies.

Peter lived as a woman until his late forties when, after extensive therapy, he became a trans man. “I just knew I had to do this to be happy. I was simply not a woman.” He now runs a trans support group and is aghast at an online culture pushing young lesbians into hasty transition. “I think some of them actually want to hold on to the transitional state. For a girl who was once marginalised, it has prestige. You post videos updating your progress. You get endless attention.” But actually living in your new gender can be a letdown. “They find their old problems have not gone away. And we pick up the pieces.” Peter knows trans boys who consulted private doctors to obtain hormones without prior counselling “and now they’ve had a breakdown and are asking Facebook friends to donate money for therapy they should have had first.” ^{^[34]}

One of the most compelling reasons for carrying out serious research on the link between the exceptionally high number of children and adolescents who are autistic and presenting with gender dysphoria is that the number of detransitioners with the same traits is again, far higher than one would expect from a community that makes up 1% of the population. There are a significant number of detransitioners who are autistic – this in itself is reason enough to give pause because something somewhere has gone wrong with the system within healthcare that is assessing and processing and suggesting pathways for these children.

A 2021 research paper by Elie Vandenbussche, Detransition related needs and support; a cross sectional online survey showed that 54% of the detransitioners surveyed experienced at least three diagnosed co-morbid conditions. The three most common were depression (70%), anxiety disorders (63%) and PTSD (33%). Among the detransitoners surveyed 20% had a confirmed Autism diagnosis with a further 26% with suspected autism. This is in line with the prevalence of reported autism and autistic traits among referees to gender identity development clinics and so it is expected that similar figures would be reflected in detransitioners.^{^[35]}

A recurrent theme in the research was that a significant number found it difficult to talk about detransition within LGBT spaces, with some mentioning feeling rejected. In addition many reported finding it difficult to find a therapist who was willing to discuss the reasons behind detransition with one saying “I was doubtful that transition would help my dysphoria before beginning and was assured by multiple professionals that transition was The Solution and proven to work for everyone with dysphoria. A ‘gender specialist’ therapist flat-out told me that transitioning was the only method of reducing dysphoria that worked when I expressed my desperation for an alternate solution.”

Reasons given for detransition indicated that 70% felt that their gender dysphoria was related to other issues. 50% felt that transition didn’t help with their dysphoria and 45% found alternatives to help with dysphoria. The vast majority have given reasons for detransitioning that strongly indicate that the assessment processes for transition are simply not robust enough.

These are all young people, whose average age at detransition was 22. Many autistic children are incredibly intelligent and it may be assumed by clinicians that they are not capable of giving consent if they are non-verbal or selectively mute; while these things do not correlate with being incompetent, all autistic children and adolescents need to be screened for their ability to genuinely give consent given that 70% of the detransitioners realised that their dysphoria was not related to gender identity.

Pablo Expositos-Campos, in the paper A Typology of Gender Detransition and Its Implications for Healthcare Providers, highlights the need for a robust set of supportive clinical guidelines to support detransitioners to include therapy, support in coming off medical regimes such as hormones as well as reversing, where possible, surgical procedures, and support informing friends, family and community that de-transition is taking place.^{^[36]}

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