Pride is in a month so here is a little something for all of us.
We have always had both LGBTQ+ members and neurodivergent people all around us. It is now that the LGBTQA+ community is starting to recognize the place of neurodivergent members in the community and the need for their (our) inclusion.
At first glance, sexuality seems to have little in common with neurodiversity. Sure, the two communities fight for recognition and legal rights, but that can be said about many other causes, such as environmentalism or animal rights. However, if we dive down into research, the connection is very clear: as many as 40% to 80% of autistics are non-heterosexual, and children who are ADHD or autistic are more likely to experience gender identity differently.
“Most of the data that we’re seeing is that [the LGB rate] is two to three times higher,” says clinical psychologist Eileen T. Crehan, Ph.D., an assistant professor at Tufts University. But larger studies need to be done before the true rate is known, she says. In a Dutch study, for example, only 57 percent of autistic women reported being straight compared to 82 percent of autistic men.
Neurodivergence remains a taboo topic often clouded by stereotypes and prejudice, based upon past and current stigmatization.
In addition, neurodivergent people experience discrimination and harassment in and out of the workplace because of these prejudices. There are also higher incarceration rate of those who are neurodivergent (see this article in Psychology Today). As most people who do not fit into the “norm”, neurodivergent people are often bullied, shunned, treated as outcasts, or are otherwise looked down upon as not equal with other human beings.
On explanation is that if you are positioned to question “norms” than you are automatically more willing to embrace a non-conforming gender identity. Similarly, an international study published in 2018 this year revealed that nearly 70 percent of autistic respondents identify as non-heterosexual — more than double the rate in the general population. There is growing evidence that there are more neurodivergent people in the LGBTQ+ community making it an important topic for our community which often has a tendency to focus on the needs of the mainstream.
The parallels with the LGBTQ+ struggle whether it is socialization through television and media, early adopters, court cases affirming neurodivergent clients, and organizations who are commoditizing the strengths of those on the spectrum. Perhaps more strikingly was the fact that LGBTQ+ members described their “coming out” as neurodivergent people at home, in the workplace or to partners.
New research suggests that non-heterosexual orientation relates to specific cortical structures in neurodivergent individuals’ brains. A small study from 2017 found a relationship between certain brain structures and sexual orientation in females with ADHD and bipolar disorder. Transgenderism is also correlated to brain differences and connectivity. More research found differences in the hypothalamus. Since neurodivergent brains are, well, divergent, those developmental and psychiatric alternative connections might relate to the difference in brain structure and connectivity of non-heterosexual orientation and trans or nonbinary identity.
Major obstacles Neurodivergent people (with a focus on autism) face at the workplace
- Interviewing: Between artificial-intelligence based hiring and “gut-checks” a lot of neurodivergent individuals are weeded out of the candidate pool when they actually have the skills needed for the job. A candidate who does not make eye contact during an interview, something common with autistic candidates – is mistakenly interpreted as being “shifty” making it impossible to get to the next round of interviews. Inclusive hiring begins with making interviews more neurodivergent friendly. Companies should be mindful of who they are interviewing;
- Career progression: Neurodivergent indivisuals are often criticized for struggling so much with public speaking and with “tailoring communications to the right audience”.
- Feedback: The 360-degree feedback process as an example is based upon feedback from neurotypical peers who may or may not know neurodivergent may have a different way of looking at things. Someone with ADHD might be able to take calculated risks, someone with autism might pay close attention to detail, important traits but their lack of awareness of politics, or unwritten rules plague their 360 feedbacks hiding their performance;
- Retention: Most autistic people switch jobs often because they do not feel included or they don’t see pathways for advancement. This is a clear need to educate people on neurodiversity because it is often the elephant in the room when it comes to teams, and all sort of other relevant factors for employee engagement and retention.
Asexuals and Aromantics
A large portion of non-heterosexuals in the neurodivergent community are asexuals and aromantics. Asexuals, or Aces, are individuals who don’t experience sexual attraction, or do experience it (gray asexuals) but prefer not to engage in sexual contact. This preference might arise from sensory sensitivities (especially for autistics and people who are ADHD) or those who have experienced trauma (for psychiatric conditions, such as PTSD or BPD). A lot of aces desire to be in a romantic relationship, one that lacks attraction or sexual acts, and asexuality doesn’t always come with aromanticism.
Aromantics are individuals who aren’t interested in forming romantic connections. This does not mean that they don’t love others, or don’t seek to settle down, but instead it means they would prefer a deep friendship rather than a romantic connection.
It is no secret to us that many neurodivergent people struggle with forming and maintaining lasting interpersonal connections, and many of them need a lot of time for themselves. Because of that, maintaining a strong friendship for life might be preferable over an intensive romantic relationship.
Of course, that is not to say that you cannot have a romantic relationship with a lot of space, but it’s important to remember that aromanticism is a valid sexual orientation that a person is born with or predisposed to, just like the others.
The trans* advocacy tries to remind us all that gender is a social construct. We live in modern societies, that tend to treat gender as binary: you’re either a man or a woman. However, many cultures have more than two genders, and in some, up to six distinct genders.
A lot of us wouldn’t describe ourselves as girly-girls or manly-men, sometimes because we don’t see a point (why should I wear heels if they are uncomfortable?), and some because of personal preferences that stem from our neurotype (Why is being a My Little Pony collector less manly than collecting miniature car models?).
Gender fluidity is so vast in the autistic community that at least two genders related to neurodiversity are recognized in the LGBTQA+ community.
What is surprising to discover is that the sexual orientation a person identifies themselves with is also affected by social expectation. Obviously, many LGBTQA+ individuals stay in the closet and mask as straight in order to protect themselves, but recent studies show that most people are in fact bisexual, or pansexual and attracted to multiple genders.
Social experiences are likely a main component, experts say. Compared with neurotypical people, autistic people may be less influenced by social norms and so may present their internal selves more authentically. “You could then understand the co-occurrence as perhaps a more honest expression of underlying experiences,” says John Strang, director of the Gender and Autism Program at Children’s National Hospital in Washington, D.C.
It’s possible that autistic people may come to conclusions about their sexual identity differently than neurotypical people do, says Jeroen Dewinter, senior researcher at Tilburg University in the Netherlands. Some autistic people have told him they would be likely to identify as bisexual after one same-sex sexual experience, but neurotypical people may be less likely to adopt that terminology based on a single same-sex encounter.
Biological factors may also play a role. Exposure levels to hormones such as testosterone in the womb may be linked to autism, some research shows; increased prenatal testosterone may also lead to more typically ‘male’ behaviors and to less common sexualities and gender identities, although there is some evidence against that link. Regardless, prenatal testosterone does not explain why autistic people assigned male at birth might identify as more feminine, Dewinter says. But the biology of sexuality and gender in the general population is not well understood either.
Experts say it’s likely that a combination of these and other factors contribute to the increased variety of gender identities and sexualities among autistic people.
You might be sitting there thinking, “Um no, I’m straight” – but the fact is that most bisexuals aren’t as attracted to one gender as they are to the other: a pansexual person can be mostly attracted to one gender, or choose to only date people of one gender.
The truth is that most of us aren’t even aware of our bisexual tendencies, because we are expected by society to only have heterosexual and romantic relationships. Neurodivergent people tend to be less affected by societal expectations, especially autistic people, who might not even understand or fit themselves into those constructs.
We are honest individuals, in and out, and this honesty allows for introspection. Yes, we might be less mindful of our bodily needs or the emotions that arise in us, but our analytical and open minds allow for introspection.
Those of us who had to mask – which is basically all of us, to an extent – learned to become extremely self-aware and sensitive to criticism, which brought a keen awareness of our thoughts and orientations, including sexual orientation. We are less able to bury our needs and wants, and more open to accepting ourselves as we are.
Since both the neurodivergent community and the LGBTQA+ community fight for recognition and equal rights, our communities have a lot in common. Both recognize that different is OK, that different doesn’t mean broken.
Both of our communities suffer the terrible effects of behavioral “therapies” that aim to fix an individual by making him or her “normal”. In fact, ABA therapy (which was shown to cause PTSD symptoms in autistics) and conversion therapy are built on the same foundations.
Lovaas, a prominent pioneer of ABA therapy for autistic children, is quoted as saying the following in regards to this therapy,
You see, you start pretty much from scratch when you work with an autistic child. You have a person in the physical sense – they have hair, a nose and a mouth – but they are not people in the psychological sense. One way to look at the job of helping autistic kids is to see it as a matter of constructing a person. You have the raw materials, but you have to build the person.
Lovaas was also a co-author of the Feminine Boy Project which was an attempt to develop a treatment that would make boys’ behavior more masculine.
We are very familiar with the damage that conversion therapy creates, and many countries recognize it as violent and abusive. So why is ABA seen differently?
Well, because autism is still a disorder in the DSM, and hence must be treated or cured. The humanity of the treatment is less relevant when moms of autistic children still refer to their kids as empty shells, even on popular media. Alas, it is important to note that some gender identities are still a part of the DSM, so we are not so far away in the mutual struggle.
Lately, LGBTQA+ communities around the world have started to recognize the need for recognition and support of neurodivergent individuals within the community. Here in Israel, I know of at least three social groups across the country, ran by the LGBTQA+ community, that are designated for teenagers and adults on the autism spectrum.
This doesn’t sound like much, but since Israel is less than 22,200 square km big, that is a significant recognition. The neurodivergent symbol, a rainbow colored infinity mark, brings the two communities even closer.
The fight to be recognized for who we are(neurodivergent LGBTQ+ members) is doubled, and even tripled, as we fight to gain more recognition within the LGBTQA+ community.
Pride parades and events can be very difficult for neurodivergent individuals, and a lot of the activism within the community consist of social gatherings and connections. Trying to normalize gender and sexual orientation causes many organizations and individuals within the LGBTQA+ community to distance themselves away from neurodiversity in order to show that “nothing is wrong with them.”
There isn’t enough understanding and open communication about the differences of neurodivergent individuals, and the understanding that neurodevelopmental conditions are not diseases to be cured.
An interesting phenomenon that is relatively new is the concept of a neurogender. People who feel that their gender differences are a product of their neurodiversity may identify themselves with a neurogender.
A well-known example is the tern Neuroqueer, which is an identity I consider one of my own. The word queer used to be a slur used against gay and lesbian people, that was embraced and re-branded by the LGBTQA+ community. A person who identifies as queer doesn’t necessarily mean an actual gender identity, and some LGB+ cisgender individuals (people who identify with the gender assigned to them at birth) describe themselves as queer as a sign of activism.
LGBTQA+ philosophy and history are vastly referred to as queer philosophy and queer history, so the term as become an identifier for an activist, as well as for someone who is gender creative, vague, fluid, or non-binary.
In 2019, a neuroqueer manifesto, written by the blogger Roux Box was published on Medium. The manifesto is a basic call for action to all double-rainbows. It criticizes the reduction of identity theory, and the common belief that a person shouldn’t or cannot be so not-normal, namely the idea that if a person is both non-heterosexual and disabled/neurodifferent, and essentially that anyone who is, is either seeking attention or is “problematic.”
The manifesto also asserts that gender is a social construct, and that because of that, many neurodivergent people are not as girly or as manly as society expects us to be, and hence, even if we don’t experience gender dysphoria or non-compatibility, the differences in gender roles that we portray, from our looks to our behavior, have to do with our neurology.
The Endocrine Society, an international association focused on endocrinology and metabolism, recommends hormone treatment for adolescents with persistent gender dysphoria who have no unaddressed psychiatric conditions and who can understand the outcomes of the treatment4. The treatment, which typically starts around age 13, involves puberty-blocking hormones that halt the development of secondary sex characteristics.
The effects of these hormones are reversible. But if gender dysphoria persists, around age 16, teenagers can begin taking a new set of hormones that align their bodies with their perceived gender.
The new guidelines, released October 24th 2017, affirm the rights of individuals with autism to receive treatment for gender dysphoria, but the experts disagree on the best time to initiate treatment. Some say adolescents with autism and gender dysphoria should try living as their perceived gender on at least a part-time basis before beginning hormone treatment. They might, for example, change their name or wear clothing that matches their perceived gender at home or in the community.
Others say this approach would create difficulties for young people with autism, who may feel they need “the right hormones in their body” before living in the corresponding gender, Strang says. Young people with gender dysphoria who are not on the spectrum tend to be less insistent on the need for hormones before transitioning socially to their perceived gender.
The guidelines acknowledge that adolescents with autism, many of whom have trouble planning for the future, need ongoing support in discerning their gender identity, exploring the implications of living as another gender and making decisions about medical treatment. This process may take a little longer in young people with autism. Their parents, too, may be concerned about moving forward too quickly. “We are not closing doors, but we are also not rushing into treatment,” says Strang.
Blakeley-Smith says one in four people who come to her autism clinic are young adults with gender dysphoria who say they are on the spectrum. She also sees young adults that she diagnosed with autism as children come to the clinic years later with concerns related to gender dysphoria. “I think this is a severely underserved population,” she says.
Other experts say a fixed gender identity may take longer to develop for individuals with autism than it does for typically developing youth5. As a result, they say, many teenagers with autism who do not conform to gender expectations or who have a fluid gender identity may ultimately accept their birth gender.
“My concerns are less about the guidelines and more about the research used to substantiate the idea that gender dysphoria is more common in autism,” says Gerrit I. Van Schalkwyk, clinical fellow in child and adolescent psychiatry at the Yale Child Study Center. “My argument is you need to understand the normal course of gender development for people with autism first.”
Strang says he hopes that ongoing collaboration between autism and gender experts will help determine how often gender dysphoria and autism co-occur and guide clinicians to meet the needs of those with both conditions.
Gender-dysphoric people need to clear many hurdles to live comfortably in the world. They must articulate an identity at odds with their sexual anatomy and the social expectations for that anatomy, plan and execute some form of transition, and deal with incomprehension or outright hostility as they navigate the perilous territory between genders.
“That involves a lot of transitions, flexibility, self-advocacy,” says Strang. “Those are all the weakest areas for people with autism.”
At the same time, people with autism have characteristics that can make this process easier, he says. They tend to be less worried about what other people think and less concerned about their social status or reputation.
Sex Education for neurodivergent students
For years, many parents and caregivers believed that autistic people, particularly those with intellectual disability, shouldn’t be given information about sexuality and are less interested in relationships than neurotypical people are, Dewinter says. That belief is changing as researchers recognize that providing relationship support is important to ensure the overall well-being of neurodiverse people, just as it is for neurotypical people. Belonging to any kind of minority group makes a person more susceptible to mental health problems, because of a phenomenon known as ‘minority stress.’ For a person who is both neuro- and gender-diverse, belonging to several minority groups can intensify those problems12.
More comprehensive and inclusive sex education can help. In ongoing surveys, Eileen Crehan, assistant professor of child study and human development at Tufts University in Medford, Massachusetts, has found that autistic people want information about sexual orientation and gender identity more than typical people do. Research has shown that lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ+) adolescents who have more inclusive sex education in school have better mental health. But only 19 percent of U.S. sex-education materials are LGBTQ+ inclusive, according to the advocacy group GLSEN, creating an extra barrier for autistic LGBTQ+ people. “You have two hoops to jump through to get the information that you need,” Crehan says.
Eileen Crehan studies sexuality, gender identity, and sex education experiences in adults who have autism. She asks, “How do we prepare youth, particularly those with autism, to navigate sexual relationships and their own identity?” She discusses sexual orientation, gender identity, and autism in a recorded webinar for SPARK.
In an interview, Crehan says access to appropriate sex education is “an area of need” across the autism community, especially for those with minimal verbal skills. U.S. schools often teach sex education differently from state to state, and many such classes do not address LGBTQ issues, she says.
Crehan wonders about the timing of sex education for some youth who have autism. Students often take sex education classes in the pre-teen to early teen years, when most children reach puberty. But those on the spectrum may develop socially on a different timeline, Crehan says. Do they take an interest in dating and become aware of sexual orientation and gender identity at the same ages as their typically developing classmates, she asks. “Is the timeline similar in autism? There are a lot of questions to answer.”
Self Awareness in teen years
Riley Smith, 26, a neurodivergent trans woman, wonders if being on the autism spectrum delayed her recognition of her gender identity when she was younger. “That [autism] diagnosis may have made it more difficult to figure out that I was transgender, mainly because I had issues with not being fully in touch with my own feelings and desires,” explains Smith, a participant in the SPARK autism study.
Smith was diagnosed with an autism spectrum disorder in childhood, and received help with social skills. “A comparatively large part of my time at that age was spent just learning how to socially interact with people. So I guess I wasn’t doing as much active introspection. I was too focused on the performative aspect of social situations.”
Justin, who did not want his last name used, discovered in high school that he was both autistic and gay. “I knew what being gay was, but I personally lacked the emotional self-awareness for a while until I realized that’s what I was feeling toward other guys,” he explains. He only told a few trusted people. “I wasn’t openly gay in high school because I suspected very strongly I would be attacked,” he says.
Bullying is a particular risk for students like Smith and Justin. According to research, students with autism are at higher risk of being bullied. The same is true for LGBT youth. A 2017 survey of U.S. high school students found that those who are gay, lesbian, and bisexual are almost twice as likely to be bullied at school and online as heterosexual students are.
Justin, who is in his 20s, did not escape bullying in high school. “I was bullied for being autistic. It’s just that no one involved knew that’s what I was. They just saw me as this awkward nerd. My differences offended them so they wanted to be mean.”
Smith says she was “mildly bullied” in high school. “It was not due to anything LGBT-related. I don’t think they knew I have autism, but they knew I was unusual.”
Shortly after high school, Smith came out to her family as a gay man. Then in her 20s, after she realized she was transgender, she began the process of transitioning to female.
She knew she was on the right path, she says, when she asked herself a question: “If there was a button you could push that automatically switches your gender, would you push it?” And she knew that she would.
The road she is traveling is a long one, she says. “Not only is transitioning difficult and entails a lot of emotional and physical changes, but it’s also a very long process that involves a lot of minor steps.”
What does this mean for clinicians and caregivers?
Clinicians who work in gender clinics may want to screen for autism, and those working in autism clinics may want to discuss gender identity and sexual health, researchers say. They should also be sensitive to different information processing styles, Dewinter says. Some autistic people may struggle to express their feelings regarding gender. Even when they do express these feelings, they often face doubts from clinicians because of stereotypes about autistic people, which can block their access to medical care. In a 2019 paper, one autistic and gender-diverse person wrote, “The combination is seen to be too complex for the majority of clinicians, which led to long waiting times for specialized psychiatric care”11.
Screening tools may also need to be updated to better identify autism among gender-diverse children, just as they need to be adjusted to spot the condition among girls. “Clinics are working to understand what autism looks like in girls and women, and we’re going to have to take that same question with the gender-diverse youth,” Strang says. Identifying autistic children who may need support in affirming their identity is particularly important because some may seek medical interventions, such as puberty blockers, that are time-sensitive, he says.
Clinicians should be aware that autistic people may present their gender identity differently than neurotypical people do. Some autistic people who transition from one gender to another are not aware of how they also need to change their social cues, such as how they dress, if they want to clearly communicate their gender identity to others. Clinicians can help autistic people navigate these transitions and ensure they have the same access to gender-affirming medical care that neurotypical people have, says Aron Janssen, associate professor of psychiatry and behavioral sciences at Northwestern University in Chicago, Illinois.
Clinicians who work with trans people who have autism say that although some individuals do encounter difficulties transitioning, healthcare providers are not always to blame. The standards of care promulgated by the World Professional Association for Transgender Health do not bar individuals with autism or other developmental disabilities from access to treatment, including hormones and surgery.
“The same criteria that applies to anybody else looking into trans medical care would apply to people on the spectrum,” says Katherine Rachlin, a clinical psychologist who has worked with adult transgender people in New York City for 25 years and is co-author of a 2014 paper on the co-occurrence of autism and gender dysphoria. “Are they informed consumers? Do they fully understand the medical procedures and treatments they are requesting? Is their experience of gender stable and enduring?”
Even people with autism who are severely affected can meet these criteria, says Rachlin, who serves on the board of directors of the World Professional Association for Transgender Health. “My experience is that even if their interpersonal deficits are severe, people are still more comfortable in their affirmed gender, no matter what else is going on in their life.”
People with autism sometimes have difficulty getting their needs met by healthcare providers due to the social and communication deficits associated with autism, says Rachlin: They may not keep their appointments, for example. “It’s not necessarily that professionals are discriminating against them on the basis of their autism,” she says.
Also, those who struggle to understand that others have beliefs, desires and perspectives that differ from their own — an impairment in ‘theory of mind’ common in people with autism — may not comprehend that others do not see them in the same way they see themselves. A person with autism may not realize, for example, that to be seen by others as a woman, they must adjust their grooming and appearance. Some of Rachlin’s clients resist taking even small steps in that direction, she says, insisting that they don’t care what other people think at the same time that they express great distress at not being correctly identified in their affirmed gender. Some also complain of deep loneliness and isolation, yet avoid social situations, refusing to attend even trans-related events and support groups.
Still, she cautions that sometimes, what looks like autism may actually be untreated gender dysphoria. “So much of the experience of being trans can look like the spectrum experience,” she says. People who don’t want to socialize in their birth genders may seem to have poor social skills, for example; they may also feel so uncomfortable with their bodies that they neglect their appearance. “That can sometimes be greatly alleviated if you give that person appropriate gender support,” she says.
Others agree with these insights. A 2015 study by researchers from Boston Children’s Hospital reported that 23.1 percent of young people presenting with gender dysphoria at a gender clinic there had possible, likely or very likely Asperger syndrome, as measured by the Asperger Syndrome Diagnostic Scale, even though few had an existing diagnosis. Based on these findings, the researchers recommend routine autism screening at gender clinics.
But they also note that some symptoms, such as feeling different and being isolated, are associated with both conditions. Other symptoms in common include not maintaining eye contact and spending a lot of time online, according to Amy Tishelman, assistant professor of psychology at Harvard Medical School, who worked on the study. Even the preoccupation with gender is analogous to the obsessive interests common in autism.
Tishelman says better screening and diagnostic tools, as well as specific interventions, are required for children who have both autism and gender dysphoria. “We need to develop interventions that will help them with the even more complex navigation of social circumstances,” she says.
The resistance of some parents to dual diagnoses also presents challenges. At Children’s National in Washington, D.C., some parents of children being treated for gender dysphoria were reluctant to accept that their child might also have autism, Strang says. Conversely, parents of children and teens previously diagnosed with autism wonder whether what looks like gender dysphoria may simply be an obsessive interest that will disappear in time. “Parents have expressed concerns that for some kids, gender can become a passing fixation, just like trains used to be,” Tishelman says. “There can be hesitation [about allowing their child to transition] on the part of some families because of that.”
Over the past decade, people with gender dysphoria have developed new ways of expressing their sense of self. Whereas many once identified as transsexual or transgender, some now call themselves ‘genderqueer’ or ‘non-binary.’ Rates of autism and autism traits appear to be higher in those identifying as genderqueer. These people generally say they don’t feel fully masculine or feminine, and explicitly reject the notion of two mutually exclusive genders. The word ‘trans’ is often used an umbrella term to encompass all of these identities and the phrase ‘affirmed gender’ to convey a person’s sense of self.
Photos by J.M Giordano
Although some trans people opt to alter their bodies via hormones or surgery, others — particularly those who identify as genderqueer or non-binary — may adopt a name and pronouns that better reflect their sense of self, without physically changing their bodies. (Ollie, age 9 with severe sensory sensitivity who does not prefer labels, had briefly experimented with using a feminine variant of his name and female pronouns, but it didn’t feel quite right, so he switched back. 9 year old Ollie still identifies as “somewhere in between.” On a late winter day, at home with his mother, his dog and his cat, Ollie is busy with Star Wars Lego, acting out a mock battle between Stormtroopers and the Rebel Alliance. He is wearing pale pink sweatpants with a glittery dark pink stripe and a pink barrette. “I’m not meant to be squeezed in that box. I’m beside it,” he says. “I’m in-between and I’m comfortable being in-between.”)
As with autism, the causes of gender dysphoria are poorly understood. Biological factors such as genetic predisposition, prenatal exposure to hormones, environmental toxins, and various social and psychological factors have all been proposed, but none have been confirmed. Like autism, gender dysphoria is heterogeneous, meaning that there is no one profile or presentation common to all those who identify as trans.
Only recently have researchers begun systematically exploring the overlap between gender dysphoria and autism; the first study to assess the convergence of the two conditions was published just six years ago. It included 231 children and adolescents who had been referred to the Gender Identity Clinic of the Vrije University Medical Center in Amsterdam between April 2004 and October 2007. The researchers found the incidence of autism among the children was 7.8 percent, 10 times higher than the rate in the general population. Among the adolescents in the sample, the incidence was even higher, at 9.4 percent.
Another group reported last year that more than half of 166 young people referred to the Gender Identity Development Service, a specialized British National Health Service clinic, in London between December 2011 and June 2013 had features of autism, as measured by the Social Responsiveness Scale, a screening tool for autism. Of that number, nearly half of those who scored in the severe range had not previously been assessed for autism.
Strang says he is not surprised by those results. He trained as an autism specialist, but had sampled other specialties for his internship, including at the gender clinic, and he’d seen a similar overlap there. “As soon as I started to do the evaluations, I felt like I was back in the [autism] clinic,” he says.
Inspired by the Dutch study, Strang and his colleagues approached prevalence from another angle. Instead of measuring the incidence of autism among gender-dysphoric children and adolescents, they assessed gender variance — defined as a child “wishing to be the other sex” — in children with autism. “We found rates that were 7.5 times higher than expected,” Strang says.
The researchers don’t have an explanation, but they do have a few theories. First, children with autism might be less aware of social restrictions against expressing gender variance. Second, the kind of rigid black-and-white thinking that is characteristic of autism might lead people with mild or moderate gender nonconformity to believe that they are not the sex they were assigned at birth. Third, there might be a biological connection between autism and gender dysphoria.
These are only hypotheses, as is the theory that gender identity may unfold differently in people with autism — there is little data to either support or refute them.
How to Support Gender Identity Exploration
- Remain open to each patient’s perspective and lived experience; avoid using research findings to invalidate the patient’s experience:
• An example of an invalidating approach is: “I hear you saying that you have
questions about your gender. But you also have autism, so it’s possible that
you believe you are gender-diverse because it’s a special interest of yours.”
• An example of an affirming approach is: “I hear you saying that you have
questions about your gender. This is important for us to talk about. Many
young people find that they don’t fit neatly into boxes, and that they don’t
feel the same about this every day. Tell me more about how you feel
- Seek to understand the patient’s gender identity narrative:
• Ask when the patient first thought about their gender, how this evolved over
time, what their current experience is, and what goals they may have for
• Recognize that some neurodiverse youth will have difficulty fully articulating
their thoughts and feelings about their gender identity
- Explore additional perspectives with the patient:
• Help the patient reflect on potential narratives of diverse gender roles
and behaviors; patients may be encouraged to consider a variety of
ways to be gendered in the world, and how others have successfully
• Help reduce the patient’s urgency around needing to ascribe ‘meaning’
to specific gender-stereotyped interests or behaviors; explain to them it
is okay to have traditionally feminine or masculine stereotyped behavior
without needing to make broader decisions around gender identity
• Describe fluidity of gender identity, roles, and expression; if the patient
struggles with abstract and flexible thinking, further validate the experience
of having different feelings about one’s gender from day to day
• Suggest trying out different gender experiences to learn what feels
- Explore opportunities for community and peer support: •Clarify what sources are available for peer support in the autism and gender-diverse communities • Acknowledge that although gender diversity may provide access to additional supports, it may also increase social marginalization
- Provide guidance around ways gender can be explored further: • Do not try to change or test the patient’s narrative; rather, help the patient further develop their identity, and anticipate positive and negative experiences
- Understand how the patient’s gender identity exploration may be part of a broader endeavor of finding one’s place in the world: • For example, is the patient trying to define their gender while also defining their goals for transition into adulthood? In these cases, affirmation of gender identity needs to be paired with active steps to support other aspects of the patient’s development and identity formation
- Recognize that a diverse gender identity can be a source of strength: • Neurodiverse youth may see their diverse gender identity as one area of their life where they feel supported, in control, and are making progress
- Provide psychoeducational, navigation, and social support to patients and families: • Neurodiverse youth may experience challenges in advocating for gender affirming interventions, navigating health care systems, and adhering to treatment protocols; therefore, these patients and their parents may benefit from tailored psychoeducation and social support resources
Asperger/Autism Network (AANE): aane.org
See especially: Resources for Mental Health and Health Care Professionals
National LGBT Health Education Center: www.lgbthealtheducation.org
See especially: Youth Resources and Transgender Resources
Clinical guidelines: Strang JF, Meagher H, Kenworthy L, et al. Initial clinical
guidelines for co-occurring autism spectrum disorder and gender dysphoria or
incongruence in adolescents. J Clin Child Adolesc Psychol. 2018;47(1):105-115.
Book about lived experiences: Mendes E, Maroney M. Gender Identity, Sexuality, and
Autism: Voices from Across the Spectrum. London: Jessica Kingsley Publishers; 2019
Also check out ALBA NETWORK
The Organization for Autism Research publishes Sex Ed for Self-Advocates, for ages 15 and older.
Stories by LGBTQ+ Autistic authors
The following list features some amazing books by LGBTQ autistic authors. Several of these books also include main characters who are autistic and LGBTQ. (Note: I have included pronouns for each author, if they have provided any online.)
In her memoir, Dale shares her experiences with being gender-nonconfirming, gay, and autistic – taking readers on a journey from her confusing childhood to a much happier adulthood. Along the way, she talks about a wide range of topics, including mental health, addiction, suicide, sensory issues, special interests, and so much more. While some of these ideas are definitely heavy and serious topics, the overall tone of Dale’s book is a hopeful one. She writes openly about the difficulties she has experienced in her life, and shares strategies that could be useful for others. She also emphasizes the need for more autism-friendly LGBTQ spaces. Dale is also the editor of the upcoming crowdfunded anthology, Gender Euphoria: Stories of Joy from Trans, Non-Binary and Intersex Writers.
Monsters in My Mind by Ada Hoffmann (she/they)
This anthology is a collection of several smaller works by Hoffmann. Many of these short stories and poems fall under the banner of “speculative fiction,” which includes genres like science-fiction, fantasy, and horror. Hoffmann describes the theme of the anthology as “being different, monstrous, or out of place, and hoping to somehow be accepted that way” – an idea that is likely to resonate with many LGBTQ and autistic readers. Hoffmann’s stories feature several characters who are autistic and queer (though they’re not always overtly labeled as such), and being able to see these characters at the center of their own stories is a fantastic experience. Hoffmann has also written two novels for adults – The Outside and its upcoming sequel, The Fallen. On her website, Hoffmann has also reviewed and ranked representations of autism in several books, as part of her Autistic Book Party series.
Dragon Pearl by Yoon Ha Lee (he/him)
Published under the “Rick Riordan Presents” imprint, Lee’s novel mixes Korean mythology with science-fiction and fantasy, and the end result is a fascinating and fantastic read about the importance of friendships and family. Dragon Pearl is notable for its inclusion of queer and nonbinary characters, and for the way that it doesn’t make a big deal out of their inclusion. Lee’s book portrays a world where pronouns are included on military uniforms, and families come in a variety of shapes and sizes – and it’s all normalized and accepted without hesitation. Young readers need more books like this one in their lives. Lee has finished writing the sequel to Dragon Pearl, titled Tiger Honor, and he expects that it will be out sometime in 2022. Lee also writes novels for adults, most notably his The Machineries of Empire series.
Ana on the Edge by A.J. Sass (he/they)
This wonderful middle grade novel is about ice skating and being true to yourself. Ana is rising in the ranks of the competitive – and very gender-coded – world of figure skating. After befriending Hayden, a transgender boy, and learning more about gender identity, Ana realizes that she is nonbinary. Faced with this new information, Ana must decide how to balance her identity with the expectations of her friends and family. Ana tries out different pronouns, comes out to her loved ones, and shows readers that figuring out who you are is a journey – and that you shouldn’t be afraid to embark on it. Sass’s next novel, Ellen Outside the Lines, comes out this fall, and will feature a queer, Jewish, and autistic protagonist.
This novella is a prequel to the novels in Sønderby’s Xandri Corelel series, Failure to Communicate and Tone of Voice. The series tells the story of Xandri, a young autistic woman who has a special talent for understanding alien life. Readers get a glimpse into Xandri’s past, and see how she got her start as a special kind of diplomat and negotiator. Xandri is a Pandora, the result of a rare natural birth in a universe that, through eugenics, had previously eliminated disabilities completely. Xandri’s autism is strange to many of her peers, and for all her skill in understanding alien life, Xandri still struggles to understand the other humans around her. Xandri is also bisexual, and in this prequel, meets some crew members that she will have relationships with later in the series. Sønderby has finished the third Xandri Corelel book, and hopes to see it published soon. She is also working on two additional novellas for the series.
This Australian book hasn’t come out in the US yet, but it is definitely worth seeking out. The story centers on Peta, who is autistic and also has ADHD (as does the book’s author). Peta also struggles with sensory processing issues, and has to put a lot of effort into accommodating for herself. Peta has had to learn a lot of rules for how to fit in, but all of her social skills training fails to prepare her for how it feels when she falls in love with her new classmate – a girl named Sam. Peta’s been taught that she has to follow the rules if she wants to be “normal,” but hiding who she really is (also known as masking) has a cost. Peta must decide if rating normal is truly worth it, and which rules in life are meant to be broken. Whateley’s next book, Tearing Myself Together, which focuses on two neurodivergent classmates of Peta’s (one with EDS, the other with skin cancer), comes out in Australia in 2022.
Queens of Geek by Jen Wilde (she/they)
This was one of the first #OwnVoices autistic books that I read, way back in my early days of library school. I had never felt so seen. This book tells the story of two protagonists: Taylor, a plus-size autistic girl who also has anxiety, and Charlie, a Chinese-Australian girl who is bisexual and has a huge crush on Alyssa (a queer Black actress/vlogger). Taylor is also dealing with her own complicated feelings for her best guy friend Jamie, and when she and Charlie arrive at the SupaCon comic convention, everything changes. The diverse representations in the story are all very well-written, and the friendship between neurodivergent Taylor and neurotypical Charlie is wonderful and sweet. Wilde writes about autism, anxiety, bisexuality, sexism, and so much more in an amazingly authentic way. Wilde has also written two additional YA books – The Brightsiders and Going Off Script – which also feature queer protagonists.
It is important to remember that being LGBTQA+ is as natural as being neurodivergent. We should embrace all of our differences, and ourselves, if we wish to live authentic lives. Recognizing the mutual struggle of both of our communities is important, especially inside the LGBTQA+ community.
Advocacy in favor of mental health supports and in opposition of behavioral therapies and treatments can also go hand-in-hand, considering our shared histories.
Let us try to always be inclusive, compassionate, understanding and open. Let us remember that love is love, and that a brain is a brain. And don’t despair – after the storm comes a rainbow!