Brains Part 3: The Link Between Autism and Gender Dysphoria

CW: Transphobia and ableism

By Eleanor McKelvey, Head of Online Engagement (Blog)

According to the American Psychiatric Association, the term gender dysphoria describes “a conflict between a person’s physical or assigned gender and the gender with which he/she/they identify”. We are beginning to take note of how gender might affect the expression of autism (see Part 2), and so it is perhaps not surprising that some academics have suggested there is a link between autism spectrum disorders (ASD) and gender dysphoria (GD). However, research in the field is marred with controversy. Why are professionals finding it so difficult to reach a consensus about the intersection of GD and ASD?

Why might we suspect a link between ASD and GD?

Despite the suggestions of some ludicrous media reports, there is certainly no evidence that only autistic people experience gender dysphoria, nor that autism causes gender dysphoria. However, what is possible is that being autistic/on the autism spectrum might increase the chance of GD; for example because they share predisposing factors.

In the scientific literature, a multitude of biological factors have been proposed to link ASD with GD. In line with the “Extreme Male Brain” theory of autism (See Part 2), it is often suggested that exposure to high levels of male sex hormones (androgens) in utero might contribute to the chance of developing autism. It turn, this “masculinisation” has been proposed to also make girls more likely to experience gender dysphoria. But aside from the controversy surrounding the concept that being autistic means having an “Extreme Male Brain”; this theory also lacks the capacity to explain higher rates of gender dysphoria in autistic boys. Other biological factors (e.g. genetic mutations that contribute to the likelihood of GD might also increase the chance of ASD, and vice versa) are certainly possible, but there has been limited investigation into such mechanisms.

How strong is the link between ASD and GD?

Research investigating this question has so far proven inconclusive. In order to confirm that ASD and GD co-occur, studies need to be able to demonstrate a statistically significant association (confirming that any observed co-occurrence is not just a chance find). One of the best ways to do this is to recruit a large number of people into studies, so that they are representative of the overall population. However, pretty much all of the research so far has involved small sample sizes.

Furthermore, in a January 2018 publication, researchers from Harvard Medical School  highlighted the fact that researchers have sometimes conflated gender variance with gender dysphoria. A statistic often used to support the claimed GD-ASD link is that, compared to 1% of the total population, 5-7% of young people with ASD have been reported to display gender variance. However, as the Harvard researchers describe, “an adolescent birth-assigned male with ASD who enjoys knitting, for instance, might label this activity as “feminine” and therefore be encouraged to consider themselves as gender variant. This is very different from gender dysphoria, which involves a resounding desire to be the opposite gender.

Even though there has been a sudden increase in the number of publications on GD-ASD, most of these do not include any new data, and simply draw inference from the few limited studies that have already been published. Multiple scientific reviews have conceded that data on the GD-ASD link is so far not convincing. In a review published in November 2018, researchers from the Centre of Expertise on Gender Dysphoria in Amsterdam described all existing data as “low-grade evidence”, and said that although a link still seems “plausible”, they encourage “further debate on the GD-ASD literature”.

What are the concerns about establishing a GD-ASD link?

As awareness of the potential GD-ASD link grows, so does the concern about how this knowledge might be applied. One the one hand, there is the worry that clinicians may be inclined to diagnose gender dysphoria too hastily in autistic people when they see signs of gender variance – a person who is gender non-conforming is not necessarily trans. S Kilian is self-diagnosed autistic and intersex, but was coercively assigned female at birth. They describe their complex relationship with their gender identity, saying:

“I did my own thing, hated being forced in to dresses, and eventually rebelled and decided I must be a transman because I was obviously not female. After finding out that I was coerced into being female to begin with, I stepped back from being adamant that I "must be male instead". I found words like nonbinary, agender, genderfluid. I found out that I didn't need to perform one of these genders.”.

Conversely, there is also the fear that if the link is misinterpreted as a causative relationship, people could end up having their gender dysphoria invalidated as a “symptom” of autism. Lachina McKenzie is an autistic transwoman. She expresses concern that knowing about a person’s autism might allow people to think they have “a license to override their autonomy, look down on them, or be sceptical about their gender/transition”.

In fact, there is already evidence that healthcare providers are being encouraged to show excessive scepticism towards autistic people looking for a diagnosis of gender dysphoria.  Network Autism has published an article on its website entitled “Gender dysphoria and autism: Challenges and support”, which is written by Dr Sally Powis, a consultant clinical psychologist and self-claimed expert in GD and ASD. “Sully” (non cis-gender and on the autism spectrum) worries that the article “reads like someone who wants to talk people out of doing things that alleviate their gender dysphoria.”

For example, in the article, Powis writes, “I have worked with autistic people with GD...outcomes have ranged widely [from] wanting to transition fully to the opposite gender with hormone treatment… [to] the desire to transition [turning] out to be more of a confusion, fetish or distress at growing up”.  Lachina describes this statement as “troubling”, since the notions of GD as fetish or confusion are little more than “myth…used to invalidate people's transitions or deny them medical autonomy” – it is pertinent that these ideas, long established as outdated by most GD experts, have had a resurgence in the context of ASD.  

Nonetheless, it is important to acknowledge that autistic people might need specialised help during gender transition. Awareness of the GD-ASD link may encourage healthcare providers to think about the ways that they can best support their autistic trans clients. Lachina says she believes it is especially important to offer “autistic trans kids help with practical stuff like shoes, makeup etc., and that they should have early “out” experiences in a supportive environment”.

So, what can we be sure of?

Scientifically speaking – the jury is out as to whether there is a significant link between ASD and GD. The only thing that we can say with certainty at this stage is that more research is needed. In the meantime, it is important to emphasise that autism should not be used as an excuse to delegitimise a person’s gender identity.

A recurring theme throughout this three-part article series has been the importance of using precise and careful language when it comes to discussing gender in the context of neuroscience/psychology. Feminism is often scalded for pedantry; but I would hope that these articles have been able to exemplify how seemingly “minor” instances of inconsiderate language choice can have significant ramifications. These problems can emerge from the accumulation of small-scale microaggressions, (e.g. use of the terms “female brain”), to the perpetuation of key misunderstandings (e.g. the idea that autism “causes” gender dysphoria).