This is a 1997 case of a Swedish teenager who had autism as well as symptoms of gender dysphoria, selective mutism, and obsessive compulsive disorder (OCD).
Treatment with clomipramine decreased her symptoms of OCD and mutism, but not her symptoms of gender dysphoria.
Unlike this earlier case study of two American boys, this patient had clear symptoms of gender dysphoria:
“At the age of 8 years, B had started to claim that she was a boy. She refused to wear girls clothing and jewelery. B corrected persons if she was being addressed as ‘she’ and used her brothers’ shaving machine. At twelve years of age, B refused to visit the girls toilet but was forbidden by the parents to use the boys toilet. She has now been told to use the one and only gender neutral toilet in the school.”
And, at follow up:*
“She refuses to wear women’s clothes or to appear in swimsuit on the beach. Moreover, she claims that she is a boy, although she has discontinued the habit of correcting peers for addressing her ‘her’.”
The authors discuss three possible ways to interpret her symptoms of gender dysphoria and the implications for treatment.
First they suggest that the gender dysphoria could be part of the autism, specifically a “ritualized and obsessive-compulsive behavior of a kind which is commonly seen in autistic syndromes.”
The authors suggest that autism makes social and sexual relationships difficult, although people with autism are attracted to others. The expression of these feeling may be unusual. “A minority of people with autism display a variety of paraphilic behaviour, e.g., exhibitionism, voyeurism and fetishism, and the desire for a beloved person may find expression in an obsessive manner.”
Gender dysphoria then might be “a paraphilic consequence of the impairment in social interaction” due to her autism. In that case the proper response would be “similar to the one employed when encountering other sexual manifestations with autistic people: a gradual firm correcting of the behavior in the direction of gender concordant behavior, but without anger or distress.”
The authors do not discuss the possibility that the gender dysphoria could be part of the autism in some other, non-sexual way. They should have.
Second, they suggest that the gender dysphoria might be seen as an obsessive-compulsive disorder and separate from the autism. In that case the proper treatment would be clomipramine.
There have been cases where patients with obsessional gender dysphoria were successfully treated with lithium carbonate, but the symptoms were different from the ones in this case.**
More importantly, in this case, treatment with clomipramine relieved the symptoms of OCD and mutism, but not the gender dysphoria. In fact, her symptoms of gender dysphoria increased, although it may be that they only became more apparent – for one thing she was talking more.
Third, they suggest that the gender dysphoria could be viewed as a disorder on its own and not a symptom of autism or OCD. In that case, the proper approach would be to treat both the autism and the gender dysphoria. When the teenager was of age,*** she would then be eligible for sex reassignment surgery.
They caution that “this patient suffers from a putative risk factor (autism), which has to be seriously considered before any intervention can be performed. “
As with other case studies, this is about one person. We can only draw limited conclusions from it.
It does show, however, that a person with autism can have symptoms of gender dysphoria. Further, in this case, the symptoms were probably not caused by OCD, as treatment for OCD did not relieve her gender dysphoria.
We could use further research to determine the relationship between gender dysphoria and autism and the best way to treat children and teenagers who have both.
*It’s not perfectly clear in the case report, but the therapists seem to have seen her initially at age 12 and the follow-up seems to have been at age 14.
***The first reference I can find to using puberty blockers for teenagers with gender dysphoria is a case study of one teenager in 1998, a year after this case study. Thus at the time of this case study, medical transition would not have begun before age 18. (Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent.)