By: Jacquelyn Reinert, Psy.D., LMHC
Pediatric Neuropsychologist, NESCA
“Transgender and autism, that’s not a thing, is it?” Since joining NESCA last September, I have encountered countless parents, teachers, and professionals who ask this exact question in feedback sessions, case consultations, and team meetings. The conversation that typically follows often calls into question the validity of the intersectionality of Autism Spectrum Disorder (ASD), Asperger Syndrome, and trans-identities and gender variance, as well as that of sexual orientation.
ASD is a neurodevelopmental disorder which impacts an individual’s communication, social interactions, play, interests, and behaviors. ASD presentations vary according to age, gender, and development. While functionally these communication and behavior patterns can assist clinicians to make diagnoses and inform interventions, we recognize that there can also be a stigma attached to diagnostic codes and labels. As such, we embrace an affirming stance, recognizing neurodiversity within the ASD community.
One commonly utilized phrase at NESCA is Stephen Shore’s quote, “If you have met a person with autism, then you have met one person with autism.” The same can be said for an individual who questions or is exploring their gender expression. There is a spectrum of gender diversity, ranging from gender non-conforming to non-binary, to transgender, and so on. The terminology and classifications within the community are fluid and ever-evolving, but for now, key terms are provided below. It is estimated that gender diverse youth may make up 5 to 12% of birth assigned females, and 2 to 6% of birth-assigned males; transgender youth, 0.5% (APA Fact Sheet). Of those, how many are also neurodiverse?
Courtesy of the Boston Children’s GeMS Clinic and the American Psychological Association
Sex: the biological category or identity that a person belongs to; based upon chromosomes, genetic makeup, and internal/external reproductive organs.
Gender identity: a person’s inner sense of oneself as either a woman (female), a man (male), or other/something different.
Gender expression: refers to the way in which we display our gender identity to other individuals and to the world around us.
Cisgender: a person whose gender identity and/or expression are aligned with the sex/gender that they were assigned at birth.
Non-binary: identifying as a gender other than exclusively female/woman or male/man.
Gender nonconforming, gender variant, or gender diverse: an individual who has a gender identity and/or gender expression that does not conform to the gender they were assigned at birth. They may prefer clothing, accessories, hair length/styles, and activities that are not expected in the culture based on their sex assigned at birth.
Transgender: individuals who typically consistently, persistently, and insistently express a cross-gender identity and feel that their gender is different from their assigned sex.
Gender dysphoria (GD): the distress an individual experiences when their assigned gender does not match their gender identity.
* In April, NESCA had the opportunity to meet with Dr. Kerry McGregor, Attending Psychologist at Boston Children’s Hospital in the Division of Endocrinology and Gender Management Service (GeMS) to learn more about the intersectionality of ASD and gender dysphoria and ways in which NESCA clinicians can provide gender affirmative care.
Emerging research suggests that indeed there is a relationship between gender variance and autism, although not without reservation and mixed approval. Researchers exploring the link between these spectrums suggest that gender variance is present in 5 to 7% of adolescents with ASD (Van Der Miesen, Hurley, & De Vries, 2016). Opponents suggest that the co-occurrence is merely a manifestation of restrictive, repetitive behavior, interests, and or activities, a hallmark symptom of ASD. Further, they suggest that due to the inherently negative experiences gender variant adolescents face, these individuals are more likely to demonstrate behaviors consistent with social impairments rather than a primary diagnosis of ASD (Turban & van Schalkwyk, 2018).
Regardless of whether a link is clearly identified at this point in time, individuals, families, clinicians, and communities are faced with navigating the complexities of the intersectionality of gender variance and ASD. Further, they face the complex dilemma of who to seek out should a child, adolescent, or family need support, guidance or targeted intervention to address gender dysphoria and other co-occurring challenges, such as anxiety and depression.
Where to start and what can families do to help?
- This is a marathon, not a sprint, and the race begins with balanced acceptance. Validating an individual’s disclosure with empathy and understanding is the first step in providing children and adolescents the space to begin exploration. Parents and caregivers should try to avoid either quick dismissal or accelerated enthusiasm. For many adolescents (gender variant, neurodiverse, or not), self-exploration is an essential part of growing up and being allowed a space with which to question and explore in a safe way is key.
- Be an advocate for your child or adolescent; ask questions and be curious. If adolescents are disclosing, be willing to have an open conversation. When you are unsure of what a term is, ask permission to clarify. Promoting a culture of acceptance and validation is essential.
- Not all challenges are central to either gender exploration or ASD. Navigating adolescence is difficult and although neurodiverse adolescents exploring gender expression may struggle, these concerns may be attributed to other emerging challenges. Parsing out typical adolescence and emerging mental health difficulties should be done in partnership with knowledgeable professionals who can thoroughly explore the issues.
- Be kind to yourselves and know that you will not have all the answers immediately. Parents and caregivers can often experience elevations in stress, particularly when outcomes are vague and without the opportunity to truly digest information. Resources provided below are initial starting points to learn more about gender variance, as well as the intersectionality with the neurodiverse community.
- Seek support for yourself. Parents and caregivers can benefit from working through concerns and worries, such as how other family members may react to an adolescent’s gender exploration. Working with an individual therapist or in a support group can be highly beneficial in providing the space for adults to process outside of the relationship with your child.
- Seek support for the child or adolescent. If your child is currently working with a mental health provider, working with an existing person in tandem with a gender specialist can be highly beneficial. One excellent area resource is Boston Children’s Gender Management Service (GeMS) Program which provides physical and psychological evaluations which inform individualized treatment plans for children. With a comprehensive plan, GeMS multi-disciplinary team can coordinate with existing providers (e.g., clinicians, primary care physicians) and can make referrals as needed. NESCA also has clinicians who provide a variety of services including individual therapy and neuropsychological and psychological evaluations and who are highly versed in the literature surrounding the intersectionality of neurodiversity and gender.
Gender Born, Gender Made by Diane Ehrensaft, Ph.D.
The Gender Creative Child: Pathways for Nurturing and Supporting Children by Diane Ehrensaft, Ph.D.
The Transgender Teen: A Handbook for Parents and Professionals Supporting Transgender and Non-Binary Teens by Stephanie Brill and Lisa Kenney
AANE Gender Identity and the Autism Spectrum Support Group for Transgender Adults on the Spectrum (link: https://www.aane.org/event/gender-identity-autism-spectrum-support-group-transgender-adults-spectrum-13/)
ASAN, NCTE, and LGBTQ Task Force Joint Statement on the Rights of Transgender and Gender Non-Conforming Autistic People (link: http://www.thetaskforce.org/wp-content/uploads/2016/06/joint_statement_trans_autistic_GNC_people.pdf)
Family Acceptance Project (link: http://familyproject.sfsu.edu/publications) Spectrum News – Living Between Genders (Link: https://www.spectrumnews.org/features/deep-dive/living-between-genders/)
Boston Children’s Gender Management Services (GeMS) Program (link: http://www.childrenshospital.org/centers-and-services/programs/a-_-e/disorders-of-sexual-development-dsd-and-gender-management-service-program
Sexual Orientation, Gender Identity, and Asperger/Autism by Jamie Freed, MSW for AANE
About the Author:
Dr. Reinert is a Pediatric Neuropsychology Postdoctoral Fellow who joined NESCA in September 2017. Dr. Reinert assists with neuropsychological and psychological (projective) assessments in the Newton office and in the Londonderry office. In addition to assisting with neuropsychological evaluations, Dr. Reinert co-facilitates parent-child groups and provides clinical consultation. Before joining NESCA Dr. Reinert worked in a variety of clinical settings, including therapeutic schools, residential treatment programs and in community mental health. She has comprehensive training in psychological assessment, conducting testing with children, adolescents, and transitional-aged adults with complex trauma. Dr. Reinert is particularly interested in researching the intersectionality of ASD and gender exploration.
Reach out if you would like to work with Dr. Reinert: Email firstname.lastname@example.org
Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email email@example.com or call 617-658-9800.