Autism and Gender Dysphoria, Part 5
By Mary Smith
In this concluding part—recapping social and digital drivers (Part 1), sensory appeals (Part 2), puberty and nonconformity (Part 3), and cognitive rigidities (Part 4)—we explore ADHD’s role, offer actionable guidance for parents, examine therapy challenges for autistic clients, and reflect on broader implications for neurodiversity and safeguarding.
ADHD
This brief film gives some insight into the condition of ADHD, which is divided into three main groups:
Impulsive/hyperactive: the least common type of ADHD, where children are hyperactive and impulsive, yet able to concentrate.
Inattentive/distractible: children with this type of ADHD find it hard to focus on the task at hand.
Combined: the most common type of ADHD, where children are impulsive and hyperactive, as well as being easily distracted. They also experience difficulty in staying attentive.
NICE, the UK’s National Institute for Health and Care Excellence, estimates that 5% of children in the UK are diagnosed with ADHD. However, this figure could be much higher when factoring in undiagnosed children. Furthermore, this percentage soars to 20% within the autistic population. As with autism, the ratio of diagnosed boys to girls is much higher, in clinical settings rising to 10:1. Again, a suggested reason for this skewed ratio is that boys tend to show more challenging behaviour within the school environment, and so are pushed towards diagnosis earlier. Girls are more prone to the inattentive type of ADHD, which is less obviously disruptive in the classroom.
Unlike autism, the relationship between ADHD and gender dysphoria has not been widely addressed in the scientific literature or more mainstream discourse. Where it does appear, ADHD is often conflated with autism. What follows is therefore a speculative exploration of why this particular pairing, or ‘comorbidity’, might be so prevalent. Perhaps it would be more productive to think about an overlap of traits than to reach for diagnoses.
Both children with autism and those with ADHD are especially prone to peer group bullying. This may take place in the classroom, online or outside of school.
‘ADHD children are sought out by school bullies as they overreact to taunting. Though they did not start the incident, they are blamed for the fight that follows.’
From Understanding ADHD: A parent’s guide to Attention Deficit Hyperactivity Disorder in Children, Dr Christopher Green and Dr Kit Chee, Vermilion, 1995, p.6
Reasons for the potential bullying of kids with ADHD include a perceived ‘difference’, which can resemble that of autism. The key reasons for bullying are outlined here and include hyperfocus, which can resemble the special interests of autistic people, as well as impulsivity, difficulty following social rules – again, much like their autistic peers – and trouble managing emotions and low self-esteem. The latter problem is, of course, exacerbated by the bullying itself. As we have seen with autism, being the subject of in-person or online bullying can make the validation that comes with adopting a trans identity very attractive to children and young people with ADHD.
People with ADHD are especially susceptible to addiction, and an obsession with the world of trans can be just that. Late nights due to online activity worsen the symptoms of ADHD. Although, as we have seen, part of the appeal of gender ideology is its techy flashiness – soundbites providing a quick fix, punchy influencer videos, anime cartoons, etc, – the fact remains that kids with ADHD, like their autistic peers, are very prone to sensory overwhelm. These online habits, combined with lack of sleep, not only exacerbate ADHD symptoms, but also cement gender fixations.
Children and young people with ADHD are more likely to engage in risky behaviours than neurotypicals. These may include smoking, drinking, taking drugs, having unprotected sex and acting impulsively in a range of contexts. A fascination and engagement with gender ideology is just such a risky behaviour, one with potentially lifelong consequences.
Helpful Advice
Many parents report being unable to address the subject of gender head-on with their children. Positions become entrenched and it’s easy to reach an impasse. This is true of all children with a gender fixation, but it is particularly pertinent to children and young people with autism, whose black-and-white thinking often does not allow for contradiction or questioning. It is a normal for teenagers to rebel against their parents and prioritise their peer groups, but when children latch onto gender as the main source of conflict, it puts parents in an almost impossible position.
Interpersonal conflict can involve name-calling and sloganeering. Concerned parents may be dismissed as bigots and transphobes, which is an example of cancel culture entering the domestic context. Unlike with other sources of conflict, parents daren’t take a laissez-faire stance or use reverse psychology. This would involve seemingly endorsing their child’s newfound identity in the hope that it might defuse their passionate adherence to it. However, in a situation in which gender identity is affirmed in every area of public and private life, parents find themselves in the unenviable position of having to hold the line, without being dogmatic or overtly insistent. They adopt an approach of ‘watchful waiting’, the essential powerlessness of which can be extremely disheartening. And meanwhile, transgenderism becomes the perfect launch pad for a child to reject parental control and embrace a seemingly ready-made, rebellious autonomy that is rubber-stamped with societal approval.
Having to maintain this sceptical stance with regard to gender ideology could include preventing children from wearing respiratory-restricting breast binders while allowing gender-nonconforming clothes that do not harm the body. It could include gentle reminders about the inherent dangers of taking wrong-sex hormones or undergoing invasive surgeries. This could be done in a non-confrontational way, such as by leaving info lying around and taking a drip-feeding approach rather than adopting a polarised position. Equally, suggested reading matter can address the subject of belief in an ideology, without doing so explicitly, e.g. 1984, Brave New World. It’s a good idea to have the difficult conversations as and when they arise, usually initiated by the child or by something contextually relevant. When these conversations do take place, try to stay calmly factual, almost bullet pointing the issues you wish to raise. Abstract, ‘free floating’ conversations don’t always go down well with neurodiverse kids! You might find that writing letters or sending texts is a less intense way of communicating your worries to your child. The advantage of this method is that your child can easily discard the tangible existence of a message to begin with, yet perhaps return to it in a calmer mood. It plants a seed. But it does mean choosing your words very carefully.
Maintaining a warm relationship wherever possible is crucial to helping loosen a gender fixation with neurodiverse children. You know your child better than anyone else; this is your superpower. Keep telling your child that you love him or her, reminding them wherever possible about other passions they may have, be it windsurfing or macramé! Key to all of this is validation without affirmation.
Outdoors and physical activities are very helpful, too. With younger children, you can join in. With older kids this gets trickier. In this case encourage them to meet up with friends in person, rather than online. One major problem with the espousal of a trans identity is the loss of connection with the physical self. Time spent online, and the body hatred implicit in considering damaging drugs and mutilating surgeries, can lead to a sense of disembodiment which may be countered by adopting a more active lifestyle. Interacting with flesh and blood people rather than strangers online who might appear to be friends, or ‘glitter families’ who validate and love bomb (and who tend to disappear when the glitz and glamour of coming out as trans has real-life consequences), can only be a good thing.
Therapy
Therapy can be immensely helpful. However, therapy with autistic clients isn’t as straightforward as that for neurotypicals and therefore might demand a different approach. The ‘talking cure’ was first developed by Freud and Breuer to work with people’s everyday neuroses. While it was not originally designed with the needs of a neurodiverse population in mind, it can be adapted to provide considerable benefits to individual clients. People with autism don’t always appreciate lengthy explanations and explorations of possible unconscious motivations for their words and actions. They also often experience difficulty in identifying and understanding their emotions. Hence, traditional therapy’s emphasis on interpretation is often discarded in favour of more embodied approaches that seek to help clients understand their feelings: the more overt, easily identifiable feelings and the more inaccessible unconscious ones. This understanding may be achieved during the sessions themselves.
Let’s unpack these terms. Below is a (very) brief glossary of psychotherapeutic terms:
- Alexithymia – difficulty recognising emotions and putting them into words
- Mentalisation – helping a client recognise the thoughts and feelings others may be experiencing
- Transference – tendency for clients to transfer onto the therapeutic relationship dynamics that mirror their own psychological histories
Sessions might involve an element of physicality, with clients squeezing a stress ball as they talk. Some clients appreciate deep tissue stimulation, like acupuncture, in tandem with talking therapies. Or the focus might be on linking physical responses with emotions through talking itself.
A Case Study
A trans-identified autistic client reported feeling nauseous from Saturday morning throughout the weekend prior to Monday’s session. The therapist enquired what had happened on Friday night. ‘Oh, nothing much,’ the client responded, ‘but I did have an argument with my mum.’ It transpired that the client’s mum had forgotten to buy her the usual Friday night takeaway. Since the client had already more or less written her mum off due to their clashing stances on trans ideology, she claimed to be unaffected by this oversight on her mum’s part. However, the client was encouraged to view the two events as linked to the pair’s disagreement about gender identity ideology. The takeaway provided their weekly moment of bonding. The client left the session and returned to the next one with a dream to analyse: in it, she was starving and in need of nourishment, and yelled at her mum for ignoring her. The dream enabled her to recognise her feelings. A real-life consequence of bringing this unconscious content to the fore and working with the associated feelings was that the client was able to talk to her mum about how she had felt both hungry and overlooked. The mum immediately bought her a takeaway to make up for things, and they ended up discussing gender identity ideology over it.
A more in-depth and traditionally psychodynamic analysis might have considered the role of breastfeeding in early bonding/nourishment between mother and daughter for example. It would also have considered the daughter’s plans to get a double mastectomy in light of this. However, the therapist did not pursue any interpretative line of speculation because the symbolic content was deemed to be potentially inaccessible to the client.
Psychotherapist Bob Withers cautions that great care and some medical knowledge are required on the part of the practitioner, especially when hypothesising psychosomatic causes of a client’s distress. Had the client’s nausea, in the above example, been a physical symptom of an underlying medical condition, analysis of its provenance within a psychotherapeutic context may have proved fruitless at best, damaging at worst. But the relationship between mind and body, always important in therapy, is given extra weight with autistic, trans-identified clients.
The idea that the body is the locus of damage/lack may lead trans-identified clients to demand a practical ‘fix’. Rather than exploring possible reasons for a pervasive sense of discomfort in one’s embodiment, alexithymic young people are especially prone to the snake oil peddled by Big Pharma, such as the removal of healthy body parts and a commitment to becoming a lifelong medical patient by taking wrong sex hormones. This is presented as a physical ‘remedy’ for a mental problem. Psychotherapists may find that the technique of mentalisation mitigates this potentially damaging ‘cure’. For example, if a client is able to view themselves from an alternative perspective, that of the external ‘other’, they may be more likely to perceive the effects of a massive social contagion and position themselves more realistically within this paradigm, whilst coming to terms with the impact of self-alienation evidenced by planning to do harm to one’s own body.
The emergence of transference usually cements the client-therapist bond, yet this can be problematic with autistic clients. Neurotypical clients may experience strong feelings, whether loving or antipathetic, about the therapist. These feelings are a kind of shorthand for earlier significant relationships. Clients may find themselves imagining the therapist’s life in great detail, creating an elaborate fantasy version of his or her life outside the consulting room. This imaginative bond serves as a kind of springboard to exploring a client’s emotional inclinations and assumptions with wider significance, providing a blueprint for forming relationships in the future. With autistic clients, however, the transference may not appear to occur at all because they are often cut off from their own experience – another example of alexithymia. When these feelings do break through into consciousness, they can be utterly overwhelming and unmoderated, hence the autistic meltdown.
An additional challenge for therapists working with trans-identified autistic clients is that, within the confines of a 50-minute session, they must attempt to counteract the endless hours clients may have spent reading gender ideological propaganda online. They are also working in a generally affirmative climate that has captured all major institutions, including certain professional bodies representing psychotherapy itself. Accusations of transphobia are being used to shut down exploratory therapy. A trans identity is seen as sacrosanct, unquestionable, set in stone – a paradox given that one tenet of gender identity ideology is that gender is fluid.
Roberto D’Angelo addresses this situation persuasively in his paper, Do we want to know?
There is a prohibition on knowing wherein certain zones are kept “off limits” to exploration and thinking. Nothing is surprising about the existence of prohibitions on knowing in individual analytic work: they are arguably a fundamental aspect of the functioning of human subjectivity. They are not particular to work with young patients experiencing gender dysphoria. Loosening such prohibitions is at the heart of the analytic project. However, we are currently immersed in a wave of political activism that regulates how gender identity can be understood – allowing a certain discourse and prohibiting others. Questioning why someone feels such unbearable distress that hormonal and surgical intervention seems like the only solution is framed by advocates as transphobic and a disguised form of conversion therapy: a targeted strategy to talk them out of their trans identification and to eradicate any gender diversity.
We have already seen that a diagnosis of gender dysphoria often functions as an all-enveloping cloak, masking the near identical symptoms of autism itself, smothering the painful intangibles of growing up, and often covering up a history of trauma, which can also manifest in self-harm and anorexia (medical transition could be considered the ultimate in self-harm). Working to identify and transform childhood trauma is a huge part of the therapeutic project. Addressing such formative experience may allow the issue of gender dysphoria to be reframed.
However, finding a ‘neutral’ therapist is not straightforward. The ‘neither one side nor the other’ argument is ethically bankrupt, presenting the possibility of a client’s medical transition as an almost inconsequential lifestyle choice, rather than a major safeguarding issue. In other words, therapists who don’t understand the current climate and snowballing social contagion are not ‘neutral’ because they will likely affirm, which is a judgemental stance from the outset and not in keeping with exploratory psychotherapy. The British Association of Counsellors and Psychotherapists (BACP) is ‘captured’ and pushes for the ban on conversion therapy to be extended to trans-identified clients. A quick look at their journal articles on the subject reveals ideologically loaded and unsubstantiated claims. For example, they claim that trans-identified clients are vulnerable to suicidality. The figures surrounding suicidality and trans are deliberately obfuscated. The charity Mermaids cites inflated and distorted Pace stats on child suicidality in order to argue for early medical intervention, such as blockers and hormones. See here for a full analysis. This is especially pernicious in the light of Emile Durkheim’s theory about the relationship between suicidality and contagion. If people are repeatedly told that they will end their lives unless they undergo irreversible ‘life saving’ surgeries, they may be more likely to act on such ideas. The source of these ideas is misplaced and relocated yet again within the body.
The Anti Conversion Bill, which is currently in draft form only, effectively conflates the abhorrent historical practice of gay ‘conversion’ with standard exploratory psychotherapy where trans-identified people are concerned. Here is D’Angelo again, on the subject:
Numerous jurisdictions worldwide have passed legislation that bans conversion therapies, and some appear to purposefully conflate psychotherapy with conversion therapy, specifically mentioning psychoanalysis as a problematic practice… These developments constitute an increasing rejection of, and prohibition of, exploratory, analytic thinking when applied to trans identities. It is hard to imagine any other clinical situation where the prohibitions on knowing that patients bring to treatment are reinforced and reified by the dominant socio-political trends that saturate the contexts in which young people dwell.
D’Angelo identifies the affirmative stance adopted by some therapists from the outset as a fundamental problem. Their ideological position not only runs counter to the open-minded premise of psychotherapy, but the fixity of an affirmative stance also implies that gender dysphoria should be treated medically. Ironically, the very therapists who are accused of bias and practising ‘conversion therapy’ are those who see what’s going on and are willing to explore the issue rather than shut down the conversation before it has even begun.
The proposed Anti-Conversion Bill could make it harder for parents to find impartial therapists. The following links provide suggestions for therapists who have in-depth knowledge of gender dysphoria, who offer standard psychotherapy and who do not adopt an affirmative stance prior to engaging with a client:
https://thoughtfultherapists.org
Some Final Thoughts
The difficulty lies in the fact that, while it is certainly cause for celebration that the stigma surrounding neurodiversity is being lifted, it is not so obvious what is being overlooked in the process. By no longer classifying gender dysphoria as a mental disorder, the World Health Organisation (WHO) has indirectly invalidated non-invasive approaches such as therapy. Similarly, autism is no longer considered a ‘disorder’. This means that difficulties with rigid thinking, obsessional tendencies, and decision-making with lifelong implications, for example, are easily written off by clinicians who deem autistic young people to have Gillick Competence the minute they hit 16, provided they are verbal and assumed to have mental capacity. Does de-pathologising gender dysphoria and autism offer a green light for radical physical interventions, such as wrong-sex hormones and irreversible surgeries, on the basis that these are a necessary lifestyle, albeit one that is heavily marketed?
The neurodiversity movement’s commendable emphasis on bodily autonomy overlaps with the fact that gender dysphoria is no longer classified as a mental health condition by the WHO, despite remaining listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We have to interrogate, on a moral and philosophical level, whether bodily autonomy can include harm to the body. An extreme parallel could be drawn with the current situation in Switzerland, where assisted dying is offered to people with severe mental health problems.
The co-morbidity of gender dysphoria alongside a diagnosis of autism, ADHD or other neurodiverse condition has not, thus far been considered a red flag by clinicians when deciding to put a gender dysphoric child or young adult onto a medical pathway.
To recap: we need to rethink what is lost in translation when setting the deficit model against the neurodiversity model. The neurodiversity model would appear to be the ideal progressive approach to mental health conditions: on the plus side, neurotypical norms are questioned and autistic identities are validated. However, by abandoning the sense of atypicality in the outmoded deficit approach, autism is no longer viewed as a disorder. Similarly, gender dysphoria is no longer listed as a mental health condition. This means that the two conditions can be meshed without throwing into question the negative outcomes that the comorbidity of two ‘disorders’ would inevitably flag up in terms of clinical practice.
Could it be that the reach to diagnose in the first place goes hand in hand with the current push to concretely label manifestations of identity like ‘trans’? Does the ever-expanding set of diagnoses in the DSM correspond, as it does with marketable gender identities, with a push by Big Pharma/Big Finance to categorise and therefore treat? The lure, though, is that an autism diagnosis might help in understanding the constellation of traits typically exhibited by ROGD kids. This might in turn not only help us to better understand and protect this cohort, it could also be used by parents as part of their armoury in attempting to prevent their children from undergoing the harms of ‘gender affirming care’. However, the recent scandal around the release of the WPATH files tragically showed us that diagnoses of autism, and other conditions including psychosis, were not considered reason enough to prevent clinicians from experimenting on children. We can only hope that as more genuine curiosity arises about the group of children who are both autistic and gender nonconforming, we may find less brutal and avaricious ways of addressing the troubles they experience during adolescence.
Read Part 1, Part 2, Part 3 and Part 4
Mary Smith is a UK writer, researcher, and parent, engaged in resisting gender ideology and its harms.
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