Gender Histories, Life Experiences, and Future Plans and Hopes of Gender Dysphoric Autistic Youth: A Framework Analysis

Background: Despite evidence that autism spectrum disorder (ASD) and gender dysphoria (GD) commonly co-occur, no studies to date have captured the life experiences and perspectives of autistic gender dysphoric youth through their own voices.

Objectives: Identify primary themes in the lived experiences and ambitions of gender dysphoric autistic youth. Reduce researcher bias through participatory methods including the involvement of key stakeholders in the qualitative data analytics.

Methods: We conducted 22 semi-structured clinical interviews of adolescents and young adults (age 12-20 years) who met DSM-V criteria for ASD and current (N=20) or historical/desisted (N=2) GD. 64% of participants were assumed male at birth, and 36% were assumed female at birth, paralleling population-based sex ratios in ASD. Data was analyzed using framework analysis, which systematically analyzes qualitative data in a 5-step process (Ritchie et al., 2003; Bargiela et al., 2016): familiarization with the data, identification of the thematic framework, indexing of statements and related units into the thematic framework, graphic representation of the data and distribution of the participants’ responses, and final analysis. The analytic team included key stakeholders (autistic, transgender, and autistic-transgender self-advocates).

Results: The framework analytic process categorized 92% of participant responses, revealing eight categories of thematic statements: feelings about gender and body, gender in social situations, gender discernment, needs, future plans and ambitions, meeting other gender-spectrum people, the existence of bias, and the experience of being both neurodiverse and gender diverse. Twenty-three subthemes were identified under the criterion of >25% participant endorsements. Theoretical saturation for themes and subthemes occurred at 6 participants (van Rijnsoever, 2017). Almost all participants noted that expressing interests and behaviors of the other gender was not enough for them, and that they needed to live as their affirmed gender (i.e., transgender). Further, most indicated that their gender experiences were not related to anxiety about puberty, noting that they wished to go through the puberty of their affirmed gender. About half of the participants described their gender expression as somewhat non-traditional/non-gender binary. Nearly three-quarters described their gender identity as coming into focus over time through development; a similar number of participants believed that their affirmed gender would remain constant in the future. One-quarter of participants discussed the possibility that their gender identity might change in the future (i.e., gender dysphoria desistence). A majority of youth reported that their worries about societal disapproval of transgender and gender diverse people inhibited their gender expression and exploration of gender identity.

Conclusions: Numerous similar life experiences, perspectives, and ambitions emerged among gender dysphoric autistic youth. In directly capturing the perspectives of these individuals, this study gives voice to a previously unheard population. Results are relevant to gender and autism clinicians and researchers, given that up to one quarter of adolescents referred for gender dysphoria have significant co-occurring autism characteristics.