Link Between Autism and Gender Dysphoria?

Underwhelming results suggest a link between autism and gender dysphoria.

Posted Nov 09, 2014

For some time, I've been watching as research emerges suggesting some link between autism and gender dysphoria (formerly termed gender identity disorder).  I worried about how the public would interpret the results of these studies.  I hope that the public will recognize that autism and gender dysphoria are distinct entities that may be merely associated.  And there's only so much you can extrapolate for factors that are associated.  For example, every time I wear a condom the lights are off, but the lights have little to do with the condom. 

Granted, there may be very limited causal inferences gleaned from the autism and gender-dysphoria link, but, in my opinion, and especially at this point, not much more.  After all, the researchers are using lower-power, bias-riddled studies to come up with causal explanations that are sometimes asymmentric (apply to men or women but not both). So, with all that being said, I throw my hat in the ring and give you my take on the underwhelming link between autism and gender dysphoria.

Defining autism and gender dysphoria

Let's start with some basic definitions.

According to the CDC:

Autism spectrum disorder (ASD) is a developmental disability that can cause significant social, communication and behavioral challenges. There is often nothing about how people with ASD look that sets them apart from other people, but people with ASD may communicate, interact, behave, and learn in ways that are different from most other people. The learning, thinking, and problem-solving abilities of people with ASD can range from gifted to severely challenged. Some people with ASD need a lot of help in their daily lives; others need less.

According to the DSM-5:

For a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be present and verbalized. This condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Gender dysphoria is manifested in a variety of ways, including strong desires to be treated as the other gender or to be rid of one’s sex characteristics, or a strong conviction that one has feelings and reactions typical of the other gender.

The research linking autism and gender dysphoria

To date, there have been only few lower-power systematic studies and case studies that associate autism and gender dysphoria.  For instance, in one British study conducted by Pasterski and colleagues, researchers examined 91 patients at a London-based gender clinic (63 male-to-female and 28 female-to-male) and found that, overall, 5.5 percent of transgender individuals exhibited autistic traits.  (According to researchers, the prevalence of autism in the general population is anywhere between 0.5 and 2 percent.)  In another study, Dutch researchers examined 204 children and adolescents (115 boys and 89 girls) with gender dysphoria and found a 7.8 percent prevalence of autism.  Finally, Simon Baron-Cohen (AKA Borat's cousin), a researcher at the University of Cambridge, found a 2.3 percent prevalance of caseness (jargon for autism traits) in 840 college-age participants (454 men and 386 women).

In an admirable effort to overreach, researchers have suggested various causes that link autism and gender. 

First, the Extreme Male Brain (EMB) theory suggests that prenatal exposure to an excess of androgens predisposes a person to later develop both gender dysphoria and autism.  In other words, an excess of male hormones in the womb influences a girl or woman to go on to develop a desire to be a boy or man and somehow infleunces this same girl or woman to develop autism.  Conspicuously, this "theory" fails to explain why male fetuses go on to develop gender dysphoria and autism. 

Second, researchers suggest that psychological and behavioral symptoms of autism may lend themselves well and even augment or synergize with aspects of gender dysphoria. For example, a little boy may become preoccupied with the tactile sensation of touching clothes that are usually worn by little girls; clothes that are either worn daily or for play--think lacy dresses, tutus, feather boas and so forth. Moreover, this little boy may find comfort in these clothes especailly after being bullied by other little boys.

Third, some researchers suggest that because many people with autism struggle to find acceptance and close relationships with members of their own biological sex, they start to ideate towards members of the opposite sex where they perceive more acceptance.  Such propensity is especially pronounced during childhood when social groups are most segregated based on sex, and thus facilitates gender dysphoria at a young age.

A few words on the link between autism and gender dysphoria

For various reasons, I take issue with these very few studies linking autism and gender dysphoria.  First, with the exception of the Baron-Cohen study, I question the power of these studies.  Granted, gender identity disorder is rare, affecting an estimated 1:10,000 to 1:20,000 men and 1:30,000 and 1:50,000 women, and research efforts are usually underfunded; nevertheless, I'd like to see more people involved in more studies before we start batting around some causal link between these two conditions.  Second, there's selection bias in some studies.  For example, in the Pasterski study that I previously discussed, participants were solicited using a note on a notice board.  Moreover, in the Baron-Cohen study, participants were solicited from Cambridge where lots of math nerds have an obsession with numbers (suggestive of autism).  Finally, I don't like how some of these studies rely on self reporting--like a quick questionnaire on autism--instead of a more robust diagnosis   To their credit, many researchers exploring a link between autism and gender dysphoria readily recognize and admit many of the limitations that I've cited.

On a personal note, I dislike the conflation of autism and gender dysphoria.  I worry that linking autism and gender dysphoria, especially based on an incipient body of evidence, can lead to excuses and undue concerns.  I would hate for somebody to somehow illegitimize a diagnosis of gender dysphoria by blaming it on autism.  Conversely, it would suck if a parent freaked out every time her son with autism donned his sister's tiara.  (Who hasn't good-naturedly tried on a tiara?  More rhinestones the better!  You better work!  Fierce and fine!)  More generally, I'm getting sick of our universal tendency to make a big deal of positive and negative associations especially by "journalists" attempting to lure clicks in an increasingly fragmented readership space. 

To my credit, I was a relatively early adopter of causation-correlation skepticism--something that was ingrained in me durng science journalism school and a point that I make in my book The Complete Guide to Article Writing: How to Write Successful Articles for Online and Print Markets (F+W Media/Writer's Digest Books).  (Sorry for the plug but it's relevant, and hell, I have to sell some books in order to keep the lights on, the coffee lukewarm and the Internet high speed.)

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