The Times- Are autism and gender dysphoria linked? This professor thinks so
Are autism and gender dysphoria linked? This professor thinks so
When Michael Craig, an expert in neurodevelopmental conditions, sat in with the Tavistock’s gender identity development service, he began to question diagnoses
Professor Michael Craig: “Some days I was fairly convinced 40-50 per cent of the patients I was seeing were autistic”
TIMES PHOTOGRAPHER RICHARD POHLE
The Times
For six months during the Covid lockdown, Professor Michael Craig sat in remotely on sessions with patients at the Tavistock gender clinic in London. They were children who were being seen for gender dysphoria, the term used to describe a sense of distress caused by somebody feeling that their biological sex does not match their gender identity. But as Craig watched them pass through he says he was “perturbed” by how many also seemed to have another condition: autism.
“There were certainly some days where I was fairly convinced 40-50 per cent of the patients I was seeing were autistic,” he said. Overall, he estimates about 20 per cent might have qualified for an autism diagnosis.
“I was trying to find out what it is that might explain this overlap, but it’s a difficult area to research for all sorts of reasons.”
NHS Tavistock Centre was home to the gender identity development service for children, which closed last month
HENRY NICHOLLS / AFP
Craig, who is based at King’s College London, was the clinical lead for the NHS National Autism Unit from 2007 until 2023. He has studied sex differences in “typical” brains, neurodevelopmental conditions including autism and ADHD, and the links between sex hormones and mental health. As an observer at the Tavistock, where the gender identity development service (Gids) was closed last month after whistleblowers repeatedly raised concerns, he found himself grappling with a puzzle at the heart of how best to help a growing number of young people: how exactly are autism and gender dysphoria linked?
In the 1980s, autism was thought to affect about 1 in 2,500 children; by 2018 about 1 in 34 of those aged 10-14 in England was estimated to have a diagnosis.
Experts ascribe that growth to rising awareness, broader definitions of “autism spectrum disorder”, reduced stigma and a realisation that girls and women — once essentially thought to be immune — can be on the spectrum but are often able to mask their symptoms. Some overdiagnosis is another possibility, they add.
There are far fewer gender dysphoria cases, but the rise has been similarly steep. In 2009 Gids saw fewer than 50 children a year. By 2021-22, demand had increased a hundredfold, with more than 5,000 seeking help.
That the two conditions often seem to occur together was highlighted in a review by Dr Hilary Cass this month, on the state of NHS services for children identifying as trans. One of its recommendations is that children presenting at gender clinics should be screened for neurological conditions, especially autism. “Clinicians report seeing teenage girls who have good cognitive ability and are articulate, but are struggling with gender identity, suicidal ideation and self-harm,” Cass explained. “In some of these young people the common denominator is undiagnosed autism, which is often missed in adolescent girls.”
To support this anecdote, she cited a study which estimated that people who are transgender and gender diverse are three to six times more likely to be autistic than those who are not. Professor Simon Baron-Cohen, from Cambridge University, was the senior author of that research. His paper argued that there were possible mechanisms that may explain the link, such as hormone exposure in the womb. He told The Times, though, that it was clearly sensible to check for both when people present at clinics with gender dysphoria.
“If at present many young people are being referred for gender dysphoria as an explanation for their depression, and an underlying autism diagnosis is being missed, then it makes good clinical practice to also check for autism too, in case the person’s mental health struggles might also be partly due to not getting support for their autism,” he said.
“The two are not mutually exclusive but could be co-occurring conditions, each of which deserves support.”
Professor Simon Baron-Cohen, whose paper was used in the Cass review, said autism and gender dysphoria both deserved support
There’s no doubt that failures to recognise the true nature of neurodevelopmental conditions have done harm in the past. When Dr Wenn Lawson was two years old, a doctor wrongly told his parents that he was intellectually disabled. When he was 17, another misdiagnosis saw him labelled schizophrenic. He spent years on antipsychotic drugs, passing in and out of mental institutions.
It wasn’t until he was 42 that it was realised that he was actually autistic. “I have some learning difficulties, dyslexia, dyspraxia, and so on — but it’s very different to being mentally ill,” he said. “Today, you’d hope that a psychiatrist would know the difference.”
Lawson, who is now 72, is also transgender and he says that it makes sense to him that gender dysphoria is more prevalent in the autistic population. People with autism feel less compulsion to conform to societal norms, he says — an idea also mentioned by Baron-Cohen in his study. “This frees us up to connect more readily with our true gender,” Lawson said.
But he also warns that if they feel they have gender dysphoria and are not taken seriously, they are vulnerable to falling into confusion, depression and severe mental illness. “The suicide rate in autism, especially around gender dysphoria, is much, much higher than in the broader population,” he said.
“That doesn’t mean that you just listen to an eight-year-old and take their word for it,” he added. “You’ve got to walk with a person for quite some time. Because there are other things that could be swaying them. So you need to sift those things out. Absolutely.”
Craig doesn’t dismiss Lawson’s idea about societal norms, but thinks other explanations for the overlap could be possible. “Some people would say that gender incongruence, or dysphoria, in itself may be a neurodevelopmental condition — and therefore, it’s not surprising that you find an overlap with other neurodevelopmental conditions such as autism,” he said.
“I think that there are also probably significant aspects about the autism condition itself that lend people, particularly when they’re going through more fluid areas of their life, to be a bit more rigid in how they lock into a way of thinking. It becomes more entrenched than it would do in people whose brains don’t quite work that way.
“And I think the third thing is that there is a group of people who are very open and accepting of other people who are different in the area of gender incongruence, or gender dysphoria — and for people who are in the autism spectrum camp, I think there is a sort of sense of inclusion there that perhaps is important.”
Autism spectrum disorder or attention deficit hyperactivity disorder (ADHD) traits or diagnoses were mentioned in
the majority of cases seen at Tavistock, the Cass review says. “But it is not clear how fully or appropriately these had been explored.”
So are people with autism at risk of being misdiagnosed with gender dysphoria? “There may be cases where gender clinics do not pick up on where the origin of their unhappiness lies,” Craig said.
“People who are on the autism spectrum feel ‘othered’, feel different, feel marginalised. And I think they can sometimes get channelled into a gender clinic, where there’s a system in place that will work with them on that level.”
He added: “My experience at Tavistock was that very complicated people were coming through, and any one clinic is going to only be able to deal with things in a relatively specific way.
“And I think unpacking all of this stuff is very difficult. And I also think there is a difficulty, politically, in trying to unpack those things without appearing to be transphobic or without challenging somebody’s perception that they are [in the wrong gender body] in a way that is perceived to be unhelpful.”
There is, he added, a chance that if better autism support had been available, some people who ended up in dysphoria clinics may not have done so. “This is speculative, but it is certainly possible. But the problem with making a bold statement like that is how it’s then reinterpreted, isn’t it? This is an area where people hold very, very strong views. And I think lots of people have found themselves on the wrong side of those strong views.
“I think there are going to be some people who are on the autism spectrum who may be vulnerable as a result of how they interpret various things — and that they perhaps arrive at clinics where maybe that isn’t being picked up.
“If one understood that somebody may be on the autism spectrum, and that that was heavily influencing the way that they were approaching [the question of whether they were experiencing gender dysphoria], then that could be something that was explored further if the resources were there.”
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