The Problem With Tethering Gender Dysphoria and Autism

Cisgenderism is gender discrimination

person
Juanmonino / Getty Images

Comorbidity is defined as two chronic diseases or conditions that occur simultaneously in one person. For example, diabetes and heart disease are common comorbidities, which makes sense because higher blood sugar present in the blood of people with diabetes ends up damaging the nerves and blood vessels of the heart. Although there is some evidence out there prompting many scientists and clinicians to label autism and gender dysphoria as comorbidities, this relationship is murky.

Unlike diabetes and heart disease, the pathophysiological relationship between gender dysphoria and autism is poorly understood. In other words, we can only guess at how one affects the other. Furthermore, the conflation of these two conditions makes treatment even more complicated. And then there’s the very real issue that tying gender dysphoria to autism is a subtle form of discrimination.

Gender Dysphoria Plus Autism

In recent years, our understanding, diagnoses, and terminology of both gender dysphoria and autism have evolved.

Originally referred to as transsexualism and later gender-identity disorder, gender dysphoria is the most recent terminology referring to a condition where a person feels distress secondary to a perceived incongruence between assigned gender and experienced gender. Furthermore, people with gender dysphoria wish to be another gender and often take steps to satisfy this desire.

For instance, a person with gender dysphoria who was assigned the male gender at birth may feel distress with this assignment because it feels wrong and instead desires to be a woman. Although gender dysphoria is most common among people assigned the male gender at birth, it also occurs in women, with frequencies ranging from 1:10,000 to 1:20,000 and 1:30,000 and 1:50,000 in birth-assigned men and birth-assigned women, respectively.

Autism, or less colloquially and more appropriately autism spectrum disorder, is a wide range of symptoms, skills and disabilities which affect socialization, behavior and independence. People with autism often display repetitive behaviors and limited interests. These people can have difficulty In social situations, at school, and at work. According to the CDC, one in 68 people have autism.

A few smaller studies have been done attempting to quantify the association between autism and gender dysphoria. For example in 2010, de Vries and colleagues reported that 7.8 percent of children and adolescents diagnosed with gender dysphoria were also diagnosed with autism. In 2014, Pasterski and colleagues found that 5.5 percent of adults with gender dysphoria also had symptoms suggestive of autism.

Hypotheses Connecting Autism and Gender Dysphoria

Although several hypotheses have been proposed to causally link autism to gender dysphoria, there’s a lack of hard evidence supporting many of these guesses. Furthermore, the evidence that does support these “theories” (more accurately, hypotheses) is all over the place and often hard to piece together into cogent and coherent arguments. Nevertheless, let’s look at some of these hypotheses:

  1. According to the extreme male brain theory, women are wired to think in more empathetic terms; whereas, men are more systematic in their thinking. Moreover, high levels of testosterone (a male hormone) in the womb results in an extreme male brain or male pattern of thought, which leads to both autism and gender dysphoria. Although there is limited evidence supporting some of the reasoning behind the extreme male brain theory, one glaring discrepancy is that increased levels of testosterone leading to a male brain don’t explain why gender-assigned boys, who already have a male brain, develop autism and gender dysphoria when exposed to higher levels of testosterone. Instead, these boys should be hypermasculinized and even more male in their thinking. Thus, this hypothesis explains only why girls may develop these conditions.
  1. Difficulty with social interactions has also been used to explain the development of gender dysphoria in children with autism. For instance, a boy with autism who is bullied by other boys might come to dislike other boys and identify with girls.
  2. People with autism have difficulty communicating with others. This deficit may contribute to others missing social cues about assigned gender which might increase the chance of developing gender dysphoria. In other words, because other people don’t pick up on cues of a child’s assigned gender, then the child isn’t treated in a fashion concordant with this assigned sex and may therefore be more likely to go on to develop gender dysphoria.
  3. Gender dysphoria could be a manifestation of autism, and autistic-like traits could drive gender dysphoria. For instance, a child with the male-assigned gender and autism may become pre-occupied with female clothes, toys and activities. In fact, this apparent gender dysphoria may not be gender dysphoria at all but rather OCD.
  4. Children with autism can demonstrate rigidity with respect to gender differences. They may have a hard time reconciling the difference between their assigned and experienced or desired gender. This increase in distress could possibly exacerbate gender dysphoria and make it harder for them to manage these feelings.
  5. Some research shows that unlike most adolescents with only gender dysphoria, adolescents with autism and gender dysphoria aren’t usually attracted to members of their birth-assigned gender (i.e., the non-homosexual subtype of gender dysphoria). This group of people may experience more severe autism symptoms and psychological problems.
  6. In the past, some experts argued that people with autism were unable to form a gender identity—this was subsequently repudiated. However, either confusion in the development of gender identity or an altered pattern of gender identity development might contribute to gender dysphoria. Furthermore, deficits in imagination and empathy, which are common in people with autism, may make it hard for people with autism to recognize that they belong to a certain gender group.

Treatment Implications

Although we still don’t understand the exact relationship between autism and gender dysphoria, it hasn’t stopped certain clinicians from diagnosing these two conditions together in the same person and then treating these conditions, too.

The treatment of gender dysphoria in adolescents with autism is fraught with the potential of unintended and irreversible consequences.

Even though there is as of yet neither formal consensus opinion nor formal clinical guidelines on how to treat gender dysphoria in those with autism, in 2016, researchers published an initial set of clinical guidelines in the Journal of Clinical Child & Adolescent Psychology based on the input of various experts. Here are some of the recommendations:

  • When there is no clinician skilled in both autism and gender diagnoses, the co-occurrence of gender dysphoria and autism should be diagnosed by a clinical team consisting of both gender and autism specialists. Furthermore, it should probably take more time to diagnose and treat the co-occurrence of these conditions. In other words, it’s best not to rush into diagnoses and treatments and think things through among a group of specialists.
  • The treatment of gender dysphoria and autism often overlap. After undergoing treatment for autism, an adolescent may attain better insight, flexible thinking and communication skills that aid with understanding gender. Gender-related needs should be assessed on a continuous basis. Limited insight into gender may make it difficult for a person with autism to conceive the long-term effects of their decisions. Adolescents should be given time to understand their gender concerns and understand their own needs and desires. Moreover, sometimes there are non-binary expressions of gender that require specific accommodations. Perhaps, an adolescent with gender dysphoria does not care to dress in a gender nonconforming fashion or take on another name.
  • Adolescents and their parents should receive psycho-education and counseling regarding the co-occurrence of autism and gender dysphoria.
  • No consensus on medical treatment could be drawn. Consenting to treatment may be difficult for adolescents with autism and gender dysphoria because these people have difficulty understanding the long-term risks and irreversible effects of certain gender interventions. The clinician should develop a specialized consenting plan with risks and benefits presented in a concrete, step-wise and accessible manner. Puberty suppression using hormones is a good option for adolescents who consent because it’s reversible. Whereas even if they’re discontinued, cross-sex hormones may have more permanent effects. Other researchers recommend waiting to administer cross-sex hormones and to perform surgical treatment until adulthood when gender identity is clearer.

What Is Cisgenderism?

At the 2012 Psychology of Women Section (POWS) conference, Natacha Kennedy delivered a keynote address that makes a strong argument that delineating a causal relationship between autism and gender dysphoria is actually a form of cisgenderism, or discrimination.

According to Kennedy, cultural cisgenderism is defined as follows:

  • the systemic erasure and problematising of trans people
  • the essentialising of gender
  • the gender binary
  • the immutability of gender
  • the external imposition of gender

Cultural cisgenderism enables and empowers the observer to characterize an individual with gender, without the input of the individual.

This process begins at birth when a baby is assigned gender and continues throughout life as others make attributions about a person’s gender. Transgender people are then subjected to diagnosis and treatment to have a new gender externally confirmed and imposed. However, this whole process assumes that gender is binary (either male or female), unchangeable, essential, and not fluid.

Although it is experienced by all of us, cisgenderism isn’t spoken about much in public discourse. It just happens. For example, we automatically attribute the pronouns he and she to others, identify clothing as masculine or feminine and expect others to use the male or female bathroom.

Adolescents with gender dysphoria pick up on this cisgenderism and realize that it’s usually socially unacceptable for them to make nonconforming decisions with respect to gender. Consequently, these adolescents suppress non-gender-conforming decisions for fear of judgment and ridicule.

How Does Cisgenderism Affect Children With Autism?

Because cisgenderism is tacit and not talked about in public discourse, children with autism probably don’t recognize it. Moreover, even if these kids did recognize cisgenderism, they may not care. Thus, these children with autism are more likely to make gender nonconforming decisions that are recognized by others as gender dysphoria.

It’s plausible that gender dysphoria is just as common in children and adolescents both with and without autism. However, those with autism won’t suppress themselves in light of prevailing mores that perpetuate cisgenderism. By not hiding their preferences, children with autism are more likely to be identified as also having gender dysphoria.

In addition to cultural cisgenderism, Kennedy argues that clinicians and researchers also perpetuate cisgenderism by seeing gender as merely binary, unchangeable, and essential. According to the experts, it’s automatically pathological to identify in a gender nonconforming way. Experts fail to see that gender isn’t merely male or female but rather a spectrum.

Furthermore, experts delegitimize different gender experiences by labeling them as “phases” that will pass. Consider the following advice from the NHS, the national healthcare system in the UK:

In most cases, this type of behaviour is just part of growing up and will pass in time, but for those with gender dysphoria it continues through childhood and into adulthood.

Bottom Line

Although documented, we still understand little about the co-occurrence of gender dysphoria and autism. Attempts to pinpoint causality between these two things are poorly substantiated. Experts also don’t understand how best to treat these two conditions when they present at the same time.

It’s possible that the frequency of gender dysphoria among children with autism is equal to that of children without autism. However, children without autism will suppress the desire to act in a gender nonconforming way because of society’s gender expectations; whereas, children with autism either don’t recognize these expectations or don’t care.

Although rarely spoken about, gender is viewed as essential, unchangeable, and binary by all members of society including experts doing studies and giving treatments. The world is set up for two gender presentations: male and female. We routinely assign gender to others with little thought, and experts pathologize unusual presentations with diagnoses like gender dysphoria. In reality, much like sexual orientation, gender is likely fluid and lies on a spectrum.

Society expects that people fit nicely into one of two gender boxes, which is why there are separate male and female bathrooms, changing rooms, sports teams and so forth. It's possible that the distress that trans children feel may stem from the universal expectation that gender is binary. Perhaps, if society better accepted and accommodated the fluidity of gender, then these kids would feel more comfortable and less distressed.

Sources

Anna, I.R., et al. Gender dysphoria and autism spectrum disorder: A narrative review. International Review of Psychiatry. 2016; 28(1):70-80.

Baron-Cohen, S. The Extreme Male Brain Theory of Autism. TRENDS in Cognitive Sciences. 2002; 6(6):248-254.

George, R, and Stokes, M. “Gender Is Not on My Agenda!”: Gender Dysphoria and Autism Spectrum Disorder. In: Mazzone, L, and Vitiello, B. Psychiatric Symptoms and Comorbidities in Autism Spectrum Disorder. Switzerland: Springer; 2016.

Kennedy, N. Cultural cisgenderism: Consequences of the imperceptible. Psychology of Women Section Review. 2013; 15(2):3-11.

Strang, JF, et al. Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents. Journal of Clinical Child & Adolescent Psychology. 2016; 1-11.

Continue Reading