The headline I chose for this post comes from the oft-repeated axiom (unsupported by any robust research to date) that kids who are “insistent, consistent, and persistent” in their assertion that they are, or want to be, the opposite sex, are somehow innately “transgender.” Yet rigidity (a concise paraphrase for that three-word catchphrase) is also a hallmark of autism spectrum disorder (ASD).

In May, I posted about a recent Finnish study which found that girls presenting to gender clinics in that country have an increased rate of autism spectrum disorder as well as other mental health problems. The researchers found a 26% incidence of ASD in the study cohort.

Sixty-four per cent … were having or had had treatment contact due to depression, 55% … due to anxiety disorders, 53% … due to suicidal and self-harming behaviours, 13% due to psychotic symptoms …, 9% … due to conduct disorders, 4% … due to substance abuse, 26% … due to autism spectrum disorder, and 11% …due to ADHD… …Gender identity issues could arise from autism spectrum people’s predisposition toward unusual interests, or gender dysphoria in ASD could represent OCD rather than genuine gender identity issues. The cross-gender behaviour in ASD minors could also rather represent non-normative sexual interests or unusual sensory preferences. Our clinical impression is that a long-standing feeling of being different and an outsider among peers could play a role in ASD children developing gender dysphoria in adolescence. In our clinical sample of gender dysphoric adolescents, autism spectrum disorders by far exceeded the prevalence of 6/1000 suggested for general population .

It turns out that the link between ASD and GD has been noted by many other researchers, clinicians, and (if the mothers and fathers who comment on this blog are any indication), many parents as well. Poor social and/or communication skills, a hallmark of ASD, as well as a tendency to have obsessive interests, to isolate socially and spend inordinate and unusual amounts of solitary time on the Internet, have been noted by both professionals and parents. I’ve also noticed, on several of the blogs run by parents who are supporting their child’s transition, a theme of frequent temper tantrums and refusal to wear certain clothing.

A 2014 study from Washington, DC found that

compared with normally developing children, young people with ASD were nearly 8 times more likely to express a desire to be other than their biological sex — a phenomenon the authors describe as “gender variance.” Those with a diagnosis of ADHD had more than 6 times the odds of communicating gender variance, according to parent-reported data.

Dr. Strang said they were initially surprised to find an overrepresentation of gender variance among children with ADHD. However, they later realized that prior studies have shown increased levels of disruptive behavior and other behavioral problems among young people with gender variance.

A 2010 Dutch study on found an increased rate of autism in the gender dysphoric children referred to their clinic.

Most individuals with co-occurring gender dysphoria and ASD fulfilled the strict criteria of autistic disorder. For several youth with ASD, their ASD-specific rigidity made enduring gender variant feelings extremely difficult to handle. After all, in our society a considerable amount of flexibility is needed to deal with gender variant feelings. Normally developing young children (age 3–5) display more rigidity in gender-related beliefs than older children; this rigidity decreases after the age of five … Individuals with ASD may not reach this level of flexibility in their gender development.

The implications of this are profound: If some of the very young children with GD (many of whom are currently being profiled in celebratory media portrayals) have co-occurring ASD, yet are being socially transitioned and then put on puberty blockers, how much of their distress is due to the rigid thinking and behavior characteristic of ASD?

Social difficulties are a key trait of people on the ASD spectrum. A 2011 study published in the Journal of Autism and Developmental Disorders that focused particularly on female-to-male transsexuals found that

Autism Spectrum Conditions (ASC) are characterized by difficulties in social interaction and communication, along-side restricted interests and repetitive behavior. … A recent study of play by girls with ASC found they show masculinization in choosing toys that do not require pretend play …, and women with ASC report higher rates of tomboyism in childhood. …We speculate that this increased number of autistic traits is likely to have made the transmen (in their childhood and adolescence) less able to assimilate in a female peer group, instead gravitating towards males. This may also have led to difficulties socializing in a female peer group, and a feeling of belonging more in a male group, thus increasing the probability of GID.

One comment on my earlier post on the Finnish study submitted by a teen girl who says she is autistic, appears to support some of these findings.

I’m autistic and a LOT of autistic girls my age (teenagers) I know from support groups (to learn social skills, etc) are questioning their gender/thinking about transition. I mean a much much higher percentage than not-autistic girls I know… The majority of girls in those groups consider themselves genderqueer/bigender/nonbinary & some talk about transitioning or at least “presenting” as a boy… I wonder if the number of transgender/gender questioning autistic girls is bc autism makes all this gender stuff really hard – there’s hypersensitivity to touch/smell/etc which means many of us can’t shave, can’t wear makeup or tight-fitting feminine clothing, can’t have long hair (bc it touches your skin in unpleasant ways), wear nail polish (it smells too strong) etc. Also ppl think girls have better social skills than boys… so a lot of autistic teenage girls end up feeling like they’re “not girl enough”, like all the other girls can do those things easily and they can’t & that probably means they should be a boy. Idk if this explanation is too simple, there’s probably more to it, but I’m really noticing how MANY autistic girls are in this situation, of wanting to be called “he”, to pass as a boy, to get breast surgery, etc, compared to not-autistic girls my age, and I wish the links between autism and transgender/discomfort with gender were explored more, so we could better help them. If autistic/other disabled people are more affected by dysphoria than the general population, we really should be wondering why? instead of just “accepting that their body is wrong for them”… Why would so many autistic girls’ bodies be WRONG? For no reason???”

An adult woman, also diagnosed with ASD, adds

People on the autistic spectrum feel very different from others, and often “wrong”. We often have trouble fitting in and understanding social situations. Since femininity is a social construct that requires a lot of work, autistic girls and women might not feel or be able to act feminine enough. One common thing is “special interests”. People with AS can easily be obsessed with certain topics. So, with the combo of feeling different and not like a real girl/boy and all the info about transgenderism on the internet, it could lead to people going from feeling wrong, seeing others online talking about being trans, to researching the topic intensively and thinking it could be me, that it could solve their problems to be trans.

In “Musings of an Aspie” (highly recommended), a blogger diagnosed with high-functioning autism offers insights about her experiences with disconnection from female stereotypes.

Women are expected to be intuitively skilled at social interaction. We are the nurturers, the carers. To be born without natural social instincts can leave you questioning your innate womanhood. The first hint of what was to come arrived long before I’d given any thought to what being a woman would mean. At some point in sixth grade, many of the girls in my class became huggers. They hugged when they met each other and when they said goodbye. They hugged when they passed in the hallway. They hugged when they were happy or sad. They hugged and cried and squealed with excitement and I watched from a distance, perplexed. What did all this hugging mean? And more importantly, why wasn’t I suddenly feeling the need to hug someone every thirty seconds? This was the first of many confusing conversations I was to have with myself.

In a very recent review of research (publication date November 2015), the authors observe that

…kids with autism spectrum disorder may hold more rigid views of what it is to be male or female and thus be more at risk toward developing gender dysphoria if they do not feel fit within their binary categories of girls and boys. …and that … the fragility of identity experiences in gender dysphoric minors leads to a more rigid fixation on gender-based stereotypes.

As a critic of pediatric transition, all of this research evidence, as well as the personal anecdotes I’ve shared here, lead me to question: Is it wise to subject children who might have autism to “treatments” that involve permanent administration of hormones, repeated plastic surgeries, and likely sterilization? And further, is a child with ASD even capable of giving “informed consent” for such treatments?

As you might suspect, trans activists–and increasingly, gender specialists and researchers–don’t appear to be much troubled by such questions. In the UK, written evidence recently submitted to Parliament by the Tavistock clinic, one of the key providers of transition services, included this passage:

We offer assessment and treatment not just to those young people who are identifiably resilient and for whom there is an evidence base for a likely ‘successful’ outcome. We have carefully extended our programme to offer physical intervention to those who have a range of psychosocial and psychiatric difficulties, including young people with autism and learning disabilities, and young people who are looked after. We have felt that these young people have a right to be considered for these potentially life-enhancing treatments. This has involved careful liaison with local service mental health providers and Social Care, who may know these young people well and who have particular responsibilities for their well-being. Indeed, the service has no record of refusing anyone who continues to ask for physical intervention after the assessment period. Some young people back off from physical treatment at an early stage, but the majority who choose to undertake physical interventions stay on the programme and continue through to adult gender services where surgery becomes an option.

This March 2015 article, published in the Yale Journal of Biology and Medicine, draws a similar conclusion.

Individuals with ASD have the same rights as other individuals to appropriate assessment, diagnosis, and treatment of gender-related concerns. The challenge that exists surrounds being attentive to the particular concerns that may influence this presentation in ASD individuals; the goal should be to facilitate improved understanding and patient satisfaction and not to increase the number of barriers to appropriate treatment.

It’s likely that some parents might disagree with some of these statements when it comes to their underage kids (though they’d be out of the loop in Oregon, which recently approved gender “confirming” surgeries on children as young as 15 years without parental consent.) But judging by this comment on the publicly viewable Facebook page of Jenn Burleton, the executive director of TransActive, which lobbied for the lowering of the age of consent for gender “transition,” some family members of kids with ASD are aboard the bandwagon, too.

“Gatekeeping”–the imposition of any restrictions on obtaining transition services–is a dirty word to trans activists, and increasingly, compliant gender specialists. “Informed consent” (essentially, giving the patient whatever they ask for, based strictly on self identification) is the new norm. And this push for an end to gatekeeping extends to children and people with disabilities; the hot term is personal “agency,” and trans activists have little patience for the idea that perhaps not all people have equal capacity to make sound decisions. To take but one recent example, the mother of a young woman with Down Syndrome created a fundraising website, which, while mentioning that her daughter had been hospitalized in an intensive care unit, insisted that she still needed “top surgery.” A prominent Los Angeles gender therapist, who happens to be FTM, helped with fundraising for the double mastectomy on a public post on Facebook, which as of this writing is still a live link, despite some scathing coverage in the gender critical blogosphere.

But I digress.

Providers are now recommending treatments for childhood gender dysphoria (puberty blockers followed immediately by cross sex hormones to prevent the “wrong” puberty) that will result in sterilization of minor girls, at least some of whom will have ASD. This is a strange reversal, given that sterilization of minors with any sort of disability is controversial, to say the least. Another hotly debated issue is the sterilization of intersex children. In fact, as this article emphasizes,

“Generally, consent of a parent or guardian is not legally adequate to authorize sterilization — a court order is necessary… How can a physician address this uncertainty? It is certainly prudent to consult with an experienced attorney before undertaking elective gonadectomy or other procedures that could affect fertility. To avoid conflicts of interest, the attorney should represent the medical providers, not the parents. The child may need separate representation. It will be important for counsel to understand the medical issues involved…”

In another strange twist, Lupron, a puberty blocker, is administered to prepubescent children (some, obviously, with diagnosed ASD), despite the fact that lawsuits have halted the drug’s use by some doctors to treat ASD.

So off-label Lupron is the answer for gender dysphoria in a child with autism, but is forbidden to be used to treat the autism? Well, given the current trend in medicine and psychiatry to treat GD as the core problem, perhaps this is not so strange. None other than the American Psychological Association, in its recent guidelines for treatment of trans-identified young people, actually supports the notion (on page 21) that treating GD is something of a panacea for all and sundry mental disorders:

In addition, the presence of autism spectrum disorder may complicate a TGNC person’s articulation and exploration of gender identity (Jones et al., 2012). In cases where gender dysphoria is contributing to other mental health concerns, treatment of gender dysphoria may be helpful in alleviating those concerns as well (Keo‐Meier et al., 2015).

With the lofty endorsement of the APA, what parent wouldn’t look to “transition” as the magic answer for their gender dysphoric, autistic child? And what APA-certified therapist would dare to question these guidelines? (We know of at least one who is raising concerns.)

The sister of an autistic FTM has written an article cheering on her “female-born” sibling. As is usual in such articles, the preference for stereotypical male clothing, interests, and haircuts is used as evidence that this natal female is actually male.

Draped in a royal blue wool cape, my female-born autistic brother wears a homemade pin that reads, “I am a transgender male and I’m proud.” The 23-year-old points to it whenever he’s at restaurants, anticipating people making pronoun mistakes, which have been aggravating him for nearly two years. For several years, he has been dressing like a boy, though his interpretation of what is “masculine” differs from most transgender males. For him, the color blue signifies masculinity more than attempting to “pass” as a man, and so he chooses to wear only monochromatic blue athletic clothing all the time. He has been cutting his hair at a man’s barbershop for a decade, but he only came to identify as male roughly two years ago. He said the epiphany came to him after waking up from a nap, kind of like in Virginia Woolf’s Orlando, in which the male-born protagonist suddenly awakens a woman.

And Wenn Lawson, a trans-identified “highly regarded psychologist, lecturer and author” on the autism spectrum, pushes the idea that stereotyped interests and gender presentation in an autistic child are indicative of true “gender dysphoria”:

But, in children especially, the possibility of gender dysphoria must be considered, and parents need to watch out for the clues. These might be:

looking for gender biased separate interests

wishing they were a girl (or boy)

dressing in girls (or boys) clothes,

wanting to play with toys stereotypically used by the opposite gender

But what of the young people who are “on the spectrum” themselves? Are they all on board with the no-questions-asked, informed consent model of treatment? Put another way: Are the gender specialists providing these people with the best possible care, care that actually provides the most benefit with the least harm?

There is a large online support forum for the autism community called “Wrong Planet.” A search for “gender dysphoria” turns up numerous threads, with commenters discussing their feelings of discomfort or confusion with their bodies and gender identity. Opinions appear to be mixed, with some commenters attributing their dysphoria to their ASD (and denying the need for “transition”), and others discussing their desire to change genders. Interestingly, another commenter on my earlier Finland post had this less-than-rosy observation:

[Wrong Planet] has been co opted by the trans community in other places, and they skew the facts about ASD, and some get kicked off the board for pushing an agenda and posting incorrect facts[which bother people with AS like myself]. I don’t even like to talk about my own AS, because- ‘Maybe you are trans’ gets forced on me[been there-done that] outside of a Wrong Planet board. Men also use this as an excuse to bully women online. The trans community tries to convince non conforming ASD people to join their cult, but some can’t stand it if someone keep misquoting science, or making things up even after corrected[like they do]. That is a dead give away too, Many ASD people, if you can prove your facts, they will correct themselves with the new information, and not feel badly about having the wrong information previously. They will update everything accordingly. If you are saying ‘bullshit’ and non reality is true, they will kick you off that site for teasing them.

It does appear that at least some people on the ASD spectrum have come to terms with their childhood feelings of gender incongruence and resolved them as adults. Once again, we hear from the author of “Musings of an Aspie”:

At five, I wanted to be a boy. I don’t know what I thought being a boy meant. Maybe I thought it meant playing outside in the summer, shirtless and barefoot. Maybe I thought it meant not wearing dresses. Dresses were all scratchy lace trim and tight elastic sleeves. Stiff patent leather shoes pinched my sensitive feet. Perfume tickled my nose. Tights made my legs itch and had maddening seams at the toes. Too young to understand sensory sensitivities, I followed my instincts. While other girls favored frilly clothes, I gravitated toward the soft comfort of cotton shirts and worn corduroys. Somehow, comfort got mixed up with gender in my head. For decades, “dressing like a girl” meant being uncomfortable. And so began a lifelong tension between being female and being autistic.

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