Relationship Between Autism Spectrum Disorder and Gender Dysphoria
There is a significant association between autism spectrum disorder (ASD) and gender dysphoria, with the incidence of gender dysphoria in people with ASD being approximately eleven times higher than in the general population. 1
Evidence for the Association
The relationship between ASD and gender dysphoria is well-documented in recent medical literature:
- Multiple studies confirm an overrepresentation of gender dysphoria among individuals with ASD compared to typically developing populations 2
- Clinical evidence suggests a two-way relationship: a person with gender dysphoria is more likely to be diagnosed with ASD and vice versa 3
- Individuals with ASD report a higher number of gender-dysphoric traits when compared to neurotypical individuals 2
Biological Mechanisms
Several biological theories have been proposed to explain this association:
- Female-protective effect (FPE): Evidence suggests specific factors protect females from developing ASD, resulting in a higher threshold for clinical impairment in females 1
- Sex chromosome factors: Either the Y chromosome may be a risk factor or a second X chromosome may be protective, supported by increased rates of ASD in Turner syndrome (XO) and 47,XYY syndrome 1
- Hormonal influences: Fetal testosterone levels correlate with systematizing traits, social impairments, and reduced empathy seen in ASD 1
Cognitive and Behavioral Factors
The 2024 Psychiatry Research review suggests several cognitive mechanisms that may explain the relationship 1:
- Concrete thinking: People with ASD may have more rigid views of gender roles and stereotypes
- Black-and-white reasoning: Instead of seeing gender as fluid, individuals with ASD may be more inclined to make absolute categorizations
- Identity processing: ASD may affect how individuals process and understand their gender identity
For example, a biologically female person with ASD who has masculine traits might be more inclined to self-identify as a man due to rigid gender stereotyping, rather than identifying as gender-nonconforming while maintaining a female identity 1.
Clinical Implications
When treating individuals with co-occurring ASD and gender dysphoria:
- Extended diagnostic period: An extended assessment period is often necessary, with overlap between assessment and treatment phases 4
- Screening: Screen for ASD in individuals presenting with gender dysphoria and vice versa 4
- Addressing comorbidities: Treatment should address common comorbid conditions such as anxiety, depression, and social phobia 5, 3
- Gender-affirming approach: Creating an affirming environment that respects gender identity reduces psychological distress and suicidal ideation 5
Treatment Considerations
For individuals with co-occurring ASD and gender dysphoria:
- Social transition: May proceed at a slower pace than in neurotypical individuals 3
- Hormone therapy: Can be appropriate after thorough assessment 3
- Surgical interventions: Should be considered after appropriate psychological evaluation and hormone therapy 5
- Fertility preservation: Counseling about fertility preservation options should be provided before starting interventions that may affect fertility 5
Potential Pitfalls to Avoid
- Misattribution: Mistaking ASD special interests for gender dysphoria or vice versa 3
- Overlooking comorbidities: Failing to address co-occurring mental health conditions like depression and anxiety 5
- Assuming contraindication: ASD is not a contraindication to gender transition 3
- Rigid approach: Not recognizing that not all transgender individuals desire all available interventions 5
The relationship between ASD and gender dysphoria represents an important area for clinical awareness. While the exact mechanisms underlying this association are still being investigated, clinicians should be prepared to provide appropriate support and treatment for individuals experiencing both conditions.