Society has a way of looking at behaviors and labeling them with terms. This has given rise to many debates that denote our evolving understanding of the terms themselves as well as of the behaviors that define them. Terms such as gender and sex that were once used interchangeably now make reference to distinctive entities. It is important to understand these differences.
At present, the basic societal perception is that gender is a reflection of both practiced behaviors and feelings rather than inherited biological characteristics. In modern society, one term does not fit all, nor can it be inclusive of all sexual preferences. Indeed, the indiscriminant use of the term gay, was abandoned in the late 1980’s for more specific ones. The terms now used reflect a better understanding of human diversity, e.g., lesbian, gay, bisexual, and transgender. These terms have melted together into the acronym LGBT with some proposals expanding the descriptor to include queer, questioning, asexual, and intersex individuals.
The prevalence of LGBT among autistic individuals has not been properly studied. The first case of gender identity disorder (now called gender dysphoria) in autism was reported in the 1990’s (Landen and Rasmussen, 1997). Ever since, most of the literature has been confined to case reports. Indeed, most of the available information comes through anecdotal reports on the internet. A Google search (1/16/19) using as key terms both autism and LGBT reveled 9,530,000 results in .45 seconds. High on the list of views are sites such as “Twainbow” (people living under a double rainbow), “Sexual Orientation, Gender Identity and Asperger”, and “Dual Spectrums”. A screening survey using the Sell Scale of Sexual Orientation suggests that individuals with ASD report increased homosexuality, bisexuality, and asexuality as compared to neurotypicals (George and Stokes, 2018). Most observations seem confined to children or younger adults with a dearth of literature involving older individuals (Glidden et al., 2016).
Before we proceed with our discussion, it will be helpful to clarify the meaning of some of the terms used. In the majority of cases, sexual orientation and personal identity match with their biological sex. This is called cisgender, commonly abbreviated as cis. A female (biological sex) that identifies herself as a female is cis gender. However, this cis gender individual may be attracted to other women, meaning she is a cisgender lesbian. The opposite, when personal identity does not match with birth sex, is called transgender. The T in LGBT acronym denotes transgender. A trans man, for example, is somebody who may have been identified biologically as a woman at birth but who identifies herself as a man. On the other hand, non-binary or gender queer, are those individuals who may feel that, sometimes, they are at different places along the gender spectrum.
Illustration: The Genderbread Person is a model for better understanding the social construct of gender.
Illustration: Jazz Jennings is probably the most famous transgender teen. She has publicized her experiences in a book, “Being Jazz: My Life as a (transgender) Teen”. Jazz’s biological sex was male at birth but identifies herself as a female. Her parents were extremely supportive and very public with her transition process.
Some trans people, but not all, exhibit a gender conflict (dysphoria). The term denotes a state of distress or discomfort with one’s own body. Although conflicts with one’s gender may be normal, when the feelings are persistent, consistent, and insistent they may amount to a mental health condition affecting the way you relate to others and the ability to cope with everyday life. In children one often has to wonder whether feelings of gender incongruence are a normal part of development. Exploration of the other gender is common in prepubertal children and typically resolves by late adolescence.
Recognizing these feelings is of importance in our ASD population. A significant portion of LGBT individuals are verbally, physically and/or sexually harassed. Perpetrators may be family members, peers, teachers, coaches, employers or police. Childhood sexual abuse in LGBT people is linked to a variety of future health challenges including: HIV, substance use, poor mental health, and sexual re-victimization. Lesbian, gay, and bisexual adolescents are more likely to engage in binge eating or report using laxatives to control weight. Between 30 and 40% of homeless youth seeking shelter identify themselves as LGBT. More importantly, about 40% of trans people will attempt suicide at some point in their lifetime.
LGBT individuals may receive pre-exposure prophylaxis (or PrEP, an antiretroviral therapy) in order to lower their chances of getting infected with HIV. Daily PrEP decreases the risk of getting HIV by more than 90%. Among those that use drugs it reduces the chances by more than 70%. Physicians can follow adherence to the medication by measuring blood levels. Before starting treatment a physician will have to document negative HIV status, and normal renal function. Patients receiving this therapy need to be followed-up at least every 3 months (e.g., test for bacterial STD symptoms and renal function)
There are many gender bender resources available that may help a youth on his journey. A list of them can be found at LGBTQ Resources http://genderbenders.org/resources.html The links provide references for a hotline as well as a list of friendly general practitioners, attorneys, and more.
George R, Stokes MA. Sexual orientation in autism spectrum disorder. Autism Res 11(1):133-141, 2018.
Glidden D, Bouman WP, Jones BA, Arcelus J. Gender dysphoria and autism spectrum disorder: a systematic review of the literature. Sex Med Re 4(1):3-14, 2016.
Landen M, Rasmussen P. Gender identity disorder in a girl with autism- a case report. Eur Child Adolesc Psych 6(3):170-3, 1997.
You can obtain more information about gender related issues on our previous blog: Autism: Screening for Potential Health Problems. (https://corticalchauvinism.com/2018/12/17/autism-screening-for-potential-health-problems/)