Dr Sally Powis, Consultant Clinical Psychologist at the Kingwood Trust and Spectrum Specialists, gives a clinician's view of the particular challenges for autistic people with gender dysphoria, and outlines some suggestions on how to support them through the process.
Author: Dr Sally Powis
Gender dysphoria and autism: Challenges and support
There has been a growing awareness of the increased gender variance in autistic children, adolescents and adults following studies showing higher rates of autism amongst adolescents with gender dysphoria. In the general population the prevalence of autism is thought to be at least 1% but amongst adolescents with gender dysphoria (GD), de Vries (2010) found that 7.8% of adolescents with GD were autistic. Similarly, among adults attending gender clinics 5.5% were autistic (Pasterski et al, 2014).
In my clinical practice I have worked with autistic people with GD, both with and without a learning disability and I am aware that gender transition can be particularly difficult for an autistic person. Outcomes have ranged widely:
- wanting to transition fully to the opposite gender with hormone treatment
- the desire to transition has turned out to be more of a confusion, fetish or distress at growing up.
It can be difficult to help autistic people with reduced cognitive ability understand what they think and feel, and to support them to communicate this and decide what course of action to take.
Gender clinics will usually want the person to discuss their feelings and experiences of gender difference with a therapist or psychologist to begin with, to help evaluate whether they meet criteria for GD and their suitability for ‘treatment’. The rigid thinking style and intolerance of ambiguity of some autistic people may present particular difficulties for gender identity formation, and they may also find it difficult to tolerate the ambiguous transition period when moving from one gender to the other (Jacobs et al, 2014).
Some autistic people may have difficulty feeling connected to their physical selves and may not be physically comfortable with their body. This can contribute to difficulties articulating their inner experiences relating to GD and why they want to change gender. As a result, some autistic people may be seen as not meeting the criteria for gender reassignment and thereby miss out on hormone therapy and the support they need. There is evidence however, that a substantial proportion of autistic adolescents with GD do meet criteria for gender transitioning treatment after extended psychiatric evaluation (de Vries et a 2010).
For clinicians, differentiating between GD and other possible causes for the person’s presentation can be tricky. Tony Attwood talks about girls who are perceived to be ‘different’ by their same-gender peers being more accepted by boys, and vice versa. A liking for Lego, trousers, playing with and having similar interests to boys, whilst disliking uncomfortable dresses and other girls (who can be cruel), might lead to the assumption ‘I must be a boy’.
The evidence for the female autistic brain having increased masculine characteristics and the male autistic brain having less masculine characteristics would fit with this view (Bejerotetal, 2012). Also, if an autistic child is not tuned in to what the social norms for children of their gender are, they are probably less likely to adopt them early in life. A possible fear of changes happening in the female body at puberty may lead to a desire to negate the developments by binding breasts, shaving bodily hair and a wish to avoid the implications of sexuality and relationships.
Those who struggle with theory of mind may not be aware of how others might perceive them, leaving them vulnerable to being targeted if they look conspicuously different. People can be open to ridicule and bullying if not cross-dressing particularly well or not being adept with make-up or hair.
A lack of understanding of social rules may lead someone to approach others for help inappropriately. In this way they can be unaware that they are putting themselves at risk. Sadly, being bullied is a common experience for a high percentage of autistic young people at school or college, due to being seen as ‘different’, and it takes courage to be willing to make yourself even more different by openly expressing a change in gender.
Mental health issues
High rates of depression and anxiety are common amongst autistic people (Strang et al, 2012). Higher rates of suicide have been found amongst people with GD in a survey of adults in the US, although the survey results do not indicate that medical treatment to transition gender decreases suicidal intent or self-harm (Haas et al, 2014).
For some there may be the hope that changing gender might lead to finding greater acceptance amongst the opposite gender, and that friendships and relationships will be easier. However, the realisation that the social and communication difficulties still remain could lead to disappointment and depression post-transition.
How can we help?
Initially, finding concrete means to help the person express their experiences and feelings about their gender and sexuality can be helpful. This may mean using multiple-choice type questions rather than open-ended ones, and by writing and drawing out different ways of feeling. The Genderbread Person can be a useful tool to this end.
An initial focus on how they have experienced difference, and what they expect will be different in their life as a result of gender transition, is a good starting point. Help the person understand the potential reactions of others (positive and negative) and help prepare them for how they might respond or manage negative responses and potential bullying or segregation. Likewise, they may not understand the need to explain what they are going through to others in their world (at school, college, or work).
Being clear about where is likely to be safe to go and where is best to avoid and why, could help avoid potentially risky or volatile situations. For example, suggesting that they attend a small local LGBT group to try out early experiences of trans-gender dressing in public, as opposed to going to a local busy club or bar where people will have been drinking and may be intolerant of someone obviously ‘different’. A lack of social skills and awareness on the part of the autistic person, and alcohol fuelled intolerance by others may all lead to the potential for a very unpleasant outcome.
Give practical suggestions. Some people may need practical support to source clothing or shoes (particularly large female shoes and wigs) or to apply make-up. Be aware that some autistic people may not want to join groups or support organisations for transgender people due to social anxiety, and so might need individual support with these issues.
Unfortunately people cannot self-refer to a gender clinic, so the person may need support to see their GP, a psychologist or psychiatrist who can refer them to a clinic. Health professionals at gender clinics are becoming more aware of autism, but an autism-aware advocate can improve the experience for all parties.
For details of autism-aware advocacy services please visit the Autism Services Directory
Bejerot, S., Eriksson, J. M., Bonde, S., Carlstrom, K., Humble, M. B., & Eriksson, E. (2012). The extreme male brain revisited: Gender coherence in adults with autism spectrum disorder. British Journal of Psychiatry, 201, 116–123.
De Vries, A. L., Noens, I. L., Cohen-Kettenis, P. T., van Berckelaer-Onnes, I. A., & Doreleijers, T. A. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disorders, 40(8), 930-936.
Haas, A.P., Rodgers, P.L. & Herman, J.L. (2014) Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey. American Foundation for Suicide Prevention and Williams Institute.
Jacobs, L. A., Rachlin, K., Erickson-Schroth, L., & Janssen, A. (2014). Gender dysphoria and co-occurring autism spectrum disorders: Review, case examples, and treatment considerations. LGBT Health, 1(4), 277-282.
Pasterski, V., Gilligan, L., & Curtis, R. (2014). Traits of autism spectrum disorders in adults with gender dysphoria. Archives of Sexual Behavior, 43(2), 387-393.
Strang, J. F., Kenworthy, L., Dominska, A., Sokoloff, J., Kenealy, L. E., Berl, M., & Luong-Tran, C. (2014). Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Archives of Sexual Behavior, 43(8), 1525-1533.
Date added: 16 March 2017