4. Puberty, Autism and Gender Identity

One of the aspects of Autism that can cause enormous difficulties is navigating change, or transition. Transition covers everything that happens during the day, from the moment our eyes open and we transition from asleep to awake, through getting dressed, eating, or changing activity or class in school. Anything that can be described as moving from one state to another or one activity to another, can be challenging for autistic children and young people.

Possibly the biggest transition that a young person will experience is puberty. For autistic children it can be traumatising, as the body they are growing up in suddenly starts to change. Maintaining control is a common technique for managing transition and anxiety, but puberty is the one area of change that they cannot control or stop. It is not uncommon for puberty to trigger gender dysphoria in autistic children, but it is important to note that having gender dysphoria is not the same as adopting a transgender identity. They can go together, but they are not the same thing.

We have spoken to parents whose daughters have asked for puberty blockers as a way to stop their periods, or the development of breasts or body hair. Information about gender dysphoria is widely available online; for example the Childline website contains a video ‘Trans Puberty Myths’[1] in which the presenter Tio, chats with YouTuber and transman Alex Bertie and transwoman Charlie Martin about puberty. Tio explains that young people can go to their GP or medical practitioner and be prescribed hormone blockers. He also suggests that some GPs can be ‘a bit tricky’ and if so, that young people can change their GP to find one who is more sympathetic. Alex also explains that if you change your mind, and stop taking the blockers, they are completely reversible – something we now know is not true.[2]

The physical, psychological and emotional changes that happen in puberty can trigger a very real fear of growing up. For autistic children, this can result in a denial of what is happening to them.

Parents of autistic children can find it useful to talk to their children early about puberty and the changes that will happen. Social stories, comic book conversations and Picture Exchange Communication System (PECS) cards can be very useful when explaining the changes that puberty brings.

Preparing autistic children for puberty should include introducing them to accurate, age appropriate illustrations of sexed bodies, and explaining how the human body works. This will enable them to link the physical and sensory changes of puberty to their own body.

Listed next are some of the biggest changes that occur during puberty and why they may contribute to an autistic child experiencing gender dysphoria.

4.1.1 Breast Development

The development of breast buds in girls is often the first sign that puberty is starting. It can be a difficult change to manage as it is often the first change in the developing adolescent body that is noticeable to others. For an autistic girl, seeing their body change shape can be alarming particularly if they are among the first in their peer group to start puberty.

Not only does this mark them out as different, but can also bring unwanted attention, teasing or bullying from peers. The necessity to wear a bra can add to the feeling of difference, especially if the other girls their age are not yet wearing one. Some girls may associate bras with the sorts of sexualised imagery seen in music videos or fashion adverts, or simply associate them with adulthood, which may lead to a desire to avoid growing up. Wearing a bra can also trigger sensory issues and difficulty with fastenings if they have difficulties with fine motor skills. This may lead to girls avoiding wearing a bra altogether.

Another difficult aspect of breast development is that there is no standard or predictable breast size. This can create a paradox for girls, as it may feel that however their body develops, it is wrong. Social media can compound this; a YouTube search – ‘are my breasts too small?’ shows a confusing range of videos including ‘I got a boob job at 20’, as well as ‘What men think about small boobs’ and numerous promotion videos by plastic surgeons.[3]

The onset of breast development may also signal the start of objectification by older boys and even adult men. This can be difficult to process and may engender deep feelings of internalised guilt and shame. Most girls and women will experience such objectification over several decades, and the sheer volume of media discussing female bodies in both positive and negative terms serves to reinforce the idea that objectification of their bodies is something from which they cannot escape.

4.1.2 Height

Girls usually grow in height earlier than boys, although boys will eventually overtake them once puberty has started. Being taller than their friends can lead to girls feeling out of sync and different and for boys, the reverse can be true if they are a late developer and don’t gain in height until their mid-teens.

Gendered ideas of femininity can be located in concepts such as ‘cute’ or ‘dainty’ so for girls this may be represented by the idea that girls should be small or petite, so that they can be protected and taken care of. The current trend among teenage girls for the Japanese Kawaii aesthetic is a reflection of this, as well as representing a regression to childhood. It also overlaps with the so-called Lolita aesthetic, which represents a more deliberately provocative, sexualised version of the same style.[4]

Pre-puberty most children are of a similar height, but as puberty starts, they will develop at different rates. The unpredictability of growth spurts throughout adolescence adds an additional element of uncertainty which autistic children can find hard to process. For autistic boys, who may take longer than girls to reach their full height, they may equate being shorter with femininity.

4.1.3 Menstruation

The onset of menstruation can be one of the most daunting parts of puberty for autistic girls. As a very rough guide, menstruation usually commences two years after the development of breast buds although this will vary from girl to girl.

A particular challenge can be heavy menstrual flow which can be traumatising, causing deep feelings of shame and embarrassment if it floods through clothes, particularly if this has taken place in public. If this happens in school, it can be compounded if their peers laugh or bully them because of it.

Many autistic girls have profound sensory reactions to menstrual blood; when blood mixes with air, it has a distinctive metallic smell that can seem very strong and may be overwhelming for girls with sensory sensitivities. They may also believe that if they can smell the blood, then everybody else will be able to, causing them to feel self-conscious.

The physical sensation of passing blood, especially if the period flow is heavy, can trigger a profound sensory response. It can feel sticky and uncomfortable and, in some cases, clots can be passed. This can be a particularly frightening experience, as it can literally feel as though part of the body is falling out. Many autistic girls find mess or dirt hard to cope with and so find the practicalities of dealing with menstruation extremely challenging. They can find having to touch their own blood repulsive, or it can provoke an extreme anxiety response.

In an environment where girls have immediate access to information about gender dysphoria, the profound visual and sensory experience of menstruation can be a powerful trigger to identify away from the female sex. They may decide that taking medication such as testosterone, is a useful way of stopping puberty and menstruation altogether, as YouTube contains many videos about using ‘T’ to stop periods.[5]

4.1.4 Practical ways to help

A particular challenge that comes with the onset of periods, is the irregularity. In the early stages of menstruation, it can take up to two years for a cycle to settle, which makes it harder for girls to predict when they are likely to menstruate. Once the cycle has become regular, it would be useful to download a period app for smartphones, which will help them keep track of when their period is due, so that they can feel more prepared and in control.

It can be useful to prepare girls by letting them choose a make-up bag or similar that they like, and keeping sanitary towels, spare underwear, baby wipes, disposal bags and a body spray in it. They can then keep this in their school bag in case their period starts unexpectedly. It can also be useful to practice with them how to self-care during their period; how to use sanitary protection, how to change towels or tampons, and dispose of them hygienically. This can take a lot of practice, so it is worth planning for this well in advance.

Some girls may find it more difficult than others to manage their periods independently, and in this case, identify a staff member at school who your child will trust, who will be able to help them. It may be appropriate to use school toilets at a quiet time of day, when there will be fewer pupils around. In the case of flooding through clothes, it can be worth teaching your daughter to pack a spare set of clothes in her bag (such as spare tights, a skirt, or trousers along with underwear) so that she always has something to change into, and perhaps purchase some period pants.

In the event that the school has installed gender neutral toilets, parents or carers should enquire where the single sex toilets are, that girls will be able to use in order to manage their periods with privacy and dignity. Since more schools are now refashioning their single sex toilets into mixed sex ‘gender neutral’ toilets, girls are reported as missing school rather than risk managing their periods in a cubicle next to a boy, or have to wash blood from hands, off clothes or rinse out menstrual cups at shared sinks in a mixed sex area.[6]

4.1.5 Body Hair

The thickening of body hair on legs, arms and for boys, across the chest, can seem strange and unattractive. Body hair is completely natural; we have it for a reason – to help regulate body temperature and to prevent foreign bodies from entering the vaginal canal, as well as the anus and the urethra.

Unfortunately a great deal of stigma has been attached to female body hair, and hair removal is a large sector of the grooming and beauty industry. According to the Oxford Economics ‘Value of Beauty’ report for the British Beauty Council, the UK beauty industry was worth £27.4 billion in 2018; of this, £810 million was spent on hair removal products and services alone.[7]

Notably, the report highlighted a new market sector being driven by online influencers, creating new channels for the industry to reach potential consumers (this is also reflected in the recent Transgender Trend report on the influence of social media on adolescent identity formation).[8]

Many books aimed at children and adolescents to guide them through puberty, normalise the removal of body hair by advising that some girls choose to remove armpit and leg hair. Although they don’t mention pubic hair removal, this may be reinforced via peers as well as on social media via YouTube or Instagram influencers as well as the wider media.[9]

In addition to the powerful targeted messages telling children that body hair is undesirable, it can also trigger sensory issues. Body hair can feel profoundly uncomfortable for autistic children, especially in the pubic region. Levels of hair growth will vary between adolescents, so the pressure to remove body hair can be immense if a child has dark or thick body hair or starts hair growth earlier than their peers.

Body hair can range from light to very dark depending on individual colouring, so dark-haired children may find their body hair more noticeable than blonder children. Medical conditions such as Polycystic Ovary Syndrome (PCOS), can cause hair on the abdomen, and face, as well as on leg and arms. This can lead to feelings of shame and self-consciousness and can be particularly difficult, as it can often remain undiagnosed until adulthood.

Even very young girls experience a great deal of pressure to adhere to western beauty standards including hair removal. They may pluck or pick at body hair, or may try and ‘shave’ hair with scissors or kitchen knives. In some cases, they may want to remove all their body hair. This can be because they misunderstand the unwritten rules around which areas of their body are ‘supposed’ to be hair free, or because they develop sensory issues around body hair and the way it feels. This can also be connected to the sensory feel of body hair against clothes, or even just the sight of body hair (i.e around the bikini line or under the armpits when swimming, or when wearing summer clothing).

4.1.6 Emotional Regulation

Hormones can have a devastating effect on emotional regulation and this can be very frightening for autistic children. Puberty can trigger emotional dysregulation through mental health conditions that sometimes accompany Autism, such as OCD or Generalised Anxiety Disorder which can exacerbate emotional dysregulation.

Hormones are both natural and necessary for development as they act as the catalyst or ‘switch’ for the many functions of children’s bodies that are vital to enable their bodies to mature to adulthood. However, they are powerful chemical messengers and the hormonally driven mood swings that are so common during adolescence can be very frightening in their unpredictability.

Autistic children may attempt to manage mood changes by using control mechanisms, and this may present as angry outbursts, or reactions similar to those described as part of Pathological Demand Avoidance (PDA). In fact, the perceived loss of control leads to an extreme fear reaction and this is manifested by meltdowns or outbursts of anger.

This is also accompanied by uncertainty as to the reactions of others. Autistic theory of mind suggests that autistic children are often bewildered by the reactions of neurotypical people around them, either peers or adults – which can lead to conflict in relationships and contribute to a feeling of being misunderstood or out of control.

4.1.7 Sexuality

Autistic children may not connect the onset of puberty and hormonal changes with the onset of sexual feelings. They may assume that when they do develop emotional or sexual attachments, that they will have a heterosexual orientation, as this is presented as the default norm in most societies.

In fact, a high proportion of children and young people who develop gender dysphoria or identify as trans or non-binary, have a lesbian, gay or bisexual orientation, regardless of whether they are neurodiverse or not.[10]

Children who are gay or lesbian may find themselves teased or bullied, and for those who have an emerging sexuality, it can be off putting and frightening to find themselves teased or called names for expressing feelings of admiration for other friends, or saying that another girl is pretty or that a boy is good looking.

This attitude is still expressed in wider society and crucially, in schools. In particular, coming out as a lesbian has become increasingly difficult. Many female celebrities who had previously identified as lesbian or bisexual, such as Miley Cyrus and Elliott Page (formerly Ellen Page) are now regrouping under the label ‘Queer’ or ‘Non-Binary’ and rejecting LGB identities entirely. There are very few young lesbian role models for girls to look up to.

For autistic girls in particular, this is problematic as the negative effect of homophobia leads many to reject the idea that they might be lesbian. Autistic theory of mind may also lead to heteronormative assumptions that if they are attracted to the same sex, that they must themselves be the opposite sex. If they are attracted to girls, then they must themselves be a boy.

Dr David Bell who wrote a report outlining the concerns of staff at the Tavistock & Portman Gender Identity Development Service (GIDS), noted that of the children who attended, 40% were autistic, many had experienced trauma or had complicated family backgrounds, and that a large number of girls would, if supported, grow up to have a lesbian sexual orientation. When interviewed for Channel Four News, he expressed concern that in the current climate young girls may believe that they are a heterosexual boy rather than accepting that they are lesbian.[11]

This same logic leap can also lead them to assume that others will believe them to be the opposite sex. Indeed, they may believe that their parents will be happier with a straight son rather than a lesbian daughter, no matter if this is true or not. It may be that under these pressures, identifying as a boy feels like a logical solution to what may appear to be complex or insurmountable difficulty.

4.1.8 Being Sexualised by Others

Puberty, with accompanying bodily and emotional changes, is the point at which girls become aware that they are viewed very differently than before. As their bodies start to mature and change, unwanted attention from male peers or from older boys and men, often begins. Alongside this comes the realisation that a new set of unwritten social rules has come into play, and expectations from others can change dramatically.

Sex based stereotypes mean that the expectations of girls and boys can be very different, however, at puberty the gendered expectations of behaviour become more constrictive. Pressure to conform to socially sanctioned modes of femininity increases as girls enter adolescence, and social currency is lost or gained according to how closely girls conform to societal norms.

Unfortunately the current mode of femininity in the West has been increasingly shaped by the availability and influence of online pornography, social media and selfie culture. This has created a template of a slim, large breasted girl, with long hair, full make-up, minimal body hair, and who is (or appears to be) sexually available; images shared by girls of themselves are overwhelmingly heavily filtered so that a uniform appearance is created that many adolescents feel the need to conform to and which becomes self-perpetuating.

For girls, this is a big change as before puberty they are allowed a great deal more freedom to express themselves and enjoy a certain wildness of spirit. It is little wonder then, that when these sex-based stereotypes begin to be reinforced around them, that so many are rejecting them.

Attention from older men or teenage boys can be unexpected, unwanted and upsetting. It is also possible that without clear support and information, autistic girls may believe that the expectations placed upon them to be feminine, sexually available and compliant, are a route to friendship, acceptance and love. The desire to make friends and to fit in can be a huge driver of risky behaviours that can have damaging long-term consequences.

Children can also experience a change in their relationship with their parents, who may find talking about puberty, sex and relationships embarrassing or difficult. This then provides an opening for children to seek information online. This is a risk factor as the internet has very little quality control and children and adolescents often lack the critical thinking skills required to filter out inaccurate information or to identify grooming behaviour.

4.2 Alexithymia

The Tavistock GIDS webpage features a section of parent’s stories. A parent’s story – Charlotte[12] focusses on an autistic girl who wants to identify as a boy. Charlotte’s mum mentions that autistic girls’ ‘emotional age is typically well below their chronological age’.

This is also referenced by Professor Tony Attwood who states that (as a rule of thumb) “The emotional maturity of children with Aspergers syndrome is usually at least three years behind that of their peers.’[13] This may be due in part to the phenomenon called alexithymia – difficulty in recognising or naming emotions.

If a child doesn’t understand their emotions and can’t name them, or if they don’t understand the context for those emotions, they are very likely to misunderstand the reasons for those feelings. For an autistic child, it may be easier to attribute such discomforting feelings to a contemporary phenomenon that they know their peers will understand, especially when issues relating to alexithymia are poorly understood, even by practitioners working with autistic children.

There are two types of alexithymia; cognitive and affective. Cognitive alexithymia refers to the difficulty experienced when it comes to recognising and naming how we feel, or recognising emotions when they are expressed by other people. Affective alexithymia refers to impairment in imagining emotions and feelings and recognising how emotions can make us physically feel or react. This is one reason why autistic children may not be aware that they are becoming overwhelmed by sounds, sights, crowds, or other stimuli that may eventually lead to a meltdown.

Autistic vlogger Yo Samdy Sam talks about alexithymia in her videos Demi-sexual identities and What’s it like to not know how you feel?[14] While describing her responses to dating and relationships, she talks about whether there is a link between alexithymia and sexuality, including how sexuality might be influenced by not being able to quickly label emotions, or taking longer than neurotypical people to decide whether there is sexual attraction. [15]

Alexithymia can also cause difficulty differentiating between heightened emotional states such as anxiety, fear, excitement and arousal, feelings which all share physiological similarities. In order to differentiate between them, we rely on recognition of both context and how a given situation might make us feel. This may also depend on recalling the emotional memory of a previous situation that was similar. These are all concepts that an autistic child may struggle with.

4.3 Interoception

Interoception, also known as the eighth sense, is the mechanism by which our body connects with our brain, through which we have an awareness of what our body is doing. It is interception that allows our brain to translate messages from our body, such as our awareness that we want to go to the toilet, or are too hot or too cold, or feel pain.

The brain receives and decodes signals sent to it by the anterolateral system (which carries messages about touch, temperature and pain) and the visceroceptive system (the vagus nerve, part of the parasympathetic nervous system, that sends messages from internal organs to the brain) and there is evidence to suggest that this system functions imprecisely in some autistic children. This means that they can’t always make sense of their brain’s signals and have an awareness of what their body is doing. For example:

  • Bladder fullness/Needing to go to the toilet
  • Pain
  • Feeling cold/hot
  • Recognising with what others are saying when they talk about their bodies
  • Feeling ill, or feeling pain
  • Being aware of bodily changes.

Because cognitive functions are connected to physical functions, impaired interoception can affect decision making, social understanding and processing, sensory issues, self-care, and the ability to understand and process emotions. It can manifest in numerous ways, including disordered eating, anxiety, and sleep problems.

It can also make it much harder to learn to recognise emotions, as part of emotional recall is connected to physical feelings in the body. Low levels of interoceptive awareness can leave children unable to locate the difference between excitement and anxiety, nervous energy and fear and other emotions that cause similar physiological changes in the body. If a child is unable to make sense of or recognise their heart racing, increased sweating, gastrointestinal responses such as butterflies in the stomach or diarrhoea, flushing or any of the other common physical manifestations of emotions, then it becomes harder to teach them to recognise what they are feeling or link it to the situation they are in. This can also apply to attraction, with it proving very difficult to decode what the physiological changes related to attraction and arousal signify.

Research has linked low levels of interoception with Autism.[16] [17] If an autistic child struggles with the ability to decode the internal messages sent by his or her body to their brain, as well as an inability to label emotions, then a situation is created where they can be profoundly disconnected from their own body.

4.4 Binders and sensory pressure

Autistic girls who identify as trans or non-binary may want to use a binder, or be encouraged by others online to use one.

It is important to be aware that binders, which are designed to compress breast tissue to achieve a flatter, more masculine silhouette under clothes, are known to have a damaging effect on the body particularly during adolescence when the body and skeleton are still growing. Intense pressure placed around the chest and ribcage can compress the lungs. Side effects of wearing a binder include breathlessness, bruising, rib pain, cracked ribs and chest pain.[18]

This is particularly risky in girls who already have respiratory conditions such as asthma. These effects are widespread; a research study of 1800 female to male adults reported 98% of them experiencing at least one of 28 negative effects of binding.[19]

For context, it is important to understand that many autistic children seek out sensations of intense pressure as a way of reducing anxiety or because they have difficulty assimilating sensory input. Autistic advocate and researcher Temple Grandin developed her ‘squeeze machine’ to apply deep touch pressure, finding the sensory pressure comforting.[20] Her research supports the fact that for many autistic children deep touch pressure can reduce tension and it is likely that wearing binders will, for some girls, provide a level of sensory pressure that they find calming.

If wearing a binder leads to lowered anxiety and increased comfort, it may not be possible for them to accurately identify why this is; whether the need for deep sensory pressure is providing comfort or if it is relief from gender dysphoria. It may not be possible to differentiate between the two, so some may assume that the relief they find in wearing a binder is confirmation that they are really a boy.

The recently implemented Cornwall Schools Transgender guidance, written in collaboration with The Intercom Trust, Devon and Cornwall Police, Cornwall Council and Head Teachers, contains advice that includes:

‘An F to M adolescent who is developing breasts may strap down their chest so that it is less obvious. This can be hot, uncomfortable and restrictive but very important to their psychological and emotional wellbeing. It might make certain PE lessons difficult for them to participate in and could sometimes lead to breathing difficulties, skeletal problems and fainting’[21]

The guidance recommends that pupils should take regular breaks from binding and not wear them overnight, due to health risks. As far as the school day is concerned, the guidance advises that pupils take extra care during games and PE lessons as the level of exercise undertaken while wearing a binder can cause exhaustion.

The lobby group ‘Gendered Intelligence’ link to the website Gender Construction Kit[22] for advice about binding, which contains the following concerning advice:

Use of a binder is almost always accompanied by some undesirable symptoms, most commonly back, chest or shoulder pain, overheating, shortness of breath, itching (possibly due to fungal skin infections), and bad posture. Rarer but more serious effects of binder use include scarring, swelling, rib fractures and respiratory infections’.

There is a lengthy stream of videos on YouTube, posted by teenagers and young women most not yet out of adolescence, talking about their ‘binder journey’ and reviewing and comparing binders from different manufacturers. Viewers can also find videos about creating home-made binders or for binder giveaways from the more popular trans identified vloggers. As with most social media sites, there is very little quality control over the content hosted by YouTube and none of the vloggers demonstrate awareness of the fact that their audience may be very young, impressionable and autistic.

More generally, clothes can be a strong sensory trigger with girls often rejecting the scratchy, fiddly restrictive clothes marketed at girls for the looser fitting and more comfortable t-shirts and jogging bottoms or trousers usually marketed at boys. In the same way, boys may be attracted to the softer fabrics, often pretty and sparkly, aimed at girls. There is also an expectation that girls are more tactile, engaging in hugging, touching or linking arms. For girls who find excessive touch difficult it may be easier to socialise with boys, where there is much less pressure to engage in overt displays of tactile touch. Conversely, boys who are naturally tactile and often affectionate, may feel more at home among female peers who engage in hugs and where they feel less pressure to adopt a ‘front’ of masculinity.

Noise levels as part of sensory input can also have an impact. For sensory seekers who need the input of loud noise, hobbies in adolescence based around going to gigs, joining bands, or driving cars or motorcycles might be attractive but play against type in terms of stereotypes. Children with sensory sensitivities may be the opposite and avoid learning a musical instrument or singing, or as they get older avoid loud sporting events such as football matches due to the overwhelming noise and crowds. This may be taken as evidence of gendered interests rather than simply a reaction to levels of sensory input.

5. Social Communication Issues

5.1 The Hidden Curriculum

The Hidden Curriculum, as defined by Brenda Smith Myles, refers to all the social information that we are not formally taught, but that we absorb or learn by watching the people around us.[23]

Autistic children often miss the sort of information that their peers will pick up via a process of implicit learning, as they find it hard to interpret, or to contextualise. This can cause difficulty when it comes to gendered behaviour, which is often learned this way.

Neurotypical girls learn more easily how to display the behaviours and appearance that are socially sanctioned for adolescent females. They learn that femininity is a uniform that they are expected to adopt, although they may do so to varying degrees and some reject it altogether. This process has become pathologized, with degrees of masculinity and femininity now labelled on a new spectrum of genderqueer identities[24].

However, Autism can hinder the social understanding necessary to make this jump from androgynous prepubescence to carefully constructed gender presentation and girls may confuse their struggle to read these social cues, with cross gender identification – ‘If I am not feminine, then I must be masculine’.

Smith Myles talks about autistic people interpreting things in a more literal sense, so believing that people say what they mean and mean what they say – in this sense, they have no need to search for any other meanings.

It is outside the scope of this report to list examples of the many ways the hidden curriculum is manifested, but it is important to note that autistic children and adults can be taught, or shown the many social norms, skills and expectations that neurotypical children pick up more easily.

This can include unspoken rules in the classroom (e.g. if a teacher tells one pupil to be quiet, the tacit understanding is that all the pupils should be quiet) and the playground, as well as in social interactions (e.g. understanding that lying is discouraged but there is a concept of ‘white lies’ that some people use when asked to comment on someone’s appearance).

An autistic child who rejects gendered stereotypes may do so for a variety of reasons such as sensory issues restricting the type of clothing they wear, a lack of interest in fashion or current trends, not making sense of gendered expectations, or having their focus on other interests. For this reason, it is important to explain sex-based stereotypes, and that because a child is a boy or a girl, that they are not restricted to a particular set of behaviours or appearance/dress, despite current cultural norms suggesting otherwise.

This, however, may mark them out as different and they may feel isolated from friendship groups in their class. This isolation is a common experience for autistic children and can be a contributing factor in them adopting an identity that they think will help them fit in. If they see that a trans or non-binary identity will allow them to maintain their individualism in their rejection of gender norms, it may appear to be a solution to social difficulties. The instant acceptance into online communities which often accompanies this ‘coming out’, may reinforce this belief.

For more detailed information about the hidden curriculum, please see Brenda Smith Myles’ website which outlines her work and advocacy.[25]

5.2 Communication

Autistic children learn how the world works by studying the information that we place in it. And if that information tells them that if they hate their periods, or want to wear a binder or play football, that they may actually be a boy, they may accept it as fact. As children they haven’t yet learned the critical thinking skills needed to make decisions about whether information is true or relevant to them. They may never master this skill, which is why the way that we communicate with them is so vital for their wellbeing.

Autistic children may not have the confidence to talk openly about their body or about feelings they can’t easily identify. They can struggle to accurately describe what is happening to them. The desire to fit in and find a tribe to belong to, is a powerful driver and may lead to mimicking behaviours, to facilitate a way in and ‘say the right thing’ even if it isn’t what they want.

Any adult professional working with children needs to be aware that if a child is neurodivergent, the right form of communication is key. Autistic theory of mind suggests that while an autistic child may be very clear about their own perception, that they may not be able to predict the other person’s perception of them. In the case of gender identity issues, it is vital to remember that autistic children may not understand that they cannot control how they are perceived by others. This can lead to distress and may lead the child or young person to label the responses (such as misgendering) transphobic, because this is the message they are receiving from the community surrounding them.

Autistic girls will look to the arts, celebrities, film, television, music, books, and social media to see how they are supposed to look and act, this influence on them shouldn’t be underestimated.

It is important to interrogate their understanding is of what is meant by concepts such as transgender, gender identity and transition, whether they have a trans identified child in their school or friendship group or they are talking about their own sense of self.

In the 2020 research paper, Elevated rates of autism, other developmental and psychiatric diagnoses and autistic traits in transgender and gender diverse individuals, Warrier et al & Professor Simon Baron-Cohen note that for the purposes of the research biological sex and gender identity are separate concepts, and define gender identity as a ‘person’s sense of their own gender’. While they offer definitions of biological sex and intersex conditions, they neglect to do so for the concept of gender. [26] If senior academics are unable to pin down a coherent definition of terms, it is questionable whether children and adolescents are able to do so.

When children undergo therapeutic intervention for gender identity issues, building a relationship can take a great deal of time. The Tavistock GIDS model, like CAMHS, is based on a gap between appointments, of weeks or sometimes months, which allows time for therapeutic explorations to embed and the child to give them thought. However, for an autistic child, long gaps between appointments may mean that they view the relationship as transient. Some therapists ask open questions in order to give the child time to access their thoughts and feelings about a given issue; this may be a difficult style of work for an autistic child to manage. Indirect questioning may simply cause confusion as an autistic child may not know what information is required, and end up saying nothing.

There needs to be space for them to process what they are being asked. There can be a two or three minute delay in processing information and so it may not be apparent that children have misunderstood something, or answered the wrong question until later on. It is vital that adults allow them time to process what has been said, and then check back that they have understood and decoded the correct information.

Additional time is also needed for them to formulate an answer which may not come to them until some time later. There can be an assumption in therapy and in schools, that autistic children need to be ‘taught’ conversation skills and turn taking, when one of the issues is the additional time taken – and this could be hours rather than minutes – to fully process what they want to say in return. If accommodations aren’t incorporated into conversations, it can be easy to talk at cross purposes; time needs to be given to allow them to formulate a response that is clear for both them and the other person.

Word recall can also be a problem, and if the wrong word is selected due to error, pressure or anxiety, it can change the meaning of what it being said. This may cause the conversation to shift out of context so that the child appears to understand something that he or she may not.

Sensory issues may affect conversations. The autistic brain doesn’t process sound in the same way as the neurotypical brain and cannot filter out background noise easily. Conversations shouldn’t be rushed and adults need to check that children are picking up the important points.

Finally, social understanding may cause difficulties when navigating relationships with peers or with others in wider society. The prosecution and conviction for hate crime of a young autistic adult for shouting ’is it a boy, or is it a girl?’ at a transgender police officer in 2020, is a case in point. Declan Armstrong, 19, was convicted of a public order offence for shouting abuse, which was uplifted under hate crime legislation due to what District Judge Roger Lowe described as its ‘transphobic nature’.[27] Armstrong has a diagnosis of Asperger Syndrome which, while mentioned in court by his defence team, was not elaborated upon. Armstrong may have had no comprehension that the police officer perceived his remark as hurtful and distressing. Notably, the CPS website along with the majority of press reports, neglected to mention that Armstrong was autistic which is suggestive of the importance that his disability was given.[28]

This situation is an illustration of how the depth and variation of communication difficulties in the autistic population is still widely misunderstood. Enormous care is needed when the vulnerability of an autistic child meets the sense of vulnerability inculcated in children who experience gender identity issues. The repeated reports in the media and in online communities that being transgender leads to suicidal ideation and increased likelihood of attacks both verbal and physical, cannot help but instil in children a feeling of heightened fragility.

This brings about difficulties within school communities if an autistic child perceives a peer as being the same sex as them, and the other child identifies away from it. It can be extremely confusing to be told that a fellow student is now a different sex, or identifies as neither. They may respond in a way that seems blunt, or dismissive, due to them simply stating what they see.

Misgendering is presented by the charity Mermaids as a ‘crisis’ to be addressed urgently and online communities refer to hurtful words as ‘literal violence’. When trans youth (autistic or not) internalise the message that misgendering is a deeply harmful occurrence, this places other children as the guardians of their mental health, which a huge burden for an autistic child to carry.[29]

The concept of gender as separate from sex – when the words are often used interchangeably, is inherently confusing when it is in opposition to the perceptions of autistic children. Communication differences are already a contributor of stress to autistic children, so it is vital that adults caring for or working with them understand the added complexities when autistic children are navigating concepts of their own, or others’ gender identity.

5.3 Informed Consent

In reducing complex ideas to a level that children can understand, it is clear that autistic children are being given a hugely simplistic idea of what transition means. This is important when discussing informed consent. When obtaining consent from children and young people for medical procedures, models of information are designed for neurotypical children and may not take into account the variance in cognition, communication, and theory of mind of autistic children and adults. This means that ‘informed consent’ may not be meaningful because it is based on a common understanding of the effects – both long and short term – of the procedure being discussed. This applies equally to parents, who may also be autistic or neurodiverse.

The High Court proceedings in the Keira Bell & Mrs A vs The Tavistock GIDS demonstrated the complex issues involved in consent to taking puberty blockers. Documented risks include loss of fertility, especially if puberty blockers were commenced before or in early puberty, before the egg reserve has a chance to mature or sperm production commenced. Evidence showed that nearly 100% of children prescribed them go on to take cross-sex hormones, that involve a variety of side effects such as (in biological females) chest hair, facial hair, male pattern baldness, enlarged genitals, deepening of the voice to a male register, along with an increase in risk of cardiac problems, blood lipid abnormalities, high blood pressure and an increased risk of heart attack or stroke. Having commenced cross sex hormones, many go on to have double mastectomies (or ‘top surgery’), which carry the risk of infection, wound drainage issues post-surgery, necrosis following re-siting of the nipple, as well as long term numbness and/or tingling at the site of surgery. Phalloplasty (or ‘bottom surgery’), carries a risk of loss of sexual function, urinary issues resulting from re-siting of the urethra, and significant scarring to the thigh or forearm where tissue is removed in order to form the neo-phallus.[30]

For boys, the effect of estrogen on their bodies includes reduced libido, erectile dysfunction, possible permanent infertility, mood changes, and cardiovascular health risks, especially thromboembolism. High levels of estrogen are an increased risk for heart attack, stroke and prostate disease.[31] Again, if puberty blockers are started before or early in puberty, then loss of fertility is more likely as sperm production has not initiated. The effect of puberty blockers will be to reduce the size of the penis and scrotum so they are unlikely to provide enough material to create a neo-vagina, perhaps necessitating using a section of colon. If the penis is inverted, then there is a risk of external hair follicles growing inside the neo-vagina, causing infections. Either method will result in the young person or adult having to dilate the area for many years, to prevent it closing.[32]

At the 2021 Endocrine Society conference, concern was raised about the need for more research in the area of fertility preservation in transgender adolescents. Dr Maria Menke from the University of Michigan, noted that many adolescents on a medical transition pathway have given no consideration to future fertility issues and where they are discussed with patients she noted that ‘often there is no recollection by patients of such discussion prior to referral to endocrinology’.[33]

None of these are aspects that autistic children can adequately imagine or consent to at a young age. Neither can they imagine the social side effects, such as the potential difficulties of a reduced dating pool as an adult, or the potential for social marginalisation. Idealistic notions about sexuality can further complicate this. The belief that it is common to fall in love with a personality irrespective of body type is generally unrealistic and not reflective of most relationships in current times.

As Dr David Bell, retired consultant psychiatrist at the Adult department of The Tavistock, as well as Staff Governor, observed when discussing his whistleblowing of concerns about the GIDS [on the Savage Minds political and scientific podcast with Julian Vigo]:

‘[T]he clinicians felt that children didn’t have the capacity to properly consent. How can a nine- or ten-year-old child, when they’re told for example, that if you start puberty blockers and go on to opposite sex hormones eventually, you might not be able to have an orgasm, you won’t be able to have children, what do you think the child does? The child goes “Eugh! I don’t want to talk about that. I don’t want children, I don’t want to talk about orgasms, I’m ten.” They can’t think about the long-term implications.’

He went on to comment on the original High Court judgment on the prescribing of puberty blockers [34] saying:

‘What they meant was, the children were likely to be in such an intensely conflicted and painful state of mind, with very limited ways of being able to consider things, that they couldn’t properly weigh up the pros and cons, they just wanted the treatment so to speak, and they also recognised that there was no evidence base for this treatment.’

The evidence indicates that not only are autistic children unable to fully consent to these long-term implications, they are unlikely to be able to conceptualise them in any meaningful way. It is important that services recognise this and work to safeguard autistic children.

5.4 The Influence of External Factors

As we have mentioned, internal factors that may be influencing autistic children towards a trans identity include interoception, alexithymia, social understanding, literal thinking, theory of mind, sensory processing issues, and not easily understanding the hidden curriculum. But what of the wider factors in their social landscape that may be contributory factors?

5.4.1 Online Influencers

As evidenced by the Transgender Trend report Transmission of Transition,[35] children are growing up in a hugely influential digital landscape. This has had a profound effect on the way that they interact with the world and on their mental health, something that author Jean M Twenge has linked this to the rise in ownership of mobile phones in 2012.[36] The rise in ownership of smartphones and tablets as well as increasing numbers of teenagers having laptops for schoolwork, has given children immediate access to influencers, who to younger generations are simply another facet of the constellation of celebrity. They are hugely popular but as safeguarding on the internet continues to lag behind technology, they are largely unaccountable in terms of the content they provide.

Platforms like YouTube and TikTok have very little in the way of gatekeeping and content moderation beyond cursory age limits which are unenforceable. It is possible to block anything pornographic but there is a huge array of misinformation and fake news among the videos aimed at young people, and no way for them to be able to sift out information that is inaccurate or fictional.

In addition, many autistic children, particularly girls, look to celebrities, influencers and actors as models from whom to mimic behaviour and social interactions and to base their ‘personality’. If a person they admire is successful they may become an object of mimicking.

The level of influence of social media cannot accurately be measured, and it is a mainly unregulated space where children can immediately have their beliefs affirmed while also being convinced that anyone who doesn’t affirm them is against them. This makes it profoundly difficult for parents and other adults to offer an alternate point of view, or to encourage critical thinking.

Researcher and sociologist Jonathan Haidt, author of The Dark Psychology of Social Networks, has written about the idea that words can be considered violence and the consequent rise in demand from college students for safe spaces online. He observed that the addition of the like button on Facebook and the share button on Twitter in 2009, created systems whereby young people have become dependent on ‘likes’ and ‘shares’ for validation and self-esteem. Algorithms then flood feeds with what they already like or approve of, as well as confirmation of what is offensive, creating what he describes as ‘outrage machines’.[37]

In his interview for the Netflix documentary The Social Dilemma, Tristan Harris, former Design Ethicist for Google and founder of the Centre for Human Technology, says ‘The classic saying is if you’re not paying for the product, then you are the product’.[38]

Computer scientist and author of ‘Ten arguments for deleting your social media accounts right now’, Jaron Lanier, goes further saying ‘It’s the gradual, slight, imperceptible change in your own behaviour that is the product…that’s the only thing there is for them to make money from. Changing what you do, how you think, who you are’. What Harris describes as ‘Surveillance Capitalism’, Shoshana Zuboff PhD, Professor Emeritus at Harvard Business School describes as a marketplace where tech companies ‘trade exclusively in human futures’. Part of a system that she describes as making internet companies ‘the richest companies in the history of humanity’.

The landscape of social media is still very new and for the majority of adults, it is very difficult to keep abreast of the emerging landscape that young people are navigating. In many ways, this is a huge social experiment and it will be many years before we see the true impact on society and young people in particular.

5.4.2 Public health and support websites

Information that affirms gender identity is published by organisations that children are taught to trust. At the time of press, Childline,[39] Kooth,[40] the NSPCC[41], Young Minds,[42] Mencap,[43] the NAS[44] and NHS Choices[45], all have extensive web pages about gender identity. Mencap supplement this with an animation to explain gender identity to people with learning disabilities.

The NHS Choices website has updated its guidance for gender dysphoria in children and the prescribing of puberty blockers. Although the treatment pathways for adult gender dysphoria within the NHS are well established, the evidence base for treating children with anything other than supportive therapy is thin. Nevertheless, the NHS Choices website still refers to the separate and more recent concept of gender identity as unquestionable. That no one is investigating the root cause/s of this growing cohort of gender dysphoric autistic children is a scandal in the making, because autistic children trust easily and depend upon being told the truth.

Teachers, parents, medical professionals and CAMHS are signposting children and families to these websites believing that they will be safe providers of balanced, evidence-based information and support for vulnerable children. Generally, in amongst the excellent content that many of these sites contain, we may find politicised messages about the existence of an unquestioned gender identity, along with advice about transition, and how to be an ally to any trans identified friends. There seems to be very few support organisations for children and young people that do not cover gender identity and trans issues as standard.

Kooth is a nationwide charity that is brought in by 77% of Child & Adolescent Mental Health Services (CAMHS) across the UK, providing a safe platform for children aged 11-18 to access mental health support. It has a moderated forum and a separate magazine section which contains hundreds of articles written by adults and service users. It is filled with message boards of children talking about gender identity and hundreds of editorial pieces about having a gender identity and wanting hormones, puberty blockers and binders. This website is publishing information accessed by extremely vulnerable children and teenagers, which is well-meaning but unevidenced. Although it employs a team of therapists and counsellors, Kooth isn’t run by medical staff, but by tech entrepreneurs who design health-based interfaces. Like the other websites, when it comes to gender identity, Kooth seems to be providing simplistic answers to what are usually complex difficulties.

The NSPCC provide a huge amount of information via their Childline website, but it has no safeguards to prevent younger children from accessing age-inappropriate information. Again, while presenting gender identity as an issue affecting young people, it is covered through an uncritical lens, with all aspects of gender identity and dysphoria presented as irrefutable. The screenshots here are taken from their Childline webchat function which isn’t hidden or protected but easily viewed by anyone who wants to look. These are clearly vulnerable children, having online conversations that clearly flag up potential safeguarding risks. The NSPCC and Childline’s unquestioning acceptance of the affirmation position means that these chats (and there are thousands of them) are mostly unmoderated.

If autistic children viewing a trusted web resource are informed that everyone has a gender identity, then they will believe it, and will potentially invest time and energy in trying to work out what their gender identity is.

5.4.3 The sexual landscape

Possibly the biggest change in the cultural landscape that young people are growing up in, is the rise and availability of online pornography.

Mainstream pornography has always favoured a perspective on sex that prioritises the male gaze. However, the rise in access to online porn has led to the uploading of free and homemade porn as well as spycam porn.[46] In order to compete with the proliferation of free content, major platforms like Mindgeek (owners of Pornhub) have had to modify their content in order to justify charging for it.

This has led to a gradual increase in the violent tone of porn, which commonly now includes choking, tying up, beating, urinating, slapping, hitting and spitting on women by men.

This is reported to have a significant impact on relationships and the expectations placed upon teenage girls and young women. Porn has become normalised among schoolchildren as young as 11, at a point when they are developmentally unable to understand or contextualise what they are seeing.

The Women & Equalities Committee report on sexual harassment and sexual violence in schools,[47] found that ‘Data published in September 2015 showed that 5,500 sexual offences were recorded in UK schools over a three-year period, including 600 rapes’.

In addition, researchers found that:

  • 59% of girls and young women aged 13–21 said in 2014 that they had faced some form of sexual harassment at school or college in the past year.
  • Almost a third (29%) of 16–18-year-old girls say they have experienced unwanted sexual touching at school.
  • 41% of UK girls aged 14 to 17 who reported an intimate relationship experienced some form of sexual violence from their partner.
  • 22% of young girls aged 7–12 have experienced jokes of a sexual nature from boys.

In February of this year, a website Everyone’s Invited[48] was set up by sexual abuse survivor Soma Sara to record past and present experiences of sexual assault and abuse in schools. Within weeks, over 8000 testimonies had been uploaded, leading to a government investigation into the widespread reports of sexual abuse in both private and state schools.[49]

In light of this, the advice given on the Childline website about porn is confusing and contradictory, advising children between 12 and 18 that they shouldn’t worry if they watch porn, that it is a choice, and that it is something that they may wish to send to their boyfriend, girlfriend, possibly as a joke. There is no concept of safeguarding children from harm, or from exposure to ideas and sexual violence that they have no understanding of and no context for.

5.4.4 Sex based Stereotypes

Despite the gains of previous decades in breaking down rigid gender stereotypes, the last twenty years has seen a gradual backlash, culminating in a far more rigid binary of sex-based expectations than before. Our consumer landscape is awash with a pink and blue divide, rigidly demarcating the social expectations placed upon the sexes from birth, complemented by an increasingly sexualised media landscape.

The word Tomboy is disappearing from the lexicon, replaced by transboy, transman, or transmasc as gender non-conforming girls find fewer spaces in life and online, to accommodate them. It can feel almost impossible to fight against a cultural wave of hyper femininity and sexualisation, shored up by Instagram, TikTok, and Snapchat, where self-worth is calculated by ‘likes’ and the peer approval of the latest selfie. If adolescent bodies are consistently measured against Instagram’s often filtered unreality, modifying bodies with hormones or surgery may seem like a logical extension of that same culture.

The UK statutory Relationships and Sex Education (RSE) syllabus teaches that these stereotypes are arbitrary and should be dismantled, while at the same time they are being promoted to young children in books such as 10,000 dresses[50] and Jack not Jackie[51] aimed at Key Stage One classes; stories that emphasise that boys who like dresses, or girls who want to do things that boys do, are really the opposite sex.

5.4.5 Homophobia

Despite increasing commercialisation by businesses raising the profile of events like Pride, and the welcome increase in legislation protecting the LGBT community from discrimination and harm, our society can still be hugely discriminatory. While transphobia is a genuine concern for the community, it has recently become elevated in the public consciousness, leading many to mistakenly believe that this represents a reduction in homophobia, lesbophobia and biphobia. On the contrary, despite the legislative gains of recent years, gay and lesbian young people are still the focus of tremendous bullying within schools.

For children with disabilities in particular, the Anti Bullying Alliance reports that they are more likely than non-disabled children to experience homophobic, biphobic and transphobic (HBT) bullying, with two thirds having experienced it. It was also reported that a lack of understanding of neurodiversity and LGBT issues meant that teachers were sometimes ineffective at dealing with bullying.[52]

For autistic girls, some of whom will be lesbian, homophobia in schools alongside the promotion of gender identity, may be enough to persuade them that they are actually boys. Further confusion lies in the widening of the definition of attraction by Stonewall in their LGBT RSE guide for schools:[53]

For some people, their sexual orientation (who they are physically or sexually attracted to) and their romantic orientation (who they might want to have a romantic relationship with or fall in love with) can be different. Some people may not be interested in sexual activity, or only sometimes. Some people may not be interested in romantic relationships, or only sometimes.

Not only is this new definition potentially confusing for all adolescents, but adding the concept of non-attraction, in the form of aromantic and asexual, any child who hasn’t yet reached the developmental stage to feel attraction, increases complexity.

For young Lesbians, it can appear much easier to transition than to face the levels of Lesbophobia inherent in society, in particular if they are being pressured to redefine themselves in the image of transwomen, and accept that ‘some girls/women have penises’ and accept them into their dating pool.[54]

In her article about transman Alex Bertie, Janice Turner spoke to Jessie, who observed

‘No-one uses the word Lesbian any more. It’s so uncool. It has really negative connotations’. This is echoed by Dr K, a therapist speaking anonymously about her practice.

What we can’t underestimate’, says Dr K, ‘is the sheer homophobia outside middle-class liberal bubbles. “Lesbian” is at worst a grave insult, at best uncool. “The gay hierarchy is this,” she says. “At the top are gay men who can pass as straight, then camp gay men, then pretty, straight-passing lesbians. And right at the very bottom are butch lesbians. Masculine women have no cachet. But if you transition, you zoom right over the gay hierarchy to become a straight man’. [55]

5.4.6 Peer Groups

The desire to fit in is a powerful driver for autistic children, and one of the most challenging areas for them to manage successfully. Difficulties with social understanding and social communication in a neurotypical environment can make peer relationships confusing to navigate, and lack of compliance to social rules can lead to bullying, or peers drifting away as attempts to build reciprocal friendships are unsuccessful. This can feel like an emotionally perilous landscape; and while some autistic children will respond by becoming loners, others will comply with peer demands or mimic them in order to be accepted, often to their detriment.

In addition, if an autistic child learns to fit in by mimicking those around them, but without the supporting cognitive framework, they risk adopting a persona that may cause them harm. In spite of this, reports of social contagion[56] among teenagers who are adopting trans or non-binary identities in clusters across year groups, suggests that transgender identities are considered more valuable in terms of social currency than being autistic.

5.4.7 Plastic Surgery and body modification

Over the past twenty years, plastic surgery has been normalised as a widely available consumer choice. Botox and fillers are seen as everyday procedures, and clinics advertise widely in glossy magazines.[57] Sitting alongside this is a social media culture in which girls are comparing themselves against their peers’ heavily filtered photographs, who in turn are comparing themselves to the heavily airbrushed photographs of celebrities.

Girls and young women are growing up with fabricated views of what women look like in the real world, and instead of recognising this, measure themselves and each other against impossible standards. No wonder then that they look at the boys around them and think that their lives look easier to manage!

The normalisation of plastic surgery has led to it being regarded as simply another body modification tool available to buy, which creates a vulnerability in autistic children and young people. For children growing up in the noughties, these procedures are considered part and parcel of a beauty routine for the twenty something young women who are their role models[58], and as gender has entered the lexicon of youth culture, having surgery to modify your body is no longer considered outlandish, but something aspirational. Against this landscape, altering your body with Testosterone or having the euphemistic ‘top surgery’ (bilateral double mastectomy) blends seamlessly in to the prevailing landscape.[59]

5.4.8 Special Interests

Many autistic children will develop a special interest or possibly several over a period of time. While these are usually related to areas of interest or hobbies, and can vary in intensity and length of time, autistic detransitioners have spoken of gender dysphoria, gender identity and being transgender as becoming special interests. Hours a day have been spent on the internet, on forums and websites and on social media, researching and watching every YouTube video and TikTok channel they can, as they go into a state of autistic hyperfocus. This creates a feedback loop whereby the more time they spend researching their interest and interacting with others online, the more convinced they become that this represents their true authentic self.

Although not directly linked to gender dysphoria, autistic writer Lucy Kross Wallace has written eloquently about her brief foray into autistic advocacy. Following her diagnosis in her teens, Lucy immersed herself into the autistic social justice movement, using it as a way of creating an identity via a narrative of victimhood.[60]

The implicit dichotomy underlying the social model, which divides the world into victims and perpetrators of ableism, gave me a binary choice. I could notice the ways in which I was privileged, assigning myself to the dominant group, or I could continue to concentrate on my misfortunes, convincing myself that I was innocent and helpless. I would play a constant game of sorting the world into good and bad, dominant and dominated, oppressor and oppressed. I would drift further and further from objectivity. I would grow obsessed with the injustice I saw all around me. And I would label myself the victim every time’.

When adolescents are caught up in the maelstrom of hormones and emotional uncertainty that define the teen years, finding a movement that provides a sense of purpose, particularly if it pertains to a nascent identity, can be a very powerful thing. Wallace’s essay perfectly encapsulates the combination of focus, sense of justice and ability to commit to a movement that provides social meaning that is inherent in autistic identity. What she also portrays is the often narrow autistic hyperfocus that can prevent us from clearly seeing the rest of the world around us.

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