1. Autism and the landscape of gender identity

When you are autistic you often don’t realise that your thought processes aren’t the same as everyone else. Autistic people don’t cross-reference every thought against a neurotypical one to analyse if we are correct. We simply think, make decisions – and sometimes it goes horribly wrong because our thought processes have clashed with the way the rest of the world processes information.

At the age of twelve, I went to the cinema to see a film certified for ages fourteen and over. When the usherette asked my age, I told her I was fourteen. Afterwards, my autistic brain was thrown into months of anxiety as I was convinced that I had literally become fourteen because I had said this out loud. I thought that time was fluid, and I could change my age by thinking or saying it, because no one had ever told me that it couldn’t be changed.

Growing up, every time I saw a part of my body that wasn’t like other girls, it threw the reality of my body into question. I asked repeatedly if I was a boy – just in case. I had been told I was a girl but wanted to keep checking. I also experience low levels of interoception – the ability to interpret the messages sent from body to brain. As an adolescent I had no frame of reference for what my body was supposed to feel like. I still live with this inability to always interpret how my body is feeling, but this disconnection is something I can now compensate for.

I didn’t know about nuance and I didn’t know that some things were fixed and couldn’t be changed. If I learned that one thing was fixed, I didn’t extrapolate that everything else was fixed. That the sky is always blue, or the sea is a permanent fixture or that a girl can’t become a boy.

Not recognising emotions or being able to name how we feel can lead to those feelings being misattributed. If a child at puberty feels uncomfortable with their body, or overwhelmed by hormonally driven feelings that they find it difficult to identify, they might then reject what they believe to be the source of the feelings – their body – thinking that this will make the feelings stop.

Additionally, if children are unaware that they are autistic, they may have no understanding that their theory of mind and social understanding may not be shared by others. They then continually second guess themselves. Add in alexythymia, which affects the ability to recognise emotions, alongside low levels of interoception, and a child can move through the world in a profound state of disconnection.

These are real experiences yet neurotypical Autism experts only ever have a theoretical understanding of them. Because large numbers of autistic children adopting a cross-sex or non-binary identity is such a new phenomenon, there has been little time to plan research. There are many factors that have never been taken into account when it comes to this new cohort and if a societal and medical change happens so fast that research can’t keep up, we shouldn’t risk making assumptions about what is happening and why.

CAMHS are not best placed to support these children, as not all localities have specialist teams working with neurodiverse or learning-disabled children, or expertise in supporting gender dysphoric children. It generally falls to CAMHS to refer on to the GIDS service in either London or their satellite service in Leeds for support.

The decoupling of gender dysphoria from its original ICD10 (World Health Organization) classification as a mental health diagnosis has left GIDS staff struggling to maintain a psychological basis for a condition that the WHO has reclassified as a sexual health issue, so it is unsurprising that there has been no development of a psychotherapeutic treatment pathway.

We don’t yet know the reasons why autistic children are so overrepresented at the GIDS, although issues around puberty and bodily transformation, interoception, sensory issues, theory of mind and the influence of social media all may contribute.

Autism is often described as a system of social and emotional understanding that is ‘lacking’ rather than different. In a world designed for neurotypical people, this creates vulnerability. Autistic children, on a moment-to-moment basis, are not consciously aware that they process and think differently to others, so can’t always spot the areas where their value system is different, or where others may take advantage of them.

An identity which encapsulates many of the issues experienced by autistic children: feeling othered, not fitting in, feeling different to your peers, being gender non-conforming and often feeling that the social mores, behaviours and clothing attached to your sex do not ‘fit’, will be an enticing thing for a child who is used to being ostracised, and who may not yet be aware that they are autistic.

The CQC Inspection report of the Tavistock & Portman Gender Identity Development Service recently rated the service as ‘inadequate’.^{^[1]} The following is what was confirmed by the CQC report:

In a random sample of 22 records, more than half referred to autistic spectrum disorder or attention deficit hyperactivity disorder (ADHD). These patient records did not record consideration of the relationship between autistic spectrum disorder and gender dysphoria.
Staff did not develop care plans for young people. Many records provided insufficient evidence of staff considering the specific needs of autistic young people. Further, the service did not employ a specialist to focus on this area of practice.
Staff did not sufficiently record the reasons for their clinical decisions. There were significant variations in the clinical approach of professionals in the team and it was not possible to clearly understand from the records why these decisions had been made.
Staff had not consistently recorded the competency, capacity and consent of patients referred for medical treatment before January 2020.
Staff did not always work well with other agencies to safeguard young people. Most records did not include plans agreed with other agencies on sharing information and protecting young people.

I would argue that not enough attention is being paid to the internal mental processes of autistic children. The need to confirm what is real, and the need for reassurances because their ideas are not fixed means they turn to adults to provide them with the answers. And if they are not adequately supported, they risk walking down a dangerous road looking for answers on the internet, on sites such as Reddit, Tumblr, Tik Tok, and Discord; places where online strangers are happy to affirm their identity without any understanding of how vulnerable these children are.

Detransitioner Keira Bell demonstrated exceptional courage in taking the Tavistock & Portman GIDS to a judicial review to try and prevent puberty blocking drugs being prescribed to children. The High Court decision that children under sixteen are unlikely to be able to give informed consent to a treatment that will have far reaching and permanent effects on their bodies, was overturned in 2021 following an appeal. The provision that ability to consent should be established by the courts was overturned in favour of retaining decision making within the medical sphere; however, the evidence base on which the original ruling was reached remains unchallenged. In Bell’s wake, a growing number of detransitioners, many autistic, are gathering their courage and coming forward to express regret at medically altering their bodies to match their feelings. The years to come will see yet more detransitioners and I suspect, more court cases.

A growing body of clinicians, educators, academics, therapists, social workers, autistic people and parents of autistic children are questioning the concept of gender identity and are sceptical of the regulatory capture that has seen it imposed across society.

What is clear is that the NHS, the National Autistic Society, charities, researchers and any other organisations who support autistic children and families, need to urgently review their adoption of gender identity theory and prioritise robust research into the experiences of this poorly understood group.

1.1 Autistic Girls and Gender Identity

Both anecdotally, and in quantitative exploratory research by Lisa Littman^{^[2]}, it is clear that there may be an element of social contagion among adolescent girls when it comes to adopting a gender identity, particularly within a school setting. Identifying away from one’s biological sex has emerged as a solution to the psychic pain of female adolescence as access to the internet and pressure to conform, perform and fit in has extended quite literally into teenagers’ pockets. Smartphones and tablets act as a 24-hour conduit to social media, increased risk of bullying, and socially mandated forms of acceptance.

Media is now informed heavily by online pornography^{^[3]}. The pressure on girls to locate their physical appearance within a very narrow hyperfeminine focus while remaining sexually and emotionally available is enough to drive some girls away from womanhood altogether. Social media and the influence of an increasingly sexualised culture have pushed the value of appearance to the top of many young people’s agenda, so girls who are uncomfortable with the way they look, or not at ease with their own body, will experience difficulties.

The 2020 House of Commons Body Image Survey results^{^[4]} reported that 85% of respondents under 18 thought that appearance was important or very important, with the top three reported influences on their body image being images on social media, stereotypes and celebrities. Of the under 18’s surveyed, 73.4% spent at least 2 hours a day on social media, with 34.2% spending 5 hours or more. The most popular websites visited were Instagram (95%), YouTube (90%) Snapchat (75%) and TikTok (66%). In short, it is clear that there is much pressure to look a particular way, and this may significantly affect autistic girls who are frequently gender non-conforming and much less likely to subscribe to gender stereotypes than their neurotypical peers.

Autism expert Professor Tony Attwood writes about this on his website ^{^[5]}

‘Inevitably there will be times when she has to engage with other children and she may prefer to play with boys, whose play is more constructive than emotional, and adventurous rather than conversational. Many girls and women who have Asperger’s syndrome have described to clinicians and in autobiographies how they sometimes think they have a male rather than a female brain, having a greater understanding and appreciation of the interests, thinking and humour of boys. The girl who has Asperger’s syndrome can be described as a ‘Tom Boy’ eager to join in the activities and conversations of boys rather than girls’.

An article published in ‘Clinical Child Psychology and Psychiatry’ by GIDS clinicians Anna Churcher Clarke and Anastassis Spiliadis, described a joint case review of all their patients and focused on the pathway trajectories of two patients who were representative of their caseload as a whole.^{^[6]}

They reported that between 2011 and 2018, 48% of all referees to the Tavistock indicated autistic characteristics which presented challenges to the GIDS staff working with this new cohort.

When discussing their caseloads, they identified the risks inherent in socially transitioning, that it can ‘lock in’ an identity before any in depth exploration occurs. Both the young people they discuss (using their post-assessment preferred pronouns) exhibit clear autistic characteristics: ‘Alfie’ (pseudonym) is described as experiencing bullying at school; having a difficult transition to puberty leading to the rejection of the body; expressing interest in sex and sexuality in an ‘intellectual’ way, and displaying simplistic thinking (‘I like wearing a dress therefore I must be a woman’). ‘Louise’ (pseudonym) has been caught within a ‘landscape of action’ that steers her toward medical transition as opposed to talking therapy (this is particularly relevant if, like many autistic young people, the young person has little access to an emotional vocabulary). She has a strong desire to cling to her trans identity, as the basis for her gender non-conformity.

Professor Attwood also touches on this aspect:

‘She may prefer non-gender specific toys such as Lego and not seek acquisitions related to the latest craze for girls her age to be ‘cool’ and popular. There can be an aversion to the concept of femininity in wearing the latest fashions or fancy or frilly clothing. The preference can be for practical, comfortable clothing with lots of pockets’.

Many autistic children are extremely intelligent while at the same time, finding it difficult to understand context or the long-term consequences of the actions they take.

For autistic girls who are desperate to be accepted by their peers, a trans identity presents a socially sanctioned way of being different. This identity may be considered much more socially acceptable than being autistic, as Professor Attwood explains here:

‘The girls may identify someone who is socially successful and popular, either from her peers or a character in a television soap opera and adopt that person’s persona in mimicking speech patterns, phrases, body language and even clothing and interests using a social script. She becomes someone else, someone who would be accepted and not recognised as different. . . Girls and women who have Asperger’s syndrome can be like a chameleon, changing persona according to the situation, but no one knowing the genuine persona. She fears that the real person must remain secret because that person is defective’

With an ability to perform an adopted persona so completely, not only do the girls risk believing that this is who they truly are, particularly if undiagnosed or unaccepting of their diagnosis, but they will easily convince others.

In the book ‘Women from another Planet? Our lives in the Universe of Autism’^{^[7]}, Mary Margaret wrote of her experiences of gender and sex ‘My gender came in question – the boys would say “you aren’t like other girls. You don’t cry when you get hurt, so you are better than other girls, but you aren’t a boy, so you are a Mary Margaret.” Of course it was lonely being given a category to myself and it taught me to hate my gender. It would take feminist readings many years later to move me out of my male identified position’

Autistic girls often struggle with mental health difficulties and extreme levels of anxiety, and research from the Karolinska Institute in Sweden has confirmed that autistic females have an unusually high risk of suicidal ideation; if co-morbid with ADHD they show a rate ten times higher than neurotypical females, with a high risk of completed suicide.^{^[8]} If a significant number of autistic and/or ADHD diagnosed girls are identifying as trans or non-binary, this may be a contributory factor in reported suicidal ideation that is attributed to being transgender.

In addition, access to the internet, which has been suggested as a factor in Lisa Littman’s research into Rapid Onset Gender Dysphoria, is a relatively new phenomena. The spread of information, both factual and false, facilitated by almost unfettered access to laptops and smartphones, is creating a landscape that we are unlikely to fully understand for another decade at least, as we will only be able to fully assess its effect on society and young people in particular, with hindsight.

Laura B, a young autistic detransitioner, wrote an essay on her experiences for the website DetransVoices.^{^[9]} She notes the confusion of growing up gender-non-conforming, receiving a diagnosis of Autism at eleven, but receiving no support, and the confusion of trying to find an identity while feeling increasingly isolated:

‘I wasn’t aware of many social and gender norms at the time, but I knew I hated anything “girly.” I was aware that I was different from girls, but I also did not feel connected to boys either. I felt very isolated and lonely even as young as 5-6 years old. Later I thought that this might have been proof that I was queer or trans, but now I know it’s just because I was autistic.’

Similarly, detransitioner Penny launched a GoFundMe fundraiser, to pay for breast reconstruction surgery.^{^[10]} As a result of coming out as transgender at 11, Penny was affirmed by all the therapists and clinicians who treated her. She was prescribed puberty blockers at 13, cross-sex hormones at 14 and had a double mastectomy at 15. Two months after surgery, she was hospitalised with severe depression:

‘During my hospital stay, I realized my mistake. Transition wasn’t the fix I needed and it couldn’t take away my mental health issues. I had never been tested for any body issues, so we assumed it was gender dysphoria.’

And then the familiar refrain:

‘I was diagnosed with Autism last summer, and my current doctors have researched the link between Autism and gender identity, finding that might have been the cause of my issues. I understand that I am responsible for my choices and that I have to fix it myself. But my doctors didn’t take into account my Autism, body issues, or other mental illnesses when allowing me to transition.’

Penny’s willingness to shoulder responsibility for her decision to transition, belies what we know about adolescent development. The adolescent brain doesn’t finish developing until the early to mid twenties^{^[11]} and so the clinicians and therapists involved in Penny’s care must surely be responsible for their lack of interrogation of any underlying issues contributing to her dysphoria.

The formation of identity in adolescence has always been driven by experimentation, but in such an overwhelmingly gendered world, this is now manifesting at a remarkably high cost to the young autistic community.

1.2 Autistic Girls and the Female Phenotype

** Although we talk about the female phenotype, it is also recognised that some males share what is described as a female presentation, just as some girls present in a way that is more commonly associated with boys.

It has been suggested that the idea of the female phenotype may be partly based on socialisation, and sex-based stereotypes; if this is the case, it may be that in years to come, we recognise types of Autism based purely on presentation rather than inherently ascribing them to the sexes.

Most research into Autism Spectrum Conditions has historically been carried out by observing the behaviour of autistic boys. This means that most parents, teachers, therapists and medical staff base their knowledge and understanding of Autism only on the way that boys have been understood to present.

Common diagnostic tools such as the ADOS (Autism Diagnostic Observation Schedule) were developed using data based on observing boys and although there has been talk of the development of a diagnostic tool designed around the female phenotype, as yet, this hasn’t come to fruition. In the meantime, alternative diagnostic tools like DISCO and ADI-R-are also in use and may be more sensitive to the female presentation.^{^[12]}

Girls who are autistic can present in very different ways. This can frequently lead to parents, teachers and medical staff assuming that they are not autistic at all. This can mean that their needs, both psychological and educational, are not met, which greatly affects their ability to thrive, both academically and in the future. The following list illustrates some of the ways that they might present differently to autistic boys. For more in-depth information, Staffordshire Council have produced the Autism In Girls Checklist.^{^[13]}

1.2.1 Social presentation

Autistic girls are very often quiet and therefore may be assumed to not be struggling or to ‘be fine’ when they are not. Parents may see their daughter as different or quirky, because many professionals don’t recognise autistic behaviour in females, and she may be undiagnosed.

They can have obsessive interests just like boys, but these are often overlooked, as they frequently involve topics considered stereotypically normal for girls (e.g. pop groups, film stars, make-up, vloggers, fairies, fashion).

Autistic girls can spend so long mimicking their peers in order to fit in, that they can reach their mid to late teens without a solid sense of self. This can lead to them trying a variety of identities in order to try and find out who they are, including playing with ideas around style, looks, hair and make-up, or it may take the form of other interests, such as music, or trying out different careers. In some cases, this may present as opposite sex ideation. This can lead to their struggles being underestimated and their support needs not being met.

1.2.2 Communication

Although communication difficulties can lead to problems understanding how friendships work, autistic girls often have one or more close friends. Having friends is not an indicator that someone isn’t autistic. However, they may be desperate to please in order to make and keep friends and fit in, and so can be vulnerable to peer pressure. This also applies to relationship pressure when reaching adolescence.

Understanding can be very literal and statements can often be taken at face value. This can sometimes cause difficulties when navigating social situations or relationships.

There may be a gap in processing auditory information – it is therefore important to keep instructions simple, and allow time for information to be processed and understood before moving on.

Autistic girls can often struggle reading the emotions or expressions of other people. In school settings, they may struggle to ‘read’ the expressions of teachers and other pupils. It can often be difficult to recognise and/or name their own emotions (This is called alexithymia). When listening to others, shouting or speaking loudly can often be confused with anger, causing fear or anxiety.

1.2.3 Anxiety

Autistic girls usually experience greatly heightened levels of anxiety compared to their peers. This may present as stimming (repetitive movements such as hand flapping, picking, tapping, chewing etc) in order to self soothe. When in school or college, they may need to leave the classroom for short breaks in order to reduce anxiety.

Unfortunately, rather than recognising heightened anxiety and meltdowns as possible indicators of Autism, these attributes are so often assumed to be stereotypically female that girls who are struggling can be ignored or written off as neurotic or over emotional. As a result, girls and women are statistically far more likely to be diagnosed with Anxiety Disorder, Bipolar Disorder or Borderline Personality Disorder than be recognised as autistic. This has historically led to women struggling in adulthood, because Autism has not been recognised.^{^[14]}

It is important to recognise that autistic girls are often excellent at masking or hiding their emotions. They can appear calm and composed during the school day, or when out socially with friends or family, and only feel safe enough to ‘explode’ once they are back at home. Appearing ‘fine in class’ or around others, does not mean they are not struggling.

Further, autistic girls frequently have sleep difficulties which mean they can be extremely tired the next day. This can cause them to become overwhelmed more quickly, and repetitive sleep problems will have a cumulative effect on their ability to cope on a day-to-day basis. This is an issue that is often overlooked by schools.^{^[15]}

1.2.4 Education

Autistic girls may have learning difficulties which are not be immediately obvious. They don’t need to be hugely behind their peers in order to require support or intervention. They don’t need to have an Education, Health and Care Plan (EHCP) or even a formal diagnosis in order to qualify for support in school, as it is based on need.

1.2.5 Sensory Issues

Autistic girls may become overwhelmed by noise, colour, lights or other sensory stimuli at home, in the classroom, or while out socially. While at school, they may benefit from a card system, allowing them to leave the classroom for a short break, if necessary.

There may be a sensory reaction to the type of clothing marketed to girls; clothes are more likely to be adaptations of adult fashions, and so may be manufactured with man-made materials, which can be hot and scratchy. They may have complicated fastenings, belts and zips, have trims or frills that can irritate. They may be tight fitting, or designed with fashion features like cut-out shoulders or cap sleeves which can feel uncomfortable. Therefore, autistic girls may prefer loose, comfortable clothing, or clothes that may appear to be gender non-conforming. Many autistic girls prefer wearing clothes marketed for boys, because they are designed for comfort and practicality rather than fashion. This is a choice that is usually based entirely on comfort but that may lead to negative comments or questions from peers, or family members who are unaware of these sensory issues.

Of course, conversely, autistic boys may experience sensory issues that mean that they may prefer the softer materials that are often associated with girls clothes.

1.2.6 Strengths

Autistic girls often have a good eye for detail, and an excellent memory. They can spot patterns in nature, or in their surroundings. This also extends to areas such as computer data and programmes. This often encompasses spotting errors in data patterns, or in written material and they are often excellent at proofreading and/or thinking outside the box. Autistic girls can often be extremely creative, with vivid imaginations. The idea that autistic people are not creative or imaginative is a myth.

Similarly, the idea that autistic people have low empathy is based on cognitive empathy rather than affective empathy. An autistic person may not recognise why someone is upset or struggling, and so is assumed to have low empathy. However, once the source of the upset or struggle is explained, they are generally extremely empathetic to others.

1.3 Identity Formation

When we are young, the perceived drudgeries of adulthood seem very far away. Part of adolescent identity formation involves separating from parents, and often rejecting their values, even if we later return to them. The idea of becoming like their parents can be anathaema to teenagers, just as the desire to carve their own path, change the world and achieve great things can be immensely attractive. What adolescents can’t imagine is the kind of adult they will grow up to be and this is why it is foolhardy to wrap their future up in one fixed identity at such a young age.

To understand the stages of psychosocial development that children typically experience, and for various theories of child development, the Professional Association for Childcare and Early Years (PACEY) has a useful overview.^{^[16]}

Although the development of identity can be a lifelong process, it is during adolescence that separation from parents and caregivers begins, with the aim of developing a stable personal identity and growing into an independent adult. Erik Erikson,^{^[17]} whose theory of identity underpins a good deal of our understanding of modern identity development, proposed that during adolescence, we seek to establish our sense of self as separate from our parents and their ideals. It is during this period that we turn to our peer group for reassurance and validation which is why it can feel so important to gain approval from our friends rather than our caregivers.

It is also the time in our lives when young people engage in fantasy as a precursor to real life experience, both in terms of crushes on famous people and also in terms of desiring similar careers as their idols, in what for most people are unrealistic ambitions (such as wanting to be a premiership footballer, famous musician or film actor).

Identity is comprised of both a personal and a social identity. The social identity incorporates physical and social elements such as sex, sexual orientation, age, disability, ethnicity and language, while personal identity is focused on elements such as likes, dislikes and elements that make up the personality.

For autistic adolescents, this process can be more difficult, as it can be harder for them to be accepted by peer groups and they can frequently be subjected to bullying and ostracization. This will interrupt the usual process of finding a group where they feel they belong. In this respect, the emergence of friendship clusters based around gender identity, and the fact that so many online spaces offer support and a sense of instant belonging to any young person who claims a trans identity, there may be something very alluring about the LGBT+ community.

Autism is often viewed through a deficit model so the construction of an autistic identity may focus on how different the autistic child is from their peers and this can be internalised by a feeling of being ‘less than’. This is exacerbated by the increasing complexity of social rules as children grow older, particularly as they will struggle with non-verbal communication. For autistic girls, a great deal of time is spent masking in order to fit in, which can result in overload and meltdowns once the need to mask is removed. This process of acculturation, through spending time mimicking the behaviour and personality traits of other girls, hinders the development of an authentic sense of self as it becomes increasingly buried.

Adolescents will start to develop a personal philosophy and framework of beliefs during their teen years but it can be easier in the short term to adopt ‘ready-made’ philosophies or ideologies until they have fully developed their sense of self. It is much less likely that these adopted philosophies will stick, as they are often not a true reflection of who the young person is or is becoming.

Ready-made identities such as non-binary, trans-masc or trans-femme or other trans identities fit in to this category and may seem to make sense of the sometimes overwhelming sense of isolation that so many autistic young people experience, as well as the natural tendency to gender non-conformity. There is a risk that they will then cultivate a sense of self that is not authentic, but built around a desire to remain part of a community that accepts them.

There needs to be a much greater understanding of the effect that isolation, bullying and feeling othered has on the development of self-esteem and a sense of self in autistic children, as well as the trauma that can be experienced as a result of pubertal changes. Without taking these into account as part of a wider look at identity formation, it may be easy for adolescents to adopt a trans related identity as a way of finding a place for themselves in a world that too often feels hostile and unaccepting.

2. Non Binary Identities and Autism

A new label has been added to the suite of gender identities, which encompasses the common feelings we have if our internal self- image doesn’t match what we see in the mirror: the ‘non-binary’ identity. Our personalities are a mix of likes, dislikes and emotions that society places in either the ‘male’ or ‘female’ box, upholding sex-based stereotypes. Despite these being largely arbitrary, we are told that we should fit into one box or the other, and that if we find that challenging, we are outliers.

For autistic children, the placing of clothes, toys and interests into these boxes may be seen as a rule that can’t be broken, so the parts of the personality that don’t fit the male/female binary can feel wrong. Lobby groups and charities via educational packs for schools, are confirming that having a Non-Binary identity means someone identifies as neither male or female or both so it is perhaps unsurprising that some children think ‘Well that’s me!’ What they don’t realise is that these feelings are absolutely normal.

What is striking is that despite having a solid understanding of male/female socialisation and how this has impacted their own lives as a gender non-conforming person, there is a determination by some in the wider trans community to suggest that adopting a non-binary identity somehow places someone outside the male/female binary in a literal sense.

Autistic girls or women deciding they are no longer female but non-binary, may then place themselves at potential risk by assuming the dangers they face because they are female, are no longer relevant to them. It is possible that having come out as Non-Binary, an autistic child or young person will believe that everyone else sees them the way that they see themselves and won’t then understand if people react in a way that contradicts that.

It is important that children both male and female, who adopt a non-binary identity understand that this has no effect on the reality of their sexed body, but parents, carers or friends who try to point this out may be shut out, amid accusations of transphobia. Unfortunately, organisations who are lobbying for the government to adopt Non-Binary identities into official documentation and as part of GRA reform, are reluctant to acknowledge this obvious truth.

Meanwhile, non-binary celebrities now include singers Sam Smith, Miley Cyrus and Demi Lovato alongside actors Tilda Swinton, Lachlan Watson, Indya Moore, Bex Taylor-Klaus, Ezra Miller, Liv Hewson and Amanda Stenberg. As many of them became famous following roles in films and tv shows aimed at teens, they have a huge impact both as role models and as validation of trans identities. This follows a wider trend to relabel everything that comes under the LGBT umbrella as queer as part of a reclamation of the word.

However, in doing so, there has been a gradual disappearance of lesbian role models for girls, as many female celebrities who are same sex attracted rush to relabel themselves as either queer or non-binary. Unfortunately for girls who are same sex attracted, the homophobia they often experience in school can’t be counteracted by role models if they are nowhere to be seen.

If as a society, we want to find a descriptor for people whose personality traits take in a broader spectrum of interests and feelings than just those that are socially sanctioned for them, and who don’t ‘feel’ either male or female, then non-binary is as good as any. On that basis, It’s not only understandable, but extremely common. So why might it be problematic?

By bringing this idea under a widened transgender umbrella, it not only gives the child an elevated sense of being special but also of being vulnerable and taking on the emotional load that we are told all transgender identified children carry. It confirms for them that they are now a member of an oppressed minority and as such, are owed a duty of care sometimes over and above their peers, even though their peers may be part of differing protected groups under the Equality Act; this despite the fact that identifying as neither male, female or both (the definition of non-binary) makes no difference to the reality of being male or female.

Thirty years ago, playing with gender norms was much more common because it was accepted within the music industry and within youth culture. Now we see young men in lipstick or eyeliner, identifying as non-binary in order to reject gender norms without being subjected to homophobic bullying or violence. It is notable that the majority of the female celebrities listed above have explained their identity by stating that they have never felt female, but have always wanted to reject the constraints placed upon them because they are female.

Researcher Dr Wenn Lawson, who is both autistic and transgender, has carried out a tremendous body of research into female Autism, and since transitioning, has incorporated discussing gender identity into their work. In their presentation Gender Dysphoria in persons with Autism,^{^[18]} Dr Lawson quotes a young person, Drew, who describes their gender identity:

‘I’ve recently been making exciting and very daunting discoveries about my gender. As a result, I currently identify as “30% ‘George Clooney’ and 70% ‘Georgina Clueless”. I’m frantically researching all the posh names for where I’m at and I’m guessing that I’m nonbinary / genderqueer with a degree of gender fluidity. Essentially, I live on Planet Drew, which has an erratic rotation around the Gender System. We’re currently quite close to Venus. I’m an adult fan of Lego, a sci-fi geek, Doctor Who fan and the occasional gamer. I’ve also discovered that I can ‘do’ liquid eyeliner, which is nice!’

This is presented as evidence of autistic gender fluidity, but what Drew describes is just a desire not to be pigeonholed or restricted by gendered stereotypes.

At the National Autistic Society (NAS) Women and Girls Conference in 2019, doctoral researcher Marianthi Kourti made a presentation based on her 2019 research “I Don’t Feel Like a Gender, I Feel Like Myself”: Autistic Individuals Raised as Girls Exploring Gender Identity.^{^[19]}

The research was based on self-reported accounts of female autistic identity and feelings around gender from which the following quotes are taken:

‘I believed myself to be a boy and was mortiﬁed and sick when I started developing as a girl.’ (Ruth)

‘I always had a pretty even split of ‘‘girl toys’’ and ‘‘boy toys’’ – baby-dolls, Ninja Turtles, stuffed animals, Ghostbusters, stickers, dinosaurs, crafty stuff, Lego.’ (Kate)

‘As a child and even now, I don’t ‘feel’ like a gender, I feel like myself and for the most part I am constantly trying to ﬁgure out what that means for me.’ (Betty)

In her NAS presentation Kourti includes further quotes from her research with autistic people with differing gender identities:

One such quote was ‘What’s the point of having all this (pointing at her breasts) if you’re not gonna nurse a baby with your boobs, you know? So men can objectify me?’

‘I want to empower women and all that, but at the same time, I still have these hang-ups of not wanting to be one (which came from) the stereotypes and the sexual abuse’.

And this is a summary of a non-binary person’s interview:

‘When I was growing up, I was very disappointed when I couldn’t keep playing football, because it wasn’t something that girls did. It was a big loss for me’ and later, ‘I wasn’t particularly interested in being male. It wasn’t until a few years later that I heard the words non-binary and my gender identity finally clicked’ and ‘Gender has been very frustrating for me throughout my life. On the one hand, I was frustrated for being identified as female, on the other I was also frustrated with the stereotypes that came with it’.

All of these feelings are entirely understandable but are a response to living in a society that defines and restricts males and females by a system of stereotypical behaviour.

Kourti notes that ‘the conceptual separation between gender identity and gendered stereotypes seems to be muddy’ and also the fact that ‘participants didn’t make many links between their autistic and gender identity’. Like Lawson, her research reiterates that ‘identity creation is ongoing; it is constantly changing throughout one’s life’ which sits in opposition to the ‘if you know you are, you are’ mantra of the online trans community. Kourti herself adopted a non-binary identity in between starting and completing her research and while Dr Lawson and Marianthi Kourti are rightly free to identify as they wish, identifying as non-binary is not necessarily the benign option it may appear for children.

If an autistic girl believes she is neither male or female, she may assume for example that she is no longer at risk of becoming pregnant. Autistic young people may believe that their body is literally no longer either male or female, which may have health implications if they are living independently. It may also prove difficult if the child or young person believes that everyone around them sees them the way that they see themselves.

There is also increasing normalisation among young people who identify as non-binary to incorporate medical transition as a way of consolidating their identity. On the website of transgender support charity Mermaids, in the information section Kids and Young People, is a section on non-binary information. One of the links, transitioning while non-binary leads to an article on a website The Body is Not an Apology. The article opens with information about what transitioning might mean to a non-binary person:

‘I know some people who have started hormones or had different surgeries. I know some people who started dressing differently. I know some people for whom the only transition they needed was to think of their gender in a different way, and shift their internal sense of themselves, without changing anything externally.’

While Mermaids clarify that the links are to external organisations and don’t constitute an endorsement, to a child reading the article, it confirms that medical transition is a reasonable course of action if they have a non-binary identity.

Teen Vogue, an online magazine aimed at 13-16 yr olds, published What it means to transition when you’re non-binary in 2017. In a series of interviews with non-binary individuals, the following advice was given:

‘Non-binary people might take hormones, need surgical care or other forms of medical intervention to help us align our bodies with our gender identities and expressions. Yes, some non-binary people still need medical care even if our narratives are different from trans men and trans women’. ^{^[20]}

Searching non-binary transition into the YouTube app brings up scores of videos featuring attractive teenagers and young adults discussing their medical transitions while identifying as non-binary, many of these involving taking hormones.^{^[21]}

In addition, surgeons in the US have identified non-binary identities as a lucrative income stream; the Gender Confirmation Center in San Francisco, aims to ‘empower transgender individuals to take control and become the self-made person they want to be’ and view microdosing with testosterone or estrogen or having either a mastectomy or ‘non-binary contouring’ as reasonable ways to achieve this.^{^[22]} Online clinic FOLX provides prescriptions & delivery of estrogen or testosterone to over 18s. However, they invite those under 18 to ‘keep in touch over e-mail and social… until that birthday’. Online clinic GenderGP also promotes microdosing for non-binary people, to neutralise their hormones and offers to start the process with the offer that ‘if you’re still wondering: “where can I buy male to female hormones?” Get in touch with us!’^{^[23]}

This elevates a relatively benign and actually very common concept – that one doesn’t identify solely with either male or female stereotypes – into behaviour that carries significant health risks to the children engaging in it.

In the current climate, it’s impossible not to have sympathy with children and young people who decide that they are non-binary, rather than negotiate a world that tells them that they must adhere to one set of stereotypes or the other. But the new choices they are being given aren’t really choices at all; they are socially sanctioned boxes that they may step into, with permission. Because if they don’t, criticism and rejection await.

3. Autism & Mental Health

3.1 Transgender OCD

While preliminary research suggests possible links between OCD, Anxiety Disorder, Anorexia, Bulimia and Body Dysmorphic Disorder^{^[24]}, there may also be similarities in cognitive profile between Anorexia Nervosa and Autism, with suggested similarities coming via the Autism Quotient Scale.^{^[25]} While potential links between all these conditions warrant further research, there is a form of OCD that may be mistaken for gender dysphoria or confusion about a desire to transition.

OCD typically comprises distressing intrusive thoughts and subsequent repetitive actions as a way of neutralising them. In the early 2000s, reports emerged of intrusive thoughts related to sexual orientation, with gay men having intrusive thoughts about being straight and vice versa – subsequently distress was experienced due to confusion about their established sense of self, rather than the orientation itself. Subsequently, in 2015, the same year Caitlyn Jenner came out as transgender, researchers reported on a case of OCD which manifested as intense intrusive thoughts about wanting to transition to the opposite sex.^{^[26]} Known as T-OCD (transgender OCD) it manifests around repeated distressing intrusive thoughts about transitioning or questioning gender identity. Unlike pre-pubescent feelings of confusion about gender identity, it appears as part of a wider OCD profile. Because OCD is driven by a desire to neutralise these thoughts, it becomes compulsive in nature due to the uncertainty and upset about the thoughts themselves.

An autistic adolescent experiencing T-OCD may be distressed by the uncertainty of not knowing if the feelings are real and the compulsive actions can involve: researching transition; trying to remember if these are thoughts that have always been present; looking at transgender related websites or reading about gender identity; or engaging with online LGBT communities to ask questions and try to find answers. The more these actions are taken, the more the distressing thoughts are perpetuated.^{^[27]}

Complications to recognising T-OCD in autistic adolescents comes when attempting to identify which elements of their presentation are due to Autism and which to OCD.^{^[28]} The young person may incorporate fixed repetitive routines as part of their daily life but may not be able to recognise if they are repeating actions as a compulsive behaviour to neutralise a distressing thought, or as an anxiety reducing, soothing/stimming activity. This may not be something that they themselves can identify and this may solidify the notion of a transgender identity.

3.2 Eating Disorders

Gender Dysphoria in girls appears to share a pattern with eating disorders, in that both involve adolescent girls signifying trauma on their bodies, and because for many autistic girls puberty is experienced as a traumatic event. Jungian Psychotherapist Lisa Marchiano has referenced this and has expressed surprise that clinicians within psychiatry and psychotherapy are not making connections with previous social contagions that have affected adolescent girls. In an interview with Suffragette City Radio in 2019, she observed that ‘agreeing to medicalisation halts the process of exploration and processing and confirms the idea that there is something wrong with them’.^{^[29]} She also observed that there is a crossover between eating disorders and gender dysphoria. There is also a high prevalence of eating disorders among autistic girls which suggests that research needs to be done into these obvious links, particularly given that for many autistic girls, eating disorders may well be a reaction to sensory issues with food.

3.3 Body Dysmorphic Disorder

There is a some evidence to suggest that both autistic people and people with a diagnosis of Body Dysmorphic Disorder (BDD) struggle with facial recognition and accurately appraising others’ emotional responses. BDD is an anxiety disorder diagnosed when a person is preoccupied with perceived flaws in their appearance. In both conditions, there is evidence of the involvement of the amygdala.^{^[30]}

As mentioned earlier, Gender Dysphoria has recently been declassified as a mental health diagnosis by the World Health Organisation and moved to the category of sexual health. BDD remains within the mental health classification, however given that there are similarities between them, there is an argument to be made that children may be ‘reading’ body dysmorphic disorder and interpreting it as gender dysphoria. This is important, since gender identity issues are currently being taught in schools under the new statutory relationships and sex education syllabus. Although they are defined differently, an autistic child is unlikely to be aware of the difference in definition and may feel that their discomfort is due to gender dysphoria, because it is the situation that they are being presented with.

The largest twin study to date looking at BDD in adolescents, ‘Prevalence and heritability of body dysmorphic symptoms in adolescents and young adults: a population-based nationwide twin study’ (Enander, Ivanov et al 2018) found that among a cohort of 6968 fifteen year olds, the females reporting BDD symptoms were twice as likely to show signs of ADHD and five times more likely to show autistic characteristics than their peers without dysmorphia symptoms.^{^[31]}

In unlinking gender dysphoria from mental health, has the link between interoception, BDD, and Autism been overlooked?

If an autistic child is experiencing discomfort with their sexed body, or with the way their body is changing, it is worth considering the possibility that they are describing body dysmorphic disorder through the filter of the language that they have been exposed to. Additionally, many autistic children have alexithymia and low levels of interoception, and as a result may be living with a very real sense of disconnect from their bodies without the ability to name what they are feeling. Therefore it is clear there is a need for urgent research looking at how these different elements interconnect and how they are affecting autistic children.

3.4 Trauma

Another possible factor in the development of gender dysphoria is the experience of trauma in the form of Adverse Childhood Incidents. These can include physical, sexual and emotional abuse, either witnessing or experiencing domestic violence, parental drug abuse or alcoholism, divorce or attachment issues in early childhood. This then also relates to looked after children and we know that there is a larger than average representation of local authority Looked After children identifying away from their sex; the research paper Gender Dysphoria in looked-after and adopted young people in a gender identity development service (Matthews, Holt et al) confirms that despite making up 0.58% of the UK population, Looked After children represent 4.9% of referrals to the Tavistock GIDS and adopted children make up 3.8% of referrals.^{^[32]} This is replicated in the US and also in Canada.^{^[33]}

Research suggests that autistic children have a higher than average chance of experiencing an ACE or experiencing post traumatic stress.^{^[34]} Research at the Gillberg Neuropsychiatry Centre at the University of Gothernberg has found that children with high levels of neurodevelopmental disorders are more likely to experience ACEs. This also proved to be the case in twin studies with a twin who is neurotypical.^{^[35]}

There may be traumatic issues that the child or adolescent is dealing with or exploring in a therapeutic process. Conversely it may be a trauma that they are not consciously aware of which is affecting their mental health or informing gender dysphoria.

For autistic children traumatic experiences are not limited to the overt traumas listed above; Simply navigating day to day transitions, sensory input and the stresses attached to differences in processing and communication, are now recognised by researchers as leading to a possible variation of PTSD.^{^[36]}

For many autistic children the sensory experience and communication differences that they experience during a single school day can cause a sense of overwhelm by the end of the school day known colloquially as the coke bottle effect. This means that their day may be made up of multiple small stress events, which could include being asked questions, remembering books and equipment, taking notes, keeping up with and retaining information, maintaining focus, and sensory input such as excessive noise levels, strip lights flickering or buzzing, and having to sit in one place for extended periods of time.

Additional factors can include sensory responses to school uniform and school staff not making reasonable adjustments for movement breaks, or allowing stimming (repetitive movements as a mechanism for self-soothing). This can in some cases then lead to staff holding autistic children responsible for what they interpret as challenging behaviour that results.

This is enough to cause psychological overload which is released at the end of the day when the child no longer has to mask their behaviour, and can metaphorically ‘explode’ when they are in a place where they feel safe. This can necessitate taking time to recover. Repeated on a daily basis however, this overstimulation and anxiety stress can elicit a trauma like response.^{^[37]}

In addition autistic children are frequently taught compliance behaviours with the aim that they will ‘fit in’ to school and workplace environments that are not designed to meet their needs. This can however create a vulnerability to traumatic experiences, as the compliance behaviours may lead to them following the demands of abusive or manipulative people, while not recognising that what is being asked of them is inherently abusive.^{^[38]} Autistic children can find it very difficult to recognise when someone is lying and can operate on the basis that everybody is telling the truth, thus opening themselves up to risky behaviours.

Autistic children are much likely to experience bullying than their peers however most anti-bullying programmes for mainstream schools don’t incorporate an autistic perspective or differentiate for autistic learners. Research indicates variable levels of bullying experienced by autistic children, ranging from an estimated 87% of autistic secondary age children being bullied once a week to 65% of autistic children in the US bullied each year to 77% of autistic children in Canada per month.^{^[39]}. This is likely to be in part a reflection of the Double Empathy problem as defined by Dr Damian Milton.^{^[40]}

There has been much written about autistic children and a perceived lack of empathy. However, in terms of communication, it is clear that there is an element of reciprocity in the lack of understanding between the neurodiverse and the neurotypical population. Milton’s theory is based on this idea that both populations experience difficulty decoding and understanding the other’s perspective, however it is only one population (the neurodiverse) who are expected to learn how to communicate and empathise. It is a given across society that being neurotypical is the default so again, it falls to the autistic population to bend their understanding and neurocognition to fit. In terms of counteracting bullying and traumatic experience, this is unlikely to be helpful as it places the autistic child at a disadvantage, risks increasing low level trauma by forcing an unnatural process upon them and as such, is likely to impact on their self-esteem and feelings of self-worth.

3.5 Misdiagnosis

In her book Sexy but Psycho; How the patriarchy uses women’s trauma against them, Dr Jessica Taylor ^{^[41]} discusses the experience of autistic women and the medicalisation of women’s experiences of trauma. Autism is frequently misdiagnosed in women as Borderline Personality Disorder (BPD) – a diagnosis that can lead to feelings of intense shame, as the public perception of personality disorders is negative and informed by misinformation and assumptions. In such an arena, it is unlikely that an undiagnosed autistic young person would want to admit to having such a diagnosis.

Dr Christopher Gillberg and his team at the University of Gothenberg have pioneered the ESSENCE programme, Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations. These include ASD, ADHD, Oppositional Defiance Disorder, Tourettes Syndrome, and other neurodevelopmental conditions. He has observed that a high proportion of young children diagnosed with ASD/ADHD will meet the criteria for a personality disorder by the age of 18. In addition, adults diagnosed with personality disorders on or after the age of 18, will have displayed symptoms congruent with one of the ESSENCE conditions.

He highlights in his blog the case study of a young man diagnosed with ASD and ADHD in childhood co-morbid with a personality disorder in adulthood, as well as meeting the criteria for Schizoid Affective Disorder (S.A.D). However, in the case of the latter diagnosis (and by extension the criteria for S.A.D) Gillberg hypothesises that it was in fact his Autism/ADHD masquerading as a personality disorder. He believes that the majority of cases of adult personality disorders are in fact misdiagnosed ESSENCE related conditions.^{^[42]}

Of 1019 autistic adults, of which 50.1% were women, 62.7% of females and 37% of males had a prior psychiatric diagnosis with mood and personality disorders being the most common.^{^[43]}

The diagnostic criteria for Borderline personality Disorder is listed below. Looked at through the lens of autistic traits, it is clear that there are numerous similarities.

There are difficulties inherent in diagnosing BPD^{^[44]} as the cluster of symptoms covers a variety of mental health disorders and there are no biological markers or diagnostic tests that can detect it. Based on the diagnostic criteria in the DSM V it is easy to see why autistic traits would meet the benchmark for a diagnosis.

A pattern of unstable and intense interpersonal relationships – this is not uncommon n in the autistic population due to difficulties with communication as well as unrealistic expectations for interactions with others. Many autistic people form lasting bonds both in friendship and in romantic attachments however, the ease with which autistic people can be manipulated may contribute to the statistic that autistic women and girls are more likely to be subjected to domestic abuse, either as part of a relationship or witnessing it within their family unit.

Identity disturbance: markedly and persistently unstable self-image or sense of self – forming a coherent identity can be problematic, mainly due to many years masking emotions and mimicking the social behaviours of others in an attempt to fit in. This means that it can take longer to develop a strong sense of self.

Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Does not include suicidal or self-mutilating behaviour covered in criterion 5. – again, there are reasons why an autistic adolescent may engage in behaviours that appear to be impulsive and risky. Mimicking the behaviour of others as a mechanism for finding a place within a social group, or engaging in risky behaviour because it is expected of them are both likely. Some autistic adolescents may not have a good understanding of money or financial systems so may fall into debt easily or be persuaded to take out numerous credit cards. In addition, poor mental health can lead to eating disorders which are often co-morbid with autism.

Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour. The autistic community have high levels of suicidal ideation due to multiple factors.

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days) – Autistic adolescents are often prone to anger issues and mood fluctuation; this is exacerbated by hormonal fluctuations but could also be attributed to sensory overload or communication difficulties or possible pathological demand avoidance.

Chronic feelings of emptiness – this could be a conflation with loneliness, or an underlying feeling of being ‘wrong’ within oneself. Having no or few friends may lead to internalising feelings of worthlessness and depression.

Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). Autistic sensory reaction – see book.

Transient, stress-related paranoid ideation or severe dissociative symptoms – Low levels of interoception, wherein the internal signals sent to the brain from various internal systems are not interpreted, along with alexithymia which is an inability to name and recognise emotions, could lead to a disconnection from the body that could be interpreted as disassociative.

Diagnostic Criteria of Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5.
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5.
Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour.
Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.

Detransitioner Elizabeth Hawker identified as transgender from the age of 15 to 21. She became involved in the transgender community online and now acknowledges that being trans became her autistic special interest, admitting that

‘I loved nothing more than spending hours researching and debating trans topics and online I surrounded myself with everything trans and non-binary’.

Having subsequently been diagnosed as autistic, she now believes that what we are currently seeing is another manifestation of misdiagnosis.

‘I hypothesize that we are witnessing a new wave of common misdiagnosis for ASD girls emerging: Gender dysphoria. This misdiagnosis is very different to the others; where treatment for these mental illnesses involves cognitive behavioral therapy (CBT), changes to your day-to-day living like eating healthier and sometimes medication. The treatment for gender dysphoria is physical, irreversible body-altering hormone injections and surgeries’.^{^[45]}