Jul 182016

Transgender youth are a special population. Because of the relative novelty of treatment at any age much less for youth, data are scarce. A recent review article examining the published data on transgender youth was published. Let’s take a look at what they found.

First, how about prevalence? How many youth self identify as transgender? There are very, very, few studies that get good numbers on this. One study in New Zealand found that 1.2% of secondary school children identified as transgender, and 2.5% weren’t sure about their gender.

As we well know, being a gender and sexual minority can often be associated with health disparities. And this review reports on that too. Identifying as transgender was associated with negative psychological health. Specifically, being bullied, having symptoms of depression, attempting self harm, and attempting suicide were all more common in transgender youth than in cisgender youth. How much of that was because of discrimination and how much was because of gender dysphoria was not explored.

Researchers have also found that being transgender and having autism appear to go together. No one is quite sure why yet. There’s still a lot of research to be done to figure that out.

One interesting difference in the literature stands out to me, though. It appears that transgender men are more likely to self harm and transgender women are more likely to be autistic. Among cisgender people, cis women are more likely to self harm and cis men are more likely to be autistic. There are theories for why that sex difference exists, but there’s little to no agreement. It could be related to social environments, hormones, the environment in the womb, or any number of other factors. But the observation that transgender men and women more resemble their sex than their gender for self harm and autism is worth investigating further.

What about the effects of hormone therapy for transgender youth? Especially puberty suppression, which is the unique factor for their treatment? As a reminder, the treatment of transgender youth is largely based on the Dutch model. At puberty, children go on puberty suppressing drugs. They then go on hormones (and thus begin puberty) at age 16 and are eligible for surgery at age 18. There are efforts to deliver cross-sex hormones earlier, but the Dutch model is the standard that most of the research is based on. A Dutch study found that the psychological health of transgender youth improved after surgery. Their psychological health even equalled that of their cisgender peers! The researchers also found that youth continued to struggle with body image throughout the time they were on puberty suppression only. But their self-image improved with hormone therapy and surgery. None of the children regretted transitioning. And they said that social transition was “easy”.

One challenge to that particular Dutch study is that the Dutch protocol excludes trans youth who have significant psychiatric issues. A young person with unmanaged schizophrenia, severe depression, or other similar issue wouldn’t be allowed to start hormones. So the research was only on relatively psychologically healthy youth to begin with. It’s difficult to say if that had an effect on the study’s results. It’s also difficult to say whether the psychological health of a trans youth is the cause or the result of their dysphoria. A trans youth with depression might well benefit from hormone therapy, after all.

There are multiple questions still unresolved when it comes to treating transgender children. Does puberty suppression have a long term effect on their bones? Are there long-term physical or psychological health effects of early transition? How should children with serious psychological conditions be treated (besides the obvious answer — with compassion)? And on, and on.

The medical and scientific communities are working on answering these questions. But it will take time. And in the mean time — physicians and families do they best they can with what information we have. If you have, or are, a transgender youth please consider participating in a study so we can do even better for children in the future.

Want to read the review for yourself? The abstract is publicly available.

Mar 212016
Rainbow infinity symbol -- representing the diversity and spectrum of autism

Rainbow infinity symbol — representing the diversity and spectrum of autism

Recent evidence suggests that there may be an association between autism spectrum disorders and being transgender. What started as an observation made by a few physicians is now gaining evidence in peer-reviewed research. This week, I take a look at a new research paper that shares new data on the association.

First, some background. Autism is a spectrum of disorders. The core is difficulty with social interactions along with repetitive or restricted interests or behaviors. People with autism lack an innate sense of the “socially correct” thing to do. They may struggle to see the world from other people’s perspectives. People with autism are often said to think in a “quirky” manner, different from many people. At its most severe, an individual with autism can be unable to take care of him or herself. They may be profoundly mentally disabled and need life-long care. At its least severe, a person with autism can be a socially awkward but brilliantly intelligent scientist. They may make critical breakthroughs because of that “quirky” thinking.

So — did this study find that trans people were more likely to be autistic? Or that people with autism are more likely to be trans? It’s more subtle than that. Let’s look at the methods…

This study reviewed the medical records of roughly 2,000 children in a specific center in New York. Roughly 3/4 did not have autism. The other 1/4 were diagnosed with autism. They did not have a subgroup of individuals who were diagnosed as transgender. Instead, they looked at a specific question on a standardized clinical survey that had been used with all the children. The question asked the children to agree or disagree with the statement: “I wish to be the opposite sex”.

(edit, 3/23/16: For clarity’s sake, “I wish to be the opposite sex” is different from “I am the opposite sex” or “I should have been the opposite sex”. Different trans, genderqueer, or gender non-conforming people may agree with those different statements differently.)

So they were specifically looking at non-autistic and autistic children and asking: “Are autistic children more likely than non-autistic children to report desiring to be the opposite sex?” Technically, this isn’t the same thing as a diagnosis of gender dysphoria or transgender. The authors describe it more as “gender variance” — a pretty good description. And a decent approximation since they could’t go back to get the children an official diagnosis.

What did they find?

5.1% of the children with autism said that they did wish to be the opposite sex. Only 0.7% of non-autistic children said that they wished to be the opposite sex. It didn’t matter whether the children were assigned males or females at birth. It also didn’t matter what age they were.

That’s a huge difference. That means autistic children are 7.76 times more likely to have some gender variance.

Why might autism and gender dysphoria (transgender) be associated? We don’t know why some people are autistic, and we don’t know why some people are trans. The authors hypothesize about the effects of common environmental effects, like birth weight and autism severity.

I wonder if it has to do with some of the different ways that people with autism think. People with autism tend to think differently about the world from people without autism. They often report a sensation that they are strangers or aliens, somehow apart from the rest of the world because of that difference of thinking and perceiving. That sense of alienation can extend to one’s body. People with autism are also less likely to perceive or care about culturally defined sex roles (e.g., only girls wear dresses). Perhaps these differences play a role? I’m only hypothesizing here. If any trans people with autism would like to share their thoughts, please let me know in the comments or send me an e-mail.

Regardless, it’s slowly becoming clear as more and more papers are published that people with autism are more likely to be transgender than people without autism. It’s time we took a good look at the association and made sure that medical and psychological health care is available and appropriate for these populations.

Want to read the study for yourself? It’s publicly available from the journal Transgender Health.