is that if you have a patient with autism, you should consider evaluating them for gender identity issues. And if you have a patient who's got gender identity issues, you should evaluate them for autism traits. So, what I want to talk to you all about today is something really, really interesting, and that is there's a new paper that just came out that's a meta-analysis looking at the relationship between autism spectrum disorder and gender identity issues. And I really, really love this paper because it illustrates a lot of really cool things. So, the first thing that we've got to kind of dive into is that around 2010, there was a paper that came out that looked at the link between Autism Spectrum Disorder and gender identity or gender dysphoria. And so, this is the initial paper, and it's sort of like some people kind of caught wind of it, and it seemed kind of interesting. But over the last decade, the interest in autism spectrum disorder has increased exponentially, and the interest in gender identity issues has also increased exponentially. In the last two years, the

number of studies on autism and gender identity issues has more than doubled. This paper is really cool because what they're essentially doing is synthesizing this explosion of research. The paper essentially found something really shocking, which is that if you look at people who have autism spectrum disorder, they're 11 times as likely to have gender identity issues. Okay, so that's kind of really interesting because it suggests that there's a very strong link. So what the paper essentially did is something called a meta-analysis. So what they did is they took 41 different studies looking at the link between Autism Spectrum Disorder and gender identity disorder, and they essentially amalgamated all of that data. Because a lot of times studies will have just, you know, they'll have like 30 participants in it or the sample sizes will be small, like 100 here, 50 there. But what this study did is pooled data from 41 studies to really figure out what

kind of like high-quality conclusions can we draw. So, let's actually take a quick look at some of the findings of the study. Okay, so one thing I really like about this study is that they started by looking at the general population, and what they essentially found in the general population is that when you have a high amount of autism traits in kids, their parents reported high levels of gender identity variants. And this is something that I really like about this paper, is that they looked at different populations and actually asked a bunch of different research questions. So, the first thing is that parents reported increased gender variance when their children had more autistic traits. Then what they did is they took a look at the autism population. So, this is just looking at everybody, and then what they did is they said, Okay, so what happens if we take a group of people who have autism spectrum disorder? If we take, let's say, 100 people with Autism Spectrum Disorder, what do we find? And what they found is that if you have autism spectrum disorder, you're four

times as likely to endorse gender dysphoria or gender identity issues. So, that means that people with Autism are 400 percent more likely to have issues around gender variants. So, they also found that 15 percent of people with Autism Spectrum Disorder actually report being non-binary. So, that's a staggering amount. Okay, and so do you all understand how this is like these are two different statistics. One is a total prevalence within the population and one is a relative number. So, this is compared to people who are not on the autism spectrum. Then what they did is tried to see kind of the reverse relationship. So, they looked at studies with people who said that they have gender identity variants or gender dysphoria and they ask the question okay if someone has gender identity variance or gender dysphoria what is the likelihood that they're autistic. And this is something that they found that was really interesting. Amongst Kids 3 to 21 percent of children who reported gender identity issues actually have a high degree of autism spectrum disorder or traits. They then

looked at adults because all these different studies. 41 studies are looking at different populations, and what they found is about 4.8 to 7.8 percent of adults with autism with gender identity issues will either have autism or test highly for autistic traits. So, this is kind of interesting because these are actually two separate questions, right? So, asking the question, What percentage of people with Autism Spectrum have gender identity issues? and asking the question, What percentage of people with gender identity issues have autism spectrum? are actually two different questions. And you may wonder, Well, what's the difference? Why is it important? So, let me put it this way. Let's take an alternate consideration for a second, okay? So, let's assume for a moment that we're talking about the correlation between Indians and doctors. There are a lot of Indian doctors, right? So, asking the question, What percentage of doctors are Indian? and What percentage of Indians are doctors? Those are two very separate questions. And the other really important thing is, once we start tunneling down into the correlation, we can start to

understand causation. So, does being a doctor make you more likely to be Indian, or does being Indian make you more likely to be a doctor? And this is really important because we start with sort of correlations, and then what we end up wanting to do is actually looking at causation. So, what's the directional flow here? Which one is it? Does being autistic make you more likely to have gender identity variants, or does having gender identity variance make you more likely to be autistic? So now, what is kind of the significance of this? So, there are a couple of things that I want to share with you all. So, the first is that this study, I think, is important for a couple of really important... This study is important for a couple of reasons. The first is that autism spectrum disorder is a neurodevelopmental disorder, and what that sort of means is that you're not necessarily born with all of the traits of autism. The way that you develop as a human being, if you have autism spectrum disorder, changes.

over time, it's an altered course of development. We also know that gender identity or gender dysphoria also develops over time, right? So, a one-year-old will have a different sense of gender identity than, let's say, a 15-year-old or even a 25-year-old or even a 35-year-old. So, both of these sort of have developmental tracks, and the interesting thing is that since gender identity is developmental and we know that the brains of people with Autism Spectrum Disorder have different neurodevelopmental trajectories, that sort of gives us a clue as to how these two things could interact. The next thing that's really important about this is that it sort of touches on the causes of both of these potential issues. So, this is kind of where we're starting to understand a little bit about genetics and epigenetics. So, in the case of people who have autism spectrum disorder plus gender identity issues, you know, is there one gene that leads to both of these things, or is there like a gene that makes people more

likely to be autistic, which in turn informs the way that they develop their gender identity, or is it some kind of epigenetic phenomenon that sort of that autism spectrum disorder changes the way that we activate our genes, which in turn changes, determines our gender identity. So, it's kind of a really interesting look into the genetic impact or epigenetic impact of the development of both of these things. The third reason why this is really important is because it sort of gives us a clue how these conditions develop, or potentially how to help these people. So, for example, one of the theories that people have posited, which I place a lot of emphasis in just based on my clinical work, is that people with Autism Spectrum Disorder have difficulty mentalizing. So, let's understand what mentalizing is. So, generally speaking, when someone acts, when there's some kind of behavior, human beings have the capacity to understand what is in the mind of someone who performs an action, and that's not only the actions that other people commit, but our own actions. So, for

example: if someone gives me a birthday present, I am able to understand. I'm able to mentalize and think, Okay, this person gave me a birthday present, which means that they care about me. So, if someone, for example, gives me a valentine, I'm able to mentalize and try to understand, Okay, what does this mean about what's going on in the other person's head? So, people with Autism Spectrum Disorder have difficulty mentalizing. Mentalizing doesn't just have to do with external people; it also has to do with internal thoughts. So, people with Autism Spectrum Disorder have difficulty understanding their internal environment and how it shapes their actions. So, this is what leads to a lot of things like social difficulties because they're not really aware of sometimes what they're feeling or experiencing on the inside. In my work with people on the autism spectrum, I've maybe sort of realized how much they look at certain things like social interactions, like mathematical problems, as opposed to sort of empathically or being able to mentalize and sort of

understand it intrinsically, and what we kind of know about gender identity is if you kind of think about it, gender identity is internally determined, right? Especially when we're talking about gender identity variants. So, there are certain physical features that I have that may make me a man, but my sense of being a man is sort of determined somewhat internally. There's an external component, and there's an internal component. And if we have people who struggle to understand their internal state, it sort of makes sense that they would struggle to understand what their gender identity is, because a lot of that comes from actually the inside. So, this is really important because it sort of gives us a clue that if you have autism spectrum disorder and you have gender identity variants, maybe what we need to do is insert some amount of mentalization training. And if we can do that, we can help people sort of figure out what their gender identity is. The last thing, the last reason why this is kind of really important, is that it's actually applicable for the people

involved. So, what that sort of means is that if you are someone who is struggling with gender identity issues and you haven't been evaluated for autism, that may be something that you should really consider doing. If you're someone who struggles, who's been diagnosed with autism or has high levels of autistic traits, and you haven't really explored gender identity issues, but maybe this kind of manifests. This is kind of what I've seen is that people with autism. Sometimes this manifests as difficulties forming relationships, and you may sort of think, Okay, this is a lack of social skills. But sometimes what I've actually found is part of the reason that it's difficult to form romantic relationships is because there's some amount of confusion about my own gender identity. And once that confusion gets resolved, it becomes far easier to engage in significant romantic relationships. So, if you've got autism, you should get gender identity stuff kind of checked out. If you've got gender identity variants, you should potentially get evaluated for autism spectrum disorder. And then the last thing is that if

You're a clinician who's listening to this. I think it's really important because these percentages of comorbidity are incredibly high. Okay, and so what that sort of means is that if you're a clinician who's working with a client who's on the spectrum, it's probably worthwhile to evaluate them for gender identity issues, maybe help them with those issues. And if you're working with someone who's got gender identity issues, it may be worthwhile to evaluate them for autism. Because what we know is that both of these things independently increase the risk of mental distress. And so what we're sort of doing is that some people even hypothesize that these will have a multiplicative effect. And so if you really want to help these people as a clinician, you should really be thinking about both of these things. So this has been a really quick overview of a really interesting meta-analysis that just came out about autism spectrum disorder and gender identity. The big takeaway is that these two things seem to be highly, highly linked.

We're not really sure why, but we're talking about 11 times the population average in terms of what the linkage is. We're not really sure which one comes first. Is it a chicken or egg issue? Does gender identity come first? Does autism spectrum come first? But we can absolutely see some sort of hypotheses why. For example, if you're on the spectrum and you have difficulty mentalizing, why it may be difficult to understand what your gender identity is. And once we sort of understand that, that becomes really important because that gives us a road forward in terms of how to actually resolve these issues, questions. Where can we find the paper? So the paper is, I can give you all the, it's autism spectrum disorder and gender dysphoria incongruence, a systematic literature review published in March of 2022. The primary author is Khalid Sunaki. We'll get around to, okay, what's epigenetic? Great question. So epigenetic is, so we know that genes influence stuff.

epigenetic is the turning on or turning off of genes, so it's not sufficient to have a gene, but there are certain things that will activate a gene and certain things that will turn off a gene. So, if you look at, for example, how trauma affects our cortisol system, our stress response system, what we recognize is that some people who experience some degree of trauma will turn on a bunch of genes. So, if you do a chromosomal analysis of two people, they can have the exact same genes, but one of them can wind up with PTSD and one of them won't. And what's the difference? It's whether the genes are turned on or off. So, what we're sort of starting to realize is it's not enough to just look at chromosomes, right? So, you can't like take an embryo that has 46 chromosomes and determine whether that person has PTSD. What determines whether that person has PTSD is not only the experience but which genes are turned on and which genes are turned off. So, this is a really good

question Soul Dragon Bane is saying why are autism, uh, ASD, and gender dysphoria called comorbidities. Morbid sounds bad, yeah. So, the term morbid has its roots in sort of the assumption of illness, right? And this is something that's really important to understand is that in the medical field and in society, we are grappling with what constitutes a disorder versus is an acceptable normal variant of human beings. So, are people, so when people say we, when we diagnose someone with autism spectrum disorder, we are making an assumption or we're making a value judgment that this is an illness, right? That's why we're calling it a disorder. And so, some people, this is why some of this phrasing around neurodiverse and neurotypical is starting to arise, right? Because people are sort of recognizing that, okay, some of this may not actually be an illness, this may just be a variant of the population. Now, this is where generally speaking the dividing line that we have tends to be in terms of function. So, if I

have someone who has severe autism spectrum disorder, so I've worked with some people like that who are non-verbal, um, you know, are not really able to regulate their emotions, can do a certain amount of like feeding themselves or toileting or things like that, but like need assistance with their ADLs, which are activities of daily living. So like that person, if they were, you know, left in a house by themselves for 30 days, would probably not be able to survive, right? So would that classify as a disorder? I personally think so. Now, if you disagree with that, I'm open to discussion. I'm not saying I'm right there, but I think generally speaking, the way that we define disorders is by impairment of function, and definitely in the case of some autism spectrum disorder patients I've worked with, they're not functional without a substantial amount of help. It doesn't mean that they're good people or bad people or worth less or worth more than other people in society. We're not placing a value judgment on the

value of a human life. What a disorder usually means is how is there is there an impairment of function. It's a great great conversation. So what's the age of people involved in the meta-analysis um so that's a great question too. So the age is variable. That's the whole point of the meta-analysis is that there are some studies that look at kids, some studies that look at adults, and what these people did is look at the differences. So for example, what they found is that children with gender identity variants, there's a 3 to 21 percent chance that they have autism spectrum disorder. But adults have a five to eight percent chance of autism spectrum disorder. And so what does that mean? That's really interesting, right? So we're not entirely sure, but that sort of suggests this neurodevelopmental link that the two conditions, let's just call them that for now, seem to have a developmental aspect to it. So as people grow up and change, the numbers start to change as well. So some things get resolved, some things don't.

what's the most important clinical data to track in private practice as related to this. I think the most important clinical takeaway for me is that oftentimes patients who come in with autism spectrum disorder. It is not a routine part of a clinical evaluation to assess their gender identity, right? So you may assess suicidality or coping skills or communication skills or social interactions, but it is not a routine part, at least as far as I know. I could be wrong. I'm not specialized in, you know, it's not like 99% of my practice or 90% of my practice is autism spectrum disorder. I'm sure that the good clinicians have figured this out, but for other clinicians who have a more general practice, I think the most important clinical takeaway is that if you have a patient with autism, you should consider evaluating them for gender identity issues. And if you have a patient who's got gender identity issues, you should evaluate them for autism traits because then you can work on those things, right? So you can like teach them how to mentalize and things like that.

and that could in turn. So this is kind of the way I'm envisioning it, and I've almost not quite done this, but I've grappled with this before, where a big part of working with people with Autism Spectrum disorders is helping them be comfortable within themselves. And so, a big part of that could be mentalization. And so, the neat thing about that is that, like, if the person with autism spectrum disorder, if you talk to them about their social difficulties, some of that could be rooted in gender identity and, like, some amount of gender identity variants, which makes it hard for them to figure out, like, how they plug into a particular social circle. Wait, wait, how do you communicate poor ADL skills if you are that person who's left by themselves? So, generally speaking, like, there's two kinds of challenges with ADL communicating ADL skills. So, most people who struggle with their ADLs are not, I don't know about most, but many of those, many of the groups of people who struggle with ADLs aren't going to be.

able to accurately communicate them. So let's say that like I've got, you know, something close to anencephaly. So, anencephaly is being born without a brain, which is not really a condition that is conducive with life. But let's say that it is conducive with life. So, that person won't be able to perform ADLs, and that person won't be able to communicate that they can't perform ADLs. Another good example of people who struggle to commit to perform ADLs are people with dementia, like end-stage dementia, and they too won't have awareness to be able to communicate their difficulties with ADLs. Now, there's a lot, a lot of, there's a large group of people who struggle with ADLs and can communicate them. And so, a good example of that is like people who are actively and severely depressed. Sometimes, they struggle with ADLs like showering and grooming and cleaning and feeding themselves and stuff like that. They're more able to communicate them.

just depends on what is the cause of the inability to perform ADLs. How can I tell the difference between severe social anxiety, awkwardness, and ASD? So, this is exactly why we say, like, you know, we have this disclaimer at the beginning, but that's not just a disclaimer. It's not a medical-legal protecting thing. I mean, it does that, sure, but this is why, like, if you're trying to figure out what's the difference between severe social anxiety and autism spectrum disorder, that's absolutely, you should go see. It's not something for you to tell the difference. I'm not saying that you can't learn about it and have some insight, but that's really the job of a clinician. So, if you're trying to figure out, do I have diagnosis A or do I have diagnosis B, I'd say the most efficient way to answer that question is to go see someone who understands the difference and nuance between the two. The other alternative is, I suppose, you could go become a psychiatrist, and then you would know the

difference, and then you would be able to self-diagnose conceivably, but I don't think you need to invest eight years of your life in order to do that. I just go see a professional. Great question though. How do you tell when a teenager client is making up gender issues? I don't know that I would. I don't agree with the premise of the question. So making up implies some degree of objective reality, right? So like, sometimes they're making it up and sometimes they're not. There are ways to assess things. So you could, for example, assess malingering around gender identity disorder. So like, you could assess for that. You could also administer some scales that measure the levels of gender identity disorder and things like that. So there are some tests that you can do to sort of see, okay, like, is this person making it up or not? So there are some ways to evaluate that. I don't know that that's usually the first place that I would go though if I was working with a teenager who sort of

is quote unquote making up gender issues. If they came to me and said, Hey, I have gender identity issues, I'd explore that with them. And this is where, like, I don't know if this makes sense, but calling them fakers does not usually resolve the issue. So, if someone is making up gender identity issues, that's usually meeting some kind of psychological need. And if you point out to the person, Hey, you're faking it, what's going to happen is they're just gonna morph into something else that meets the psychological need. So, the right way to kind of handle it, in my opinion, is to actually, like, help me understand what's going on with your gender identity and, like, what's happening there, and to try to actually support them psychologically. And oftentimes, when you provide support to people with gender identity issues, those issues will resolve. And by resolve, I don't mean that they go away. I mean that you can, by supporting someone who is going through the process of discovering what their gender identity is, you can

help them arrive at a conclusion, which is ultimately the goal, right? That's like, that's the goal is I don't, I'm non-binary, okay? Is that, are you not sure if you're male or female, or are you neither male nor female? There's a difference between a question mark and slotting into one of those categories, and I think the right way to support a teenage client who's saying, I have a question mark, is to try to figure out, Okay, what's going on there? and help that person slot into one of the buckets in sort of a healthy way. And as part of that, you may discover that, Okay, this person seems to be malingering, and they're sort of saying this kind of stuff off because of something else going on in their life, which happens, but then you want to address that, right? You don't want to say, Hey, you're faking it, because then what will happen is they'll just start faking something else. Make sense?

Are Autism and Gender Identity Connected? A Psychiatrist Explains

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Are Autism and Gender Identity Connected? A Psychiatrist Explains

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