Autism Spectrum Disorders in Gender Dysphoric Children and Adolescents

Abstract

Only case reports have described the co-occurrence of gender identity disorder (GID) and autism spectrum disorders (ASD). This study examined this co-occurrence using a systematic approach. Children and adolescents (115 boys and 89 girls, mean age 10.8, SD = 3.58) referred to a gender identity clinic received a standardized assessment during which a GID diagnosis was made and ASD suspected cases were identified. The Dutch version of the Diagnostic Interview for Social and Communication Disorders (10th rev., DISCO-10) was administered to ascertain ASD classifications. The incidence of ASD in this sample of children and adolescents was 7.8% (n = 16). Clinicians should be aware of co-occurring ASD and GID and the challenges it generates in clinical management.

Full text

ORIGINAL PAPER
Autism Spectrum Disorders in Gender Dysphoric Children
and Adolescents
Annelou L. C. de Vries •Ilse L. J. Noens •
Peggy T. Cohen-Kettenis •Ina A. van Berckelaer-Onnes •
Theo A. Doreleijers
Published online: 22 January 2010
ÓThe Author(s) 2010. This article is published with open access at Springerlink.com
Abstract Only case reports have described the
co-occurrence of gender identity disorder (GID) and autism
spectrum disorders (ASD). This study examined this
co-occurrence using a systematic approach. Children and
adolescents (115 boys and 89 girls, mean age 10.8,
SD =3.58) referred to a gender identity clinic received a
standardized assessment during which a GID diagnosis was
made and ASD suspected cases were identified. The Dutch
version of the Diagnostic Interview for Social and Com-
munication Disorders (10th rev., DISCO-10) was admin-
istered to ascertain ASD classifications. The incidence of
ASD in this sample of children and adolescents was 7.8%
(n=16). Clinicians should be aware of co-occurring ASD
and GID and the challenges it generates in clinical
management.
Keywords Autism spectrum disorder 
Gender identity disorder Co-occurrence Incidence
Gender dysphoria is the distress resulting from an incon-
gruence between assigned and experienced gender. The
official DSM-IV-TR diagnosis of gender identity disorder
(GID) is characterized by a strong and persistent cross-
gender identification as well as a persistent discomfort with
one’s biological sex and a sense of inappropriateness in the
gender role of that sex (American Psychiatric Association
2000). Estimates of GID in adults range from 1:10,000 to
1:20,000 in men and 1:30,000 to 1:50,000 in women (for a
review, see Zucker and Lawrence 2009). Prevalence rates
of autism spectrum disorder (ASD) in various recent
studies are generally in the range of 60 per 10,000 (for a
review, see Fombonne 2005) although some studies report
a prevalence above 1% (e.g. Baird et al. 2006). With the
reported prevalence rates of ASD and GID, the random co-
occurrence of both would be extremely rare. However,
gender identity clinics are now reporting an overrepresen-
tation of individuals with ASD in their referrals (Robinow
and Knudson 2005). The putative co-occurrence is not only
relevant for diagnostic and clinical management reasons,
but it also raises important theoretical questions if, indeed,
there would be evidence for co-occurrence.
To date, however, studies using systematic measures on
this co-occurrence have not been published. The literature
on the co-occurrence of ASD and gender dysphoria con-
sists of seven papers describing nine case histories of
individuals with ASD and concomitant gender identity
problems, mostly children (Gallucci et al. 2005; Kraemer
et al. 2005; Landen and Rasmussen 1997; Mukaddes 2002;
Perera et al. 2003; Tateno et al. 2008; Williams et al.
1996). Authors show various perspectives in how to
understand the co-occurrence of ASD and gender dys-
phoria. Some of them state that gender dysphoria and
autism can be truly co-occurring disorders (Mukaddes
2002; Tateno et al. 2008). Others assume that cross gender
A. L. C. de Vries (&)T. A. Doreleijers
Department of Child and Adolescent Psychiatry, VU University
Medical Center, PO Box 7057, 1007 MB Amsterdam,
The Netherlands
e-mail: alc.devries@vumc.nl
I. L. J. Noens
Child Welfare and Disabilities, Department of Educational
Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
P. T. Cohen-Kettenis
Department of Medical Psychology, VU University Medical
Center, Amsterdam, Netherlands
I. A. van Berckelaer-Onnes
Department of Educational Sciences, Leiden University, Leiden,
The Netherlands
123
J Autism Dev Disord (2010) 40:930–936
DOI 10.1007/s10803-010-0935-9

behavior results from the inherent predisposition toward
unusual interests characteristic of ASD (Williams et al.
1996). It is also suggested that gender dysphoria in indi-
viduals with ASD may be considered an obsessive com-
pulsive disorder, separate from both ASD and GID
(Landen and Rasmussen 1997; Perera et al. 2003).
In sum, the co-occurrence of gender dysphoria and ASD
is of current clinical interest. This study was conducted to
establish the incidence of ASD in gender dysphoric chil-
dren and adolescents, and to describe the specific clinical
characteristics of individuals with both gender dysphoria
and ASD.
Method
Participants
Participants were 231 children and adolescents who had
been referred to the Gender Identity Clinic of the VU
University Medical Centre in Amsterdam between April
2004 and October 2007. This is the only clinic in the
Netherlands with a multidisciplinary team examining
gender dysphoric children and adolescents. Nineteen chil-
dren and eight adolescents were excluded from the study
because they were not able to complete the assessment
procedure. Reasons were cessation of the gender identity
problems at the time of assessment (in some cases due to
the waiting list), or serious other psychopathology making
a referral to a local mental health clinics necessary and
completing the assessment not possible. This resulted in a
study group consisting of 108 children (mean age 8.06,
SD =1.82) and 96 adolescents (mean age 13.92,
SD =2.29) consecutively assessed of whom 11 ASD
suspected children and 15 ASD suspected adolescents were
identified.
Procedure
All 204 individuals received a standardized clinical
assessment, according to the Standards of Care of the
World Professional Association for Transgender Health
(Meyer et al. 2001). A separate protocol is followed for
children under the age of 12 and adolescents between age
12 and 18, respectively. It includes psycho-diagnostic
interviews with the child or the adolescent, interviews with
the parents about topical functioning as well as the devel-
opmental history of the child or adolescent, psychological
testing by a trained psychometrist and collection of school
information (for a detailed description of the clinical pro-
cedure and used instruments, see Cohen-Kettenis 2006).
Persistence of the gender dysphoria of the children and
adolescents with ASD was evaluated in 2008 or 2009,
which was at least 1 year and in some cases 4 years after
the initial assessment. The clinical files were evaluated for
those individuals who still attended the gender identity
clinic. If no recent information was available, the parents
were called.
The study was approved by the Ethical committee of the
VU University Medical Centre. Informed consent was
obtained from the parents as well as the adolescents age 12
and older.
Measures
Intelligence
IQ was assessed by use of the Dutch versions of the
Wechsler Intelligence Scale for Children or the Wechsler
Adult Intelligence Scale depending on the participant’s age
(Wechsler 1997; Wechsler et al. 2002).
Autism Spectrum Disorders
ASD suspected children and adolescents were identified by
discussing potential characteristics of ASD of all new
referrals in weekly team meetings. Further diagnostic
assessment for ASD was considered when either earlier
reports suggested an ASD or the examining psychologist or
psychiatrist (first author AV) suspected an ASD. Parents or
caregivers of ASD suspected individuals were then invited
for a diagnostic ASD interview. ASD diagnoses were
confirmed using the Dutch version of the Diagnostic
Interview for Social and Communication Disorders-10th
revision (DISCO-10 Wing 1999; Dutch version Van
Berckelaer-Onnes et al. 2003). The DISCO-10 was chosen
for its particular effectiveness for diagnosing disorders
within the broader autism spectrum. The DISCO is a semi-
structured 2–4 h interview. Its algorithms enable to
investigate whether the necessary criteria of different
diagnostic systems for ASD are met. During the interview,
answers to over 300 questions are coded for computer
entry. Inter-rater reliability for the items in the DISCO
interview were high, with a kappa coefficient or intra-class
correlation at .75 or higher achieved for over 80% of the
interview items (Wing et al. 2002). The DISCO-10 was
administered by two of the authors (IvBO or IN), who were
formally trained in the use of the DISCO-10. The diag-
nostic algorithms that were used in the current study reflect
DSM-IV-TR and ICD-10 criteria for Pervasive Develop-
mental Disorders (American Psychiatric Association 2000;
World Health Organization 1993). From the DISCO-10,
one obtains an ‘ever’ diagnosis, which is retrospective, as
well as a ‘current’ diagnosis, with ‘ever’ including ‘cur-
rent’. In the current paper, only ‘ever’ diagnoses are
reported.
J Autism Dev Disord (2010) 40:930–936 931
123

Gender Dysphoria
Based on the DSM-IV-TR criteria, children and adoles-
cents were classified as GID, the subthreshold GID not
otherwise specified (GID-NOS) or no GID (APA 2000).
Additionally, the list of Dimensional Diagnostic Criteria of
the GID (DDC-GID) was used. This list was constructed by
one of the authors (PCK) and describes DSM-IV-TR sub-
criteria of the GID A and B criterions (cross-gender iden-
tification and discomfort with his or her sex, respectively).
Each sub-criterion can be rated dimensionally with regard
to strength, persistence, and duration. Whether criterion A
and B are fulfilled remains a clinical decision. Criterion C
is an exclusion criterion (no intersex condition). Criterion
D (the behavior should reveal clinically significant distress
or impairment) may range from no distress, mild distress to
strong distress (or unclear) in social, occupational, family
or other areas of functioning. GID diagnostic criteria of the
individuals who had received a DISCO interview were
specified (e.g. sexual orientation, history of childhood
GID) by making use of the DDC-GID. Clinical consensus
was met for each case by the first author (AV) and one of
the other members of the gender identity clinic team for
children and adolescents.
Analyses
Incidence of ASD in the referred children and adolescents
was calculated by the percentage of DISCO-confirmed
ASD diagnoses in the total number of referrals of children
and adolescents separately as well as in the combined
sample. Fisher exact tests were used to analyze differences
in incidence of individuals with ASD in individuals with
GID compared to individuals with GID-NOS.
Independent t-tests were used to ascertain differences in
age and IQ between all referred children and adolescents
with and without an ASD.
Specific clinical characteristics and follow-up reports of
the gender dysphoria were collected from the clinical files
and described with regard to GID classification, ASD
classification, age of onset of GID, the persistence of a GID
diagnosis at follow-up, and, for the adolescents, sexual
orientation.
Results
Children
According to the DISCO algorithms, seven (six boys, one
girl) of the 11 ASD suspected children had ASD. The inci-
dence of ASD in all 108 assessed children (70 boys, 38 girls)
was 6.4% (n=7). The incidence of ASD in the 52 children
with a GID diagnosis was 1.9% (n=1), which was signifi-
cantly lower than the incidence of 13% (n=6) of ASD in the
45 children with a GID-NOS (gender identity disorder not
otherwise specified) diagnosis (p\.05). In the 11 children
with no GID diagnosis, none had ASD.
The mean age of children with ASD (M=9.1, SE =0
.47) was not significantly different from the children
without ASD (M=8.0, SE =0.18, t=-1.63, df =106,
p=0.11). The mean IQ (M=82.00, SE =3.74) of the
children with ASD was significantly lower compared to the
mean IQ of the children without ASD (M=103.92,
SE =1.18, t=4.88, df =101, p\.001).
Table 1presents the specific clinical characteristics of
children with co-occurring GID and ASD. Most remark-
able results were that six of the seven children with GID
and ASD were male, all seven children fulfilled the strict
criteria of autistic disorder, and in six of the seven children
the gender dysphoria had alleviated when outcome was
evaluated at least 1 year after the initial assessment.
Adolescents
According to the DISCO algorithms, nine (six boys, three
girls) of the 15 ASD suspected adolescents had ASD. The
incidence of ASD in all 96 assessed adolescents (45 boys,
51 girls) was 9.4% (n=9). The incidence of ASD in the
77 adolescents with a GID diagnosis was 6.5% (n=5),
which was significantly lower than the incidence of 37.5%
(n=3) of ASD in the eight adolescents with a GID-NOS
diagnosis (p\.05). In the 11 adolescents with no GID
diagnosis, one suffered from ASD and transvestic fetishism
but no gender dysphoria.
The mean age of the adolescents with ASD (M=15.41,
SE =0.65) was significantly higher than the adolescents
without ASD (M=13.77, SE =0.24, t=-2.09,
df =94, p\.05). The mean IQ of adolescents with an
ASD (M=89.88, SE =5.52) was not significantly dif-
ferent from the mean IQ of the adolescents without ASD
(M=96.67, SE =1.72, t=1.20, df =85, p=.23).
Table 2presents the specific clinical characteristics of
the adolescents with co-occurring GID and ASD. Most
remarkable results were that six of the nine adolescents
fulfilled the strict criteria of autistic disorder (the other
three Asperger’s disorder), four adolescents were eligible
for sex reassignment, of whom two were female, but none
of them as yet had their sex reassignment surgery. Two
adolescents dropped out of care, of whom one was reported
to have sex reassignment surgery abroad.
Children and Adolescents Combined
The incidence of ASD in the combined sample of children
and adolescents was 7.8% (204 individuals, 115 boys and
932 J Autism Dev Disord (2010) 40:930–936
123

89, mean age 10.8, SD =3.58). The incidence of ASD in
the combined sample of 129 individuals with a GID
diagnosis was 4.7% (n=6), which is significantly lower
compared to the incidence of 17.0% (n=9) of ASD in 53
individuals with a GID-NOS diagnosis (p\.05).
Discussion
The incidence of 7.8% ASD in gender identity clinic
referred children and adolescents is ten times higher than
the prevalence of 0.6–1% of ASD in the general population
(Baird et al. 2006; Fombonne 2005). This important finding
confirms the clinical impression that ASD occurs more
frequently in gender dysphoric individuals than expected
by chance.
Most remarkable in the clinical presentation of indi-
viduals with co-occurring GID and ASD in this study was
the considerable diversity concerning: sex (both male and
female), GID classification (GID, GID-NOS, transvestic
fetishism), ASD classification (autistic disorder, Asperger’s
disorder), age of onset of GID (before or after puberty),
and the persistence of cross-sex behavior (ceasing or
persisting).
The overrepresentation of males in our study is in
accordance with the epidemiology of both ASD and GID
(Fombonne 2005; Zucker and Lawrence 2009). Studies in
girls with congenital adrenal hyperplasia, who are prena-
tally exposed to high levels of testosterone, showed that
they had more traits of ASD than controls and some
developed gender identity problems (Dessens et al. 2005;
Knickmeyer et al. 2006). However, the idea that prenatal
testosterone may be involved in the vulnerability to both
ASD and gender dysphoria, seems not applicable in our
sample. In that case, especially girls with ASD would have
been susceptible to develop gender dysphoria. In addition,
Table 1 Demographic and clinical characteristics of children diagnosed with both GID and ASD
No Sex Age IQ ASD
classification
GID
classification
GID symptoms: history At time of assessment Follow-up
1 Boy 7 88 Autism
a
GID-NOS
b
From toddler age on,
fascinated by jewelry,
girls’ toys, female bodies
(mother)
Seems to get sexually aroused
by touching women’s breasts
and dressing up
No GID
c
; at age 10, no female
preferences anymore, still
attracted to female bodies
with some sexual arousal
2 Boy 8 108 Autism GID-NOS Obsessive dressing up as a
girl, wearing high heels,
interested in make-up
No further interests in girls’
toys, no wish to be a girl
No GID; at age 10, obsessive
dressing up reduced by
behavioral program, still
wearing high heels
3 Boy 9 69 Autism GID-NOS From toddler age on,
playing with dolls,
dressing-up in robes, high
heels, make-up
Likes cars as well, but rather
wants to be a girl
No GID; at age 12 happy
being a boy, but still female
behavior resulting in
difficulties with peers
4 Boy 9 75 Autism GID-NOS From toddler age on
fascinated by mermaids,
fairy tales, dolls, ballet,
dressing-up, did not like
his penis
No interest in dolls and
dressing up any more, now
fascinated by nature and
culture, still liking ballet and
theatre
No GID; at age 10, no explicit
wish to be a girl
5 Boy 10 95 Autism GID From toddler age on
interested in dolls,
dressing up, pink, wishes
to be a girl
Wearing girl’s clothes
restricted, but looks and
behaves like a girl with long
hair and bright colored
clothes
Persisting GID; at age 12,
explicit wish to be a girl
6 Boy 10 72 Autism GID-NOS From toddler age on,
fascinated by music,
dancing, dressing up,
glitter, long hair, girls’
clothes
Still interested in music and
girls’ clothes, but does not
want to be a girl
No GID; at age 12, no female
preferences, likes music,
happy being a boy
7 Girl 10 81 Autism GID-NOS From toddler age on, only
wearing trousers, short
hair, playing with boys’
toys
Hates being a girl, but being
called a boy irritates her,
anxiety about any medical
intervention
No GID; at age 13, happy
being a ‘tomboy’ girl
a
Autism autistic disorder
b
GID-NOS gender identity disorder not otherwise specified
c
GID gender identity disorder
J Autism Dev Disord (2010) 40:930–936 933
123

why gender dysphoria and ASD co-occur in males is
unexplained by prenatal androgen exposure. This finding
adds to the lack of experimental evidence for a link
between low testosterone and GID in males.
Symptoms of GID displayed by individuals with ASD
varied substantially. Individuals with an ASD frequently
received a GID-NOS diagnosis. GID-NOS appeared to be
given when the cross gender behavior and interests were
merely subthreshold (mostly in children), or atypical or
unrealistic. For example, an adolescent with ASD, who
always had the feeling of being different from his peers in
childhood, but had no history of childhood cross-gender
behavior, became convinced that this feeling of alienation
was explained by gender dysphoria. He had the hope that his
communication problems would alleviate by taking estro-
gens. In another adolescent, the cross-gender behavior
indicated transvestic fetishism rather than gender dysphoria.
This corresponds with the findings of frequent non-norma-
tive sexual interests and behaviors in adolescents and adults
with ASD (Hellemans et al. 2007). Feminine interests of
many gender dysphoric young boys with ASD concerned
soft tissues, glitter, and long hair and could be understood as
a preference for specific sensory input typical for ASD.
While almost all adolescents with GID are sexually
attracted to individuals of their birth sex (Smith et al. 2005;
Wallien and Cohen-Kettenis 2008), the majority of the
gender dysphoric adolescents with ASD was sexually
attracted to partners of the other sex. This may be clinically
relevant since adult transsexuals not sexually attracted to
their natal sex show in some studies less satisfactory
postoperative functioning compared with birth-sex attrac-
ted transsexuals (Smith et al. 2005).
Most individuals with co-occurring gender dysphoria
and ASD fulfilled the strict criteria of autistic disorder. For
Table 2 Demographic and clinical characteristics of adolescents diagnosed with both GID and ASD
No Sex Age IQ ASD
classification
GID
classification
GID
symptoms:
history
At time of assessment Follow-up
1 Girl 12 82 Asperger’s
a
GID-NOS
b
Childhood
GID
Sexually attracted to males Not eligible for SR
c
; happy being a
‘tomboy’ after counseling
2 Boy 13 92 Autism
d
GID
e
Childhood
GID
Sexually attracted to neither boys nor
girls, no sexual arousal while cross-
dressing
Eligible for SR; delayed start puberty
suppression, waiting to start cross-
sex hormones
3 Boy 14 106 Asperger’s GID Childhood
GID
Sexually attracted to boys, no sexual
arousal while cross-dressing
Eligible for SR; delayed start puberty
suppression, now on cross-sex
hormones
4 Boy 15 62 Autism TF
f
No
childhood
GID
Sexually attracted to both girls and
boys, sexual arousal while cross-
dressing
Not eligible for SR; referred for
cognitive behavioral therapy
around disturbing sexual arousal
5 Boy 16 NA
g
Autism GID-NOS Childhood
GID-NOS
Sexually attracted to homosexual boys,
no sexual arousal while cross-
dressing
Dropped out of care
6 Boy 16 104 Autism GID-NOS No
childhood
GID
Sexually attracted to girls, sometimes
sexual arousal but no sexual
motivation while cross-dressing
Not eligible for SR; referred for
autism treatment, still strong wish
for SR
7 Girl 17 110 Asperger’s GID Childhood
GID
Sexually attracted to girls, no sexual
arousal while cross-dressing
Eligible for SR; delayed start cross
sex hormones, waiting for
mastectomy
8 Boy 17 81 Autism GID Childhood
GID
Sexually attracted to girls, no sexual
arousal while cross-dressing
Dropped out of care; unwilling to
assent to treatment plan, got
himself a SR surgery abroad
9 Girl 18 86 Autism GID Childhood
GID
Sexually attracted to girls, no sexual
arousal while cross-dressing
Eligible for SR, delayed start cross
sex hormones, waiting for
mastectomy
a
Asperger’sAsperger’s disorder
b
GID-NOS gender identity disorder not otherwise specified
c
SR sex reassignment
d
Autism autistic disorder
e
GID gender identity disorder
f
TF transvestic fetishism
g
NA not available
934 J Autism Dev Disord (2010) 40:930–936
123

several youth with ASD, their ASD-specific rigidity made
enduring gender variant feelings extremely difficult to
handle. After all, in our society a considerable amount of
flexibility is needed to deal with gender variant feelings.
Normally developing young children (age 3–5) display
more rigidity in gender-related beliefs than older children;
this rigidity decreases after the age of five (Ruble et al.
2007). Individuals with ASD may not reach this level of
flexibility in their gender development.
In most gender dysphoric children, gender dysphoria
will cease when they reach puberty, whereas adolescents
with a GID will likely pursue their wish for sex reassign-
ment into adulthood (Cohen-Kettenis and Pfa
¨fflin 2003;
Wallien and Cohen-Kettenis 2008; Zucker and Bradley
1995). Likewise, in children under age 12 with co-occur-
ring ASD the gender dysphoria alleviated and in adoles-
cents between age 12 and 18 their GID persisted.
The present findings should be considered in the light of
limitations in sampling and assessment. First of all, it is apt
to realize that the actual incidence of ASD in gender clinic
referred children and adolescents is probably higher than
the reported percentage. One of the reasons to assume an
underestimation is that some children and adolescents with
ASD (as diagnosed elsewhere) were unable to fulfill the
assessment procedure due to serious impairment. In other
cases, features of ASD were observed, but parents tended
to underreport the ASD symptoms in the DISCO-10
interview, as that was not the primary concern about their
child. Finally, it was not feasible to administer a DISCO-10
interview to all participants. Clinicians of the gender
identity clinic identified suspected cases. Based on the
epidemiology of ASD, the majority was expected to fall
into the broader spectrum, whereas in this study no per-
vasive developmental disorder not otherwise specified was
classified. This may reflect that our clinicians had a high
threshold for suspecting ASD, as their primary focus was
gender dysphoria.
Second, the individuals who investigated whether cri-
teria for ASD were met, were aware that the reason for
referral was a possible GID. This study was performed at a
specialized gender identity clinic, and therefore blinding
was not feasible.
Third, we studied a gender identity clinic referred popu-
lation. Whether the same high incidence of co-occurring
ASD and gender dysphoria will also be found in individuals
with ASD as primary concern remains unknown and should
be of interest for further studies. One might expect milder or
more atypical types of gender dysphoria as part of other non-
normative sexual behaviors and interests, as was found in a
study of males with ASD (Hellemans et al. 2007).
Third, the categorical DSM-IV-TR classification
approach is not appropriate to study more subtle expres-
sions of both ASD and GID. Future studies should focus on
dimensional measures and specific cognitive or neuropsy-
chological profiles of individuals with co-occurring gender
dysphoria and ASD. For example, the observed rigidity in
gender related beliefs in young children may make children
with ASD more prone to develop gender dysphoria (Ruble
et al. 2007). Furthermore, it seems important to address the
broader autism phenotype (clinical traits that are milder but
qualitatively similar to the characteristics of autism (Losh
et al. 2009) in upcoming studies in a gender identity clinic
referred population. It may be that these traits occur more
often in gender dysphoric individuals than a full-blown
ASD as was found in, for example, children with mood and
anxiety disorders and ADHD (Nijmeijer et al. 2009; Pine
et al. 2008).
For clinical management, our findings on clinical char-
acteristics of individuals with co-occurring gender dys-
phoria and ASD have consequences. In all cases described,
the diagnostic procedure was extended to disentangle
whether the gender dysphoria evolved from a general
feeling of being ‘different’ or a ‘core’ cross-gender iden-
tity. Most helpful seemed an individual approach that took
into consideration that rigid and concrete thinking around
gender roles and difficulty developing aspects of personal
identity may play a part. Concerning sex reassignment,
ASD does not have to be a strict exclusion criterion. Only
one case study described a woman with an Asperger’s
disorder who received sex reassignment (Kraemer et al.
2005), although we know of more cases in clinical practice.
In our sample, almost half of the adolescents with both
ASD and GID started with gender reassignment. Worri-
some are the adolescents that dropped out of care, probably
finding their own ways to sex reassignment, without psy-
chiatric treatment or medical attention. It remains a chal-
lenge to provide individuals with co-occurring gender
dysphoria and ASD with proper care.
Acknowledgments This research was supported by a personal grant
for the first author from the Netherlands organization for health
research and development (ZonMw). The authors thank the study
families for participating in this study. Results of this study were
presented on the 8th International Meeting for Autism Research being
held in Chicago, May 7–9, 2009. The authors report no conflict of
interest.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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