Gender change is ‘no fix for autism’

An Asperger’s expert has called for a searching inquiry into the dramatic overrepresentation of teenagers with autism in gender clinics.

Teens with autism are desperate to “find their tribe”, and may find “intoxicating” connection and acceptance in social media trans forums, clinicians say. Pic:iStock

 

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.

A world-renowned expert on Asperger’s syndrome Tony Attwood has called for a searching inquiry into the dramatic overrepresentation of teenagers with autism in gender clinics.

Professor Attwood, a psychologist based in Brisbane and author of the guide known globally as the “Asperger’s bible”, said unhurried and thoughtful gender change could be a success but he worried about a crash back into depression if trans status was embraced with impulsive and unrealistic hopes of a fix for autism.

“Once they’ve changed gender, they still have autism and when (gender) transition doesn’t solve their problems they think, Oh no, that was the only option I had, what’s the point of life?,” he told The Australian.

“One of the characteristics of autism is what we call a one-track mind, and sometimes the issue of gender dysphoria (discomfort with one’s body) and changing gender becomes a special interest with a phenomenal knowledge and determination.”

He said it was vital for an inquiry and research projects to look beyond the politics and “evangelising” of trans identity in order to assess not just medical treatments but the psychological outcomes, the fortunes of former patients from the clinics, the role of social media and schools in the rising caseload, and any neurological factors.

In the country’s busiest youth gender clinic, at the Royal Children’s Hospital in Melbourne, 45 per cent of 383 patients — 275 of them born female with an average age just under 14 — showed mild to severe autism features on a screening test.

Among young people generally Australia’s reported rate of diagnosed autism is about 3 per cent; autism features may not lead to a formal diagnosis. There is debate about the accuracy of screening tests, and whether autism spectrum disorder has become too broad a category.

RCH clinic director Michelle Telfer told an inquiry in July that many of her recent intake of female-born patients wanted “top surgery” or mastectomies to look more like boys.

Often her patients told her, “I don’t need to talk about this any more, I just actually need to transition (with medical intervention)”, she said. RCH, which has defended its treatment as guided by “strict clinical governance standards”, would not comment on the autism issue.

Dr Telfer has said assessment of young patients possibly on the autism spectrum may have to “take the autism traits into account when we try to find out what those young people are trying to tell us.”

Just under 50 per cent of a group of 104 patients at the Perth Children’s Hospital gender clinic — with an average age of almost 15, and 76 per cent of them born girls — showed mild to severe autism features.

Screening for autism was part of the clinic’s “thorough assessment” of patients, a spokesman for the hospital said. The clinic lacks capacity for a proper diagnosis.

Australia’s other large specialist clinic, at the Queensland Children’s Hospital, would not comment on the autism issue, and told a member of the public last year it kept no data on how many biological girls given puberty blocker drugs were autistic.

However, de-identified case notes by a psychiatrist at Queensland’s clinic, Brian Ross, speculate about the role of foetal testosterone in girls with autism and gender dysphoria, and acknowledge concern that gender change may “worsen” autism.

Dr Ross discusses a 12-year-old male patient whose “desire to be a girl arose from his need to have friends and be accepted in the context of his lifelong social skills deficits” but the psychiatrist says autistic youth have “the same rights” as others to gender treatment.

‘Transition can succeed’

Professor Attwood, whose book The Complete Guide to Asperger’s Syndrome has been translated into 18 languages, said he was not ruling out gender transition, but the reasons for it mattered.

“A girl that I knew wanted to become a boy — where did this come from? She was bullied by girls who didn’t bully boys, so her autistic logic was, if I become a boy they will stop bullying me,” he said.

“You’ve got to look at aspects of sexuality, and whether the (gender) transition has been viewed as a psychological as opposed to a medical success.”

High rates of mental illness have been documented in the surge of teenagers diagnosed with gender dysphoria since the mid-2000s but debate about rates of suspected autism ranging from 20-50 per cent hardly figures in mainstream media.

Clinicians say if social contagion online and in school peer groups is driving some of the global spike in trans identity, then teens with autism are especially at risk because of their desperation to fit in, rigid and concrete styles of thinking, immaturity and obsessional interests. Girls are thought to be better than boys at “masking” high-functioning autism.

Multiple autism clinicians and advocacy groups refused to talk on the record about autism in gender clinics for fear of being branded “transphobic” and hauled before professional bodies and health regulators.

Professor Attwood said he was not saying autism necessarily stood in the way of successful gender change for under-18s but a trans declaration should be carefully looked into, and medical intervention to block natural puberty called for “extreme caution”.

There is growing international concern about whether often troubled minors can give informed consent to hormone drugs and surgery with risks including sterility, brittle bones, loss of sexual pleasure, cardiovascular problems and other as yet unknown long-term outcomes.

A leading Dutch gender clinic uses pictures and drawings to try to communicate with autistic youth.

Dr Telfer has said assessment of young patients possibly on the autism spectrum may have to “take the autism traits into account when we try to find out what those young people are trying to tell us.”

The high-profile US gender physician Johanna Olson-Kennedy, cited by Dr Telfer as an authority on the mental health benefits of top surgery, has claimed there are cases where “symptoms of autism go away when (patients) are affirmed in their (self-identified) gender”.

Dr Olson-Kennedy, who runs America’s biggest youth gender clinic at the Children’s Hospital Los Angeles, said last year she had sent “about 200” patients born female, as young as 13, for “chest reconstruction”.

On Monday, one of Australia’s best known “gender affirming” surgeons and a popular choice on trans social media, Andrew Ives, was set to resume operations at a private hospital in Melbourne as elective procedures ramp up.

He did not reply when asked if under-18 patients were in the queue. A typical cost estimate for “top surgery” or mastectomy is about $10,000. Under-18 trans surgery is thought to be rare in Australia but public data is lacking.

In August Dr Ives put his name to a statement from the gender clinicians group AusPATH — run by Dr Telfer — criticising this newspaper’s reporting of the debate, and claiming evidence for affirmative treatment had been “publicly scrutinised in Australia through both academic and legal processes at the highest level and is currently standard clinical practice”.