Gender Identity Disorder and Autism Spectrum Disorder in a 23-Year-Old Female – Review

From the Abstract:

“We describe the case of a 23-year-old woman with Gender Identity Disorder (GID) asking for a cross-sex hormonal treatment with sex reassignment surgery and who was recently diagnosed with Autism Spectrum Disorder (ASD). Gender identity clinics are now reporting an overrepresentation of individuals with ASD among GID patients. The prevalence of ASD is 10-fold higher among GID patients than in general population.”

This paper is mostly a detailed discussion of a young woman with gender dysphoria who was found to have autism during her treatment. The therapists worked with her to provide therapy in other areas before her sex reassignment surgery. She eventually came back for the surgery.

The authors say that there have only been 10 other published case studies of people with both gender dysphoria and Asperger’s or high-functioning autism (the cases looked at six young boys, two young girls, one adult man, and one adult woman). I think they may have missed a 2014 article I reviewed that looked at two adult men.

This is the first case study about someone with gender dysphoria and “typical autism and borderline intelligence.”

I found their general discussion of the issue to be the most interesting part of the article.

Diagnoses of autism and gender dysphoria are both rising:

“The prevalence of ASD is around 60–70 per 10,000. This increase of prevalence is mostly due to the improvement in diagnostic procedures (Fombonne, 2009). ASD begins in childhood and persists in adulthood, and is clinically characterized by impaired social interactions and communication and restricted and repetitive behaviors and interests. Mental retardation is not the rule and around 30 % (Fombonne, 2005) and recently 62 % (Autism and Developmental Disabilities Monitoring Network Surveillance Year 2008 Principal Investigators, 2012) of ASD patients did not have intellectual disability (IQ ≤ 70). This form of ASD without mental retardation is often misdiagnosed.

The prevalence of GID (ranging from 1 per 11,900 to 1 per 45,000 for male-to-female individuals and 1 per 30,400 to 1 per 200,000 for female-to-male individuals) seems to be rising as well, at least as reflected by referrals to GID clinics (De Cuypere et al.,2007). Reed, Rhodes, Schofield, and Wylie (2009) reported a doubling of the numbers of people accessing care at gender clinics in the United Kingdom every 5 or 6 years. Similarly, Zucker, Bradley, Owen-Anderson, Kibblewhite, and Cantor (2008) reported a four- to five-fold increase in child and adolescent referrals to their Toronto, Canada clinic over a 30-year period and, in their last report, this increase persisted (Wood et al., 2013).”

 Autism may make people more prone to developing gender dysphoria:

 “In our Western society, a considerable amount of flexibility is needed to deal with gender variant feelings. ASD-specific rigidity makes enduring gender variant feelings extremely difficult to handle. Thus, the observed rigidity in gender-related beliefs in cases of ASD may make patients with ASD more prone to develop gender dysphoria (de Vries, Noens, Cohen-Kettenis, van Berckelaer-Onnes, & Doreleijers, 2010).”

One study found that children and teens with gender dysphoria were more likely to have autism spectrum disorder than is usual:

“There are very few published studies describing the use of systematic measures for this co-occurrence. In a sample of 204 children and adolescents with GID referred to a gender identity clinic, the incidence of ASD was 7.8 %. Thus, the prevalence of ASD in this population was 10-fold higher than that in the general population (de Vries et al., 2010).”

This might confuse the diagnosis:

“This co-occurrence is relevant for diagnostic and clinical management. First, it is important to disentangle whether the gender dysphoria arose from a general feeling of being “different” or from a “core” cross-gender identity (de Vries et al., 2010). De Vries et al. suggested that the diagnostic procedure has to include consideration of the contributions of the rigidity and reality of attitudes to gender roles and of difficulties in developing aspects of personal identity.”

Gender Dysphoria might hide the autism, autism may make dysphoria worse:

“In our case, the GID may have masked the diagnosis of ASD which was not treated, and the ASD may have enhanced the GID symptomatology. Hence, ASD rigidity and maybe low IQ may contribute to the difficulty in coping with gender dysphoria, especially without sex reassignment surgery like most gender dysphoric people do.”

A patient with autism might still get sex reassignment, but first there should be rehabilitation for other issues:

“De Vries et al. do not believe that ASD is a strict exclusion criterion for sex reassignment. There has been only one case report describing a woman with Asperger’s disorder who received sex reassignment (Kraemer et al., 2005), although more cases are known in clinical practice (Gallucci et al., 2005). However, if ASD is diagnosed, rehabilitation centered on social interactions and communication should be proposed before sex reassignment surgery. In the case of Ms. G, although she consistently and resolutely requested the sex reassignment surgery, the requests stopped temporally once rehabilitation was proposed.” (I think they mean the requests stopped temporarily.)

It could be that gender dysphoria is related to autism because autism is an example of an extreme male brain:*

“This co-occurrence also raises important theoretical questions regarding gender identity in autism. There are four times as many males than females with autism and this has led to an extreme male brain theory (EBT) being developed to explain the physiopathological process (Auyeung et al., 2009). The EBT is an extension of the empathizing–systemizing theory of typical psychological sex differences which proposes that females, on average, have a stronger drive to empathize (to identify another person’s emotions and thoughts and to respond to these with an appropriate emotion) whereas males have a stronger drive to systemize (to analyze or construct rule-based systems, whether mechanical, abstract, natural, or other) (Auyeung et al.,2009). Consistent with this theory, autistic individuals have more lateralization of the brain, like typical males, and some studies suggest a link between fetal testosterone level and autistic traits (Auyeung et al., 2009). Furthermore, a study found that females with GID had elevated autism spectrum quotient scores (Jones et al., 2012). Altogether, these studies provide a theoretical basis for a link between GID and ASD.”

People with gender dysphoria should be screened for autism:

“To conclude, we believe that it is important to consider the diagnosis of ASD in children, adolescents, and adults referred for a GID to evaluate the specificity of the demand of sex reassignment surgery or to guarantee the best condition of the success of the sex reassignment surgery.”

*There is a problem with this theory. It would only explain females who have both gender dysphoria and autism. In fact, there are many males with gender dysphoria who also have autism spectrum disorder – why would people with an “extreme male brain” feel that they were female?

Original Article:

Gender identity disorder and autism spectrum disorder in a 23-year-old female by Lemaire M, Thomazeau B, Bonnet-Brilhault F. in Arch Sex Behav. 2014 Feb;43(2):395-8

 

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