Category Archives: Children with Aspergers/Autism

Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood – Review of a case study

This is a follow-up case study of a Japanese boy with both Asperger’s syndrome and gender dysphoria. It is the first long-term follow-up case study we have for a child with autism and gender dysphoria.

The young man no longer had gender dysphoria at the 11-year follow-up.

This is a highly significant case study; we know that most children with gender dysphoria desist around puberty, but we have had no data on what happens to children with both autism and gender dysphoria.

We need more studies to find out how common this is for children with autism and gender dysphoria.

In addition, we need studies to look at how persistence and desistence from gender dysphoria work for children with autism. Is the developmental process different from neurotypical children? How should parents, educators, and therapists work with children who have both autism and gender dsyphoria?

As the authors say, “Careful long-term clinical observation and further studies are needed.”

More details on the boy’s gender dysphoria:

[The boy came to the clinic at age 5 for behaviors related to autism] At the age of 7, he verbalized a strong aversion to being a boy and desired to be a girl. The boy behaved as if he were a girl and preferred to play with girls. Based on his clinical symptoms that lasted more than 6 months, the comorbid diagnosis of GID was made according to ICD-10 criteria.

After entering school, he exhibited behaviors such as using stationery with Disney princesses and dressing himself in clothes with flowers. He rarely went to the bathroom because he did not want to be seen urinating in a standing position. He skipped swimming classes at school to avoid exposing his chest. Only at his home, the boy wore skirts and makeup. At school, he was bullied by classmates because of his feminine behaviors. However, as school teachers were supportive and intervened appropriately, he never refused to attend school.*”

You can also read more about his earlier gender dysphoria in this previous case study.

More details on the change at puberty:

“At the age of 11, when puberty started, he became confused and repeatedly shaved his body hair. He tried to keep his voice tone high. However, as puberty progressed his gender dysphoria gradually alleviated.

In Japan, in general, junior high school students are required to wear school uniforms based on their biological sex, typically a skirt for girls and trousers for boys. They are also requested to obey school regulations related to length of hair, though the strictness is highly school-dependent. Our patient entered a public school in his residential district and had to behave as a typical male student. As a consequence, his gender-related manifestations fell below the threshold for the diagnosis of GID as of age 16 (the time of this writing).”

Note: This is not just a question of changes in behavior – the authors also say that his gender dysphoria gradually alleviated as he went through puberty. In addition, the authors got informed written consent before publishing this study.

 

*School refusal is a significant problem for students with gender dysphoria in Japan. (Bullying seems to be a problem everywhere.)

Original Source:

Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood by Tateno M, Teo AR, Tateno Y, in Psychiatry Clin Neurosci. 2015 Oct;69(10):658.

Gender identity problems in autistic children – Review of a case study

This is a case report of two Turkish boys with autism and gender dysphoria. Unlike this earlier study of two boys with autism, the boys in this study verbalized a clear desire to be a girl.

In the earlier case study, the boys had cross-gender interests, but probably did not have gender dysphoria. In this case study, however, the boys had cross-gender interests and gender dysphoria.

This study followed the boys for at least four years, so we know that the gender dysphoria was not transient.

We do not, however, know if their gender dypshoria will persist. Most children with gender dysphoria desist around the time of puberty. What happens with children with autism? Are they more or less likely to persist in their gender dysphoria? How should parents and educators handle their gender dysphoria? Is their gender dysphoria different from gender dysphoria in neurotypical children? How common is gender dysphoria among children with autism?

In the first of these two cases the patient was treated with behavior modification, encouraging separation from the mother, and establishing a bond with his father. His cross-gender behavior continued. In the second case his parents tried to establish a good bond with his father, but again, his cross-gender behaviors have continued.

The author of this study suggests that gender dyshoria in children with autism may be underreported and might be interpreted as unusual interests rather than actual gender dypshoria. At this point, however, we don’t have enough data to know if that is the case. This is a case study of only two children.

This case study does, however, show that children with autism can have genuine gender dypshoria, like the Swedish teenage girl in this case study and the Japanese boy in this one.

“This case study, which is a preliminary attempt to report the developmental pattern of cross-gender behaviour in autistic children, tries to underline that (1) diagnosis of GID in autistic individuals with a long follow-up seems possible; and (2) high functioning verbally able autistic individuals can express their gender preferences as well as other personal preferences.

Finally, this report points to the need for further study of gender identity development as well as other identity problems in individuals with high functioning autism.”

(Emphasis mine)

Original Source:

Gender identity problems in autistic children by N. M. Mukaddes in Child: Care, Health and Development Volume 28, Issue 6, pages 529–532, November 2002.

More details about the case studies:

Case 1 – 10 year old boy with autism:

“One year after the referral [for autism], when he was aged 6 years, he started to show improvements in spontaneous speech and imitative play, and displayed more interest in his peers and other people. At the same time, his mother reported some cross-gender behaviours such as wearing his mother’s dresses, putting lego bricks in his socks under his heels and pretending to have high-heel shoes. Along with the improvement in spontaneous speech and imitative behaviour, he started to state his disappointment about his gender. Sometimes, he prayed and begged God to make his penis disappear. After these verbal expressions, he shared his fantasy about his wish to become a bride, married to a man from the age of 8 years. He never shows interest in male activities, he always avoids rough-and-tumble play and prefers to play with girls. Although he has shown some improvement in his social relatedness and language, his social difficulties in terms of reciprocal relationships with peers and sustaining a conversation with others still remain. Despite the eclectic treatment approaches (behavioural modification, encouraging separation from his mother and establishing a bond between him and his father), his cross-gender behaviours show a persistent pattern.”

Case 2 – 7 year old boy with autism:

He started to use phrases at age 4 years [he was referred to the clinic at age 3 for autism], showed improvement in social relationships and sharing interests with peers at nursery school. He also started some make-believe play. At the same time, he had shown persistent attachment to his mother’s and some significant female relative’s clothes and especially liked to make skirts out of their scarves. After age 5 years, he started to ‘play house’ and ‘play mother roles’. This was the most persistent and most pervasive pattern of his play, and he pushed his therapist as well as his peers and family members to ‘play house’ with him. He avoids rough-and-tumble play and likes to share his interests with one or two of his female classmates. His parents were worried about his behaviour and tried to prevent it, but he reacted aggressively. He started to state his desire to grow up as a woman (like his mother). He gave up his attachment to some feminine objects, but still shows persistence in playing the ‘mother roles’ and expresses his desire to be a woman. Although there are some improvements in terms of social relatedness, language and the disappearance of stereotypical behaviours, his social interaction pattern is still inappropriate for his age. His parents have tried to establish good bonding between him with his father as a identification object. Despite this, his cross-gender behaviours are persistent.

Review of Gender identity disorder in a girl with autism – a case report

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.

Original Source:

Gender identity disorder in a girl with autism – a case report by Landén M., Rasmussen P. in Eur Child Adolesc Psychiatry. 1997 Sep;6(3):170-3.

*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.

**Skoptic syndrome: the treatment of an obsessional gender dysphoria with lithium carbonate and psychotherapy.

***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.)

Case study: cross-gender preoccupations in two male children with autism

This is a 1996 case study of two boys with autism who had cross-gender interests, but probably did not have gender dysphoria.

Both boys liked dolls, although the way they played with them was not typical. In addition, one of the boys liked to imitate the scenes of cartoons with female characters. Both boys cross-dressed and created long hair with cloth.

Neither of them played with other children of either sex. One boy ran around and screamed until the other children left and the other fought with others if they bothered him.

Neither of them expressed a dislike of being a boy or a desire to be a girl – although, on the other hand, their language was limited.

The parents of one of the boys thought they might have reinforced his interest in dolls. They had been so excited to see him using toys of any sort that they bought dolls for him.

The mother of the other boy was anxious about her son’s cross-dressing and reluctant to discuss it.

The authors suggest that for these boys the cross-dressing may represent an unusual preoccupation rather than a sign of gender identity. “This preoccupation may relate to a need for sensory input that happens to be predominantly feminine in nature (silky objects, bright and shiny substances, movement of long hair, etc.).”

The authors suggest that cases like these could lead to misdiagnosing gender dysphoria:

“These cases also point to the potential for confusion of primary gender identity disorders with preoccupations in high-functioning individuals with autism.”

They make recommendations for treatment in cases like these:

“Rather than a narrow focus on altering the preoccupation, a broad intervention addressing social, communication, and play skill development appears to be important. Thus, identifying other interests in the children to be developed in the context of social situations may aid social skill development by increasing opportunities for interactive play. Parents and others working with the children may need help in understanding the nature of feminine preoccupations in boys and in destigmatizing these interests.”

The authors conclude by saying:

It is our hypothesis that the feminine preoccupations of these children with autism may have resulted from an inherent predisposition toward unusual interests combined with the boys’ social environment. The sensory aspects of the feminine objects may have contributed to the development of these preoccupations. It seems less likely that the feminine interests are related to issues of gender roles/confusion. This report points to the need for future study of the complex interplay of environmental and neurobiologic factors affecting gender identity roles and preoccupation in autism.

More Details About the Boys’ Cross-Gender Interests and Behavior

The first patient was five years old.

“Although his parents report no truly imaginative play, M.C. will imitate the scenes from a video having to do with female cartoon characters (e.g. Cinderella, Snow White, and Ariel). He likes to hold Barbie dolls, but frequently will rip off the dolls’ heads and play with parts of the doll, particularly the hair. He enjoys bright, shiny objects. He often dresses up using female clothing and uses towels or other fabric to fashion long hair for himself. M.C. demonstrates little interest in male toys or other toys in general.”

The second patient was three and a half years old.

“His favorite toys are a Minnie Mouse doll and a Barbie doll although his play consists mostly of shaking the hair of the Barbie doll. He enjoys wearing his sister’s or mother’s clothing, including high heeled shoes, bras, and underwear. He often puts a shirt over his head and acts as if it is long hair.”

More Details about the Patients

The first patient lived with his parents and older brother. There was nothing unusual about his birth, although his later medical history included “hospitalization for dehydration/gastroenteritis and right inguinal hernia repair.”

Behaviorally, “M.C.’s speech is characterized by short sentences which are often stereotyped. He recently began requesting objects by pointing. His parents report that he is an active, impulsive, moody child with a good memory. M.C. frequently engages in perseverative motor activities. He is generally a loner. When with other children he frequently runs around and screams until the children go away.”

The second patient lived with his mother, older sister, fraternal twin, and his mother’s boyfriend. The pregnancy and birth were complicated. The patient had also had frequent upper respiratory infections and ear infections and a hospitalization for reactive airway disease and pneumonia.

In terms of his development, “although he learned the words to several songs at an early age, he did not begin using phrases until approximately 3 years of age. C.W. is described as a loner who does not play with others. He engages in perseverative activities such as opening and shutting doors as well as running his hand repeatedly through water. He watches commercials, music videos, and ‘Wheel of Fortune’ on television. He fights with others if they bother him, and screams if unable to do what he wants.”

More Details about the Patients’ Treatments

The first patient was treated with special education services after kindergarten and consultation with a school specialist in autism. His communication skills improved and his interests broadened somewhat. However, he was still interested in dolls and requested a Pocahontas doll for his birthday.

In the second case, the boy was enrolled in a school program that included special education services. His mother had a home consultation visit with a specialist in autism. He continues to cross-dress, although his mother only allows it when he comes home from school.

 

Original Source:

Case study: cross-gender preoccupations in two male children with autism by Williams PG, Allard AM, Sears L. in J Autism Dev Disord. 1996 Dec;26(6):635-42.

 

 

 

 

The development of gender identity in the autistic child – Extremely Brief Review

A 1981 study of autistic children found that gender identity was related to “mental age, chronological age, communication skills, physical skills, social skills, self-help skills and academic/cognitive skills.”

The study looked at 30 children and gave them the Michigan Gender Identity Test. The goal was to see if they could demonstrate a sense of gender identity.

This study is not available online, however, I was able to get some more information on it from another study (Case study: cross-gender preoccupations with two male children with autism.)

According to Williams et al., Abelson’s study indicated that “the establishment of gender identity in children with autism (as demonstrated by recognizing one’s own self as a boy or a girl) appeared to be dependent on mental age and cognitive abilities, and was correlated with the establishment of other social and self-help skills. Abelson expressed some optimism that many children with autism have the ability to recognize themselves as boys and girls, and thus form effective ties with the identified group, which leads to more acceptable social interaction patterns.”

Original Source:

The development of gender identity in the autistic child by Abelson AG in Child Care Health Dev. 1981 Nov-Dec;7(6):347-56.

At the Intersection of Gender and Autism – Part 3

The final part of a great series on gender and autism from the point of view of a woman with autism.

One thing I found interesting was the ways autism may be hidden with girls. For example, the author of the article played with dolls, but she played with them by lining them up.

Musings of an Aspie

The final post of a three part series (read Part 2)

While many of the intersections of autistic and female in my life have been social, there are undeniable physical intersections too.

The arrival of adolescence brought with it hints of what it would mean to be an autistic adult. My first real meltdowns. My first experience with depression. My first confusing encounters with physical intimacy.

With nothing to compare those experiences to, I assumed they were a normal part of being a teenager. Everyone said that being a teenager was hard. I couldn’t dispute that. It didn’t seem necessary to look beyond the explanation of “this is hard for everyone.”

That would become a theme. Pregnancy. Breastfeeding. Postpartum depression. My body’s reaction to birth control pills. Countless books and magazine articles assured me that these things were no walk in the park. Not knowing that I was autistic…

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At the Intersection of Gender and Autism – Part 2

“Perhaps rather than extreme male brains, autistic women have extreme individual brains. As a group we seem to be less influenced than typical women by the roles society expects us to play.”

Part 2 of the 3 part series by a woman with Aspergers.

A moving account of being a mother with autism as well as a discussion as growing up as a girl with autism.

Musings of an Aspie

Continued from Part 1

There was joy in that realization and also sadness. My diagnosis came too late to help me in my role as a mother when my daughter was young, a role that I often struggled with. Many aspects of being autistic can make the child-rearing years of motherhood challenging.

Babies have round-the-clock needs. They’re stressful, messy, unpredictable and demanding. Basically they are everything that an autistic person finds hard to cope with. Gone was my precious alone time. Gone were my carefully crafted routines. Even my body was no longer my own, transformed first by pregnancy then by postpartum hormones and breastfeeding.

I was completely unprepared for how hard motherhood would be. Unaware that I was autistic, I often felt like a bad mom. What kind of mother breaks down sobbing uncontrollably and bangs her head against the dining room wall? Certainly none that I was aware…

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