Autism and gender dysphoria

[LadyHalcyon]

I recently tested a teenage girl who has accumulated the following diagnoses in 5+ years: ADHD, ASD, OCD, Bipolar, MDD, GAD, and Gender Dysphoria. Has anyone ever worked with a someone with ASPERGERS (I know it isn't technically a diagnosis anymore but I feel it better captures her presentation) and Gender Dysphoria? I am certain she is on the spectrum, but I can't really discern if she thinks she is meant to be a boy because she feels different than everyone else, or if it's true gender dysphoria.

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[PsyDr]

This looks like someone that didn't read the intro to the DSM.

ASD + OCD? So is it perserverations or obsessions? Or does no one actually care? Or is this is stupid game to get fluvoxamine reimbursed by insurance, despite it not being evidence based in ASD?

Bipolar +MDD? Which is it? Are the depressive symptoms from Bipolar or what?

Bipolar + ADHD. Let me guess. Tons of stimulants.

ADHD +MDD+GAD. So what is causing the concentration problems? Cause all of those have that as a symptom.

MDD+GAD Why not with anxious distress?

You can obviously have ASD and Gender Dysphoria. I had one, but he was extremely depressed much more for reasons of having no friends, never leaving the house, etc. I explained that I wouldn't help with pursuing reassignment surgery until all of that was fixed. Might have been mean, but the suicide rate issue was a huge concern.

 

[LadyHalcyon]

She doesn't have OCD, she has normal compulsive behavior commonly seen with Autism. She is emotionally labile and extremely impulsive, but working memory is poor for autistic individuals, she is a teenager, and she is sad because she is rejected by her peers and lives in an invalidating home environment. Last month she was diagnosed with Bipolar after an inpatient hospitalization for suicidal ideation. It's the same psychiatrist at this one CMHC who believes mood swings= Bipolar. She said she doesn't feel like a girl or a boy really, she just feels strange and isn't like other girls (and she is correct). She feels more comfortable using the "he" pronoun.

I think we should literally start chucking the DSM at people's heads and call it an intervention. Would take the term "throwing the dsm at them" to an entirely new level.

 

[psych.meout]

She doesn't have OCD, she has normal compulsive behavior commonly seen with Autism. She is emotionally labile and extremely impulsive, but working memory is poor for autistic individuals, she is a teenager, and she is sad because she is rejected by her peers and lives in an invalidating home environment. Last month she was diagnosed with Bipolar after an inpatient hospitalization for suicidal ideation. It's the same psychiatrist at this one CMHC who believes mood swings= Bipolar. She said she doesn't feel like a girl or a boy really, she just feels strange and isn't like other girls (and she is correct). She feels more comfortable using the "he" pronoun.

I think we should literally start chucking the DSM at people's heads and call it an intervention. Would take the term "throwing the dsm at them" to an entirely new level.

Well, the ADHD diagnosis (if it's accurate) may explain some of this. Emotional dysregulation is very common and poorly understood by clinicians. It includes rapid mood swings, lability, overreactivity, and impulsivity.

 

[PsyDr]

Yeah, I figured this is a crappy doc. My concern is that diagnosis can become an identity for some people who haven't really figured out who they are. Most people are much more interesting than their diagnosis.

Just eyeballing this case: it's clear that this is a very unhappy person who really doesn't know who they are, and periodically wants to die. Usually trans people are pretty damn sure of who they are, it's just not their assigned gender.

 

[MiniLop]

There's research out there suggesting that ASD is over represented in the trans and gender nonbinary population (but may be a result of drawing conclusions from clinical samples), so this isn't necessarily an uncommon presentation. If the issue is wondering if their reported gender dysphoria might actually be just a sense of feeling different from others, you would probably want to assess whether they have a significant sense of discomfort with their own body or a strong sense of themselves as male outside of social contexts. If the answer to this is yes, then probably the issue isn't their feeling different from others because of ASD.

This may also be a helpful article: Autism Spectrum Disorders in Gender Dysphoric Children and Adolescents

 

[LadyHalcyon]

Exactly. I also wonder if there is a hormonal component for her, moreso than with your average teenage girl. I don't feel comfortable elaborating on that for confidentiality reasons, but there are definitely some unusual things going on.

Well, the ADHD diagnosis (if it's accurate) may explain some of this. Emotional dysregulation is very common and poorly understood by clinicians. It includes rapid mood swings, lability, overreactivity, and impulsivity.

 

[LadyHalcyon]

Yes. I was expecting a borderline presentation based on the referal and was thinking she was probably misdiagnosed with ASD as a child because she was displaying reactive attachment disorder symptoms. Then I met her, and it was immediately clear my initial hypothesis was incorrect.

Yeah, I figured this is a crappy doc. My concern is that diagnosis can become an identity for some people who haven't really figured out who they are. Most people are much more interesting than their diagnosis.

Just eyeballing this case: it's clear that this is a very unhappy person who really doesn't know who they are, and periodically wants to die. Usually trans people are pretty damn sure of who they are, it's just not their assigned gender.

 

[LadyHalcyon]

Thank you so much! Autism is definitely not my area of expertise, but I get the feeling she is trying to make sense of why she is different. Her mother also indicated she is highly influenced by social media and other children in her high school. That being said, I don't want to be insensitive and automatically presume that because she has ASD she doesn't have gender dysphoria. In the span of 10 min she described herself as trans and then gender fluid and then she basically was like, "I don't know who I am I just know I don't feel like a girl and something is wrong with my brain."

There's research out there suggesting that ASD is over represented in the trans and gender nonbinary population (but may be a result of drawing conclusions from clinical samples), so this isn't necessarily an uncommon presentation. If the issue is wondering if their reported gender dysphoria might actually be just a sense of feeling different from others, you would probably want to assess whether they have a significant sense of discomfort with their own body or a strong sense of themselves as male outside of social contexts. If the answer to this is yes, then probably the issue isn't their feeling different from others because of ASD.

This may also be a helpful article: Autism Spectrum Disorders in Gender Dysphoric Children and Adolescents

 

[MiniLop]

"Not a girl" is a pretty common way that nonbinary folks describe their experience of their gender. Definitely be aware of the impact their ASD may have on this, but I'd recommend assessing rather than dismissing their gender identity. If the evidence points to their being trans/nonbinary, this might actually be at least a partial explanation for the preponderance of diagnoses they're carrying, as dysphoria often presents in a lot of different ways. Research suggests that affirming one's identity has a large positive effect on their mental health overall, and some of those other symptoms may fall below clinical significance (or not, as the case may be).

 

[LadyHalcyon]

Completely. I think her symptoms of depression stem from peer rejection and an invalidating home environment in terms of supporting her nonbinary identity.

"Not a girl" is a pretty common way that nonbinary folks describe their experience of their gender. Definitely be aware of the impact their ASD may have on this, but I'd recommend assessing rather than dismissing their gender identity. If the evidence points to their being trans/nonbinary, this might actually be at least a partial explanation for the preponderance of diagnoses they're carrying, as dysphoria often presents in a lot of different ways. Research suggests that affirming one's identity has a large positive effect on their mental health overall, and some of those other symptoms may fall below clinical significance (or not, as the case may be).

 

[temppsych123]

Yeah, I think the idea that all TGNC folks know and strongly identify with a gender identity from early on is only true for a subset of people - the sort of stereotypical "I always knew I was born into the wrong body" type idea - but many people struggle with their gender identity in a way that sounds pretty consistent with what this pt is reporting, with or without ASD symptoms. Do you have any colleagues with expertise in ASD or with expertise in gender transition issues in youth that you could touch base with?

 

[LadyHalcyon]

Yes. We have a meeting set up Tuesday to discuss. There is some info on adolescent-onset gender dysphoria, the research is mixed (shocking). Also, it seems non PC research on the topic of adolescent-onset gender dysphoria is getting some backlash.

Yeah, I think the idea that all TGNC folks know and strongly identify with a gender identity from early on is only true for a subset of people - the sort of stereotypical "I always knew I was born into the wrong body" type idea - but many people struggle with their gender identity in a way that sounds pretty consistent with what this pt is reporting, with or without ASD symptoms. Do you have any colleagues with expertise in ASD or with expertise in gender transition issues in youth that you could touch base with?

View attachment Gender dysphoria in adolescence.pdf

 

[ClinicalABA]

I recently tested a teenage girl who has accumulated the following diagnoses in 5+ years: ADHD, ASD, OCD, Bipolar, MDD, GAD, and Gender Dysphoria. Has anyone ever worked with a someone with ASPERGERS (I know it isn't technically a diagnosis anymore but I feel it better captures her presentation) and Gender Dysphoria? I am certain she is on the spectrum, but I can't really discern if she thinks she is meant to be a boy because she feels different than everyone else, or if it's true gender dysphoria.

I have worked with several individuals (children through adults) with and ASD diagnosis who did not identify with their sex at birth. For some it led to some specific interventions (mainly related to social interaction skills, as it added a degree of difficulty to an already tricky area from them). For others, it was not a focus of my work with them. I would be more cautious than normal regarding confusion with use of gender pronouns, particularly with younger children with an ASD diagnosis. I'd want to be asses that any pronoun "confusion" was limited to just self-referencing before attributing it to anything to do with gender identity. I've worked with MANY MORE individuals with ASD and pronoun confusion behaviors than I have those with gender identity related concerns. In the absence of other behaviors, use of non-birth-sex or other-sex/gender language maybe more attributable to the ASD than to other things.

 

[singasongofjoy]

There's research out there suggesting that ASD is over represented in the trans and gender nonbinary population (but may be a result of drawing conclusions from clinical samples), so this isn't necessarily an uncommon presentation. If the issue is wondering if their reported gender dysphoria might actually be just a sense of feeling different from others, you would probably want to assess whether they have a significant sense of discomfort with their own body or a strong sense of themselves as male outside of social contexts. If the answer to this is yes, then probably the issue isn't their feeling different from others because of ASD.

This may also be a helpful article: Autism Spectrum Disorders in Gender Dysphoric Children and Adolescents

Higher representation in trans and gender non-binary is also supported in non-clinical populations. Agreed with need for further assessment of feeling a sense of being different than others versus discomfort with body/sense of self outside of social context. I feel like this comes up pretty commonly in adolescents I assess. IME it's most often (but certainly not always) the former combined with some degree of black and white thinking / realizing they don't "check the boxes" of what it stereotypically means to be feminine/masculine/etc. and working more towards loosening up that black & white rigid thinking while also validating that maybe it is the latter but it's worth a full assessment of both and consideration of both to foster greater self-understanding.

 

[foreverbull]

I’ve worked with an adolescent on the spectrum who identified as transgender and strongly identified as the opposite gender than assigned at birth, but generally speaking I’ve also worked with folks who didn’t identify strongly with male or female at all. Gender is complex and not always binary with trans folks, so I would encourage a lot of careful exploration around behaviors, feelings/beliefs about gender and their own bodies, preferences, and even dreams if the clients are inclined to remember them (I’ve had trans clients dream as their inner identity self). Some folks see themselves as genderqueer rather than male or female, so separating gender identity concerns from other diagnoses is important. It’s always helpful to approach the topic with curiosity and non-judgment, and go slowly to tease out whether there is black-and-white thinking contributing to the presentation (don’t jump to conclusions or recommend any particular treatment for the gender dysphoria with adolescents until it is very clear and there has been a long period of assessment, observation, and consistency in patterns).

Research suggests that most children with gender dysphoria will later identify as lesbian, gay, or bisexual cisgender adults without gender dysphoria, but for a small percentage whose dysphoria persists through adolescence into adulthood, it will continue to persist and be stable through adulthood (without treatment).

EDIT: Just remembered I worked with another adolescent on the spectrum (former Asperger's diagnosis) who identified as transgender very briefly but it was influenced by the client's peers in the residential environment and was forgotten pretty quickly. You might want to consider this possibility as well (as questioning and exploration that may be temporary?). Hence the need for deeper exploration.

 

[Groupthink]

John Strang at Children's National has conducted a ton of research on the comorbidity of Gender Dysphoria and Autism Spectrum Disorder (and, ironically, he interviewed me when I applied to grad school a decade ago, even though he was just an external supervisor for my program):

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents

https://www.tandfonline.com/article/10.1080/15374416.2016.1228462

Increased Gender Variance in Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder

Increased Gender Variance in Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder - Archives of Sexual Behavior

Evidence suggests over-representation of autism spectrum disorders (ASDs) and behavioral difficulties among people referred for gender issues, but rates of the wish to be the other gender (gender variance) among different neurodevelopmental disorders are unknown. This chart review study explored...

link.springer.com

“They Thought It Was an Obsession”: Trajectories and Perspectives of Autistic Transgender and Gender-Diverse Adolescents

“They Thought It Was an Obsession”: Trajectories and Perspectives of Autistic Transgender and Gender-Diverse Adolescents - Journal of Autism and Developmental Disorders

Despite research exploring autism in gender-diverse adolescents, no studies have elicited these individuals’ perspectives. In-depth interviews with 22 well-characterized autistic gender-diverse adolescents revealed critical themes, including: recollections of pre-pubertal gender nonconformity...

link.springer.com

Worthwhile reading, solid science, and these articles are a highlight among his others for your presenting concerns.

And for normalization's sake, I work at a university counseling center and in the last couple years the need for better tools for making this differential has skyrocketed.

 

[LadyHalcyon]

Thank you so much!

John Strang at Children's National has conducted a ton of research on the comorbidity of Gender Dysphoria and Autism Spectrum Disorder (and, ironically, he interviewed me when I applied to grad school a decade ago, even though he was just an external supervisor for my program):

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents

https://www.tandfonline.com/article/10.1080/15374416.2016.1228462

Increased Gender Variance in Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder

Increased Gender Variance in Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder - Archives of Sexual Behavior

Evidence suggests over-representation of autism spectrum disorders (ASDs) and behavioral difficulties among people referred for gender issues, but rates of the wish to be the other gender (gender variance) among different neurodevelopmental disorders are unknown. This chart review study explored...

link.springer.com

“They Thought It Was an Obsession”: Trajectories and Perspectives of Autistic Transgender and Gender-Diverse Adolescents

“They Thought It Was an Obsession”: Trajectories and Perspectives of Autistic Transgender and Gender-Diverse Adolescents - Journal of Autism and Developmental Disorders

Despite research exploring autism in gender-diverse adolescents, no studies have elicited these individuals’ perspectives. In-depth interviews with 22 well-characterized autistic gender-diverse adolescents revealed critical themes, including: recollections of pre-pubertal gender nonconformity...

link.springer.com

Worthwhile reading, solid science, and these articles are a highlight among his others for your presenting concerns.

And for normalization's sake, I work at a university counseling center and in the last couple years the need for better tools for making this differential has skyrocketed.

 

[LadyHalcyon]

Yes. She is very impressionable in regard to social media and her peers. She was recently placed in an alternative school and most of her classmates are diagnosed with conduct disorder and on juvenile probation. I recently scored her MACI and she had a mild elevation on identity disturbance but not on the scale measuring sexual distress/concerns. I think those results seem to align with her more gender fluid/non-binary presentation vs someone who says "I feel like I am a boy trapped in a girl's body."

I’ve worked with an adolescent on the spectrum who identified as transgender and strongly identified as the opposite gender than assigned at birth, but generally speaking I’ve also worked with folks who didn’t identify strongly with male or female at all. Gender is complex and not always binary with trans folks, so I would encourage a lot of careful exploration around behaviors, feelings/beliefs about gender and their own bodies, preferences, and even dreams if the clients are inclined to remember them (I’ve had trans clients dream as their inner identity self). Some folks see themselves as genderqueer rather than male or female, so separating gender identity concerns from other diagnoses is important. It’s always helpful to approach the topic with curiosity and non-judgment, and go slowly to tease out whether there is black-and-white thinking contributing to the presentation (don’t jump to conclusions or recommend any particular treatment for the gender dysphoria with adolescents until it is very clear and there has been a long period of assessment, observation, and consistency in patterns).

Research suggests that most children with gender dysphoria will later identify as lesbian, gay, or bisexual cisgender adults without gender dysphoria, but for a small percentage whose dysphoria persists through adolescence into adulthood, it will continue to persist and be stable through adulthood (without treatment).

EDIT: Just remembered I worked with another adolescent on the spectrum (former Asperger's diagnosis) who identified as transgender very briefly but it was influenced by the client's peers in the residential environment and was forgotten pretty quickly. You might want to consider this possibility as well (as questioning and exploration that may be temporary?). Hence the need for deeper exploration.

 

[LadyHalcyon]

Just curious, what are thoughts about diagnosing ADHD and ASD together even when the executive functioning dysregulation presents as more emotional lability and impulsivity rather than problems with focus, effort, and sustained attention?

 

[erg923]

Just curious, what are thoughts about diagnosing ADHD and ASD together even when the executive functioning dysregulation presents as more emotional lability and impulsivity rather than problems with focus, effort, and sustained attention?

I would like feedback on this too. Particularly as it related to diagnostically established (or highly probable... based on developmental history and DSM symptom criteria) ASD. Do you really treat a child with ASD with stimulants if they have enough criteria of the other disorder (ADHD) too? If not, how does the treatment plan actually change?

A child that, developmentally and otherwise, seems to have ASD would probably have most all symptoms of ADHD anyway? No? In this case, what is the point of diagnosing ADHD on-top of the ASD?

 

[LadyHalcyon]

I would like feedback on this too. Particularly as it related to diagnostically established (or highly probable) ASD. Do you really treat a ASD child with stimulants if they have enough criteria of the other disorder (ADHD)?

I would think that a child that, developmentally and otherwise, seems to have ASD would probably have most all symptoms of ADHD anyway? No?

For this particular case the child apparently did HORRIBLY on stimulants, which doesn't surprise me since I imagine her CNS to already be pretty sensitive/keyed-up. She is now on a nonstimulant ADHD med (as well as every other med out there). She was diagnosed with ADHD at the age of 8 for hyperactivity, but was likely self-stimming behaviors (walking around her desk while doing her school work), inattention (possible sensory overload?), and emotional lability/anxiety. She is extremely perfectionistic about school and will freak out if she gets a B, but obviously her ASD impacts her working memory and her organizational skills aren't amazing. I feel like I can make a case for ADHD or I could subsume her symptoms under the ASD umbrella. Is there a good rationale to diagnose both or just one? I agree with @erg923 that most ASD kids easily meet criteria for ADHD. So, now what?