By: Christina Buttons
Published: Mar 24, 2023
Children and adolescents on the autism spectrum are disproportionately represented among the large, newly emerging cohort of young people self-identifying as transgender.
In recent years there has been an exponential rise in the number of adolescents and young adults adopting transgender identities, stirring intense debate about its underlying causes. Mainstream discourse on this issue has centered on factors such as social influence, greater societal acceptance, and expanding definitions of what it means to be transgender.
However, an important yet largely unexplored factor that may be contributing to this trend is undiagnosed autism, particularly in young girls. Without a diagnosis, and even with a diagnosis but without a clear understanding of how autistic traits can present, these traits can be easily confused for gender dysphoria and cause individuals to pursue inappropriate and irreversible medical interventions.
Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition that affects communication, social interaction, and behavior that presents in varying degrees of severity from individual to individual. However, despite its history and prevalence, it remains a highly misunderstood disorder, especially in girls.
As many as 80% of girls with autism are not diagnosed until they reach adulthood, which can cause significant mental health problems and incorrect early diagnoses. This underdiagnosis is primarily due to the common misconception that autism is a predominantly male disorder. In fact, the Centers for Disease Control and Prevention (CDC) still maintains that “ASD is more than 4 times more common among boys than among girls.”
However, autism experts now believe that the sex ratio is much more evenly matched than previously thought. Girls often fly under the radar because the diagnostic criteria is better at detecting male-typical traits. Girls are also better at masking their symptoms, adapting to social situations, and tend to have interests that don’t fit the stereotypical profile of autism.
During puberty, autistic girls often experience exacerbated social and sensory challenges due to hormonal changes affecting their bodies and brains. These difficulties can be compounded by the pressure to navigate unfamiliar social situations and expectations, which can lead to the development of co-occurring conditions such as depression, anxiety, and body image issues. Unfortunately, the challenge of communicating their experiences may cause mental health professionals to overlook their underlying autism.
Given that autism is greatly underdiagnosed in young girls, I do not believe it is a coincidence that we are seeing a significant surge in adolescent girls self-diagnosing with gender dysphoria. An incorrect early diagnosis can lead to inappropriate treatment, which can result in devastating effects to their mental health and well-being.
This issue is very personal to me because I went through severe mental health struggles during my adolescence. It required multiple psychiatric hospitalizations and a long-term stay in a residential treatment center before I finally received an Asperger’s diagnosis at the age of 30. When I came across the stories of detransitioners, many of whom also came to understand they had autism after their misadventure, I felt a strong connection to them that motivated me to become a journalist and bring attention to their stories.
I’ve interacted with many of these young men and women who formerly identified as transgender, and some I now consider friends and have met in person. The prevalence of autism among them, and how these traits may have played a central role in their transition journey, is too significant to ignore.
While my observations of this cohort are neither comprehensive nor conclusive, I believe they nevertheless provide some much needed insight into this understudied population. These observations were gleaned from my conversations with 48 detransitioners and their written testimony.
Out of the 48 detransitioners whom I’ve come into contact with, 42 (32 females and 10 males) have confirmed autism or suspected autism (identification with autistic traits). Although the remaining 6 were confident they were not autistic, they believe their perceived gender dysphoria was due to a variety of other reasons, including other psychiatric disorders. Among the 42 detransitioners who have confirmed or suspected autism, only 5 had been diagnosed before or during their transition. All 5 told me that if they had fully understood what being autistic entailed and how it could manifest in their lives, they probably would not have believed they had gender dysphoria. They also said that “gender identity” and transgender issues became their “special interest” for a period of time.
This observation was also made by Dr. Kenneth Zucker, a psychologist with 30 years of experience running the largest Canadian childhood gender clinic, who believes that many autistic teens identify as transgender because of their tendency to fixate or obsess over a “special interest.”
As for the remaining 37 detransitioners, about half obtained an official diagnosis after they detransitioned and said that an earlier autism diagnosis could have prevented them from seeking medical transition services they now regret. Some detransitioners have written about these revelations. The other half are either in the process of seeking a diagnostic evaluation or are not interested, but found that they identify with autistic traits. Some of the reasons for not actively seeking an evaluation include long wait times and a general skepticism of mental health professionals who had previously failed to properly assess them.
Detransition among young people is growing. A forum for detransitioners on Reddit now exceeds 45,000 members and is adding roughly 1,000 members per month. In the United States, a 2022 study found that 29% of 68 patients seeking medical transition care changed their requests for hormone treatment, surgery, or both. Another U.S. study from 2022 found that 30% of patients who commenced cross-sex hormone treatment discontinued it within four years for unknown reasons. Two small studies in the U.K. report that between 7% and 10% of patients initially assessed for gender-related medical services later detransitioned.
Detransitioners have described being immediately “affirmed” in their recently adopted transgender identities without careful assessment. Some of them were teenagers when they began transitioning, and many now feel that they have been medically harmed due to the various chemical and surgical interventions they underwent. This is unacceptable and nobody should have to experience this.
One way to help mitigate such outcomes would be to improve education on autism, particularly how it presents in girls, and advocate for early diagnosis. This isn’t to diminish the experiences of transgender adults on the spectrum but rather to rule out false positives. An earlier diagnosis of autism may prevent some from mistaking their autism for gender dysphoria.
Aside from early screening for autism, the affirmative care model used by many US medical organizations poses a significant risk to vulnerable autistic individuals who may self-diagnose with gender dysphoria and seek irreversible medical interventions to alleviate their distress.
The gender-affirmation model that has been adopted widely across the US prevents medical professionals from questioning an individual’s self-reported transgender identity or exploring possible underlying factors causing their perceived dysphoria. The standard protocol for gender affirmation in minors involves administering puberty blockers, followed by cross-sex hormones, and then surgery if desired.
Despite research indicating that roughly 60-90% of children who identify as transgender but do not socially or medically transition will no longer identify as transgender in adulthood, children are still put in the driver’s seat of their own sex change operations.
The affirmative model of care has been abandoned in Florida and in progressive European countries like Finland, Sweden, the UK, and most recently Norway, after conducting systematic reviews of the available evidence and concluding that the risks of pediatric medical transition far outweigh any purported benefits. This resulted in the closure of prominent gender clinics, strict restrictions on the use of cross-sex hormones, and a ban on gender-related surgeries for minors. Italy, Australia, and Spain's medical bodies have also recently raised similar concerns.
If US-based medical organizations were willing to walk back the affirmative model of care and prioritize thorough evaluations and thoughtful, individualized assessments that explore why someone might be feeling distress over their gender, they could prevent misdiagnosis and inappropriate treatment.
It is important to understand how autistic traits can be mistaken for and misdiagnosed as gender dysphoria. I have therefore compiled a list to help with this understanding.
Traits of autism that may be mistaken for gender dysphoria
Autistic people face a number of challenges that are intensified when they don’t have a proper diagnosis or are not adequately educated about how their traits can present. Some of the attributes that can lead to confusion over their “gender” include identity issues, rigid or “black and white” thinking, intense and restricted interests, gender nonconforming behavior, social difficulties and a preference for online socialization, incongruence with the body, and other comorbidities.
Identity
By adolescence, autistic people typically intuit that they differ from their peers, but are unable to pinpoint or describe the reason, which can be distressing. As they struggle to assimilate, they may become preoccupied with understanding themselves and how they fit in with those around them. In a desperate attempt to resolve their distress, they may “try on” different identities or diagnoses to see what “fits.”
Rigid thinking
One of the core features of autism is rigid thinking, a cognitive style that is characterized by inflexible and repetitive thought patterns, behaviors, and routines.
- In recent years, the significance of gender dysphoria as a meaningful diagnosis has been deemphasized in favor of a broader definition of what it means to be transgender, or “gender diverse,” which includes mere nonconformity to sex-based stereotypes. Autistic people could easily interpret this definition to mean they are transgender.
- Autistic people may prefer simple explanations, and be prone to black and white thinking. When they come across overly simplistic views about gender, it can provide them with a quick explanation for their troubles (they are transgender) and a ready-made solution (transition) to achieve what they hope will be a sense of normalcy and comfort in their bodies.
- Sometimes girls who are more gender nonconforming will feel they cannot compete with girls they perceive as more feminine, popular, and attractive. Because autistic girls can easily get locked into black and white thinking, this may cause them to reject femininity and embrace masculinity.
- Autistic people have an aversion to inauthenticity. Once introduced to the concept of “gender identity,” they may reexamine their life history through this lens, looking for signs they may be transgender. Through a process of confirmation bias, they may find traits and life events that conform to a transgender narrative.
- Autistic people have difficulty with flexible thinking and are less likely to change their minds once convinced something is true. They may become deeply attached to their beliefs and find it difficult to consider alternatives. If they become convinced they are transgender, it can be difficult to dissuade them.
- Autistic people also tend to be very literal and so when they come across statements meant to be figurative and promote inclusivity like “trans women are women” and “trans men are men,” they may take it literally. They may come to believe they can actually change their sex.
- Their naivety may also play out in their expectations of social and medical transition, and they can become extremely frustrated if their expectations are not met.
- Their tendency towards rigidity in thinking can make it challenging to adapt to changes in gender norms or expectations. This rigidity may be misinterpreted as a strong identification with one sex and discomfort with another.
Intense and restricted interests
One of the hallmarks of autism is intense and obsessive interests in certain topics or hobbies, also known as “special interests.” Special interests are a common characteristic of ASD and can become all-consuming passions that provide individuals with a sense of comfort, enjoyment, and mastery.
Research suggests that there may be sex differences in the types of special interests that autistic boys and girls develop. For example, one study found that autistic girls were more likely to have interests in people and animals, while autistic boys were more likely to have interests in objects and systems.
It’s quite possible for individuals with ASD, especially females, to become deeply interested in social justice and transgender issues. They may become fixated on exploring and understanding “gender identity,” including their own and the experiences of other “gender diverse” individuals. This interest may involve reading and researching about gender identity, attending support groups or advocacy events, or engaging in creative expressions online or joining online communities.
- Autistic people have a strong sense of justice and fairness, and may become interested in topics of "social justice" they come across in online communities on social media.
- Autistic people may find themselves fascinated with the transgender community and its cultural significance, with its many charismatic transgender influencers and frequent relevance in the news. With the transgender community’s growing popularity, there are endless ways to interact with this special interest.
- “Gender identity” ideology comes from a postmodern social theory developed in college Humanities departments called “Queer Theory,” which has been written about and lectured on extensively. It can provide endless hours of learning for anyone interested in the subject.
- “Consistent, persistent, insistent” are the words used by medical providers as strong indicators that someone has gender dysphoria, but they could easily also describe a autistic person’s relationship to their special interest.
Gender nonconformity
Historically, autistic people have been more likely to display sex atypical behavior. Young people should not be discouraged from gender nonconformity. It is perfectly natural and okay for a girl to have more stereotypically masculine traits and interests and for a boy to have more stereotypically feminine traits and interests – this does not equate to gender dysphoria.
- A 2014 study found that children with ASD were 7.59 times more likely to be gender non-conforming or “express gender variance.”
- A 2021 study found that gender nonconformity is substantially elevated in the autistic population.
- Several studies have suggested that autism spectrum disorder (ASD) and gender nonconformity co-occur more often than by chance in adolescents.
- Sexuality also appears to be more varied among people with autism than among those who do not have the condition. Only 30% of autistic people in a 2018 study identified as heterosexual, compared with 70% of neurotypical participants. And although half of 247 autistic women in a 2020 study identified as “cisgender,” just 8% reported being exclusively heterosexual.
- Gay males may also not be well-detected by standard diagnostic criteria, as some may have more female-typical traits.
- Because of the expanding definition of what it means to be transgender, now defined by major institutions as an “umbrella term” which encompasses mere gender nonconformity, autistic people might believe that because they don’t conform to sex-based stereotypes, they could be transgender.
- Autistic people may socially gravitate towards the opposite sex. They may find it easier to communicate with and have more in common with the opposite sex. This may lead them to believe they actually are, or should become, the opposite sex.
Social Difficulties
Gender is often presented as a “social construct,” and one of the hallmark traits of autism is a host of social challenges. Struggling to adapt to “gender roles” can significantly contribute to a rejection of their perceived “gender role” which can lead to a rejection of their biological sex by extension.
- Difficulty with social communication: Individuals with autism may have difficulty with social communication and understanding social cues, which can make it challenging to navigate gender norms and expectations. These experiences can be frustrating and cause them to reject the norms associated with their sex.
- Repetitive behaviors: Individuals with autism may engage in repetitive behaviors, or “stims,” that can sometimes be misinterpreted as sex-atypical behaviors.
- For girls, repetitive or disruptive movements may be viewed as unfeminine and may lead to social rejection from peer groups.
- Difficulty with social imagination: Individuals with autism may have difficulty with social imagination, which can make it challenging to envision oneself in different roles or identities. This difficulty may be misinterpreted as a lack of identification with one's biological sex.
- Difficulty with perspective-taking: Individuals with autism may have difficulty understanding other people's perspectives or social expectations, which can make it challenging to navigate gender roles and expectations.
- Difficulty with emotional regulation: Individuals with autism may have difficulty with emotional regulation, which can lead to intense and distressing emotional responses to certain situations or social expectations related to gender roles.
- Autistic people often learn to adopt alternative personas to cope with and blend in with different social settings, which may make it easier for them to adopt a cross-sex identity.
Preference For Online Socialization
Individuals with autism have more difficulty with in-person social relationships, leading them to prefer online socialization, which can be easier and less stressful for them to navigate. One reason is that online interactions can provide a sense of control and predictability that may be lacking in face-to-face interactions.
Autistic individuals may find it easier to communicate online because they have more time to process and respond to messages. They can also avoid nonverbal communication that they find difficult to interpret. Additionally, online communication can be less overwhelming and less sensory-stimulating than in-person communication.
Another reason is that online interactions can provide opportunities to connect with others who share similar interests or experiences, which can be more difficult to find in-person.
Currently, there is heavy cross-over between the online autism community and “social justice.”
- Autistic people lack an understanding of social behavior and may be prone to mimicking what they see online. Social media algorithms may feed them a steady stream of content from the online transgender community that may lead them to believe that it is how they are “supposed” to act to fit in.
- They may discover a transgender influencer who is popular as “socially successful” and try to mimic their behavior, clothing, body language, and interests to assimilate. They may desire to create “content” like other transgender influencers.
- Autistic people typically like rules, as they provide a sense of structure and predictability. They may like that the social rules enforced by online Social Justice communities are made explicitly clear in shareable Instagram infographics.
- Some autistic people have a particular talent for visual-spatial skills, which could lead to an aptitude for creative fields such as art or design and some are creative musically or with writing. Creative autistic types may be influenced by “gender expressions” they see online, which include making up your own “neopronouns.” They may want to express their own creativity through their understanding of “gender.”
- Many autistic people feel socially awkward, have difficulty making friends, and are lonely. The growing population of the transgender community that embraces people who are different may seem welcoming and a built-in network of friends and support may be appealing.
- In the online world, people are encouraged to create their “brand.” They may want to find an online persona in a niche community.
- They may be influenced by others to reject the people in their life who do not “accept” them, join “glitter families” or go “no contact” with their real families. With fewer people offline to keep them tethered to reality and provide different points of view, they may further succumb to the echo chambers of online communities.
Incongruence With Body (Disconnect and Discomfort)
Autistic people struggle with interoception (sensing internal signals from your body). They can recognize they feel discomfort but have trouble interpreting their bodily signals and pinpointing where it is coming from. This is worsened by challenges with alexithymia (an inability to identify and describe emotions). Without proper diagnosis, this can contribute to a feeling of incongruence with their body.
Autistic people, especially if they lack a diagnosis, can easily get overwhelmed by sensory input, but may not have the words to articulate what is making them feel uncomfortable. Ongoing discomfort in one’s body may be mistakenly attributed to gender dysphoria.
- Individuals with autism may experience tactical sensory sensitivity, which can make it uncomfortable to wear certain types of clothing or accessories associated with their biological sex.
- For example, girls on the spectrum may prefer clothing that is more typical for boys because it is loose-fitting and more comfortable. They may mistakenly attribute this to being more “boy-like.”
- Especially for adolescent girls, not adhering to the latest fashions of their peers may make them feel like an outcast.
- Individuals with autism may also experience sensory issues with grooming activities, which can make it challenging to adhere to gender norms and expectations.
- Girls may find that makeup feels uncomfortable.
- Girls may prefer to keep their hair short, or in a ponytail everyday because letting their hair down feels irritating on their skin.
- Young boys may want to grow their hair long because they hate the experience of going to the barber.
- Autistic people often struggle with proprioception, which may manifest as having difficulty understanding where their body is in space. This can result in challenges with coordination, balance, and fine motor skills, which may lead to feelings of frustration or disconnection from their physical body.
- Adolescents with developing bodies that don’t feel like they meet stereotypical ideals for their sex may reject their bodies and hyperfocus on their perceived flaws, leading to body image disorders.
- For adolescents, discussions of gender dysphoria in the classroom may be the first time that “discomfort of the body” is introduced and articulated to them, which they may find they can relate to and begin to associate their own bodily discomfort with gender dysphoria.
- The succession of steps involved in social transition and then in medical transition may make them feel that they are on the path towards finally feeling “right” in their body.
Comorbitities
Individuals with autism, especially without a diagnosis, are more likely to experience co-occurring mental health conditions, such as anxiety or depression, which can complicate the assessment of gender dysphoria.
Depression:
Autistic people have social difficulties that make it harder to make and maintain friendships, leading to isolation and depression, and this effect is worsened when individuals do not receive a diagnosis of autism until adulthood.
- A 2022 study found people diagnosed with autism in adulthood are nearly three times as likely as their childhood-diagnosed counterparts to report having psychiatric conditions.
- A 2021 study shows that receiving an autism diagnosis in adulthood rather than childhood can lead to lower quality of life, more severe mental health symptoms, and higher autistic trait levels.
Suicidal Ideation
A growing body of research has found that autistic youth and adults appear to have higher rates of suicidal thoughts, plans, or behaviors than non-autistic youth.
- A meta-analysis found that one in four autistic youth experience suicidal ideation and almost one in ten attempt suicide.
- A Danish study found that autistic individuals had 3 times higher rates of both attempted and completed suicide.
- A 2022 UK study found a significant number of people who died by suicide were likely autistic, but undiagnosed.
Obsessive Compulsive Disorder
Autistic people are more prone to obsessive compulsive disorder and may obsess over their desire to become the opposite sex to escape their unhappiness.
- One study found 17% of autistic people may have OCD.
- An even larger proportion of people with OCD may also have undiagnosed autism, according to one 2017 study.
- It might be helpful to view gender dysphoria as a form of OCD, in which the individual attributes their biological sex as a source of distress and obsesses over the desire to become the opposite sex. Alternatively, some OCD clinics have attempted to distinguish between gender dysphoria and what they termed as “Trans OCD,” which is “an obsession over gender identity.”
Body Image Disorders
Autistic people are more prone to having body image issues that may make them fixate on their weight (eating disorders like anorexia or bulimia) or perceived flaws (body dysmorphia).
- Roughly 20% of people with anorexia are autistic.
- Body dysmorphia is a disorder in which one develops a fixation on perceived flaws on the body that become exaggerated in the mind. It is part of a new category of “obsessive-compulsive and related disorders” that autistic people are over-represented in.
Anxiety
Anxiety is a common co-occurring condition in autistic individuals.
- Research suggests that up to 40-50% of autistic individuals may experience clinically significant anxiety symptoms at some point in their lives.
- One study found that up to 84% of autistic people have some form of anxiety.
Gastrointestinal Distress:
Gastrointestinal (GI) disorders are one of the most common medical conditions that are comorbid with Autism spectrum disorders (ASD). This can contribute to discomfort and incongruence with the body.
- Some studies have suggested that up to 90% of individuals with autism may experience GI symptoms, such as abdominal pain, constipation, diarrhea, and reflux.
- A comprehensive meta-analysis revealed that children with ASD were more than 4x more likely to develop GI problems than those without ASD.
Polycystic Ovarian Syndrome (PCOS)
Research indicates an association between Polycystic ovary syndrome (PCOS) and autism. PCOS is a hormonal condition that involves intricate interactions among the ovaries, androgens, other hormones, and insulin. One prominent feature of this condition is increased levels of androgens or "male hormones." The heightened androgen levels, along with virilization, can be a source of considerable distress for several women and result in a form of gender dysphoria.
- One study found autistic women in the UK have an almost two-fold increase in the risk for PCOS.
- A 2012 study found that women with PCOS have ”problems with psychological gender identification. Duration and severity of PCOS can negatively affect the self-image of patients, lead to a disturbed identification with the female-gender scheme and, associated with it, social roles.”
Trauma:
If an autistic person has a traumatic experience, they are more likely to internalize it. If they are sexually abused or groped they may develop negative associations with the part of their anatomy that was abused and feel the need to reject it.
- Autistic girls are at heightened risk of sexual abuse.
- Research has shown that individuals with autism who have experienced sexual abuse may be more likely to experience internalizing symptoms such as depression, anxiety, and post-traumatic stress disorder (PTSD) compared to non-autistic individuals who have experienced sexual abuse.
- One reason for this may be that autistic individuals may have difficulty communicating their experiences and feelings about the abuse, which can lead to a sense of isolation and helplessness.
- Autistic individuals may also struggle with processing and regulating their emotions, which can make it more difficult to cope with the trauma of sexual abuse.
Other contributing factors:
- The Pandemic: When non-emergency clinics were closed, many young people were socially isolated and depressed, turning towards online mental health communities and self-diagnosing. We saw this happen with the emergence of “TikTok tics” and the resurgence of the once-extremely rare Dissociative Identity Disorder (DID).
- Puberty: Puberty is a time of significant changes in the body and brain, which can affect individuals with autism in different ways. During this window, they may experience worsening mental health, bodily discomfort and social difficulties. Without a diagnosis, autistic adolescents may not understand why they are experiencing these difficulties and may feel isolated and confused.
- Stressful life events: Stressful life events can be particularly challenging for autistic individuals due to difficulties in coping with changes, uncertainties, and unpredictability. Autistic individuals may struggle with changes in routine, unexpected events, and situations that require flexibility and adaptability.
- Loss of Asperger’s as a diagnosis: The diagnosis of Asperger’s Syndrome was merged into an umbrella diagnosis called Autism Spectrum Disorder (ASD) in the DSM-V update in 2013, which may contribute to a lack of diagnosis in those who appear to have less visible symptoms. The general population associates autism with severe disability, and those without an intellectual disability may be less likely to get diagnosed.
- Misdiagnosis: The difficulty that autistic people face in regulating emotions and the trouble they have in relationships can be misinterpreted and is often misdiagnosed as Borderline Personality Disorder, Bipolar Disorder and more.
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~11% of trans identifying people have autism, whereas ~1% of people in the general population have autism.
I'm just going to say it: maybe don't trans the autistic.
Sorry, not sorry.