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Letter to the Editor

Autism and Gender Dysphoria: Searching for the Holy Grail

Ahmed Naguy, MBBch, MSc

Published: March 5, 2020

Autism and Gender Dysphoria: Searching for the Holy Grail

To the Editor: Empirical reports1-3 indicate that gender dysphoria is overrepresented in the autism spectrum disorder (ASD) population. Pasterski et al1 found that 7.1% of women and 4.7% of men with gender dysphoria met diagnostic criteria for ASD on the Autism Spectrum Quotient. Strang et al2 measured gender variance and found it to be 7.59 times higher in the ASD population than in the 2 nonreferred comparison groups in the study. Bejerot and Eriksson3 found a gender-atypical pattern in 50 adults with ASD compared to 53 typically developing individuals. Here, I attempt to speculate on the link between ASD and gender dysphoria.

Hormonal factors might be at play. Lower levels of the sexually dimorphic sex hormone, anti-Mullerian hormone, have been tied to increased ASD symptoms in males.4 Anti-Mullerian hormone is thought to impact the masculinization or defeminization of the male fetus.5 Moreover, the extreme male brain theory of ASD6 posits that fetal testosterone (fT) is a strong candidate for contributing to sexually dimorphic cognition and behavior and might present as a risk factor for conditions characterized by social impairments such as ASD. High levels of fT are positively correlated with autistic traits and masculinizing neural development.7 Similarly, evidence suggests that excess prenatal testosterone exposure increases the odds of a homosexual orientation in men.8 Studies looking into somatic features, eg, finger length ratios9 and male genitalia proportions,10 tend to support this notion.

Furthermore, Parker and Asher11 have shown that early positive social interactions are crucial to the development of higher-order social sills, which are central to the development of gender role and sexuality. Given social deficits in ASD, establishment of gender identity could become complex. Theory of mind deficits in ASD might further explain the inherent difficulty to view oneself as belonging to a gender group.

At times, gender dysphoria in ASD is "counterfeit." Sensory issues (eg, haptic) might derive gender dysphoria behavior. A male might feel more comfortable in glittery and silky fabrics for instance. Gender relies on semantic factors; hence, language delay in childhood in ASD might interfere with a developing sense of gender-related discourse and behavior. Also, gender dysphoria might be part of the restricted and repetitive behaviors seen in ASD. Thus, unusual preoccupation with transvestism, for instance, might be a reflection of circumscribed interests, preoccupations, or attachments in ASD rather than bona fide gender dysphoria.

Ahmed Naguy, MBBch, MSca

aAl-Manara CAP Centre, Kuwait Centre for Mental Health, Jamal Abdul-Nassir St, Shuwaikh, State of Kuwait

Potential conflicts of interest: None.

Published online: March 5, 2020.

Prim Care Companion CNS Disord 2020;22(2):19l02492

To cite: Naguy A. Autism and gender dysphoria: searching for the holy grail. Prim Care Companion CNS Disord. 2020;22(2):19l02492.

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© Copyright 2020 Physicians Postgraduate Press, Inc.


1.Pasterski V, Gilligan L, Curtis R. Traits of autism spectrum disorders in adults with gender dysphoria. Arch Sex Behav. 2014;43(2):387-393. PubMed CrossRef

2.Strang JF, Kenworthy L, Dominska A, et al. Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Arch Sex Behav. 2014;43(8):1525-1533. PubMed CrossRef

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7.Auyeung B, Baron-Cohen S, Ashwin E, et al. Fetal testosterone and autistic traits. Br J Psychol. 2009;100(pt 1):1-22. PubMed CrossRef

8.Hines M. Prenatal endocrine influences on sexual orientation and on sexually differentiated childhood behavior. Front Neuroendocrinol. 2011;32(2):170-182. PubMed CrossRef

9.Robinson SJ, Manning JT. The ratio of 2nd to 4th digit length and male homosexuality. Evol Hum Behav. 2000;21(5):333-345. PubMed CrossRef

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