Emily Maddox
This article approaches the over-representation of autistic young people accessing gender identity services in the United Kingdom. It will argue that historically autism and gender have been causally connected to one another in unproblematized ways and that this tendency is persistent in the ongoing narratives which suggests that there is something about autism that troubles gender. Notably, these discussions rarely include the voices of autistic gender divergent people themselves who often do not fit into binary understanding of gendered identity. This article will suggest that this is imperative for offering holistic services to these individuals.
Recent figures from the only NHS run gender clinic for young people, the Tavistock Gender Identity Development Services (Tavistock from here on), suggest that there has been almost a doubling of young people accessing the services each year since 2010. Within this group there is an overrepresentation of those with an Autistic Spectrum Condition (ASC), or those who are clinically observed to have autistic traits. Though there are no exact figures, estimates suggest that around 1 in 100 hundred people in the U.K has a diagnosis of ASC, this equates to around 700,000 people or one percent of the population. Rates of people who do not identify with the gender they were assigned at birth are, again, not fully identifiable, but are cited at similar occurrence of around one percent of the population from data gathered in a sample of 10,000 people by the Equality and Human Rights Commission in 2012. Those accessing gender clinics with ASC have been placed as high as 19% in the years 2015-2016 by the Tavistock..In particular, there has been an increase of assigned girls with ASC accessing the gender clinics. This quite substantial over-representation of the overlap between these two relatively small groups has become the focus for discussions within medical communities and non-medical communities alike.
Autism is a condition which is identified by its core differences or difficulties within the realm of sociality. For diagnosis, the Diagnostic Statistical Manual V cites that ‘deficits’ must be present in social imagination and social communication ‘across multiple contexts’. Restricted and repetitive patterns of behavior, interests or activities must be also present. As with all perceived medical pathologies, attempts to find a causality of autism have been sought. These have ranged from MMR vaccinations, theories of a disordered splitting of the ego caused by parental neglect to genetic differences. However, it is the exploration of the causal link autism may have to gender and sex difference which is the one which is of interest to this article. Autism and its interaction with gender have become an important part of medical and social research alike. However, this investigation into the connection of autism to sex difference is not new. In the 1940s Hans Asperger determined that the condition he was seeing in his clinics was a form of extreme ‘male intelligence’. Simon Baron-Cohen took up this assertion in the mid 2000s to claim that autism was in fact an ‘extreme male brain’. Baron-Cohen argued that exposure to pre-natal testosterone could be held responsible for the over-representation of assigned males with autism. This theory can also be utilized to explain the perceived masculine traits and behaviours of assigned girls with ASC. This theory was possible due to the repositioning of autism from a psychological condition to one that is situated in bio-neurology and one which can be tested for biometrically. Baron-Cohen asserts that gender presentation can become a key tool for diagnosing autism.
The recent suggestions of the over-representation of those with ASC accessing gender clinics has led to an increase in considerations around the connections of autism and gender. Notably, the Empathy Quotient (Baron-Cohen’s preliminary diagnostic questionnaire for identifying ASC traits) is sometimes included in the initial paperwork assessing the suitability of an individual for gender services. Until the early 2000s there was only one article published which explicitly suggested a possible link between autism and gender divergent identities, since then research has increased with some studies suggesting that autism can be highlighted as the cause of some ASC individuals seeking gender identity services. Gillis-Buck and Richardson have suggested that autism has become a disorder of gender.
Of course, not all of the discussions around sex difference and ASC situate biological differences as a potential cause of the over-representation, and efforts are being made to think carefully about interactions between biology, genetics and the social world. A Dutch study conducted in 2010 with young people with ASC argued that exposure to pre-natal testosterone is not a relevant control in their study as it cannot account for the over representation of assigned males accessing gender services. Rather, they suggest that individual considerations of gender identity may in fact arise because of the social differences common to autism. However, they situate autism as the cause of these considerations to argue that gender becomes the preoccupation or ‘special interest’ to the young person who is negotiating the social world.
They also suggest that the sensory issues that often go hand in hand with autism may cause a young person to choose to wear girl’s clothes or wigs due to the pleasure this can give sensually, and that without the ability to understand the normative conventions of gendered performance boys will wear feminine clothing. For girls and women sensory issues could play a part in choosing comfortable androgynous clothing over uncomfortable hyper-feminine clothing. Importantly though, clothing choices do not equate to a person being transgender or non-binary identifying. This focus on gendered behavioral manifestations can also potentially work against people with ASC when they access gender transition or explorative services.
A comparative study by the Tavistock suggests that young people with ASC show less social transition (living in the gender they wish to rather than their assigned gender). The clinical observation of social transition is part of the process in which it is determined whether a young person should have access to gender specialist services. It is well documented that a coherent narrative must be given which is often pre-rehearsed, often not in a conscious sense but discursively framed by what is knowable and understandable about trans identities. Sometimes, this can take a conscious effort to learn what this means in medical and social terms in order to re-tell this, even if it doesn’t quite ‘fit’ with how they understand their own gender. This can be particularly the case for non-binary identifying individuals who do not identify at either end of the binary and as Ben Vincent has highlighted trans healthcare is often centered around binary transitional paths. For someone with autism who may have different modes of communicating in reciprocal conversation, and also in negotiating social rules and gendered conventions this may prove more difficult to articulate. Tavistock have also suggested that young people with an ASC lack a ‘theory of mind’ and this may not enable them to understand the need to state or express their gendered identity so clearly in a clinical setting.
The Theory of Mind hypothesis is the suggestion that autistic people cannot have access to what other people may be thinking or feeling. This is argued to account for the lack of empathy perceived to be common to autistic people. However, this theory is somewhat contentious, and it has fed into the belief that autistic subjectivity is deficient and lacking. Furthermore, it suggests that autistic individuals are unable to narrate their own gendered experiences coherently. As scholar Damien Milton suggests, we should think of this as a ‘double empathy problem’. By this Milton means that it would be beneficial for autistic people and allistic or neurotypical people (those who do not have ASC or a related condition) to consider the potential communication differences between them, rather than privileging normative modes of communication above others. This seems especially pertinent when thinking about how people with ASC are experiencing their gender and how this is experienced and narrated.
People with ASC are not a homogenous group, nor are those who are thinking about and questioning their gendered identities. A person’s gendered narrative should be able to be incoherent at times, or all the time, it should be allowed to exist in a binary, or elsewhere within the gendered space, or sometimes both. Crucially what is needed is gender services which isn’t only aware of the multiplicities of autism and of the multiple ways that those with ASC choose to present or think about their gender, but which also listens to and adapts its practices to these individuals. Likewise, it must be both aware and critical of the residual discourses and ideas around autism and gender which can, in some cases, be detrimental to a young person gaining the support needed around their gender identity.
Emily Maddox is a PhD student in the School of Sociology and Social Policy at the University of Leeds