Abstract
Background
Gender dysphoria (GD) appears disproportionately common in people with autism spectrum disorders (ASDs). Concurrent intellectual disability (ID) may limit assessment of these individuals and their access to gender-affirming healthcare. This study aims to summarise knowledge on the presentation of GD in those with co-occurring ASD and ID.
Methods
A systematic search was conducted of five online databases from 1984 to September 2021, for articles pertaining to GD in people with ASD and ID. Additional studies were obtained from personal research. Results were screened against defined eligibility criteria, with data extracted on participant characteristics and clinical presentation.
Results
From 149 total articles, 10 were included (case studies (n = 4), cross-sectional studies (n = 2), systematic reviews (n = 4)).
Conclusions
GD does affect this population and can cause significant distress; two cases reported subsequent self-harm or suicidality. Further conclusions were limited by the paucity of relevant literature and further research is required.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Abelson, A. G. (1981). The development of gender identity in the autistic child. Child: Care, Health and Development, 7(6), 347–356. https://doi.org/10.1111/j.1365-2214.1981.tb00851.x
Abelson, G., & Paluszny, M. (1978). Gender identity in a group of retarded children. Journal of Autism and Childhood Schizophrenia, 8(4), 403–411. https://doi.org/10.1007/bf01538046
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). https://doi.org/10.1176/appi.books.9780890423349
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (5 ed.) . American Psychiatric Publishing, Inc. https://doi.org/10.1176/appi.books.9780890425596
Arcelus, J., Bouman, W. P., Van Den Noortgate, W., Claes, L., Witcomb, G., & Fernandez-Aranda, F. (2015). Systematic review and meta-analysis of prevalence studies in transsexualism. European Psychiatry, 30(6), 807–815. https://doi.org/10.1016/j.eurpsy.2015.04.005
Atkinson, S. R., & Russell, D. (2015). Gender dysphoria. Australian Family Physician, 44(11), 792–796.
Bedard, C., Zhang, H. L., & Zucker, K. J. (2010). Gender Identity and Sexual Orientation in People with Developmental Disabilities. Sexuality and Disability, 28(3), 165–175. https://doi.org/10.1007/s11195-010-9155-7
Bem, S. L. (1981). Gender schema theory: A cognitive account of sex typing. Psychological Review, 88(4), 354–364. https://doi.org/10.1037/0033-295X.88.4.354
Bevan, R. (2016). Gender Dysphoria and Intellectual Disability. Newsletter of the Faculty of Intellectual Disability January 2016, (18).
Bevan, R. (2017). Gender dysphoria, autism and intellectual disability. Royal College of Psychiatrists’ Intellectual Disability Trainee Conference.
Bonifacio, H. J., & Rosenthal, S. M. (2015). Gender Variance and Dysphoria in Children and Adolescents. Pediatric Clinics of North America, 62(4), 1001–1016. https://doi.org/10.1016/j.pcl.2015.04.013
Bowler, C., & Collacott, R. A. (1993). Cross-dressing in Men with Learning Disabilities. British Journal of Psychiatry, 162(4), 556–558. https://doi.org/10.1192/bjp.162.4.556
Bryson, S. E., Bradley, E. A., Thompson, A., & Wainwright, A. (2008). Prevalence of Autism among Adolescents with Intellectual Disabilities. The Canadian Journal of Psychiatry, 53(7), 449–459. https://doi.org/10.1177/070674370805300710
Bussey, K., & Bandura, A. (1999). Social cognitive theory of gender development and differentiation. Psychological Review, 106(4), 676–713. https://doi.org/10.1037/0033-295x.106.4.676
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . Zucker, K. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165–232. https://doi.org/10.1080/15532739.2011.700873
Coleman-Smith, R. S., Smith, R., Milne, E., & Thompson, A. R. (2020). “Conflict versus Congruence”: A Qualitative Study Exploring the Experience of Gender Dysphoria for Adults with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 50(8), 2643–2657. https://doi.org/10.1007/s10803-019-04296-3
Cooper, S. A., Mohamed, W. N., & Collacott, R. A. (1993). Possible Asperger’s syndrome in a mentally handicapped transvestite offender. Journal of Intellectual Disability Research, 37(2), 189–194. https://doi.org/10.1111/j.1365-2788.1993.tb00587.x
de Vries, A. L., Noens, I. L., Cohen-Kettenis, P. T., van Berckelaer-Onnes, I. A., & Doreleijers, T. A. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disorders, 40(8), 930–936. https://doi.org/10.1007/s10803-010-0935-9
Deogracias, J. J., Johnson, L. L., Meyer-Bahlburg, H. F. L., Kessler, S. J., Schober, J. M., & Zucker, K. J. (2007). The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. The Journal of Sex Research, 44(4), 370–379. https://doi.org/10.1080/00224490701586730
Dewinter, J., Vermeiren, R., Vanwesenbeeck, I., & van Nieuwenhuizen, C. (2013). Autism and normative sexual development: A narrative review. Journal of Clinical Nursing, 22(23–24), 3467–3483. https://doi.org/10.1111/jocn.12397
Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: A review of the literature. International Review of Psychiatry, 28(1), 44–57. https://doi.org/10.3109/09540261.2015.1115753
Elsabbagh, M., Divan, G., Koh, Y. J., Kim, Y. S., Kauchali, S., Marcín, C., . . . & Fombonne, E. (2012). Global prevalence of autism and other pervasive developmental disorders. Autism Research: Official Journal of the International Society for Autism Research, 5(3), 160–179. https://doi.org/10.1002/aur.239
Evans, D. (2003). Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12(1), 77–84. https://doi.org/10.1046/j.1365-2702.2003.00662.x
Glidden, D., Bouman, W. P., Jones, B. A., & Arcelus, J. (2016). Gender Dysphoria and Autism Spectrum Disorder: A Systematic Review of the Literature. Sex Med Rev, 4(1), 3–14. https://doi.org/10.1016/j.sxmr.2015.10.003
Heasman, B., & Gillespie, A. (2019). Neurodivergent intersubjectivity: Distinctive features of how autistic people create shared understanding. Autism, 23(4), 910–921. https://doi.org/10.1177/1362361318785172
Institute of Medicine (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. The National Academic Press.
Jacobs, L. A., Rachlin, K., Erickson-Schroth, L., & Janssen, A. (2014). Gender Dysphoria and Co-Occurring Autism Spectrum Disorders: Review, Case Examples, and Treatment Considerations. LGBT Health, 1(4), 277–282. https://doi.org/10.1089/lgbt.2013.0045
Janssen, A., Huang, H., & Duncan, C. (2016). Gender Variance Among Youth with Autism Spectrum Disorders: A Retrospective Chart Review. Transgend Health, 1(1), 63–68. https://doi.org/10.1089/trgh.2015.0007
Kallitsounaki, A., & Williams, D. (2020). Mentalising Moderates the Link between Autism Traits and Current Gender Dysphoric Features in Primarily Non-autistic. Cisgender Individuals. J Autism Dev Disord, 50(11), 4148–4157. https://doi.org/10.1007/s10803-020-04478-4
Killerman, S. (2018). The Genderbread Person. www.genderbread.org. Accessed March 2019.
Kohlberg, L. (1966). Cognitive stages and preschool education. Human Development, 9(1/2), 5–17.
Kraemer, B., Delsignore, A., Gundelfinger, R., Schnyder, U., & Hepp, U. (2005). Comorbidity of Asperger syndrome and gender identity disorder. European Child and Adolescent Psychiatry, 14(5), 292–296. https://doi.org/10.1007/s00787-005-0469-4
Kristensen, Z., & Broome, M. R. (2015). Autistic Traits in an Internet Sample of Gender Variant UK Adults. International Journal of Transgenderism., 16(4), 234–245. https://doi.org/10.1080/15532739.2015.1094436
La Malfa, G., Lassi, S., Bertelli, M., Salvini, R., & Placidi, G. F. (2004). Autism and intellectual disability: A study of prevalence on a sample of the Italian population. Journal of Intellectual Disability Research, 48(3), 262–267. https://doi.org/10.1111/j.1365-2788.2003.00567.x
Lai, M. C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015). Sex/gender differences and autism: Setting the scene for future research. Journal of the American Academy of Child and Adolescent Psychiatry, 54(1), 11–24. https://doi.org/10.1016/j.jaac.2014.10.003
Lemaire, M., Thomazeau, B., & Bonnet-Brilhault, F. (2014). Gender identity disorder and autism spectrum disorder in a 23-year-old female. Archives of Sexual Behavior, 43(2), 395–398. https://doi.org/10.1007/s10508-013-0141-x
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., . . . & Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ, 339, b2700. https://doi.org/10.1136/bmj.b2700
Matson, J. L., & Shoemaker, M. (2009). Intellectual disability and its relationship to autism spectrum disorders. Research in Developmental Disabilities, 30(6), 1107–1114. https://doi.org/10.1016/j.ridd.2009.06.003
McKenzie, K., Milton, M., Smith, G., & Ouellette-Kuntz, H. (2016). Systematic Review of the Prevalence and Incidence of Intellectual Disabilities: Current Trends and Issues. Current Developmental Disorders Reports, 3(2), 104–115. https://doi.org/10.1007/s40474-016-0085-7
Meyer, M., & Gelman, S. A. (2016). Gender Essentialism in Children and Parents: Implications for the Development of Gender Stereotyping and Gender-Typed Preferences. Sex Roles, 75(9), 409–421. https://doi.org/10.1007/s11199-016-0646-6
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097
Moola, S., Munn, Z., Tufanaru, C., Aromataris, E., Sears, K., Sfetc, R., Currie, M., Lisy, K., Qureshi, R., Mattis, P., & Mu, P. (2020). Chapter 7: Systematic Reviews of Etiology and Risk. JBI Manual for Evidence Synthesis.
Mukaddes, N. M. (2002). Gender identity problems in autistic children. Child: Care, Health and Development, 28(6), 529–532. https://doi.org/10.1046/j.1365-2214.2002.00301.x
Nabbijohn, A. N., van der Miesen, A. I. R., Santarossa, A., Peragine, D., de Vries, A. L. C., Popma, A., & VanderLaan, D. P. (2019). Gender Variance and the Autism Spectrum: An Examination of Children Ages 6–12 Years. Journal of Autism and Developmental Disorders, 49(4), 1570–1585. https://doi.org/10.1007/s10803-018-3843-z
Nissen, T., & Wynn, R. (2014). The history of the case report: A selective review. JRSM Open, 5(4), 2054270414523410. https://doi.org/10.1177/2054270414523410
Nobili, A., Glazebrook, C., Bouman, W. P., Glidden, D., Baron-Cohen, S., Allison, C., . . . & Arcelus, J. (2018). Autistic traits in treatment-seeking transgender adults. Journal of Autism and Developmental Disorders, 48(12), 3984–3994. https://doi.org/10.1007/s10803-018-3557-2
Øien, R. A., Cicchetti, D. V., & Nordahl-Hansen, A. (2018). Gender Dysphoria, Sexuality and Autism Spectrum Disorders: A Systematic Map Review. Journal of Autism and Developmental Disorders, 48(12), 4028–4037. https://doi.org/10.1007/s10803-018-3686-7
Parkes, G., & Hall, I. (2006). Gender dysphoria and cross-dressing in people with intellectual disability: A literature review. Mental Retardation, 44(4), 260–271. https://doi.org/10.1352/0047-6765(2006)44[260:Gdacip]2.0.Co;2
Parkes, G., Hall, I., & Wilson, D. (2009). Cross dressing and gender dysphoria in people with learning disabilities: A descriptive study. British Journal of Learning Disabilities, 37(2), 151–156. https://doi.org/10.1111/j.1468-3156.2008.00538.x
Pasterski, V., Gilligan, L., & Curtis, R. (2014). Traits of Autism Spectrum Disorders in Adults with Gender Dysphoria. Archives of Sexual Behavior, 43(2), 387–393. https://doi.org/10.1007/s10508-013-0154-5
Richards, C., & Barrett, J. (2021). Trans and non-binary gender healthcare. Cambridge University Press.
Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood. International Review of Psychiatry, 28(1), 13–20. https://doi.org/10.3109/09540261.2015.1115754
Royal College of Psychiatrists (2013). College Report CR181: Good practice guidelines for the assessment and treatment of adults with gender dysphoria. (R. C. o. Psychiatrists, Ed.) https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-reportcr181.pdf?sfvrsn=5ba8dd13_2&sfvrsn=5ba8dd13_2
Sommarö, S., Andersson, A., & Skagerström, J. (2020). A deviation too many? Healthcare professionals’ knowledge and attitudes concerning patients with intellectual disability disrupting norms regarding sexual orientation and/or gender identity. Journal of Applied Research in Intellectual Disabilities: JARID, 33(6), 1199–1209.
Strang, J. F., Meagher, H., Kenworthy, L., de Vries, A., Menvielle, E., Leibowitz, S., … Anthony, L. G. (2018). Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 47(1), 105–115. https://doi.org/10.1080/15374416.2016.1228462
Thomas, P. R., & DeAlwis, K. (1995). Transvestism in a person with learning disabilities presenting with behavioural problems. Journal of Intellectual Disability Research, 39(5), 454–456. https://doi.org/10.1111/j.1365-2788.1995.tb00552.xst
Thompson, D. (1994). Sexual experience and sexual identity for men with learning disabilities who have sex with men. Changes-Sheffield, 12, 254–254.
Turban, J. L., & van Schalkwyk, G. I. (2018) “Gender Dysphoria” and autism spectrum disorder: Is the link real? Journal of the American Academy of Child & Adolescent Psychiatry, 57(1), 8–9e2. https://doi.org/10.1016/j.jaac.2017.08.017
Williams, J. C. A. (2019, October). The clinical complexities involved in diagnosing gender dysphoria in transitional-age youth (TAY) with ASD. In 66th Annual Meeting. AACAP. https://doi.org/10.1016/j.jaac.2019.07.115
Williams, P., Allard, A., & Sears, L. (1996). Case study: Cross-gender preoccupations in two male children with autism. Journal of Autism and Developmental Disorders, 26(6), 635–642. https://doi.org/10.1007/BF02172352
Wood, E., & Halder, N. (2014). Gender disorders in learning disability - A systematic review. Tizard Learning Disability Review, 19, 158–165. https://doi.org/10.1108/TLDR-01-2013-0004
World Health Organisation (2020). International statistical classification of diseases and related health problems (11 ed.) https://icd.who.int/
World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders. World Health Organization.
Van Der Miesen, A. I., Hurley, H., & De Vries, A. L. (2016). Gender dysphoria and autism spectrum disorder: A narrative review. International Review of Psychiatry, 28(1), 70–80. https://doi.org/10.3109/09540261.2015.1111199
van der Miesen, A. I. R., de Vries, A. L. C., Steensma, T. D., & Hartman, C. A. (2018). Autistic symptoms in children and adolescents with gender dysphoria. Journal of Autism and Developmental Disorders, 48(5), 1537–1548. https://doi.org/10.1007/s10803-017-3417-5
Zosuls, K. M., Ruble, D. N., Tamis-Lemonda, C. S., Shrout, P. E., Bornstein, M. H., & Greulich, F. K. (2009). The acquisition of gender labels in infancy: implications for gender-typed play. Developmental Psychology, 45(3), 688–701. https://doi.org/10.1037/a0014053
Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sexual Health, 14(5), 404–411. https://doi.org/10.1071/SH17067
Zucker, K. J., & Lawrence, A. A. (2009). Epidemiology of gender identity disorder: Recommendations for the standards of care of the world professional association for transgender health. International Journal of Transgenderism, 11(1), 8–18. https://doi.org/10.1080/1553273090279994
Zucker, K. J., Mitchell, J. N., Bradley, S. J., Tkachuk, J., Cantor, J. M., & Allin, S. M. (2006). The recalled childhood gender identity/gender role questionnaire: Psychometric properties. Sex Roles, 54(7–8), 469–483. https://doi.org/10.1007/s11199-006-9019-x
Acknowledgements
The authors would like to acknowledge the support from Dr Ruth Bevan and Dr Derek Glidden, both of whom reviewed the manuscript and offered constructive feedback.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The Authors have no conflict of interests to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Walker, E., Walton, C. Gender Dysphoria, Autism and Intellectual Disability: A Systematic Review. Rev J Autism Dev Disord (2023). https://doi.org/10.1007/s40489-023-00365-7
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s40489-023-00365-7