Black transgender woman dealing with her problems in online psychotherapy.

For transgender people, accessing gender-affirming health care can be a challenge—and if you’re autistic, it can be even harder, especially given the growing and concerted push by anti-trans activists to deny gender-affirming care to anyone they suspect of being autistic. Those in the “gender critical movement” have gone as far as claiming that those diagnosed as autistic are unable to know their own identity—or, in an even more sinister turn, accusing the transgender community of preying on vulnerable autistic youth.

While medical ableism is always a cause for concern, it’s a particularly urgent issue in gender-affirming care. According to advocates, this is part of a general trend to force trans people to choose between either gender-affirming care or mental health care. Despite how gender-affirming care and mental health are connected, accessing adequate care for both is already a considerable hurdle.

“It’s a common issue I’ve seen where trans folks will sign up for [insurance] so they can have access to easy transition care, but that provider is shit at mental health,” said James Pisani, an agender person who was recently diagnosed with autism as an adult. “So they basically have to choose to let their mental health issues slide, which is a terrible thing, or they have to put their transition on pause.” 

In recent years, several studies have found that autistic people are far more likely than the general population to identify as “gender diverse,” a term encompassing all gender identities that do not correlate to one’s gender assigned at birth, such as nonbinary, transgender, Two-spirit, and genderqueer, among others. This makes access to reliable mental health care and autism-related resources particularly important for trans communities. But while an autism diagnosis can help foster greater understanding of one’s own needs and better access to accommodations and services, it can also come with a price, particularly when those needs include gender-affirming health care.

Anti-trans activists target autistic youth

While much has been said about J.K. Rowling’s anti-transgender rants, less attention has been paid to how she’s spoken about autism. She has made reference to “autistic girls” being overrepresented among the transmasculine population, both misgendering trans men and boys and implying that neurodiverse people are incompetent and incapable of understanding their own identities. 

Gabriel, a peer support specialist currently working on a counseling degree, refutes this idea from both a personal and professional standpoint. His dedication to his work is due in part to his own transgender, autistic identity.

“I think there’s a [desire] to deny agency to people who are different in this idea that neurodivergent folks aren’t capable of understanding themselves and making their own choices,” Gabriel said. “It’s a fundamental misunderstanding of what autism is and what autistic people are capable of.”

Rowling is not alone in pushing this narrative. In Abigail Shrier’s book, “Irreversible Damage: The Transgender Craze Seducing Our Daughters,” Shrier writes that transmasculine teenagers aren’t able to really know their gender identities, and are simply “fixated” on the idea of being trans due to external influences. Both authors are part of a wider effort to promote the idea of “rapid onset gender dysphoria,” (ROGD) a discredited belief that teens are being influenced to become trans by their peers, transgender adults, and internet content. Frequently, promoters of this theory focus on autistic teens, whom they paint as uniquely vulnerable to manipulation.

The problem is that the 2018 study that legitimized ROGD as a form of “social contagion” interviewed no transgender teens—only a self-selected sample of unhappy parents recruited exclusively from anti-transgender websites. Follow-up studies have shown the theory to be based on seriously flawed and unscientific research methods.

Zee Huselid, a transgender woman pursuing a master’s degree in epidemiology at Oregon Health & Science University, disputes the social contagion theory. 

“When I look at the ‘science’ these people are doing, it’s faulty science,” Huselid said. “The selection bias is absurd. If you submitted it to a peer-reviewed journal, you would be laughed out of the academy.”

Zee also believes these researchers are confusing cause and effect. She pointed out how people tend to form communities with one another, including neurodivergent people and gender-diverse people. It’s not so much an increase in the existence of these communities, rather it’s an increase in visibility and reporting.

“It’s like the graphs that show the rate of left-handedness increasing once teachers stopped hitting kids with rulers for using their left hand,” Huselid said. “We are seeing more and more people being their true selves in this world, and that can only be a good thing.”

The concept is based on a misunderstanding of the coming out process: while a teenager announcing they’re not cisgender may be a surprise to the adults in their life, the decision to do so is rarely sudden. Pisani’s coming out process, for example, took place over the course of several years. They can recall being uncomfortable with their gender assigned at birth for 15 or 20 years before they understood that what they were feeling was dysphoria. And it wasn’t until last year that Pisani started talking about being nonbinary.

“Just because it’s the first time I said it to the world doesn’t mean it’s the first time I said it to myself or anybody else,” Pisani said. “When people think it’s just so quick, out of nowhere? You’re not inside my head. If it’s coming out of nowhere for you, that means you’re not a trusted person.”

And though anti-trans activists often adopt the guise of protecting children, the concept of ROGD has been used to deny adult trans men agency over their medical choices. These sort of attacks on trans youth are only a first step toward trying to deny gender-affirming care for trans adults.

The overlap between autism and gender diversity

One large-scale 2020 study found that gender-diverse people are about 3-6 times more likely to  be autistic than cisgender people. Gender-diverse people are also more likely to report suspecting they had undiagnosed autism. 

The reasons for this correlation are still being studied. Some researchers believe autistic people are less concerned with “fitting in” socially, making it easier to explore their gender identity. In other words, there may be large numbers of closeted, non-autistic transgender people who are not reflected in self-reported statistics.

It’s also possible that minority stress may cause pre-existing autistic traits to be more pronounced in gender-diverse populations, making diagnosis easier. Because transgender people are often required to engage with the mental health system to access gender-affirming care, that could also account for higher diagnosis rates.

Some researchers have theorized that autism and gender diversity are both genetic in origin and could share a common cause. And in speaking to gender-diverse autistic people, many of them believe that their autism is related to their understanding of gender.

Masaru Tanabe, a nonbinary fiber artist and content creator with multiple disabilities, says being diagnosed as autistic helped them understand how they fit into the world. 

“I finally understood why my brain functioned and looked at things the way it did,” Tanabe said. “And that’s about everything, not just my gender. Gender has never made much sense to me. I’ve never really understood why people made such a big deal out of it.”

Pisani says that for them, their neurodivergence and gender identity are intrinsically intertwined—understanding that they were autistic helped them also realize that they were agender. They need context to have a more solid grasp of things like concepts of gender, and listening to trans and nonbinary people they know share their own experiences of their gender helped Pisani make sense of their own feeling and identify themselves as agender.

The idea that gender identity is biological in origin has received some pushback—perhaps rightly so—from those concerned that this could result in eugenics practices, or that it could be used to gatekeep who is “trans enough” to receive gender-affirming care. This echoes concerns from adult autistic advocates concerned that pushes to “cure” autism are essentially a form of conversion therapy to suppress and punish autistic children under the guise of “fixing” them.

Ultimately, no one is sure why these two traits are connected, but there are real implications for access to health care. One small study from 2018 found that a majority of autistic gender-diverse teenagers in the study reported an urgent need for gender-affirming care, and several reported having their gender identity questioned based on their diagnosis. Unfortunately, this is not a surprise.

When transgender youth are denied the opportunity to live as their professed identities, the consequences can be dire. A recent study in the journal Pediatrics found that access to gender-affirming care was associated with a 60% lower rate of moderate-to-severe depression and 73% lower odds of suicidality. Given that 43% began the study reporting self-harm or suicidal thoughts, the effect of receiving appropriate care cannot be overstated. These findings are in line with years of previous research on the subject.

Gabriel stressed how it’s already been proven that gender-affirming care is life-saving, necessary, basic health care. Being diagnosed with autism doesn’t make a trans person any less trans, nor does it remove the need for an autistic trans person to receive gender-affirming health care. 

“I think it comes down to a misunderstanding of autism and, on some level, of dehumanization,” Gabriel said. “[It’s as if] an autistic person is not fully human and thus not in need of or deserving of the same basic human things that other people need.”

Multiple marginalized identities make access to care even more difficult

The push to prevent autistic gender-diverse people from accessing affirming care is only one of many barriers facing the community. For those who are BIPOC, transgender, and neurodivergent, matters can be considerably more complicated.

For one thing, racism within the transgender community is still a factor that can make it very hard for intersectionally marginalized people to find the support and resources they need. Tanabe shared that they sometimes feel alone on many social issues and only have a select few people they feel comfortable enough to talk about those things with, especially when they’re about race.

“I don’t really know how people are going to handle it,” Tanabe said. “During the pandemic, there’s all of this anti-Asian violence that’s been happening. All the hate crimes, and [it feels like] no one is talking about them except for Asian folks.”

Another issue is that autism tends to be underdiagnosed in BIPOC communities, and when it is diagnosed, it happens later than for white children, leading to a lack of appropriate support at home and in school during critical early years of life. Additionally, racial bias can cause educators and clinicians to interpret autistic traits as bad behavior rather than a potential cause for evaluation. One 2007 study at the University of Pennsylvania found that Black children were 5.1 times more likely than white children to be diagnosed with a conduct disorder before eventually receiving an autism diagnosis.

Transgender BIPOC are also less likely to receive the care they need compared to their white counterparts. The 2015 National Transgender Survey found that transgender BIPOC  were less likely to be insured and more likely to avoid medical care due to fear of mistreatment. In 2018, the Center for American Progress reported that nearly a third of transgender patients had been turned away from a health care provider based on their gender identity, and that being misgendered, verbally abused, and physically assaulted were common experiences. This becomes even more complicated when race enters the picture.

For example, patients are sometimes forced to choose which oppression they would rather endure. One 2019 study in Chicago found that many trans BIPOC chose to see providers from their own background—in an attempt to avoid racial discrimination—despite concerns about providers’ transphobia. When attempting to access LGBTQ+-centered resources, some reported experiencing racism. Faced with no good options, the study’s authors recognize that some chose to avoid the doctor’s office completely, leading to worse overall health outcomes.

Combined with the gatekeeping and ableism autistic people face, this paints a grim picture for the ability of neurodiverse gender-diverse people with intersectional identities to receive the care they need.

Organizing to support autistic gender-diverse communities

Despite all of these challenges, there are organizations working to provide support, resources, and aid to this intersectionally marginalized community without speaking over autistic people’s stated needs and desires.

The Autistic Women & Nonbinary Network (AWN) is primarily BIPOC-led and advocates for autistic trans people of all gender identities. Lydia X. Z. Brown, director of policy, advocacy, and external affairs, said that AWN is currently partnering on several major research projects to integrate gender justice and racial justice perspectives into new autism assessments, health care access for autistic adults, and health equity in general. AWN’s work is led and informed by community members who are trans, nonbinary, genderqueer, and Two-spirit. In addition to all of these projects, the organization offers support grants for autistic people of color.

“Even though autistic people are more likely to be queer and trans than non-autistic people, our perspectives remain marginalized, excluded, and erased from most mainstream research and policy development,” Brown said. 

The Autistic Self Advocacy Network (ASAN) works to advance the disability rights movement and create a more inclusive society for autistic people. The organization has advocated against Trump-era attempts to allow health care providers to discriminate against trans patients on religious grounds, defended patients’ rights to report such discrimination, and opposed anti-trans legislation such as the recent Texas letter that designated gender-affirming care for minors as child abuse under state law.

“Access to gender-affirming care is a critical part of health care for autistic people, who are more likely than non-autistic people to be transgender or nonbinary,” said Zoe Gross, ASAN’s director of advocacy.

Beyond the organization’s advocacy work, Gross noted how ASAN has also been creating educational resources, including a series of toolkits aimed at intellectually and developmentally disabled LGBTQ+ people. The toolkits provide information unpacking common terminology used to discuss sexuality and gender, and an upcoming toolkit will focus on LGBTQ+ rights and how to ensure that support workers respect their clients’ sexuality and gender identity.

While the legislative assault on autistic and transgender people continues in the U.S. and abroad, advocates say there are also many options for individuals who want to support trans rights to show their support. The Equality Federation has an online tracker of proposed laws in different states (both those attacking LGBTQ+ rights and those protecting them) so people can contact their elected officials to voice their opinions. They also maintain a list of state-level LGBTQ+ advocacy organizations for those who wish to donate to or volunteer with a local group. People can encourage Congress to pass the Equality Act, which would address critical gaps in federal anti-discrimination protections for a variety of marginalized groups.

Neurodiversity shouldn’t prevent trans people from making decisions about their own health and identity

There is no evidence that being neurodivergent prevents trans people from being able to make informed decisions about their own care—in fact, most experts believe the opposite. In 2016, more than 20 such experts co-authored a paper outlining best practices for helping autistic trans patients. These recommendations include referrals for gender-diverse patients to be screened for autism so they receive appropriate services; the authors also stress the need for gender specialists to collaborate closely with mental health professionals and that gender dysphoria should not be dismissed as simply “an overfocused or unusual interest.” According to Gabriel, that characterization of gender dysphoria is “hot nonsense.”

“Identity is not a special interest,” Huselid said. “I have a special interest in giant robots. I don’t identify as a giant robot.”

Tanabe remains baffled by the obsession others seem to show about their gender. 

“Why on earth would someone else’s gender interest me?” they said. “If it weren’t my identity I wouldn’t spend hours and hours learning about it.”

Major advocacy organizations are taking the same positions. In 2016, the ASAN, the National Center for Transgender Equality, and the National LGBTQ Task Force issued a joint statement condemning the idea that autistic people should be denied the right to express their gender however feels right to them. The groups further call out ableist barriers to treatment, such as institutionalization and legal guardianships with caregivers who refuse to affirm the autistic person’s sense of self.

While the autistic community considers Autism Speaks to be at best ineffective at advocating for autistic people, and at worst a hate group, it’s worth noting that even this organization states that autistic trans youth should have their identities supported.

For Pisani, it doesn’t matter how someone comes to the conclusion that they’re trans and neurodiverse, and they encourage others to embrace what their identity means to them. 

“[Learning about being trans] brought you to a really cool discovery about yourself, and you’re probably also full of a lot of really great knowledge that’s useful for other people,” Pisani said.

Orion Rodriguez (he/they) is a nonbinary writer, artist, and activist. His writing has been published in Salon, Lightspeed Magazine, Inhabitat, and elsewhere. He is currently working on "The Life and Times...