What are co-occurring issues for children and young people with gender dysphoria?

Clinicians note that children and young people presenting with gender dysphoria often have significant co-occurring challenges, such as mental health problems, and/or other difficulties in their lives (Kaltiala-Heino et al., 2018). Some of these issues are rooted in societal attitudes. As always, correlation is not the same as causation. While case studies (and personal descriptions of lived experiences) are helpful to communicate patient stories, they carry less weight in terms of evidence-based medicine. Therefore, anecdotes ought not be afforded undue significance. More research, using sound methodology and careful data analysis, is vital to further scientific understanding and provide better services that support people with gender dysphoria. Challenges for young patients with gender dysphoria may include: obsessional thinking and rumination, autism and autistic traits, homophobia and sexual aggression.

Obsessional thinking and rumination

This is a pattern of thinking seen in people diagnosed with obsessive compulsive disorder (OCD) but it can also be a feature of people with an obsessional style of personality (previously known as anankastic). They harbour the belief that there is a perfect way of doing things, or being, and will keep pursuing their goal until they feel it is right. In small measure and certain jobs, this feature of personality has its place. Once it reaches the level described as ‘clinical perfectionism’ it can impact detrimentally on a persons life. People’s thoughts frequently return to the focus of their obsession, and these thoughts turn over and over in their head. Eventually, this preoccupation can be debilitating, and clinicians may feel a need to help them enact some method of making things right. Generally, these patients do not respond long-term to an intervention that obtains the ‘desired’ outcome; their thoughts will return, maybe with a different focus. 

Similar patterns of thinking may be seen in individuals with gender dysphoria, and as such they may benefit from specialist therapy to address this underlying issue. This type of thought pattern may not be evident without a careful and sensitive assessment. Therapeutic assessments take time and involve a significant level of trust between the clinician and the individual. Patients may feel the process is challenging and difficult, as people frequently harbour shame and guilt about their inner thoughts and preoccupations. 

Autism and autistic traits

Mounting scientific evidence points to a high frequency of autism in people who have gender dysphoria and/or identify as transgender (Murphy et al., 2020; Warrier et al., 2020). More research is required before this co-occurrence and its significance can be understood fully. Autism, or autism spectrum disorder (ASD), is a complex diagnosis to make and requires specialist assessment (NHS, no date). Unfortunately, in the UK the NHS has long waiting lists for assessments, so young people are often left feeling stressed and depressed; entering adolescence they start to realise they are different to their peers. Whilst some young people are valued just for who they are and what they can do, others are considered ‘difficult’ or ‘weird’ and rejected. There are two main groups of symptoms that underpin autism – social communication difficulties, and restrictive and repetitive interests and behaviours. People with autism also have high levels of abnormal sensitivities (either hyper- or hypo-sensitivities). Young people can feel as if they don’t fit in and at times they might be bullied and excluded, particularly for communication and behavioural mistakes they do not even fully understand.

Certain traits of autism may explain the increased rates of ASD in people with Gender Dysphoria:

• Not fitting in. This can be the result of a person’s difficulty understanding and keeping up with the social communication that becomes increasingly complex in early teenage years. Teenagers are expected to quickly learn new rules of social behaviour as they begin to embark on romantic relationships. Competitive peer relationships and communications that have multiple meanings can be challenging or difficult for autistic individuals to fathom. 
• Odd or awkward social behaviours. People with ASD can be experienced as blunt, intrusive or bossy, and may have unusual preoccupations. Rather than accepting ‘this is the way they are’, or setting and explaining simple, clear boundaries, this may lead to them being excluded, and overtly or covertly being targeted or bullied.
• Sensory differences. Tactile and interoceptive (internal) sensory differences may mark them as different, and they may interpret these experiences as related to their gender. For example, asexuality is more common in ASD. The sensations related to their pubertal development may be distressing. 
• Rumination and special interests. Young people with ASD may follow chat boards on platforms such as Tumblr or Reddit and become influenced by ideas that they read about or videos that they watch. Gender can become an all-consuming obsession, and can lead them to spend a lot of time online as they research every aspect of the area. Certain popular assertions in these Internet spaces, such as ‘if you think you may be trans then you are,’ may suggest to young people with ASD they should adopt a trans identity.
• Literal, black and white style of thinking. Rigidity is frequently seen in people with ASD. For this reason, change and flexibility is difficult, including changing their minds. It can be very hard for people with ASD to see things from other peoples’ perspectives. Their ability to understand metaphors or analogies may be limited, so it becomes difficult to explore abstract ideas. 
• Prone to anxiety and depression. People with ASD have higher rates of mental health difficulties than neurotypical individuals.
• Friendship difficulties. The stereotype of the autistic person as a loner means their need for social interaction frequently is not recognised. Many people with ASD are keen to find friends who are like them and who ‘get them’. The trans community can be a lifeline for young people who are desperate to be accepted. 

Homophobia

In the past, the majority of children referred to clinic for gender dysphoria were boys (Butler et al., 2018). Research suggested most of these boys would cease to experience gender dysphoria by the end of adolescence; they grew up to be happy with themselves as men, and frequently developed a bisexual or homosexual orientation (Singh, Bradley and Zucker, 2021). This indicates that clearer understandings are needed to differentiate between emergent sexual orientation versus gender dysphoria in children and adolescents. How sexual orientation develops is complex. Research to date has shown this to be a combination of biological and social factors. For young people who are experiencing confusion and difficulties around their development of sexual orientation, they can be counselled, as their and their family’s acceptance of this is important. If a young person is struggling to accept their sexuality, or experiencing hostility (overtly or covertly) from home or elsewhere, then this can be explored and action and support provided where necessary. This may involve probing safeguarding concerns, or getting school involved in the case of bullying.

For young people who are lesbian, bisexual or gay, growing up in a homophobic environment can be crushing. They can internalise the stigma, aggression or disgust that is directed at them. This can lead to the development of debilitating mental health conditions (including depression, anxiety, self-hatred, and self-harming behaviours). Internalised homophobia has been identified as one cause of gender dysphoria. This is evident from the accounts of some detransitioners (people who socially or medically transitioned but who have then come back to their original gender). Lesbian and gay people may not behave in stereotypically masculine or feminine ways. If these behavioural traits aren’t acceptable to other people, the result can be bullying and teasing. Or, a young person may be told perhaps they were born in the wrong body, and actually are (or ‘should have been’) the opposite gender. Girls who are lesbian may sometimes feel (consciously or unconsciously) that they are somehow unacceptable, as they don’t fit the overtly feminine and highly sexualised caricature of how a woman is ‘supposed to be’ that is widely perpetuated.

For an extreme example of an interaction between homophobia and gender dysphoria consider Iran, a country where homosexuality is a capital crime. Iranian lesbian and gay people are reportedly coerced into changing their legal gender and undergoing hormonal and surgical interventions so they will look more like the opposite sex, which thereby socially reconceptualises their homosexual orientation as ‘heterosexual’ (Ahmadzad-Asl et al., 2010; Hamedani, 2014; Jafari, 2014). 

Despite progress in the area of equalities and law related to sexual orientation, homophobia is still a problem across society. Clinicians in the field of mental health are trained to consider the individual’s internal and contextual experiences. Asking about bullying at school, or attitudes at home is vital, as is addressing these difficulties directly, or supporting the individual to address them.

Sexual aggression

Another co-occurring experience, especially for girls whether or not they are experiencing gender dysphoria, is the common experience of sexual aggression, sexual assault, or rape that rises sharply with the onset of puberty. The problem of sexual violence is pervasive even between students within educational settings; while members of both sexes are harmed, the general trend is that the majority of victims are female and the majority of perpetrators male (Department for Education, 2021). A helpline set up to provide support to victims noted that “incidents reported include sexual name-calling, unwanted sexual touching, sexual assault and rape by other pupils, as well as online abuse such as sharing nude images without consent.” (Weale, 2021) Girls may be affected even when they have not themselves been sexually assaulted, but have a close friend or relative who was. A girl (indeed, any child or young person) may be feeling extremely self-conscious, constantly aware of being stared at and afraid of being groped or assaulted, perhaps on top of dealing with a history of sexual violence and trauma. This severe discomfort can then become directed towards her own body. It can make her feel consciously or unconsciously that she wants her emergent bodily features to disappear from view. This plays a part in anorexia and eating disorders. It may also lead girls to express dysphoria directed towards their sprouting breasts, and perhaps partially account for the desire expressed by many girls to wear breast-concealing binders or have mastectomies (also known as ‘top surgery’), in an attempt to alleviate what can be severe distress. The high rates of sexual aggression directed towards young girls has recently been re-recognised, for example in #MeToo(MeTooMovement, no date) and #EveryonesInvited(Everyone’s Invited, no date). There is a huge amount of denial, stigma and shame experienced by victims of sexual assault. Some support services are available (Sexual Abuse Support, no date; Survivor’s Trust, no date; Want to Talk? Rape Crisis England and Wales, no date). However, in general, the sexual violence sector would benefit from better funding, more specialist facilities and greater provision of care for those in need of help. 

Personal account of a young woman with ASD and gender dysphoria who has transitioned.

While further research is pending, clinicians might benefit from seeking to understand the lived experiences of people who have an autism diagnosis and who have detransitioned (see FAQ What do the terms ‘detransition’ and ‘desistance’ mean?). Here is an account by a young adult female (Alleva, 2021). She was diagnosed with gender dysphoria and prescribed cross sex hormones. A few years later she was diagnosed with autism. She has since detransitioned, and below is her personal story of what happened and why (reproduced from her Substack with permission). The narrative provides insight into what it is like to have ASD and to be gender questioning. 

Professionals working in all fields of healthcare should acknowledge, report and learn from mistakes. There are many accounts of people who are fully satisfied with their medical transition. However, clinicians must continue to aim to reduce the possibility of negative outcomes for their patients. Thus, healthcare professionals in this field ought to pay particularly close attention to the accounts of people for whom these medical interventions for gender dysphoria are now experienced as harm. 

‘Michelle’s Story’

In 2010, I apparently gave “informed consent” to start taking cross-sex hormones. However, in 2017, I was diagnosed with autism spectrum disorder (along with a few other diagnoses).

After a lot of soul-searching, I started to realize how my autistic traits played into my adoption of a transgender identity. Now I wonder how it can be possible to give “informed” consent when I was never screened for something that can play such a huge factor in how someone experiences the world and develops.

I’ve spoken before about being bullied as a child. When I was introduced to the idea of being transgender, I thought I had uncovered the reason that everyone excluded me — why I felt different and everyone else seemed to know it. “Oh,” I thought. “I was different because I was trans, and everyone seemed to pick up on it.” That wasn’t quite it. It was that I was autistic and everyone picked up on it.

I believed that kids were seeing “masculine” traits in a girl and were bullying me for that reason; in reality, they were seeing traits of a neurodevelopmental disability and were bullying me for those reasons. I spoke out of turn and interrupted; I was blunt; I was a bit of a know-it-all; I was bossy because I liked things a specific way; and I was emotionally reactive. So when I was bullied, I had a larger-than-average reaction — crying and becoming extremely frustrated, which is amusing to children who bully, so it only reinforced their desire to harass me.

I did have stereotypically “masculine” traits as a child. I liked what I liked and didn’t have any desire to be different to “fit in.” My favourite animals were dogs, so I crawled around pretending to be a dog when I was younger. I liked climbing trees and getting dirty. I participated in sports and track events.

I felt like I was out of place and “different,” especially after I lost the girl friends that I did have. But even though I knew girls who were like I was, when I was introduced to the concept of being trans, I clung to that idea as the “reason” I felt different. I figured that none of the girls liked me because I didn’t act like a girl; none of the boys liked me because I didn’t look like a boy. That made sense to me at the time.

But at that time, I had no idea I could be autistic. I had no idea that autistic girls had girlhoods exactly like mine.

Clothing played a big part in “discovering” my gender identity. I marvelled over the fact that, when I started buying clothes from the men’s section, I suddenly enjoyed shopping. This was another thing that reinforced my conclusion that I must actually be male — these feelings of “right-ness”.

After I was diagnosed with autism and my paradigm shifted, this took on a new meaning for me as well. What bothered me about women’s clothes was not that they were “women’s” clothes, but that a lot of women’s clothing is designed in a way that aggravates my tactile sensitivity.

Women’s clothing is often tight-fitting when I prefer loose and flowy. It often has extra seams which bother me. There are also many different types of fabric, and I only like a very small range of soft, flat fabrics.

Men’s clothing has much less range (which is kind of unfortunate for men who want more fashionable options). But most pairs of men’s jeans, for example, don’t really hug curves the way women’s clothing tends to do. They’re more boxy and leave more space.

At the beginning of me testing boundaries with clothing, my mom asked why I couldn’t just buy the same style of clothing I liked in the men’s section from the women’s section. In her mind, the women’s clothing fit me better, but to me, they were just literally uncomfortable. I guess that frustration with what feels like an arbitrary boundary of what I can or can’t wear is an autistic trait, too.

The frustration with having to wear uncomfortable bras played into this, as well.

(Today I shop in both sections.)

One other sensory difference that I want to mention is something called “interoception.” Interoception refers to a person’s sense of what is going on inside of their own body — this can relate to personal feelings, own temperature, feeling hungry or thirsty, having to use the washroom, and being sexually aroused. Many people with neurodevelopmental disabilities have difficulty with interoception.

With all sensory differences in autistic people, the difference can go to either end of the extreme. In terms of arousal, for example, someone could be hypersexual (feeling aroused very frequently) or they could be hyposexual (very rarely feeling aroused).

I am hyposexual — enough that I identified as asexual for quite a few years. The majority of my feeling “attracted” to people was more of an aesthetic attraction than a sexual one. I was rarely aroused when engaging in sexual activities; in fact, I didn’t really feel anything except discomfort. Most times I dissociated and then cried afterwards.

When I identified as trans, I believed that the reason I was so uncomfortable during sex was because I was “in the wrong body.” The reasoning went something like, “Of course, I’m uncomfortable; my partners are treating me like a girl when I’m not a girl!”

Today I believe it’s a combination of being autistic (which I believe contributes to both my low libido and an inability to recognize of when I am aroused in the first place) and internalized homophobia. It wasn’t necessarily that I was turned off because I was being treated like a girl; it was because I wasn’t turned on by men.

Autistic people (and other neurodivergent people) are prone to rumination. Sometimes that rumination has positive outcomes, and sometimes negative. Autistic people often have what have been dubbed “special interests.” When something interests us, we need to know absolutely everything about that thing until we have exhausted all of the knowledge there is to be gleaned. Sometimes those interests can last years.

Gender and transitioning became a special interest for me.

For years, it was everything. I joined trans support groups in person. I spent all of my time on Tumblr talking to other trans people. I watched videos of trans men doing one-month, two-month, three-month updates. I was obsessed with the changes that testosterone did on their bodies. I made my own videos when I started taking hormones. I took pictures at regular intervals and compared the changes. I could name all of the “good” surgeons who were doing top surgery. I blogged about my transition process. I wrote response pieces to articles I disagreed with.

In other words, I went the whole nine yards.

I heard it said quite a few times that most people don’t think about their gender obsessively the way trans people do. In reality, though, anyone who is prone to rumination (autistic, ADHD, OCD, etc.) can think about anything obsessively. If you’re also prone to dissociation (and again, many neurodivergent people are), you’ve got a good recipe for gender dysphoria. It shouldn’t be all that surprising that autism and ADHD are overrepresented among gender dysphoric individuals.

There are a few other things that aren’t necessarily backed by strong evidence but are just patterns I’ve noticed among autistic people.

Many of us use escapism as a means of coping with difficult situations. The extreme end of this is a sort of desire to just erase everything we’ve done so far and start over with a clean state. When we’re on hard times, we want to delete all of our social media and create new accounts. We want to move out of our current cities and start fresh somewhere new. We tend to glorify the idea of being able to “reinvent” ourselves. Starting over with a new name and a new identity is very tempting.

Another is that we can be very gullible. We can fall into conspiracy theories very easily. We can have a black-and-white perception of the world (e.g., “well, if I don’t feel comfortable being a girl, I must be a boy”) with little nuance. It’s easy to fall into the trap of believing that if one thing is bad, the opposite thing must be good, without thinking about the pros and cons of both. We might believe it is possibly to literally “change sex” with no problem… and we don’t stop to think about how everyone else in the world might perceive us.

Finally, so many of us feel alienated from the rest of society. Upon identifying as transgender, there’s a whole community that opens its arms to us and welcomes us in. It’s a form of instantaneous belonging. The unfortunate part, though, is that being part of the community comes with a whole lot of rules, and if you don’t follow the rules, you’re ostracized. (Ask any of the trans people who dare to speak against the mainstream narrative.) In a way, though, those clear-cut rules offer a kind of safety to autistic people. It’s a steep learning curve at first, but once you’ve learned all of the rules, you belong as long as you follow them.

The relationship between being autistic and identifying as transgender, for me, was very complex. There are probably more pieces to of puzzle that I just can’t think of right now.

I wasn’t diagnosed until years after I was prescribed hormones, but I know there are many young autistic people now who have been diagnosed prior to coming into a trans identity.

Ultimately, I feel that I was wronged by not being offered the opportunity to discuss the intersection with a professional. It took me a long time to understand it all for myself — and I’m in my 30s. I can’t imagine my younger self having that kind of self-awareness without a bit of guidance.

I think that everyone should have access to this kind of exploratory therapy before making irreversible changes to their body.

References:

Ahmadzad-Asl, M. et al. (2010) ‘The Epidemiology of Transsexualism in Iran’, Journal of Gay & Lesbian Mental Health, 15(1), pp. 83–93. doi: 10.1080/19359705.2011.530580.

Alleva, M. (2021) Detransition Diary #5, Some Nuance, Please Substack. Available at: https://somenuanceplease.substack.com/p/detransition-diary-5.

Butler, G. et al. (2018) ‘Assessment and support of children and adolescents with gender dysphoria’, Archives of Disease in Childhood, 103, pp. 631–636. doi: 10.1136/archdischild-2018-314992.

Department for Education (2021) Sexual violence and sexual harassment between children in schools and colleges. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1014224/Sexual_violence_and_sexual_harassment_between_children_in_schools_and_colleges.pdf.

Everyone’s Invited (no date). Available at: https://www.everyonesinvited.uk.

Hamedani, A. (2014) ‘The gay people pushed to change their gender’, BBC Persian, November. Available at: https://www.bbc.com/news/magazine-29832690.

Jafari, F. (2014) ‘Transsexuality under Surveillance in Iran’, Journal of Middle East Women’s Studies, 10(2), pp. 31–51. doi: 10.2979/jmiddeastwomstud.10.2.31.

Kaltiala-Heino, R. et al. (2018) ‘Gender dysphoria in adolescence: current perspectives’, Adolescent Health, Medicine and Therapeutics, 9, pp. 31–41. doi: 10.2147/AHMT.S135432.

MeTooMovement (no date). Available at: https://metoomvmt.org.

Murphy, J. et al. (2020) ‘Autism and transgender identity: Implications for depression and anxiety’, Research in Autism Spectrum Disorders, 69, p. 101466. doi: 10.1016/j.rasd.2019.101466.

NHS (no date) Autism, NHS.UK. Available at: https://www.nhs.uk/conditions/autism/ 

Sexual Abuse Support (no date) HM Government. Available at: https://sexualabusesupport.campaign.gov.uk.

Singh, D., Bradley, S. J. and Zucker, K. J. (2021) ‘A Follow-Up Study of Boys With Gender Identity Disorder’, Frontiers in Psychiatry, 12. doi: 10.3389/fpsyt.2021.632784.

Survivor’s Trust (no date). Available at: https://www.thesurvivorstrust.org 

Want to Talk? Rape Crisis England and Wales (no date). Available at: https://rapecrisis.org.uk/get-help/want-to-talk/.

Warrier, V. et al. (2020) ‘Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals’, Nature Communications, 11(1), p. 3959. doi: 10.1038/s41467-020-17794-1.

Weale, S. (2021) ‘Hundreds of calls made to UK helpline about sexual abuse in schools’, The Guardian, 6 December. Available at: https://www.theguardian.com/education/2021/dec/06/hundreds-of-calls-made-to-uk-helpline-about-sexual-abuse-in-schools.