A new pilot study found that psychotherapy – without medical intervention – improved the mental health of autistic adolescents with gender dysphoria.
The study, published in the Journal of Autism and Developmental Disorders, found that guided, peer support group therapy showed positive mental health outcomes for autistic adolescents struggling with gender dysphoria. The study, conducted in the Netherlands, emphasized the importance of mental health treatments, while deprioritizing medical interventions like puberty blocking drugs, cross-sex hormones, and surgery.
“These findings add to a quickly growing stack of evidence suggesting that it’s the psychotherapy and support that is improving these kids’ well-being, not medicalized transition,” said Dr. James Cantor, Director of the Toronto Sexuality Centre, and associate professor of the University of Toronto Faculty of Medicine.
The authors of the study chose mental health as their treatment goal, as their aim wasn’t to “cure” gender dysphoria (or autism), but to “reduce their distress and increase positive feelings about their overall lives.”
“In the current study, we looked at psychological well-being and psychological complaints as measures of quality of life,” the introduction read.
“In a pilot study, we evaluate the effect of a newly developed peer support group for adolescents with [Autism Spectrum Disorder] and [Gender Dysphoria] on their quality of life,” the introduction continued. Data was collected from four consecutive cycles of the peer support group that were completed between March 2019 to December 2021.
The researchers contrasted mental health interventions with medical treatments, and emphasized the effectiveness of psychotherapies that are aimed at “learning to think in more nuanced ways about gender identity,” and “identifying and treating other problems.”
Dr. Cantor’s website, Sexology Today, is often cited as a resource that documents eleven studies finding that roughly 60–90% of children who identify as transgender, but do not socially or medically transition, will no longer identify as transgender in adulthood. These studies were referenced by the group of researchers, who acknowledged that gender dysphoria may resolve on its own.
“In a large proportion of children who express their desire for medical gender-affirming care, this seems to disappear during puberty,” the study read.
Many studies that were designed to find out whether medical transition improves mental health could not adequately do so because the patients were simultaneously receiving psychiatric medication, counseling, and had supportive family environments, all of which are factors that are known to independently improve mental health.
Dr. Cantor agreed. “In the studies suggesting medical transition improves quality of life, the kids were also receiving psychotherapy at the same time,” he said.
There were some concerning elements to the study, including their inclusion of terms like “gender identity,” “gender journey,” and “gender spectrum,” which lack a scientific basis. Participants were also given free range to change their names and pronouns from “session to session.” Small sample sizes were also indicated as a limitation of the study.
The results found that while mental health outcomes improved significantly due to peer support, so did feelings of gender dysphoria.
“The kids in these support groups reported experiencing gender dysphoria more, even though their mental health was improving in other ways,” said Dr. Cantor. “This challenges simple ideas, such as that social minority stress is driving the mental health issues.”
It also challenges the “affirm-or-suicide” narrative, which implies that medically transitioning adolescents will prevent them from committing suicide. And it adds evidence to the “social contagion” theory, that finds peer influence contributes to youth gender dysphoria.
“But the paradoxical pattern is consistent with the possibility that the reported levels of dysphoria reflect the desire to continue qualifying for and receiving the support provided by these groups,” said Dr. Cantor.
“We need to remember this is only a pilot study,” he added. “It’s not the final word on anything.”
The study recognized the importance of taking both autism spectrum disorder and gender dysphoria into account, highlighting some of the important challenges that autistic people face that may lead them to become confused about their sex, including preoccupation, rigid thinking, and a lag in socio-emotional development.
“It is possible that kids who have a tendency to get obsessed or fixated on something may latch on to gender,” said Dr. Kenneth Zucker, a psychologist with 30 years of experience running the largest Canadian childhood gender clinic.
Dr. Zucker believes that many children identifying as transgender may do so because they are on the autism spectrum. The psychologist credits this confusion to the autistic tendency to fixate or obsess over a “special interest.”
“Just because kids are saying something doesn’t necessarily mean you accept it, or that it’s true, or that it could be in the best interests of the child,” he added.
Children and adolescents on the autism spectrum are disproportionately represented among the large, newly emerging cohort of children claiming to be transgender. Over the past 10 years, there have been at least nine studies connecting Autism Spectrum Disorder (ASD) and transgender identities. Rates of autistic traits in these studies range from five percent to 54% among those with gender dysphoria, significantly higher than among the general population.
Data from the now-shuttered Gender Identity Development Service (GIDS) at the U.K.’s Tavistock Centre found that autistic adolescents were significantly overrepresented in the population of referrals to the clinic. Pediatrician Dr. Hilary Cass was commissioned to conduct a review of the services provided by the National Health Service and investigate why there has been such a huge rise in the number of adolescent biological girls seeking referrals to gender clinics.
Dr. Cass found that approximately one third of youth referred to GIDS had autism or autistic traits. By comparison, the prevalence rates of autism spectrum disorder during childhood in the UK have been estimated at 1%.
There is a growing international consensus that minors experiencing gender dysphoria should be treated with psychotherapy first, not medical interventions. Health authorities in Sweden, Finland, and the U.K. have unanimously concluded after systematic reviews of evidence for puberty blockers and cross-sex hormones that the risks and uncertainties outweigh any known benefits. Psychotherapy will now be provided as the first and usually only line of treatment for gender dysphoric youth in these countries.
The Gender Exploratory Therapy Association (GETA), a network of mental health professionals, wrote a new clinical guide for adolescents struggling with gender dysphoria. The guidance offers an alternative approach to “affirming” a minor’s chosen trangender identity to explore possible underlying factors that may be causing their dysphoria, including autism.