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.