Tag Archives: persistence of gender dysphoria

Gender dysphoria in Asperger’s syndrome: a caution – Review

The author of this paper worked with two male patients who had Asperger’s and gender dysphoria. The patients asked for hormones and surgery, but when treatment was withheld, they realized that they were not transgender.

The author concludes that:

“Patients asking for sex reassignment should be assessed for indications of Asperger’s syndrome. Irreversible treatments should be withheld until it is clear there is a genuine issue of transsexualism.”

The author points out that the incidence of Asperger’s Syndrome is above average in people with gender dysphoria. However, one of the characteristics of Asperger’s is obsessive preoccuptions (this can also be a good thing as the foundation for a hobby or career).

In the first case the author treated, the young man was socially isolated as a child, but had no sense of a female identity. At 21, he read a magazine article and decided he must be transsexual. He continued to believe this during four years of psychotherapy.

This doctor then treated the patient for six years. During this time, the patient rarely appeared dressed as a woman. He wanted hormones, but would not live as woman – apparently in Australia you must live three months as the target sex before you can get hormones.

The patient then went to live in a hostel for transsexuals where he discovered that he was not like them; he was not interested in clothes, make-up, or shoes. He realized that he was not transsexual and began to see a therapist who specializes in Asperger’s syndrome.

The doctor describes the second case this way,

“..when he was in Year 11 had worn his hair long and taken the name Marjory. He asked for hormonal transition but two psychiatrists and an endocrinologist wisely withheld hormones. He claimed that from the age of two years he had felt he was a girl. He would get emotional over trivial things – which he said was a female trait! At nine he was cross dressing, which continued into his teens.

He had always felt ‘different’ and over many years had a preoccupation with the ‘Star Wars’ saga and making model spaceships. At the age of 19 years he consulted me because of confusion over gender and sexuality – presenting, nonetheless, as quite a well-adjusted young man. Two years later he was able to say that ‘all that transgender business’ had been a waste of time and had put him a couple of years behind his mates in sexual development. Not long ago, three years after ending treatment, he told me he was married, expecting a child.”

The author is not opposed to allowing people with Asperger’s syndrome to transition; he talks about one case he had where a woman with Asperger’s presented in a very masculine manner and he helped her to transition to a man.

I am not sure what to think of this. The doctor seems sexist and the gatekeeping seems extreme – on the other hand, he was right.

The first case sounds like a good example of someone who wanted to believe he was transsexual in order to solve his problems, but did not really want to live as a woman. In the second case, the patient seemed more interested in actually transitioning, although when treatment was withheld, he decided that he was not transsexual.

The author also briefly discusses Baron-Cohen’s theories about autism:

“Given that there is an above average occurrence of ASD in young people presenting with gender dyshoria (the great majority male-to-female), it seems paradoxical that autism has been considered a case of “the extreme male brain.” Professor Simon Baron-Cohen has demonstrated that the number of autistic traits displayed in childhood relates back positively to levels of fetal testosterone. Baron-Cohen does not believe that gender identity is related to testosterone. However I am not alone in believing that it can be a factor, demonstrated for instance in the incidence of gender dysphoria in Klinefelter’s syndrome.

Hans Asperger himself wrote, ‘The autistic personality is an extreme variant of male intelligence … in the autistic individual the male pattern is exaggerated to the extreme.’”

Original Article:

Gender Dysphoria in Asperger’s syndrome: a caution by John Parkinson in Australas Psychiatry. 2014 Feb;22(1):84-5.

IMPORTANT NOTE: There are a number of other case studies of patients who have both gender dysphoria and autism. Unfortunately, there are not any large studies of patients with gender dysphoria and autism spectrum disorders.

I highly recommend Gender and Autism on Musings of an Aspie. It includes an excellent discussion of the “extreme male brain” theory of autism.

You can read more about treating patients with autism and gender dysphoria in these articles:

Gender Identity Disorder and Autism Spectrum Disorder in a 23-Year-Old Female – a 2014 case study from France.

Gender Dysphoria in Pervasive Developmental Disorders – a 2011 discussion of four patients in Japan.

Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood – 2015 follow-up study that found that a Japanese boy with Asperger syndrome no longer had gender dsyphoria at age 16 (see 2008 study below).

Comorbid childhood identity disorder in a boy with Asperger syndrome – a 2008 letter to the editor about a patient in Japan.

Comorbidity of Asperger syndrome and gender identity disorder – a 2005 case study from Switzerland.

Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study – Review, Part I

This is a fascinating study of a group of children with gender dysphoria. The authors interviewed them as teenagers when some of them had lost their gender dysphoria and some of them had not.

Most children diagnosed with gender dysphoria do not go on to transition; their gender dysphoria goes away. Gender dysphoria faded at puberty for 84% of the children in previous follow-up studies.*

In this study, the authors identified 53 Dutch speaking teenagers that their clinic had diagnosed with gender identity disorder before age 12.** Among these 53 teenagers, 55% had reapplied to the clinic for transition while 45% had not. The authors do not address the question of why their patients were more likely to still have gender dysphoria than in past studies.***

The authors interviewed only 25 of the 53 teenagers; 14 teenagers who applied for sex reassignment (7 male and 7 female) and 11 who did not (6 male and 5 female). They say that:

All adolescents were approached, orally or in writing, to participate in the study. Based on the principle of saturation in information (Glaser & Strauss, 1967), 25 adolescents were interviewed.

This limits the conclusions that can be drawn from the data, however, this is a qualitative study. It uses interviews to explore the development of gender dysphoria in these teenagers. This allows the authors to find directions for future research.****

Based on their interviews with the teenagers the authors found:

1. There were no differences in childhood behavior between the group that lost their gender dysphoria and the group that did not.

2. Both groups identified as the other gender as children, but when they were interviewed as teenagers, they explained it differently.

3. Both groups were uncomfortable with their bodies as children, but they explained it differently as teenagers.

4. The teenagers who requested transition were all attracted to people of their natal sex while the teenagers who no longer had gender dysphoria were mostly attracted to the opposite sex.

5. The years 10-13 were critical in the children’s development; this was when they either lost their gender dysphoria or became more dysphoric.

6. Important factors related to the development of adolescent feelings about gender were: changes in the social environment, the physical development of their bodies at puberty, and falling in love and discovering their sexual orientation.

7. For some of the girls whose gender dysphoria had faded, it was hard to transition back because they had worn boys’ clothing and been perceived as boys.

8. One of the teenagers they interviewed felt half female, half male. He did not want to transition.

The authors of the study conclude:

“Based on the significance most adolescents attribute to the period between 10 and 13, we suggest that clinicians should concentrate clearly on what happens in this phase of development.

It is recommended to specifically address the adolescents’ feelings regarding the factors that came up as relevant in our interviews (i.e. the effects of the changing social environment, the response to anticipated or actual puberty, and the emerging romantic/sexual feelings and sexual partner choice), before any medical steps are taken (e.g. to suppress further pubertal development).

As for the clinical management of children before the age of 10, we suggest a cautious attitude towards the moment of transitioning. Given our finding that some girls, who were almost (but not even entirely) living as boys in their childhood years, experienced great trouble when they wanted to return to the female gender role, we believe that parents and caregivers should fully realize the unpredicatability of their child’s pychosexual outcome.

They may help their child to handle their gender variance in a supportive way, but without taking social steps long before puberty, which are hard to reverse. This attitude may guide them through uncertain years without the risk of creating the difficulties that would occur if a transitioned child wants to return to his/her original gender role.”

(Paragraphs and bold added by George Davis.)

Short version: Children should probably not transition socially before age 10. Parents and teachers should understand that the children may lose their gender dysphoria.

Therapists should work carefully with children who have gender dysphoria in the years between 10 and 13. Before giving them puberty blockers therapists should address the teenagers’ feelings about changing social relationships, puberty, and sexual development.

End of Part I of the Review of this study.

Original Article:

Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study by Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT in Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516

*The studies the authors cite followed a total of 246 children; only 39 of them had gender dysphoria after puberty, thus the overall persistence rate for the dysphoria was 16%. The persistence rate varied among the different studies from 2% to 27% (i.e. 73%-98% of the children stopped having gender dysphoria).

**The teenagers in the study were chosen from a total of 198 children who applied to their clinic between 2000-2007. The rest of the children did not meet the criteria for the study, although the authors don’t say if this was due to not being a teenager at the time of the study, not being diagnosed with GID, or not speaking Dutch.

***A few possibilities would be: a difference in the therapy given to the children (some therapies might be more effective than others), cultural differences in the countries where the studies were done (some cultures might make it harder to be gender non-conforming while others might make it easier to transition), a difference in the diagnostic methods (perhaps this clinic did a better job of diagnosing gender dysphoria), cultural differences in different eras, environmental differences in different eras (perhaps hormones are affecting children more now), or something about the way this study chose the 53 teenagers (this seems unlikely).

****A more serious question is that the authors do not say if they heard back from all of the teenagers they contacted. They cannot be sure that all of the teenagers who did not request further treatment were no longer dysphoric if they did not speak to them. This does not effect the results of their interviews, but it is an important issue.