"his sudden interest in changing gender may have been another of his autistic obsessions"

A recent (online) newspaper report from here in Blighty included the quote used in the title of this post: "his sudden interest in changing gender may have been another of his autistic obsessions" (see here).

The report describes how a male - born biologically male - teenager diagnosed with autism expressed an opinion that "he believed he was female" and how his opinion was received by his parents and other professionals. Differences in the reception and perception of that opinion eventually led to some 'frustration' and, worryingly, the eventual intervention of social (child) services.

I decided to blog about this report primarily because (a) it ties in with some important peer-reviewed science discussions about gender identity and autism (see here and see here), and (b) there is a distinct possibility that the headline accompanying the report - "Social services threaten to take autistic boy into care after his parents refuse to let doctors give him powerful sex-change drugs" - is likely to be replicated again. Such a headline also taps into some wider debates about an increasing number of children talking about their gender and the decision-making rights and abilities of children both on and off the autism spectrum.

First things first, I know there are lots of strong opinions about sex and gender and 'what's right for children' these days. I don't offer an opinion either way nor do I claim to be an expert on issues such as gender dysphoria - "where a person experiences discomfort or distress because there's a mismatch between their biological sex and gender identity" - or gender reassignment or related issues. As mentioned, I'm interested in the science behind such discussions because autism has been discussed, on more than one occasion, as being potentially 'over-represented' among those with gender dysphoria [1] and/or wanting to/going through gender reassignment services. I say 'potentially over-represented' but wouldn't want anyone to think that any scientific debates have been settled at the current time: they haven't [2] (see here). I'm also interested in this topic because, aside from any gender reassignment issues, autism not so long ago was faced with something called the 'Lupron protocol'. Then leuprorelin, a drug sometimes used to 'delay puberty', was touted as something important to autism for very, very different reasons. I might add that the story of such a 'protocol' did not end well, as words like 'chemical castration' were banded around (see here).

I selected the quote that heads this post because it strikes me that there are some 'unique' issues that arise in the context of autism being mentioned alongside gender dysphoria and/or reassignment. Issues that don't seem to have been properly considered at the time of writing. Indeed, when I first tweeted about the source article for this post, a couple of response summed up the positions taken. First: "That child is not a boy. She is a girl and she needs the medical transition that will treat her dysphoria and allow her to live her best life." Another response was from someone who is themselves autistic and mentioned an important word: 'impulsivity'. Indeed, the article itself also mentions some similarly important phrases which require consideration. So: "they [his parents] suspected his abrupt decision to change sex was a result of his autism" and "All we were doing was trying to get him to pause and think about his actions" and "The school and social workers took what our child said as gospel. But considering he has autism, his perception of social scenarios is seen through an autism lens." An autism lens?

As you can see, a lot of those quotes/opinions focus on the idea that the traits that stem from or follow autism are potentially important to this debate. Minus any 'pity me' sentiments, they imply for example, that autism confers some specific 'vulnerability' that cannot simply be brushed under the carpet particularly when a person makes, or wants to make, important, potentially life-changing, decisions. I've talked about the issue of vulnerability and autism before on this blog (see here and see here) with some equally life-changing issues in mind. The topics differ but the sentiments remain the same. It's highly likely that the parents discussed in that news report know a little a bit about such vulnerability and autism purely in the context of raising their offspring.

Such vulnerability does however have to be balanced with individual rights; that is the rights of an individual to make important decisions that affect them. Such decisions might not always be 'the correct ones' or the ones that significant others necessarily want them to make but nonetheless, still need to be valued particularly within the context of assumed competence (see here). Indeed I get the impression that it's the possibility that the child has expressed an opinion with future consequences - "My biggest worry as a mum is my child gets pushed down this route, becomes a woman, goes through the surgery, then gets to 25 and says, “I’ve made a mistake.”" - that seems to worry the parents in the news report more than anything else. The use of the word 'surgery', implying the degree of 'invasiveness' needed and potentially also inferring 'irreversibility', is perhaps also an important part of their response.

What else? Well, without heading too far into scientifically unexplored territory I think there are other issues that come into play in such a scenario. Going back to the comment on impulsivity and the 'abrupt decision' talked about in the article, another important (and contentious) issue is potentially introduced: rapid-onset gender dysphoria (ROGD) [3]. ROGD is something that is not well-liked in some quarters (see here) and still remains a topic of some (heated) discussion (see here). It defines a state whereby "teens and young adults who did not have symptoms of gender dysphoria during childhood but who were observed by their parents to rapidly develop gender dysphoria symptoms over days, weeks or months during or after puberty." I don't make any comment on the rights or wrongs of something like ROGD but would encourage further study. Specifically with autism in mind and on the basis of the case being reported, questions like: 'how abrupt was the decision?' (or was the decision taken many moons ago but just communicated recently?) are important. Whether those who are diagnosed with autism or present with significant autistic traits are 'over-represented' among cases of ROGD is another research question that perhaps needs considering. And then there's the possible question of why?

Ultimately there are no easy answers to the issue described in today's post despite some significant strength of feeling. What will help however, is research; good quality research that is not afraid to test difficult hypotheses. And whilst individuals should always be empowered to make decisions for themselves, there should always be an appreciation that decision-making typically does not occur in a vacuum...

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[1] Janssen A. et al. Gender Variance Among Youth with Autism Spectrum Disorders: A Retrospective Chart Review. Transgend Health. 2016 Feb 1;1(1):63-68.

[2] Nobili A. et al. Autistic Traits in Treatment-Seeking Transgender Adults. J Autism Dev Disord. 2018. April 13.

[3] Littman L. Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PLoS One. 2018 Aug 16;13(8):e0202330.

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"Further studies are required to understand links between ASD, ADHD, and gender identity..."

The findings reported by Ada Cheung and colleagues [1] provide the blogging fodder today, and specifically the observation that: "depression was prevalent in 55.7%, anxiety in 40.4%, ASD [autism spectrum disorder] in 4.8% and ADHD [attention-deficit hyperactivity disorder] in 4.3%" in an Australian adult transgender cohort.

The aim of the Cheung study was to "assess referral numbers and describe the sociodemographic and clinical characteristics"of their cohort, with specific reference to the prevalence of ADHD and/or ASD (autism). The autism 'connection' (and why I'm blogging about this research) follows quite a bit of other research suggesting that gender identity issues and/or reassignment behaviours *might* be over-represented when it comes to a diagnosis of autism (see here and see here and see here for examples). I stressed the word *might* because, so far, there is still some doubt about whether autism / autistic features is / are the more important variable above other comorbid features or comorbidity (see here). I'll also come to the idea of whether 4.8% is actually 'over-represented' or not when it comes to the autism [prevalence] numbers game shortly...

Based on data for quite a large number of individuals (N=540), researchers arrived at those pretty standout figures for various psychiatric and behavioural comorbidity being present. They use the words 'not surprisingly' when it came to the depression and/or anxiety prevalence stats garnered, and how "discrimination and difficulties accessing gender-affirming treatments" may be a contributory factor. I'd also draw your attention to the finding that: "Despite relatively high levels of education, unemployment rates of 21.3% were high in this relatively young cohort, four-fold higher than the Australian general population unemployment rate of 5–6%" as another possibility to (partly) account for some of those psychiatric features / diagnoses being reported on (see here).

So, 4.8% of the cohort with ASD. Is this a particularly high figure? Well, it depends. The authors rely on data from the Australian Bureau of Statistics (2015) which listed 0.7% as the "Australian population prevalence" of autism or ASD. I've not been able to find much more in the way of published estimates of adult autism specifically in Australia but would perhaps hazard a guess that 0.7% is likely to be an underestimate of the true autism rate on the basis of other population data for example (see here). Bear also in mind that Cheung et al also relied on "consecutive consultations between 1st January 2011 and 31st December 2016" so covered quite a long period of time period over which referral data was collected.

The Cheung study also ventures into some of the possible hows-and-whys of autism (and ADHD) being potentially over-represented among their transgender cohort. I'm not going to head too much into what these might be here because the long-and-short of it is that we don't know about possible overlapping genetics for example (although autism genes aren't necessarily just genes for autism) or even whether non-genetic factors might be at work: "it has been suggested that endocrine disruptors such as prenatal exposure to phthalates or antidepressants may be an explanation for the increase of ADHD and ASD and relationship with gender variance" (authors words not mine). Likewise whether the presence of autism or autistic traits means that someone is more or less likely to be 'socially conforming' is something that cannot be confirmed or denied in relation to gender variance at the present time.

All I will say is that more research is indicated in this area. Preferential screening for a range of developmental / behavioural / psychiatric issues is probably also implied as and when someone clinically presents for gender-related issues, in order to ensure that the care they receive is tailored specifically to them.

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[1] Cheung AS. et al. Sociodemographic and Clinical Characteristics of Transgender Adults in Australia. Transgend Health. 2018 Dec 26;3(1):229-238.

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On gender reassignment seeking behaviour and autism

The results published by Josephine Fielding & Christopher Bass [1] provide the blogging discussions today. Specifically the observations that: (i) there seems to be a growing demand for gender reassignment services here in Blighty (tied into the concept of gender dysphoria: "where a person experiences discomfort or distress because there's a mismatch between their biological sex and gender identity"), and (ii) there is a "high rate of psychiatric comorbidity" present in those attending gender reassignment services, including that: "Twelve patients (7.8%) had autism spectrum disorder."

OK, first I'll mention that whilst the authors use the term 'psychiatric comorbidity' with reference to conditions like depression and social phobia (social anxiety disorder) being present in their participant group, autism really shouldn't be included under such an umbrella term. Autism is a developmental label that, whilst seemingly carrying a heightened risk for various psychiatric disorders appearing alongside (see here for example), is not currently defined as a psychiatric disorder.

Next up: this is not the first time that the words 'autism' and 'gender dysphoria' have been linked together (see here and see here). Indeed it seems to be one of the 'hot topics' of recent peer-reviewed research times (see here). There's still some 'discussion' about whether a diagnosis of autism is important to gender dysphoria, or whether one or more of the over-represented comorbidities appearing alongside *might* play a more important role, but there is some interest in this area.

Fielding & Bass examined "the pattern of referrals and characteristics of people aged over 18 seeking gender reassignment in Oxfordshire over a 6-year period (2011-2016)" as a consequence of "an extraordinary increase in the number of referrals to both adult and child and adolescent gender clinics, with services becoming overwhelmed." The included details for over 150 attendees and noted both an increase in referrals (albeit not uniform) and also a gradual reduction in the mean age of attending participants. Then to the crux of today's post: "Of those who attended for assessment, 60 (39.2%) had a current psychiatric comorbidity, and 81 (52.9%) had a past history of mental illness." Depression was by far the most common psychiatric diagnosis (approaching 20%) but a diagnosis of autism was also mentioned in a significant minority.

What does this data mean apart from the obvious? Well, it's interesting that autism is specifically mentioned by the authors. Interesting because, yet again, a diagnosis of autism is a factor to potentially consider when it comes to gender dysphoria and onward possible gender reassignment seeking behaviour. Science doesn't yet know all it needs to know about why this *relationship* should exist outside of some speculation on how those on the autism spectrum may be less likely to conform to traditional notions of gender for example. I'm sure that there's some psychobabble explanation for this talking about autism and 'social norms' and the like but...

I note that Fielding & Bass also mention a role for social media in relation to their findings and how gender identity may be developing "possibly because of the increased availability of information about non-binary genders from social media, the internet and peers." Again, I don't know if those on the autism spectrum are more likely to be on social media than their peers or are perhaps more responsive to the idea of 'non-binary genders' as a result. But I daresay there are further investigations that could be done on this topic. Minus any sweeping generalisations and without trying to depict autistic people as universally being overly responsive to gender-related observations on social media and the like, one might also be inclined to look at how the notion of an 'autistic identity' perhaps overlaps with things like sexual identity too. It's something that I've noticed before under other circumstances (see here). I'm careful not to conflate sexual identity with gender identity, but it has always struck me that there are parallels between those who see autism as so much more than a diagnostic label and how autistic identity is seen as akin to sexual identity (i.e. inborn, immutable, 'part of who I am'). I'm no expert in this area but do see the need for further study in this area.

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[1] Fielding J. & Bass C. Individuals seeking gender reassignment: marked increase in demand for services. BJPsych Bull. 2018 Jun 12:1-5.

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Higher autistic traits in those attending transgender health services don't necessarily mean autism

There are some key messages to take from the findings reported by Anna Nobili and colleagues [1] following their examination of "self-reported autism spectrum quotient-short (AQ-short) [scores] in a transgender clinical population." Not least that when compared with a control group - "cisgender individuals" - there "were no significant differences in the number of people who presented with scores suggesting a possible diagnosis of ASC [autism spectrum condition(s)]."

OK, before heading further into the Nobili findings I think it might be worthwhile setting the scene a little. So, for quite a while now there has been some increasing interest in how autism or at least some of the traits of autism, *might* be over-represented among those presenting with gender dysphoria (see here). Gender dysphoria, according to the UK NHS Choices website is "a condition where a person experiences discomfort or distress because there's a mismatch between their biological sex and gender identity." Allied to other peer-reviewed research looking at gender identity [2], sexual preferences in the context of [some] autism (see here), and combined with quite a sweeping *theory* talking about an 'extreme male brain' in the context of autism (see here), and well, let's just say some speculation about a link between some autism / autistic traits and elements of gender and sexuality has been noted. And indeed, continues to be noted [3]...

Nobili et al - including one author who is rather central in autism research circles to the promotion of that extreme male brain theory - examined AQ responses in some 650 matched pairs (transgender matched with cisgender). Among the transgender participants: "A total of 260 people (39.6%) in each group were assigned female at birth whilst 396 (60.4%) were assigned male." It's worthwhile noting that AQ is a self-report questionnaire, and whilst heralded in several quarters as a good 'are you autistic?' screener, there are some people - including me - who have some reservations about it's 'universal' usefulness to just autism (see here and see here for examples). I'll come back to this shortly...

As per the opening paragraph to this post, the numbers of participants "indicating possible ASC caseness" did not differ significantly between the groups. So, around 33% of the cisgender control group hit a score of 70 or more on their self-report responses to the AQ compared with 36% in the transgender group. The authors did detect a statistically significant difference in possible caseness when looking at those assigned female at birth in the transgender group but not for males. A similar finding has been noted in other independent studies [4]. Nobili and colleagues however concluded that their findings were in line with other observations in adults in that: "there is no evidence of increased rates of autism in transgender populations as a whole."

Going back to my reservations around the AQ as an exclusive autism screener, I also noted something important reported by Nobili and colleagues: "High AQ scores may not be indicative of the presence of an autism spectrum condition as the difference between groups mainly related to social behaviours; such scores may be a reflection of transgender people’s high social anxiety levels due to negative past experiences." I was really intrigued by this finding and interpretation, particularly in light of other recent peer-reviewed speculation by Jack Turban [5] who suggested that: "ASD [autism spectrum disorder] symptoms [in transgender youth] may represent social deficits that are secondary to social stress and deprivation, as transgender youth suffer high rates of peer and family rejection." On a previous blogging occasion, I've also discussed research suggesting that something like a generalised anxiety disorder (GAD) may 'inflate' responses/scores on the AQ (see here). Given that anxiety is an all-too-often bedfellow accompanying a diagnosis of autism, I'd be interested to see quite a bit more study on this topic in the context of AQ use. Y'know, perhaps alongside some more formal measures of anxiety both in relation to autism and also more readily pertinent to the subject matter analysed by Nobili et al. And, outside of just anxiety, other clinical features/conditions might also be thrown into the research mix [6]. Insofar as the idea that mental health may also be a topic requiring more focus in respect of the transgender population, I'll bring to your attention some other recent research by Becerra-Culqui and colleagues [7] on this point.

There is a further scheme of work to follow in this area, and I'll be interested to see what further results turn up, particularly with regards to females assigned at birth with gender dysphoria. And since I've mentioned the AQ and (once again) my reservations, I'll direct you to another paper published in the same journal at roughly the same time as the Nobili findings, where the AQ was again 'implied' as being equal to the presence of autistic traits [8]. And yet again, another example where one has to be very, very careful about making that 'exclusively autistic traits' link...

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[1] Nobili A. et al. Autistic Traits in Treatment-Seeking Transgender Adults. J Autism Dev Disord. 2018. April 13.

[2] Cooper K. et al. Gender Identity in Autism: Sex Differences in Social Affiliation with Gender Groups. J Autism Dev Disord. 2018. April 28.

[3] van der Miesen AIR. et al. Prevalence of the Wish to be of the Opposite Gender in Adolescents and Adults with Autism Spectrum Disorder. Archives of Sexual Behavior. 2018. May 7.

[4] Vermaat LEW. et al. Self-Reported Autism Spectrum Disorder Symptoms Among Adults Referred to a Gender Identity Clinic. LGBT Health. 2018 May 9.

[5] Turban JL. Potentially Reversible Social Deficits Among Transgender Youth. J Autism Development Disord. 2018. May 12.

[6] Lugnegård T. et al. Asperger syndrome and schizophrenia: Overlap of self-reported autistic traits using the Autism-spectrum Quotient (AQ). Nord J Psychiatry. 2015 May;69(4):268-74.

[7] Becerra-Culqui TA. et al. Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers. Pediatrics. 2018. April 16.

[8] Loureiro D. et al. Higher Autistic Traits Among Criminals, But No Link to Psychopathy: Findings from a High-Security Prison in Portugal. J Autism Dev Disord. 2018. April 12.

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Autism, mental health and 'sexual and gender minority' status

The findings reported by Rita George & Mark Stokes [1] piqued my interest recently, and their conclusion that various mental health issues over-represented in autism (see here and see here for examples) might not be just solely connected to the presence of a diagnosis of autism.

Yes, I know this sounds like common sense (see here), but as I've come to realise in relation to lots of diagnostic labels, assumptions very often precede actual (peer-reviewed) evidence.

Based on responses on the DASS-21 (which is fast becoming the go-to measure for the self-report of things like stress, depression and anxiety-like behaviours with autism in mind [2]), researchers compared depression, anxiety and stress scores for over 300 people with autism compared with over 250 "typically-developing individuals." Alongside, membership of a minority grouping in terms of sex and gender, e.g. non-heterosexual, was also thrown into the statistical mix. Results suggested that along with differences in DASS scores being more generally observed between the groups: "As membership to a minority group became more restrictive, mental health symptoms worsened... suggesting stressors added."

Such an investigation follows a scheme of work by this authorship group who, quite recently, also reported that within the same participant group(?), some 70% of those with autism "reported being non-heterosexual" [3]. I was quite taken aback by the high rate of non-heterosexuality reported in this study, bearing in mind that this data was derived from an on-line sample and may not be entirely representative of the full autism spectrum as a function of the use of self-report for example (see here). I might also add that focusing just on autism to the exclusion of some other potentially important comorbid labels [4] could be something that needs to be looked at in future investigations in light of other results on gender variance for example [5].

Minus however, any 'I told you so' sentiments, I have previously mentioned about how gender and sexual identity in relation to autism is both a research-rising area and can often have some quite profound implications for the person concerned (see here). We can um-and-ah about whether there is a 'connection' between autistic traits and sexual orientation (see here) or whether something like gender dysphoria is more or less likely in the context of autism (see here), but there is no denying that gender and sexual identity are variables that can and do potentially impact on mental health. In support of the George/Stokes findings, one need only look to the non-autistic focused research literature to see how various aspects of health-related quality of life for example, are seemingly influenced by variables such as sexual orientation [6] and how this potentially plays out over both childhood and into adulthood [7].

So when George & Stokes talk about: "Specialized care is recommended for this vulnerable cohort" there could be some pretty profound implications associated with timely and appropriate education and support taking into account sexual and gender identity in the context of autism...

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[1] George R. & Stokes MA. A Quantitative Analysis of Mental Health Among Sexual and Gender Minority Groups in ASD. J Autism Dev Disord. 2018 Jan 23.

[2] Nah YH. et al. Brief Report: Screening Adults with Autism Spectrum Disorder for Anxiety and Depression. J Autism Dev Disord. 2017 Dec 2.

[3] George R. & Stokes MA. Sexual Orientation in Autism Spectrum Disorder. Autism Res. 2018 Jan;11(1):133-141.

[4] May T. et al. Trends in the Overlap of Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder: Prevalence, Clinical Management, Language and Genetics. Current Developmental Disorders Reports. 2018. Jan 17.

[5] Strang JF. et al. Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Arch Sex Behav. 2014 Nov;43(8):1525-33.

[6] Marti-Pastor M. et al. Health-related quality of life inequalities by sexual orientation: Results from the Barcelona Health Interview Survey. PLoS One. 2018 Jan 24;13(1):e0191334.

[7] Petterson LJ. et al. Sex, Sexual Orientation, Gender Atypicality, and Indicators of Depression and Anxiety in Childhood and Adulthood. Arch Sex Behav. 2017 Jul;46(5):1383-1392.

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"a heightened co-occurrence rate of ASD [autism spectrum disorder] and GD [gender dysphoria]"

Gender dysphoria "where a person experiences discomfort or distress because there's a mismatch between their biological sex and gender identity" is something that has seemingly risen in research popularity in the context of autism (see here).

The findings reported by Janssen Aron and colleagues [1] (open-access available here) add to the body of research in this area where "endorsement of sex item 110, “wish to be opposite sex,” is 7.76 times more likely among participants with an ASD [autism spectrum disorder] diagnosis than in a nonreferred comparison group." 'Sex item 110' refers to a question item on the Child Behavior Checklist (CBCL) by the way.

Drawing on data derived from almost 500 participants diagnosed with an ASD and some 1600 responses to the CBCL from a 'normative sample', researchers inquired about possible gender variance. Importantly: "In the present study, all CBCL charts had been filled out by the patients' parents" so we need to bear in mind this was a study of proxy reporting albeit from those who probably know the participant pretty well. Researchers observed that some 5% of the ASD cohort "endorsed sex item 110" compared with about half a percent of the control group. Biological gender discussed in terms of 'natal gender' did not suggest that any one gender were more or less likely to endorse that CBCL question and age of participants similarly showed little impact on the endorsement of the questionnaire item.

The authors caution that response to one item on the CBCL does not a gender dysphoria diagnosis make. But they do suggest that further screening could be preferentially offered as and when either autism is diagnosed or indeed screening for autism/autistic traits when gender variance is encountered in the clinic minus any sweeping generalisations. One might also see a need for designing new questionnaires/schedules to specifically ascertain signs of gender dysphoria in cases of autism - indeed, as some have [2] - with a focus on both longitudinal research i.e. how might signs and symptoms change with age/maturation and also taking into account more direct reporting from participants themselves...

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[1] Janssen A. et al. Gender Variance Among Youth with Autism Spectrum Disorders: A Retrospective Chart Review. Transgend Health. 2016 Feb 1;1(1):63-68.

[2] George R. & Stokes MA. Gender identity and sexual orientation in autism spectrum disorder. Autism. 2017. Sept 15.

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Male and female autism might not be so dissimilar?

I read with some interest the paper by Joanna Mussey and colleagues [1] concluding that "either very small or no gender differences in age at diagnosis, intelligence quotient, cognitive profiles, or autism spectrum disorder symptom severity" were detected in their cohort of males (N=566) and females (N=113) diagnosed with an autism spectrum disorder (ASD).

Interest because, in these days of talk about a possible specific female autism phenotype emerging (see here) in light of potential sex differences in the presentation of autism (see here), one has to be quite careful not to over-generalise too much. In much the same way that terms such as 'male brains' and 'female brains' don't really do justice to the complexity of brain structure and function (see here), so one perhaps has to ensure that female autism and male autism presentation aren't offered in an 'either or' fashion despite the possibility of subtle differences in either the expression of symptoms or for example, differences in the presentation of things like over-represented comorbidity between the sexes/genders (see here).

Mussey et al reported that previous studies talking about autism 'hitting harder' when it comes to females in relation to the presence of intellectual (learning) disability and "more severe impairments" might not necessarily tell the full story. Based on the use of various instruments to to ascertain autistic traits and beyond, the authors noted some differences between the genders on measures of autism signs and symptoms but the precise significance was, in the most part, deemed "of minimal clinical significance." Such findings have also been noted in other recent research [2]. Another important message from the Mussey study results was that at least some of the instruments used to assess for autism or ASD might need some further investigation with sex/gender in mind.

Having said all that I do think there are still important issues that need to be further investigated when it comes to sex differences in autism presentation. The idea for example, of a 'female camouflage effect' (see here) still looms large in this area; where for example, verbal and non-verbal communication skills might serve to *mask* other important diagnostic features. I'm also [carefully] inclined to inquire whether gender identity over biological sex might play something of an important role in the male and female presentation of autism for some, in light of other important research (see here). There is a further scheme of work to be completed minus sweeping generalisations.

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[1] Mussey JL. et al. Are males and females with autism spectrum disorder more similar than we thought? Autism. 2017 Aug;21(6):733-737.

[2] Fulton AA. et al. Gender comparisons in children with ASD entering early intervention. Research in Developmental Disabilities. 2017. 68: 27-34.

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Gender dysphoria and autistic traits?

"Gender dysphoria is a condition where a person experiences discomfort or distress because there is a mismatch between their biological sex and gender identity."

That's how NHS Choices describe gender dysphoria illustrating how biological sex and gender identity are not always one and the same for everyone. I might add that science is also coming around to the idea that the dichotomy of two biological sexes (male and female) might also not be as accurate as we've all been led to believe.

With that short introduction in mind, I'm turning to the paper by Daniel Shumer and colleagues [1] today and their findings "consistent with growing evidence supporting increased prevalence of ASD [autism spectrum disorder] in gender dysphoric children." Based on the retrospective analysis of a small group of children and young adults presenting at a gender clinic, results using the "Asperger Syndrome Diagnostic Scale (ASDS)" suggested that "possible, likely, or very likely Asperger syndrome" might be a feature of almost a quarter of those presenting with gender dysphoria (9/39). Further: "routine assessment of ASD is recommended in youth presenting for gender dysphoria."

The issue of gender dysphoria and/or gender identity issues and autism has been popping up now and again in the peer-reviewed autism research literature for some years. The case report by Landén & Rasmussen [2] represents one of the earliest documentations of gender dysphoria alongside a diagnosis of autism and included the idea that there may be a "predisposition to gender dysphoria in autism." Whilst the small participant number included in the Shumer study and the introduction of 'possible' or 'likely' to a diagnosis of Asperger syndrome were perhaps contributory to the impressive 'correlation' posed between the label and gender dysphoria, other more controlled study has also hinted that autism or autistic traits may be over-represented among this group. de Vries and colleagues [3] for example, utilised the DISCO (Diagnostic Interview for Social and Communication Disorders) among children and adults attending a gender identity clinic and reported that ~8% of their total sample group (N=208) reached ASD thresholds. As they pointed out in their paper, the rate of ASD found in their sample: "confirms the clinical impression that ASD occurs more frequently in gender dysphoric individuals than expected by chance."

The idea that autism or autistic traits might show some link to gender dysphoria also taps into an interesting area of autism research based on the suggestion of sex hormones and cognitive styles exemplified in discussions about the 'extreme male brain theory' for example (see here for further discussions). Jones and colleagues [4] reported that Autism Spectrum Quotient (AQ) scores showed some interesting patterns particularly among transmen "(female-to-male transsexual people)" when compared to other groupings (transwomen, typical males, typical females and those with Asperger syndrome). They concluded that: "Transmen have more autistic traits and may have had difficulty socializing with female peers and thus found it easier to identify with male peer groups." Bearing in mind some words of caution about what the AQ is actually measuring (see here) and how we [structurally] define 'male' and 'female brains (see here) the results are perhaps consistent with some of the notions detailed in the extreme male brain theory.

There remains however, quite a bit more research to do looking at gender dysphoria and autism or autistic traits. That developmental processes may be part and parcel of any association has been suggested [5] and as always, I remind you that autism does not generally exist in a diagnostic vacuum (see here). Indeed, one might see some intriguing links taking into account suggestions about gender dysphoria and schizophrenia for example [6] in light of the bridges built (and destroyed) down the years potentially linking cases of autism and cases of schizophrenia (see here). That also the presence of another quite common comorbidity appearing alongside autism - ADHD (attention-deficit hyperactivity disorder) - might also play a role [7] further exemplifies just how complicated the relationships / connections might actually be.

Perhaps also we need to talk about sex and gender quite a bit more when it comes to autism...

A video and some music to close, and because its that time of year when resolutions are made to 'get fit'...

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[1] Shumer DE. et al. Evaluation of Asperger Syndrome in Youth Presenting to a Gender Dysphoria Clinic. LGBT Health. 2015 Dec 1.

[2] Landén M. & Rasmussen P. Gender identity disorder in a girl with autism--a case report. Eur Child Adolesc Psychiatry. 1997 Sep;6(3):170-3.

[3] de Vries AL. et al. Autism spectrum disorders in gender dysphoric children and adolescents. J Autism Dev Disord. 2010 Aug;40(8):930-6.

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Shumer DE, Reisner SL, Edwards-Leeper L, & Tishelman A (2015). Evaluation of Asperger Syndrome in Youth Presenting to a Gender Dysphoria Clinic. LGBT health PMID: 26651183