Gender dysphoria in Asperger’s syndrome: a caution – Review

The author of this paper worked with two male patients who had Asperger’s and gender dysphoria. The patients asked for hormones and surgery, but when treatment was withheld, they realized that they were not transgender.

The author concludes that:

“Patients asking for sex reassignment should be assessed for indications of Asperger’s syndrome. Irreversible treatments should be withheld until it is clear there is a genuine issue of transsexualism.”

The author points out that the incidence of Asperger’s Syndrome is above average in people with gender dysphoria. However, one of the characteristics of Asperger’s is obsessive preoccuptions (this can also be a good thing as the foundation for a hobby or career).

In the first case the author treated, the young man was socially isolated as a child, but had no sense of a female identity. At 21, he read a magazine article and decided he must be transsexual. He continued to believe this during four years of psychotherapy.

This doctor then treated the patient for six years. During this time, the patient rarely appeared dressed as a woman. He wanted hormones, but would not live as woman – apparently in Australia you must live three months as the target sex before you can get hormones.

The patient then went to live in a hostel for transsexuals where he discovered that he was not like them; he was not interested in clothes, make-up, or shoes. He realized that he was not transsexual and began to see a therapist who specializes in Asperger’s syndrome.

The doctor describes the second case this way,

“..when he was in Year 11 had worn his hair long and taken the name Marjory. He asked for hormonal transition but two psychiatrists and an endocrinologist wisely withheld hormones. He claimed that from the age of two years he had felt he was a girl. He would get emotional over trivial things – which he said was a female trait! At nine he was cross dressing, which continued into his teens.

He had always felt ‘different’ and over many years had a preoccupation with the ‘Star Wars’ saga and making model spaceships. At the age of 19 years he consulted me because of confusion over gender and sexuality – presenting, nonetheless, as quite a well-adjusted young man. Two years later he was able to say that ‘all that transgender business’ had been a waste of time and had put him a couple of years behind his mates in sexual development. Not long ago, three years after ending treatment, he told me he was married, expecting a child.”

The author is not opposed to allowing people with Asperger’s syndrome to transition; he talks about one case he had where a woman with Asperger’s presented in a very masculine manner and he helped her to transition to a man.

I am not sure what to think of this. The doctor seems sexist and the gatekeeping seems extreme – on the other hand, he was right.

The first case sounds like a good example of someone who wanted to believe he was transsexual in order to solve his problems, but did not really want to live as a woman. In the second case, the patient seemed more interested in actually transitioning, although when treatment was withheld, he decided that he was not transsexual.

The author also briefly discusses Baron-Cohen’s theories about autism:

“Given that there is an above average occurrence of ASD in young people presenting with gender dyshoria (the great majority male-to-female), it seems paradoxical that autism has been considered a case of “the extreme male brain.” Professor Simon Baron-Cohen has demonstrated that the number of autistic traits displayed in childhood relates back positively to levels of fetal testosterone. Baron-Cohen does not believe that gender identity is related to testosterone. However I am not alone in believing that it can be a factor, demonstrated for instance in the incidence of gender dysphoria in Klinefelter’s syndrome.

Hans Asperger himself wrote, ‘The autistic personality is an extreme variant of male intelligence … in the autistic individual the male pattern is exaggerated to the extreme.’”

Original Article:

Gender Dysphoria in Asperger’s syndrome: a caution by John Parkinson in Australas Psychiatry. 2014 Feb;22(1):84-5.

IMPORTANT NOTE: There are a number of other case studies of patients who have both gender dysphoria and autism. Unfortunately, there are not any large studies of patients with gender dysphoria and autism spectrum disorders.

I highly recommend Gender and Autism on Musings of an Aspie. It includes an excellent discussion of the “extreme male brain” theory of autism.

You can read more about treating patients with autism and gender dysphoria in these articles:

Gender Identity Disorder and Autism Spectrum Disorder in a 23-Year-Old Female – a 2014 case study from France.

Gender Dysphoria in Pervasive Developmental Disorders – a 2011 discussion of four patients in Japan.

Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood – 2015 follow-up study that found that a Japanese boy with Asperger syndrome no longer had gender dsyphoria at age 16 (see 2008 study below).

Comorbid childhood identity disorder in a boy with Asperger syndrome – a 2008 letter to the editor about a patient in Japan.

Comorbidity of Asperger syndrome and gender identity disorder – a 2005 case study from Switzerland.

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