Gender identity caught up on the autism spectrum

Autism appears to account for a sizeable share of the overwhelmingly female caseload in youth gender clinics.

Autism, often high-functioning and not an obvious candidate for formal diagnosis, appears to account for a sizeable share of the overwhelmingly female caseload in youth gender clinics.

 

EDITORIAL: We will not shy away from uncomfortable topics that deserve attention. This is particularly so when the health and wellbeing of vulnerable children are at stake.

Jane* is a Melbourne psychologist who speaks with affection and concern about the autistic teen­agers she helps to skill up for a world that’s not a natural home for them. The way she sees it, doing her job could destroy her career — if she goes public with her belief that a transgender declaration by one of these kids must be the starting point for careful psychological inquiry, not an automatic handover to the local “gender affirming” clinic at the Royal Children’s Hospital.

Jane is far from the only practitioner worried about “false positives” as these clinics proliferate globally, with vulnerable kids whose underlying problems may go untreated, even undetected, because trans is in the spotlight.

“I hate that I have to not say my name and be secretive about it,” Jane says. “People who dare speak out are being punished professionally.”

The pro-trans affirmative-treatment model, which blackens its critics as “transphobes”, has found rapid acceptance in health systems. This has happened in parallel with a surge in teenagers, disproportionately girls, crowding the gender-clinic waiting lists and seeking hormonal treatment followed by surgery to confirm the inner truth of their trans boyhood.

Gender dysphoria, or distress at being “born in the wrong body”, is the headline diagnosis but other vulnerabilities are also common. Few outsiders are aware how many of these troubled young patients — almost 50 per cent in some clinics — show signs of autism. Close observers see trans as the first identity-politics push native to social media, spreading by “social contagion” through online platforms and school friendship networks — networks that autistic kids are struggling to unlock and enter. Does trans look like a key?

The affirmative sales pitch is that the insight of children is a better guide than biological sex to their “gender identity”, and that when conflict between the two manifests itself as gender dysphoria, trans medicine can bring things into harmony and slash suicide risks. Why should autistic kids be denied this “lifesaving” help?

But critics of these treatments say they are experimental, and more cautious advocates admit the evidence is short-term, poor-quality or patchy. The clinics claim grateful patients, but regret and side effects including infertility are among the still poorly understood risks.

“I’m not saying transition is never to be but I strongly disagree with children and teenagers having any medical interventions before the age of 25 or so when that executive (decision-making) function (in the brain) is fully developed,” Jane says.

Finding a psychologist with Jane’s cautious approach was difficult — and a great relief — for Claire*, the mother of a socially awkward 14-year-old. Out of the blue, a school counsellor had summoned Claire to announce her daughter, Zoe*, was trans. But, while on the waiting list at the RCH clinic, she saw a private psychiatrist, who suggested she be assessed for Asperger’s, or high-functioning autism. “The psychiatrist said these kids feel like they don’t fit in, they can’t work it out,” Claire says. “They feel like they’re a bit odd, they go online, they come up with trans. He said don’t go (to RCH), they will affirm that she’s transgender, and with very little consultation they will put her on puberty blockers. She will be convinced (by the clinic) that she’s transgender and nothing else will be looked at.”

If her teen autism patients want to talk to Jane about gender, that’s fine, but she puts effort into work on social skills, handling anxiety and solving friendship problems.

Also helpful with “Aspie” kids such as Zoe is their high intelligence — if their rigidity in thinking can be loosened up.

Claire says her daughter, who has “quite a scientific mind”, now accepts the Asperger’s diagnosis.

“She understands that the human brain is not fully mature until at least the age of 25 — so I say to her, no permanent changes should be made to your body until you’re over 25,” Claire says.

“My feeling is she will not always feel she is transgender — and if I’m wrong, she’s making that deci­sion as a mature, fully informed adult, not as a hormonal, emotionally confused, socially awkward teenager.”

Question of influence

Autism, often high-functioning and not an obvious candidate for formal diagnosis, appears to account for a sizeable share of the overwhelmingly female caseload in youth gender clinics.

For affirmationists, the spike in teenage trans is welcome, not worrying — and testifies to social acceptance, not “social contagion”.

“The reality is, autistic people are not so influenced by societal norms, they’re purer people,” says Cheryl Dissanayake, who holds a chair in autism research at La Trobe University.

Nor does she see a risk of confused kids in autistic “problem-solving” mode latching on to a false trans identity.

“They are trying to fit in (with neurotypical kids) rather than adopt another identity that would place them on the ­fringes. I think no one would adopt a difficult path such as (trans).”

This is an issue close to home for Dissanayake. The child she gave birth to as a girl — “the prettiest girl you could imagine, completely happy in her own body” — is now a young trans man in his first year on testosterone, and “very happy”.

In Canada, child and adolescent psychiatrist Sue Bradley founded a Toronto gender clinic in 1975 that built a worldwide reputation for cautious expertise until 2016, when it was shut down after trumped-up allegations by trans activists. Years ago, Bradley says, the difficult kids often were tagged with “borderline personality” but now she believes they were on the autism spectrum, with “the high-functioning kids not picked up at all”. She has refined her understanding in recent years consulting for mental health clinics with children who don’t respond to the usual interventions.

She says autism diagnosis of these often “really bright” kids is difficult and gender clinics lack the necessary expertise.

“These kids are often very immature, but you’ve got them coming into puberty and adolescence, with their bodies changing, all the social-sexual kinds of things going on around them, kids being in cliques, and they don’t get it, they do get left out.”

Bradley says the trick is to intercept them early, work on social skills and teach self-regulation of turbulent emotions. The ideal is a less rigid take on the world, a more solid sense of self, a better fit with peers, less bullying, therefore less depression and anxiety.

“If we continue with the affirmative approach we are creating a system that pulls in these vulnerable kids, some of whom are going to regret it, and that’s not good medicine,” she says.

Brisbane-based clinician Tony Attwood, much in demand as an authority on Asperger’s, is also plugged in to the international debate about the overlap with gender dysphoria.

He recalls a patient he met as a preschool boy: “He has now become a she in her early 20s and she is the happiest I’ve ever known her.”

In his experience, the shift to trans identity is more likely to turn out well if there has been “a slow, thoughtful process” leading up to it. At other times, he says, the wish to transition is new, driven by an impulsive “one-track mind” — a feature of autism — and a confrontational “for me or against me” attitude to parents, whose support is vital with or without transition.

“Often they’re wanting to accelerate the process, whereas parents and sometimes professionals are really seeking that the person puts the brakes on a bit and thinks about it.”

Professor Tony Attwood.

And sometimes nobody knows the kid is autistic, with girls especially good at “masking” the condition.

“They have the ability to act, and this can camouflage and delay their diagnosis until another issue comes up, like an eating disorder or depression or gender dysphoria, and you see behind the mask,” Attwood says.

“So this is why there needs to be a lot of what I call psychological archaeol­ogy.

“I am not denying the transition, I am looking at the psychological processes that led to that decision, and to affirm that and look at developing the sense of self, irrespective of gender, because we know there’s a fragmented sense of self in autism.”

Grim choice

Parents hesitating on the brink of life-altering medical intervention often come across the online affirmative refrain: do you want a daughter dead by her own hand or a live trans son?

Like any devoted mother, Megan* would do whatever it takes to protect her sweet but immature 15-year-old daughter, Charlotte*, who added a trans identity to her Asperger’s profile last year. But Megan is also a psychologist and knows suicide threats are easily made and extremely difficult to assess for seriousness. She’s acutely aware of how lonely Aspie kids are vulnerable to online subcultures only too delighted to recruit them.

Charlotte coming out as trans was another case of a school counsellor doing solo diagnosis. “I later learned that my daughter, like a lot of other teenagers, was consuming YouTube and Reddit and had got into the transgender bubble online,” Megan says. Trans identity looked very like an autism “fix” spread by social contagion, and Megan could see ahead the possibility of Charlotte’s mature brain deeply regretting any invasive medical treatment as a teenager.

"Asperger’s expert Tony Attwood calls for a searching inquiry into dramatic overrepresentation of teens with autism in gender clinics. In Australia's busiest clinic, 45 per cent of 383 patients, mostly girls around 14, showed #autism features." @australianhttps://t.co/Otp4Hw6YPw

— Bernard Lane (@Bernard_Lane) June 3, 2020

The gender clinic at the Queensland Children’s Hospital was reassuring in some ways: kids wanting puberty blockers yesterday had to wait nine to 12 months before they could see an endocrinologist and the possibility they might abandon the idea of gender change was flagged.

But it struck Megan as like the marketing of cosmetic surgery. The clinic’s message seemed to be: we have hormonal treatment to reduce your daughter’s distress and make her body more like a son’s, but it’s entirely up to you.

For a psychologist and mother, the whole experience was “perplexing”. The staff were well-meaning, Megan says, and when it came to the decision to medically intervene, they seemed caught between gung-ho and gun-shy parents. But they did not take a meticulous patient history for Charlotte. And there was no psychotherapy on offer to help these troubled kids handle distress and accept their bodies and non-stereotypical gender roles. The whole operation seemed oblivious to the cultural context in which trans identity is glamorised and every step of medical transition high-fived online.

“I just don’t think the gender clinic is taking into account any of the social contagion factors,” Megan says.

For the clinic, the fact that a kid still wanted hormone drugs after a year waiting in the queue seemed good enough evidence of a stable trans identity but in Megan’s opinion it may just reflect the non-stop online barracking and the psychological difficulty of owning up to a mistake.

“The messaging needs to change — that it’s OK for parents and clinicians to be questioning, and (staff should be) taking developmental history and a whole lot of other broader contextual factors into account.”

Patience or throughput?

Gender clinics typically operate out of hospitals, which have a cultural bias towards treatment, towards outcomes, for all the talk about clinicians deferring to “expert” kids.

“The medical model is all about intervening and fixing, pumping kids through the system, and that’s the last thing they need,” Megan says. “They need exploration, they need adults to ‘hold the space’ for them, and that’s not what happens.”

By holding the space, Megan means patiently and compassionately digging, helping immature teens go beyond today’s impulsive project towards a more workable way through life.

Charlotte no longer believes she is a boy. It took a year of Megan appealing to Aspie logic with countervailing facts, as well as modest treats if she immersed herself in thoughtful commentary on the trans medical model and could summarise key points.

Mother and daughter recently had their last appointment at the gender clinic, and staff were told that Charlotte was reconciled to being an atypical girl, an Aspie kid.

“They were surprised, and there was acceptance of her decision, but there was zero celebration of her greater self-acceptance — I thought that was weird,” says Megan.

The Weekend Australian sought comment and data from the RCH clinic; it did not reply. Queensland Health said its Brisbane clinic followed the RCH treatment guidelines.

* Not their real names