Case Report: Adolescent With Autism and Gender Dysphoria

Abstract

There is increasing clinical evidence of an association between gender variability, gender dysphoria (GD), and autism spectrum disorder (ASD). This seems to be a two-way relationship, a person with GD is more likely to be diagnosed with ASD and vice versa. In youth, it is important to distinguish whether the presented symptoms are a manifestation of ASD focus on special interests or symptoms of co-occurring GD. This distinction is crucial in the process of planning reversible and especially irreversible medical procedures in the context of treatment. We present the case of a birth-assigned female adolescent with GD, who enrolled in our clinic at the age of 16.5 years with “being transgender” as her main complaint accompanied by a wish for surgical breast removal. His (as the patient prefers to use male pronouns) medical and developmental history involved obesity, hyperlipidemia, delays in social and language development and specific interests and rituals. He presented with half a year of untreated depression, suicidal thoughts and non-suicidal self-injuring, social phobia and relative social isolation. Comprehensive clinical assessments revealed a female karyotype (46, XX), normal female genitalia and unremarkable hormonal status. Clinical psychological assessments reported GD, ASD with average intellectual abilities and co-occurring symptoms of depression and anxiety. Other disorders, such as psychosis, personality disorder and dysmorphophobia, were excluded during longer-term diagnostic and psychotherapeutic processes. Our first aim was to build a good therapeutic alliance with the patient and treat depression and suicidality. He refused to take sertraline, but took a St. John's Wort over-the-counter peroral preparation in the form of infusions. His mood improved, he was no longer suicidal and started social transitioning, yet he remained socially phobic. At the time of writing, he is 20 years old, waiting for bilateral mastectomy and receiving regular triptorelin depot and testosterone depot intramuscular injections. Even though the diagnostic procedures and transition process in autistic gender diverse adolescents may take longer than in non-autistic individuals, ASD is not a contraindication to the gender transition process. We present a well-documented case of a slow social and medical transition resulting in gradual improvement of co-occurring symptoms of GD.

Supporting the health and wellbeing of trans autistic school-aged youth: a systematic literature review

“…Three studies explored the topic of clinical adaption (Cooper, Butler, et al., 2023 ; Mahfouda et al., 2019 ; Zupanič et al., 2021 ). More specifically, Cooper, Butler, et al.…”

“…For example, many autistic youths may take longer to develop rapport with clinicians than their non-autistic peers. Furthermore, many autistic children and adolescents work best in established routines with clear understanding of what is to occur (Zupanič et al., 2021 ). Cooper, Butler, et al.…”

“…Similarly, considering the overrepresentation of autism in trans persons, gender affirming care clinicians should consider it becoming a standard practise to screen for autistic traits in all children and youth who are seeking gender affirming services and (medical) care (Lehmann et al., 2020 ; Russell et al., 2021 ). Clinicians may also need to revise their typical engagement practices with trans autistic clients to allow for more time to develop rapport and establishment of routines with structured sessions comprising clear objectives and expectations that can be tracked and followed (Cooper, Butler, et al., 2023 ; Zupanič et al., 2021 ), including using visual planning tools and structured step-by-step explanations for complex procedures such as gender affirming (medical) care (Strang et al., 2022 ). Flexibility in session times and lengths are also key to facilitate shorter sessions, with more frequency allowing for information to be effectively processed and experienced as less overwhelming for the young person (Cooper, Butler, et al., 2023 ).…”

Gender diversity in autistic clients: an ethical perspective

“…Clinicians often begin by treating gender dysphoria in autistic people as though it will pass, given time. However, in several case studies, the client's gender dysphoria did not pass (20)(21)(22)(23). Autistic individuals who are TGNC report being told by parents, professionals and others that their desire to be another gender is a passing obsession (24), even when the individuals in question feel certain about who they are.…”