714587

research-article2017
AUT0010.1177/1362361317714587AutismGeorge and Stokes

Original Article

Autism

Gender identity and sexual orientation 1­–13

© The Author(s) 2017
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DOI: 10.1177/1362361317714587
https://doi.org/10.1177/1362361317714587
journals.sagepub.com/home/aut

Rita George and Mark A Stokes

Abstract
Clinical impressions indicate that there is an overrepresentation of gender-dysphoria within the autism spectrum
disorder. However, little is presently known about the demographics of gender-identity issues in autism spectrum
disorder. Based upon what little is known, we hypothesized that there would be an increased prevalence of gender-
dysphoria among those with autism spectrum disorder compared to a typically developing population. We surveyed
gender-dysphoria with the Gender-Identity/Gender-Dysphoria Questionnaire among 90 males and 219 females with
autism spectrum disorder and compared these rates to those of 103 males and 158 females without autism spectrum
disorder. When compared to typically developing individuals, autistic individuals reported a higher number of gender-
dysphoric traits. Rates of gender-dysphoria in the group with autism spectrum disorder were significantly higher than
reported in the wider population. Mediation analysis found that the relationship between autistic traits and sexual
orientation was mediated by gender-dysphoric traits. Results suggest that autism spectrum disorder presents a unique
experience to the formation and consolidation of gender identity, and for some autistic individuals, their sexual
orientation relates to their gender experience. It is important that clinicians working with autism spectrum disorder
are aware of the gender-diversity in this population so that the necessary support for healthy socio-sexual functioning
and mental well-being is provided.

Keywords
autism spectrum disorder, gender-dysphoria, gender identity, heterosexuality, homosexuality, lesbian, gay, bisexual,
and transgender, sexual orientation

Introduction
Gender is not inherently defined by one’s physical anat-
omy. It is a psychological identification of oneself as a
man, a woman, both, neither or otherwise (Prince, 2005).
Children are generally cognizant of their gender between
the ages 18 months and 3 years (Martin and Ruble, 2010),
and by the beginning of school years, most children will
have achieved a sense of their gender identity and a certain
degree of gender constancy, at which time children begin
to realize that gender is a permanent state that cannot be
altered by a change of clothing or activity (Paikoff and
Brooks-Gunn, 1991). By the age of 4 years, children typi-
cally outline preferences for same-sex companions, gen-
dered-activities, and sex-typed play (Rosenfield and
Wasserman, 1993).
While generally an individual’s gender identity corre-
lates with the gender roles that a given society considers
appropriate for males and females, this is not always the
case. Gender-dysphoria (GD) is a clinical condition
where the individual experiences a persistent sense of
discontentment over the incongruence between their self-
perceived and assigned gender, leading to significant dis-
tress to the person, challenges in social or occupational
functioning, and a desire to live a cross-gender life
(American Psychiatric Association, 2013). It is estimated
that between 0.005% and 0.014% of natal males and
0.002%–0.003% of natal females would be diagnosed
with GD, based on current diagnostic criteria (Zucker
and Lawrence, 2009). Expressions of GD include a pref-
erence for cross-dressing (dressing up in clothes typically
worn by the opposite sex as defined by the person’s cul-
tural norms), cross-gender roles, and additionally in
Deakin University, Australia
Corresponding author:
Mark A Stokes, School of Psychology, Deakin University, 225 Burwood
Highway, Burwood, VIC 3125, Australia.
Email: mark.stokes@deakin.edu.au
2 Autism 00(0)
children, make-believe play and a strong inclination for
play-mates of the opposite sex. Importantly, a handful of
case studies (Galluci and Schmidt, 2005; Kraemer et al.,
2005; Landén and Rasmussen, 1997; Mukaddes, 2002;
Tateno et al., 2008) and empirical reports suggest an
association between autism spectrum disorder (ASD) and
GD (De Vries et al., 2010; Jones et al., 2012; Pasterski
et al., 2014).
Recently, it has been apparent that there may be some
overlap between ASD and GD. For instance, researchers
from the Netherlands (DeVries et al., 2010) found a higher
incidence of ASD (7.8%) in a sample of 204 children
referred to a gender-identity clinic for management of their
GD. This rate is higher than the prevalence rate of ASD in
the general population which is estimated to be between
0.6% and 2% (Blumberg et al., 2013; Fombonne, 2005).
DeVries et al. recognized the substantial variance in GD
symptoms displayed by those with ASD, where a diagno-
sis of Gender-Dysphoria–Not Otherwise Specified
(GD-NOS) was frequently issued. GD-NOS is given when
the cross-gender behavior and interests were atypical
(interest in clothing items of the opposite sex as a prefer-
ence for specific sensory input typical of ASD; beliefs that
any existing social difficulties stem from GD, despite an
absence of any cross-gendered behavior; and transvestic
fetishism or sexual arousal when handling or wearing
female clothing).
Another group (Jones et al., 2011) examined the co-
occurrence of GD and ASD in a group of adults with GD,
by comparing scores on a measure of autistic traits, the
Autism Spectrum Quotient (AQ; Baron-Cohen et al.,
2001). Jones et al. found that when compared to typically
developing (TD) females, females with GD reported a
higher mean AQ, but males with GD did not differ from
TD males. Jones et al. suggested the increased number of
autistic traits among their female-to-male transsexual sub-
jects was due to the Extreme Male Brain (EMB; Baron-
Cohen, 2002) theory of autism. EMB theory posits that
autistic females are hyper-masculinized in specific aspects
of their cognition and behavior, related to elevated levels
of fetal testosterone (fT; Auyeung et al., 2009). At the same
time, a positive correlation has been demonstrated in neu-
robiological literature between fT and autistic traits. It is
suggested that some autistic females may more readily
identify with the male gender and may face challenges in
assimilating into a typical female peer group, which in a
minority of cases may lead to the development of a GD.
Additionally, there are a striking number of similarities
between some autistic girls and girls with GD (Green and
Young, 2001; Knickmeyer et al., 2008) such as cross-sex
typical play, reduced empathy and social skills, and hand-
edness patterns. Furthermore, higher prevalence rates of
homosexuality and bisexuality have been reported among
females with GD (Drummond et al., 2008) as well as
among autistic females (Bejerot et al., 2014; George and
Stokes, 2016; Gilmour et al., 2012), where neural mascu-
linization in some females might contribute toward attrac-
tion to other females. It is speculated that the common
denominator between female ASD and female GD might
be an excess of fT (Hines et al., 2004).
Another study that assessed for AQ traits in a clinical
population diagnosed with GD also found evidence of an
association between ASD and GD; 7.1% of the females
with GD (N = 28) and 4.8% of males with GD (N = 63) met
screening diagnostic cut off based on their AQ scores
(Pasterski et al., 2014). This finding was different from
Jones et al.’s (2011) where only females with GD reported
higher AQ scores than TD individuals. Pasterski et al.
noted that individuals with GD who met the screening cut-
off for ASD reported an onset of GD after puberty. On the
contrary, Pasterski et al. (2011) report that gender-dys-
phoric ideation is often expressed in early-to-middle child-
hood when gender-segregation or the general tendency for
children to prefer interactions with their same-sex is at its
peak. The literature also points to the role of social naivéte
in unsuccessful relationships among individuals with ASD
(Howlin et al., 2000). Pasterski et al. (2014) speculated
that this might falsely lead some individuals to attribute
their social challenges to their gender and believe that they
would better fit with the opposite gender. Other authors
similarly suggest that certain behavioral and psychological
characteristics of autism might mimic GD-like symptoms
or even lead to the development of a clinical GD (De Vries
et al., 2010; Jones et al., 2011).
While some research has assessed for ASD among clin-
ical populations treated for GD, newer research by Strang
et al. (2014) measured the desire to be the opposite gender
in a population of 147 children with ASD. On analyzing
parental responses to the item “Wishes to be the opposite
sex” on the Child Behavior Check List (CBCL), it was
noted that the desire to be the opposite gender was 7.6
times more common in the ASD group than among non-
ASD participants. However, the study assessed children
only. The desire to be opposite gender in children has been
known to often decline when they reach puberty, thus lim-
iting generalizability to adult populations. Prospective
studies on GD indicate a likely resolution of GD symp-
toms with increasing age through the adoption of a sexual
orientation that is congruent with their experienced gender
identity (Bailey and Zucker, 1995; Rieger et al., 2008).
Higher rates of minority sexual orientations are reported
among individuals with GD (Drummond et al., 2008;
Wallien et al., 2008).
Bejerot and Eriksson (2014) similarly found a gender-
atypical pattern in their sample of 50 adults with ASD
when compared to 53 TD individuals in a Swedish popula-
tion. Males were less masculine and females were less
feminine compared to TD participants, when tested on the
Bem Sex Role Inventory (Bem, 1974). It was also found
that participants with GD scored higher on the AQ
George and Stokes 3

compared to TD participants. Another study by the same Table 1. Demographic characteristics of the study sample.
group of researchers found a negative correlation between
ASD (N = 310) TD (N = 261)
AQ traits and body gender coherence. Body gender coher-
ence was estimated by assessing digital photographs and Race/ethnicity (%)
voice samples of the participants for gender-typicality Caucasian 81.6 71.4
(Bejerot et al., 2012). However, the use of a non-validated African-American 0.6 1.1
instrument to measure gender identity in a purely Swedish Hispanic 1.0 2.2
sample limits the generalizability of the study findings. Latino 0.3 0.5
The comorbidity of ASD and GD is worth noting as the Middle-Eastern 0.0 3.8
prevalence of both conditions is reasonably low. Aside Asian 1.9 8.1
from a few case reports that have indicated an association Pacific Islander 0.0 0.0
 Indigenous or Australian 0.3 0.0
between ASD and GD, and empirical studies that pointed
Aboriginal
to an increased number of autistic traits among clinical GD
Multiracial 8.1 7.0
populations, the scant evidence base that specifically Other/rather not say 6.2 6.0
assessed for gender-dysphoric traits (GDT) in ASD has Education level (%)
yielded findings limited by sample restrictions and meth- Primary school 2.7 1.3
odology. Thus, there was a need for a larger study with a High school 17.7 24.2
broader sampling methodology to explore the association Trade/vocational school 7.4 5.8
between ASD and cross-gender ideation, operationalized Some university 29.7 25.5
by measuring GDT through the use of validated psycho- Bachelor’s degree 23.2 25.8
metric measures. Previously cited literature indicates that Master’s degree 10.3 11.9
individuals with GD have an elevated number of autistic Doctoral degree 3.5 2.9
traits (Jones et al., 2012; Pasterski et al., 2014). This study Other/not sure 5.5 2.6
investigated this in the reverse direction and consequently
ASD: autism spectrum disorder; TD: typically developing.
predicted that autistic individuals would demonstrate
higher levels of GDT compared to TD individuals. Based
on observations of a large number of GD-NOS diagnoses sexual orientation and autistic traits. It was accordingly
among individuals with ASD (De Vries et al., 2010), a hypothesized that GDT will mediate between an individu-
diagnosis rendered when GD symptoms are sub-clinical, al’s autistic traits and their sexual orientation.
this study investigated for cross-gender ideation by meas-
uring GDT rather than GD diagnoses, as a continuum
might provide more statistical power than a categorical Method
approach. Moreover, measuring GDT would capture any Participants
substantial variations across the sample, without any limi-
tations imposed by a categorical approach. One study This study compared 261 TD individuals (Mage = 30.20,
found sex-specific differences in the association between standard deviation (SD) = 11.92; 103 males and 158
ASD and GD (Jones et al., 2011), while another did not females) with 310 individuals with a diagnosis of ASD
(Pasterski et al., 2014). This study chose to further investi- (Mage = 31.01, SD = 11.37; 90 males, 219 females, and 1
gate this by analyzing rates of GDT separately between individual who was intersex). The individual with an inter-
males and females by diagnosis. Based on the EMB the- sex identity was excluded from relevant analyses that
ory, it was hypothesized that autistic females would report examined sexuality by birth-sex group. Ethnic background
higher levels of GDT than males with ASD. Furthermore, is reported in Table 1. Additionally, the sample was largely
the literature suggests a high prevalence rate of non-heter- highly educated (see Table 1). There were no significant
osexual orientations among those with GD (Drummond differences between the individuals with and without an
et al., 2008; Wallien and Cohen-Kattenis, 2008) and with ASD on ethnicity or their levels of education.
ASD (George and Stokes, 2016; Gilmour et al., 2012), as
well as an elevated number of autistic traits among those Materials
with GD. While the literature informs us that autistic traits
are elevated among individuals with GD, we do not know AQ. The AQ (Baron-Cohen et al., 2001) is a screening tool
the relationship between autistic traits and GDT at this which provides a continuous, quantitative measure of
stage. This study affords the opportunity to study the rela- autistic traits. The questionnaire comprises 50 items, each
tionship of all three variables: GDT, autistic traits, and of which is in a forced-choice format. Each question allows
sexual orientation together, to better understand any poten- the respondent to indicate “definitely agree,” “slightly
tial associations between the constructs. Thus, this study agree,” “slightly disagree,” and “definitely disagree.”
explored whether GDT had a mediation effect between Approximately half the questions are worded to prompt an
4 Autism 00(0)
“agree” response from TD individuals, and half to prompt
a “disagree” response. The items cover five different
domains associated with ASD: social skills, communica-
tion skills, imagination, attention to detail, and cognitive-
inflexibility. Evidence for convergent validity is
demonstrated through the strong positive correlation of the
AQ with the Social Responsiveness Scale (r = 0.64; Con-
stantino and Gruber, 2005), which is another continuous
quantitative measure of ASD symptoms. Test–retest relia-
bility of the AQ has been reported as being substantial
(r = 0.95; Broadbent et al., 2013). At a cut-off score of 32,
the sensitivity of the AQ is 0.76 and the specificity is 0.74
(Woodbury-Smith et al., 2005). A cut-off score of 32
(Baron-Cohen et al., 2001) has been used in this study to
screen individuals with a diagnosis of ASD.
Gender-Identity/Gender-Dysphoria Questionnaire for adoles-
cents and adults. The Gender-Identity/Gender-Dysphoria
Questionnaire for Adolescents and Adults (GIDYQ;
Deogracias et al., 2007) is a standardized 27-item instru-
ment, which assesses cross-gender behavior and different
aspects of GD among adolescents and adults, with the past
12 months as the time frame. Questions have parallel male
and female versions, and participants were administered
the version according to their reported birth-sex. The ques-
tionnaire includes 13 items that assess subjective aspects,
such as “Are you satisfied with being a man/woman?”; 9
items that investigate social aspects, such as “Have you
ever presented yourself as a man/woman at social gather-
ings?”; 3 items that measure somatic aspects, such as
“Have you taken hormone treatments to change your gen-
dered-appearance?”; and 2 items for socio-legal aspects,
such as “Have you bothered with having to identify as
male/female on official forms such as your driver’s license
or your passport?” The response options are coded along a
5-point scale as 1 (always), 2 (often), 3 (sometimes), 4
(rarely), or 5 (never). A cut-off mean score of 3.00 is rec-
ommended by the authors to discriminate between indi-
viduals with and without GD, which has a sensitivity of
90.4% for clients with GD and a specificity of 99.7% for
clients without GD (Deogracias et al., 2007).
Procedure
Upon receiving ethical approval for the research from
Deakin University Human Research Ethics Committee
(DUHREC 2014-008), national and international autism
organizations were contacted. TD participants were
recruited by word of mouth and through social media such
as Facebook. Participants completed the data collection
online and first completed a series of demographic ques-
tions related to their age, country of residence, race, level
of education, birth-sex, diagnostic status, comorbid medi-
cal/psychiatric conditions, cohabitation status, gender
identity, hormone replacement related to gender identity,
and importance of partner-gender in a romantic or sexual
relationship. This was followed by administration of the
different psychometric measures, presented below in the
order they appeared in the survey.
Statistical analyses
Chi-square tests were used to examine the relationship
between different variables, including diagnosis and gender
identity, diagnosis and use of hormone replacement therapy
(HRT) in management of gender-identity issues, diagnosis
and cohabitation, and diagnosis and importance of gender
identity of romantic/sexual partner as a factor in decision-
making. Effect sizes for these tests are reported as phi (ϕ),
which estimates the proportion of explained variance
(Howell, 2013). A number of comparisons were made
between the TD and ASD groups, and across birth-sex.
These used independent samples t-tests and included tests to
establish a difference in autistic traits between diagnostic
groups and to evaluate whether there were differences
between diagnostic groups for GDT. Furthermore, the test
was also used to evaluate the hypothesis that autistic females
with ASD would report higher GDT than males with ASD.
An independent sample t-test was also used to examine
whether individuals with a non-heterosexual orientation
would report higher GDT than individuals with a hetero-
sexual orientation. Sexual orientation was coded as a dichot-
omous variable with two categories; heterosexual and
non-heterosexual orientations. The non-heterosexual orien-
tation category included all non-heterosexual response
options (lesbian, gay, bisexual, transgender, questioning,
asexual, pansexual, intersexual, and other). Effect sizes for
these tests are reported as Cohen’s d, which estimates the
proportion of an SD that is explained by the independent
variables (IVs) (Howell, 2013). A one-way analysis of vari-
ance (ANOVA) was undertaken to investigate how levels of
GDT differed between different sexual orientations. A new
variable for sexual orientation was computed, as some of the
categories had very few participants. The new variable had
five categories: homosexuality (gay and lesbian), bisexual-
ity, heterosexuality, asexuality, and other (transgender, ques-
tioning, pansexual, intersexual, other). To test the hypothesis
that GDT would mediate between an individual’s autistic
traits and their sexual orientation, a mediation analysis
(PROCESS, 2013 Andrew F. Hayes, http://www.afhayes.
com/) was undertaken to assess the relation between autistic
traits and sexual orientation, where GDT was assessed as a
mediator. Effect sizes are reported as b-weights, which indi-
cates the change required in the IV to achieve a single unit
of change in the dependent variable (DV) (Howell, 2013).
Demographic trends
Participants in the ASD group reported significantly
more traits characteristic of autism assessed by the AQ
George and Stokes 5

Table 2. Gender identities reported by individuals in the ASD and TD groups by birth-sex.

Gender identity ASD TD

Birth-sex male Birth-sex female Birth-sex male Birth-sex female

% (N = 90) % (N = 219) % (N = 103) % (N = 158)

Man 77.8 2.3 93.1 1.3
Transgender 7.8 2.3 3.9 0.6
Woman 7.8 67.1 0.0 87.3
Bigendered 2.2 3.3 1.0 3.8
Cross-dresser 1.1 0.0 0.0 0.0
Genderqueer 1.1 12.0 0.0 5.1
Other 3.3 13.4 2.0 1.9

ASD: autism spectrum disorder; TD: typically developing.

factor to their decision-making (χ2(1) = 57.83, p < 0.001,

ϕ = 0.32). Two females reported having a diagnosis of con-
genital adrenal hyperplasia (CAH), one with and one with-
out ASD. The autistic female reported an asexual
orientation, while the TD female reported being pansexual.
Both described their gender identity as a man.

Figure 1. Gender identity by relative proportion reported by
respondents by diagnosis and birth-sex.
(t(460.57) = 21.01, p < 0.001, d = 1.96; M = 34.98, SD = 7.29)
than participants in the TD group (M = 19.11, SD = 10.20).
Cronbach’s alpha for the current sample on the AQ scale
was 0.93.
Comparisons were undertaken between diagnostic
groups on various demographic variables. Results indi-
cated that gender identity was contingent on diagnosis
(χ2(6) = 34.06, p < 0.001, ϕ = 0.25). Autistic individuals
reported a more diverse range of gender identities. Table
2 and Figure 1 show the percentages of the different gen-
der identities reported by males and females in the study.
Gender diversity was overall greater among females than
males.
The results of other comparisons on demographic vari-
ables between individuals in the ASD and TD groups are
presented in Table 3 and shows number of individuals
within each category for the two birth-sexes separately.
Autistic individuals were more likely to utilize HRT related
to their gender identity than TD participants (χ2(1) = 6.99,
p = 0.006, ϕ = 0.11). Furthermore, when compared to TD
participants, autistic individuals were less likely to report
cohabitation (χ2(1) = 49.81, p < 0.001, ϕ = 0.29) and the
gender of their romantic/sexual partner as an important
Results
Data screening
Data were screened for missing values (of which there
were none), outliers, and normality. Independent samples
t-tests were conducted to analyze GD scores and AQ scores
between groups with and without an ASD. Assessments of
normality revealed significant skew and kurtosis on the
AQ and GD scales within groups. Examination of histo-
grams revealed that violations were due to a high level of
autistic traits and GD symptoms among transgender peo-
ple in each group. Based on reviewed literature, this non-
normality was not unexpected (Jones et al., 2011; Pasterski
et al., 2014). Sample sizes within each group were greater
than 250 cases. Tabachnik and Fidell (2001) advise that
non-normality is less of an issue under such conditions.
Data were thus retained in the analysis untransformed.
Where violations of homogeneity of variance were
detected, as indicated by Levene’s homogeneity test,
degrees of freedom were accordingly adjusted. ANOVAs
were conducted to analyze socializing patterns between
groups based on GDT status.
Hypothesis testing
Comparisons were made on total scores on the GIDYQ
and scores on the different subscales of the GIDYQ.
Levene’s test for equality of variances indicated unequal
group variances for each of the variables tested. The
adjusted degrees of freedom test were used to address this
violated assumption. The two groups significantly differed
from each other on all scales (see Table 4). Results
6 Autism 00(0)

Table 3. Contingency of diagnosis on various demographic variables showing number of cases in each category.

Variable ASD TD

Male (N = 90) Female (N = 219) Total (N = 309) Male (N = 103) Females (N = 158) Total (N = 261)
HRT 11 10 21 3 3 6
Cohabitation 63 153 216 39 67 106
Partner-gender unimportant 32 127 159 13 41 54

HRT: hormone replacement therapy; ASD: autism spectrum disorder; TD: typically developing.
The individual who reported birth sex as intersex was excluded from this analysis.

Table 4. Independent group t-test between diagnosis and gender-dysphoria (GD) scores.

TD (N = 261) ASD (N = 310) t-test (df = 558.39)

M SD M SD
GD total 10.00 16.48 24.11 22.20 8.54***
GD subjective 6.02 10.08 12.65 12.32 6.24***
GD somatic 0.77 2.20 2.00 3.24 5.19***
GD social 3.57 5.03 8.25 6.64 9.19***
GD socio-legal 0.34 0.98 1.05 1.73 6.08***

ASD: autism spectrum disorder; TD: typically developing; SD: standard deviation; df: degrees of freedom.
***p < 0.001.

Table 5. Independent group t-test results between males and females with and without an ASD on gender-dysphoria (GD) scores.

ASD TD

Male (N = 90) Female (N = 219) t-test Male (N = 103) Female (N = 158) t-test

M SD M SD M SD M SD
GD total 21.68 25.71 25.77 21.64 1.42 7.62 15.24 11.24 17.58 1.72
GD subjective 10.34 13.15 13.87 12.03 2.28* 3.27 8.67 5.19 9.34 1.67
GD somatic 2.24 4.17 2.02 3.03 0.52 0.56 2.08 0.93 2.35 1.28
GD social 7.38 7.68 8.65 6.60 1.47 2.66 4.31 3.81 5.50 1.79
GD socio-legal 0.97 1.87 1.07 1.66 0.47 0.22 0.79 0.43 1.09 1.65

ASD: autism spectrum disorder; TD: typically developing; SD: standard deviation.
*p < 0.05.

indicated that autistic individuals reported higher GDT
than TD individuals. Cronbach’s alpha for the study sam-
ple on the GIDYQ was 0.94.
Males and females within the TD group did not differ on
total GDT and on individual subscales of the GIDYQ (see
Table 5). Within the ASD group, females did not differ from
males on their total GDT. On individual GD subscales, rela-
tive to their male peers, autistic females only demonstrated
significantly higher scores on the GD-subjective scale (see
Table 5).
A mediation analysis assessed the relation between
autistic traits and sexual orientation, with GDT as a media-
tor. First, a Pearson correlation of the relationship between
autistic traits (as measured on the AQ) and GDT was
obtained, by measuring these rates across the entire sam-
ple, by collapsing across diagnostic groups. There was a
modest positive correlation between the two variables
(r = 0.37, p < 0.001). Increases in AQ scores were signifi-
cantly correlated with increases in GDT.
Correlations between different subscales of the AQ
with GDT were also undertaken to assess for any differ-
ences in relationships between autistic traits and GDT
across the different domains of the AQ. There were posi-
tive correlations between GDT and the different subscales
of the AQ: communication (r = 0.36, p < 0.001), social
(r = 0.35, p < 0.001), cognitive-inflexibility (r = 0.34,
p < 0.001), imagination (r = 0.17, p < 0.001), and detail
(r = 0.20, p < 0.001). The correlation between GDT with
AQ communication subscale was stronger than the corre-
lation with AQ imagination (Fisher’s Z = 3.50, p < 0.001)
and AQ detail (Z = 2.97, p < 0.01). Additionally, the corre-
lation between GDT with AQ social subscale was stronger
George and Stokes
Figure 2. Relationship between autistic traits and gender-dysphoria. AQ scores are split at AQ = 32, with separate lines of best fit
shown for each and R2 values.
Figure 3. Levels of GDT by sexual orientation.
than the correlation with AQ imagination (Z = 3.23,
p < 0.001) and AQ detail (Z = 2.70, p < 0.01). The relation-
ship between AQ and GDT was also assessed separately
by birth-sex. Results indicated that the relationship
between AQ and GDT was significant among males
(r = 0.27, N = 193, p < 0.001) and females (r = 0.40, N = 377,
p < 0.001) and that the relationship was stronger among
females than males (Z = 1.65, p < 0.05) (Figure 2).
Following this, the association between sexual orienta-
tion and GDT was examined in an independent sample
t-test. Levene’s test of homogeneity of variance was vio-
lated and degrees of freedom were adjusted accordingly.
Results indicated a significantly higher mean of GDT in
the non-heterosexual group (M = 27.13, standard error
(SE) = 1.39) than in the heterosexual group (M = 7.76,
SE = 0.75; t(446.81) = 12.21, p < 0.001, d = 1.02).
A one-way ANOVA revealed that heterosexual and
non-heterosexual groups differed significantly on GDT
levels (F(4, 566) = 47.54, p < 0.001). A Tukey post hoc test
7
revealed that compared to heterosexual individuals
(n = 179, M = 7.43, SD = 11.61), levels of GDT were sig-
nificantly higher among all other groups (homosexual:
n = 45, M = 24.36, SD = 23.72; bisexual: n = 60, M = 21.38,
SD = 21.25; asexual: n = 208, M = 22.55, SD = 21.20; and
other: n = 78, M = 34.06, SD = 25.69; see Figure 3).
Thereafter, the mediation effect of GDT was explored
between AQ traits and sexual orientation. There was a sig-
nificant direct effect between AQ traits and sexual orienta-
tion (b = 0.079, SE = 0.009, 95% confidence interval (CI):
0.062−0.096). AQ traits were significantly related to the
mediator, GDT (b = 0.66, SE = 0.071, 95% CI:
0.524−0.803), while the mediator was significantly related
to the dependent variable, sexual orientation (b = 0.05,
SE = 0.007, 95% CI: 0.036−0.063). The indirect effect of
the mediator was significant (b = 0.03, SE = 0.006, 95% CI:
0.024−0.047; Goodman’s Z = 5.68, p < 0.001). GDT par-
tially mediated the relationship of AQ traits to sexual ori-
entation (see Figure 4).
8 Autism 00(0)
Figure 4. Model of AQ traits as a predictor of sexual
orientation (heterosexual or non-heterosexual) mediated
by GDT. The confidence interval for the indirect effect is a
bootstrapped CI based on 1000 samples.
GD and transgenderism rates
Deogracias et al. (2007) found that a cut-off mean score of
3.00 on the GIDYQ could distinguish between individuals
with and without a diagnosis of GD. Mean scores of par-
ticipants indicated that there were seven individuals with
a mean score of 3.00 and above. Of these, six individuals
had a diagnosis of ASD, comprising five females and one
male. The TD individual was a female. All seven individ-
uals had AQ scores well over 32 and reported non-con-
forming gender identities. Accordingly, the rate of GD
that would otherwise have led to a clinical diagnosis in the
ASD sample was 1.9%. This is approximately 135 times
more than that found in the wider population given exist-
ing rates of GD estimated at 0.005%–0.014% among
males and 0.002%–0.003% among females (Zucker and
Lawrence, 2009). However, these conclusions are a result
of data-analyses and not clinical evaluation and thus
should be interpreted with caution, especially that the
GIDYQ has not been validated in an autistic sample
before.
Autistic individuals were more likely to report non-
conforming gender identities than their TD counterparts.
Of these, 12 individuals with ASD self-reported transgen-
derism (7 genetic males and 5 genetic females) as well as
five TD individuals (4 genetic males and 1 genetic female).
The rate of experienced transgenderism in the ASD sample
was 3.9% which was approximately 20–40 times higher
than existing prevalence estimates (1:1000–1:2000;
Olyslager and Conway, 2007).
Discussion
The aim of this study was to explore the association
between autistic traits and GD traits in a sample of indi-
viduals with ASD and compare this to TD individuals. It
was hypothesized that autistic individuals would demon-
strate a higher number of gender-dysphoric symptoms than
TD individuals, and that autistic females would report
greater rates of gender-dysphoric symptoms than autistic
males. The results of this study completely supported the
first hypothesis and partially support the second. Autistic
individuals reported a higher number of gender-dysphoric
symptoms than TD individuals on the all subscales of the
GIDYQ. However, comparison by birth-sex within the
ASD group demonstrated that females differed from males
only on one GD subscale—the subjective scale. Finally,
the hypothesis that GDT will mediate between an individ-
ual’s autistic traits and their sexual orientation was also
supported, where GDT partially mediated the relationship
of AQ traits to sexual orientation.
The finding that autistic individuals scored significantly
higher on GDT is consistent with the literature pointing to
increased gender-variance in the autistic population
(Bejerot et al., 2014; George and Stokes, 2016; Strang
et al., 2014) and supports the relationship between ASD
and GD. Reasons for the ASD-GD comorbidity has been a
topic of emerging interest and several speculations attempt
to account for this association. Previous literature has
relied on the neurobiological basis of ASD to explain
increased GDT in ASD. Baron-Cohen (2002) proposes
that ASD is an overdevelopment of certain male-typical
traits such as logical thinking, low emotionality, and high
level of perseverance. fT is the biological mechanism
implicated in this hyper-masculinization (Knickmeyer
et al., 2006) and consistently, elevated levels of fT posi-
tively correlate with autistic traits and with masculinized
neural development (Auyeung et al., 2009).
Human and non-human primate research shows that fT
levels influence human sexual behavior (Hines et al.,
2004). Rare congenital conditions such as found among
women with CAH afford opportunities to understand the
effects of altered levels of fT on sexual development. Girls
with CAH have an enzyme-deficiency driven overproduc-
tion of fT and show an increased number of autistic traits
as measured on the AQ (Knickmeyer et al., 2006),
increased male-typical play behaviors and masculinized
gender identities (Hines et al., 2004; Pasterski et al., 2005),
and an increased prevalence of homosexual and bisexual
orientations (Meyer-Bahlburg et al., 2008). Male-typical
thinking and behavior may lead some autistic females to
interpret themselves as masculine relative to non-ASD
females, and this could in some cases pave the way to the
development of GD.
However, the same reasoning does not straightfor-
wardly explain the increased prevalence of GD among
males with ASD. Higher levels of fT would support the
expression of a pronounced male gender identity (Dessens
et al., 2005). Amniotic measurements of testosterone con-
firm its role in the development of male-typical behavior
(Auyeung et al., 2009). Given the association between
elevated levels of fT in ASD, why then would autistic
males demonstrate higher GDT, when the converse would
be expected, or at the least, similar rates GDT between
ASD and TD males? Conclusions related to prenatal
George and Stokes
hormones and their effect on gender identity are often
drawn from sexual orientation studies that typically sug-
gest that male homosexuality is related to gender non-con-
formity (Bailey and Zucker, 1995; Lippa, 2003; Rieger
et al., 2008) and do not clearly explain the association
between androgen-exposure and gender-conforming male
homosexual people. Gender non-conformity among homo-
sexual individuals has been hypothesized to be an outcome
of atypical neural development as a consequence of altered
prenatal hormone environments (Blanchard et al., 2006;
Lalumière et al., 2000; Rahman and Wilson, 2003).
Manning (2002) noted that some research argued that
increased prenatal testosterone could lead to homosexual-
ity (Geschwind and Galaburda, 1985), while others argued
the opposite (Ellis and Ames, 1987). Put together, neuro-
hormonal pathways leading to higher prevalence rates of
male GD in ASD is not as clear, though potentially this is
a pathway for female GD in ASD, yet this needs to be
established. Nonetheless, this may be instructive to our
understanding for a subset of autistic males who may
develop GD as a result of an altered interaction between
the developing brain and sex hormones.
To limit a construct as complex as gender identity to
biological factors would be overly reductionistic. An indi-
vidual’s gender identity is most likely an interaction of
their biological and psychological make-up (Bradley and
Zucker, 1997) and certain ASD-specific psychological fea-
tures may increase the risk of the development of gender-
dysphoric expressions. Consistently, this study found as
autistic traits increase, there is a moderate relationship to
GD traits, a relationship that was found in previous litera-
ture as well (De Vries et al., 2010; Jones et al., 2011;
Pasterski et al., 2014; Vanderlaan et al., 2015).
This study found significant and clinically important
correlations between various subscales of the AQ and the
GIDYQ. For instance, the GIDYQ was significantly cor-
related to AQ communication skills and to AQ social
skills, and these correlations were significantly larger than
other domains measured by the AQ, suggesting that per-
haps for some autistic individuals, challenges with com-
munication and with social skills may contribute in some
way toward the development of gender-dysphoric feelings.
This is not surprising, given that gender is possibly one of
the most intensively socialized constructs with many
“rules” that are not explicit. While gendered norms are
typically intuitively understood, and followed by most
individuals, the challenges associated with negotiating
these norms involving fine judgments, understanding
abstractions, and balancing multiple considerations related
to gender and sexual innuendo might be exaggerated in the
presence of ASD-related socio-communicative features
(Abelson, 1981). Furthermore, the correlation between
scores on the AQ and the GIDYQ were higher among
autistic females than among autistic males and relative to
their male peers, females with an ASD reported higher
9
scores on the GD-subjective subscale. Compared to men,
women are generally believed to be more socially preco-
cious and empathetic (Lutchmaya and Baron-Cohen,
2002) and possess stronger verbal and communicative
prowess. These are domains that are saliently affected in
ASD, and this might explain why autistic females may
experience GD symptoms to a greater extent than their
male peers.
Another feature that may play a role in the ASD-GD
association is the frequent presence of intense obsessive–
compulsive behaviors in ASD. Pharmacological studies
have created a compelling argument for the association
between ASD and obsessive–compulsive disorder (OCD)
(Hollander and Pallanti, 2002; McCauley et al., 2004).
Cognitive inflexibility is characteristic of OCD (Meiran
et al., 2011). Findings from this study showed a significant
correlation between the cognitive-inflexibility subscale on
the AQ with the GIDYQ. It is likely that GD might develop
as a sequela to ASD, where a person’s preoccupation with
cross-gender activities and objects may not be related to
confusion over one’s gender identity, but may just be part
of the pervasive obsessions and distress with cross-gender
roles. Accordingly, several researchers view inflexible
thinking and restricted interests seen in clients with GD as
possible manifestations of the cognitive inflexibility inher-
ent to ASD (Galluci et al., 2005; Landén and Rasmussen,
1997; Perera and Gadambanathan, 2003; VanderLaan
et al., 2015).
This study investigated the relationship between autis-
tic traits, GDT, and sexual orientation and found that the
relationship between autistic traits and sexual orientation
was mediated by GDT. It is speculated that for some autis-
tic individuals, their sexual orientation relates to their gen-
der experience, which, in turn, may be associated with the
strength of their autistic symptomology. Bem (2000)
relates GDT and sexual orientation by way of the “exotic
is erotic” theory. Gender-dysphoric children often feel dif-
ferent from their same-sex peers and identify more with
their opposite-sex peers (Wallien et al., 2010). Bem (2000)
proposes that gender-dysphoric children may experience
heightened, nonspecific physiological arousal in the pres-
ence of same-sex peers from whom they feel different
(exotic) and that this physiological arousal might in later
years translate to sexual arousal toward their same-sex
peers (erotic). Perhaps for some individuals in the sample,
GDT in childhood might be one factor that contributes
toward the development of same-sex attraction and other
non-heterosexual orientations. However, it must be
stressed that the relationship between non-heterosexuality
and GDT is only one possible pathway, and we suggest
cautiously interpreting any relationship between GDT and
sexual orientation. The cross-sectional data in this study
are limited in its capacity to address the nature of different
pathways toward the development of sexual orientation,
and as such is beyond the scope of this article.
10
An interesting difference between male and female
groups with ASD was the higher rates of transgenderism,
cross-dressing, and HRT among males than females.
Despite higher rates of GDT among females, it was the
males that acted on these feelings in a remedial sense.
These trends may be reflective of the gender-polarizing
cultural climate of the times, where it is more acceptable
and easier for women to take on masculine traits, clothing,
and activities and live as a male would than vice versa.
Perhaps there are acceptable gender stereotypes for women
with GDT (“butch” lesbians) than gender stereotypes for
men with GDT. Some women with GDT may thus choose
to remain as they are, with the trappings of masculinity
rather than to resort to HRT or surgery.
Limitations
Results of this study must be interpreted in light of both
its strengths and limitations. Participants who volunteer in
a study examining gender and sexuality may have had a
pre-existing interest in such matters. Given that conveni-
ence sampling was used, and the study sample may not be
population-representative, results need to be interpreted
with this in mind, as this could have important implica-
tions for the prevalence estimates cited. Second, partici-
pants self-reported that they had a clinical diagnosis of
ASD. However, mean AQ scores of individuals with a
diagnosis of ASD fell above the recommended cut-off on
the AQ, and as such it is likely that individuals with a
diagnosis of ASD fell on the spectrum. Furthermore, par-
ticipant recruitment took place through a network of
reputed autism organizations worldwide and online autism
communities, making it likely that this study sample was
more diverse in composition than clinically referred sam-
ples. The sample had a large representation of females,
which is not common in studies of ASD. This might be
due to the online format of the study, where females are
more likely than males to rely on the Internet for interac-
tion and self-help (Addis and Mahalik, 2003; Santor et al.,
2007). As such, the study provided an opportunity to
study females with an ASD.
Finally, based on participant-feedback, a qualitative
approach to a study on sexuality and gender-related mat-
ters might be better suited for autistic individuals.
Participants from the autistic group sometimes reported
not finding response options that suit them. Other times
there were requests to the researcher to rephrase a question
or include a new option, as some participants felt margin-
alized, when having to choose an option such as “other” to
questions asking about sexual or gender identity, because
none of the existing options suited them. As such, the
GIDYQ has not been previously validated in an autistic
population and participant-feedback proved informative in
designing a qualitative questionnaire to measure sexuality
and gender identity. Qualitative responses related to
Autism 00(0)
sexuality and gender were wide-ranging, conflicting and
“fluid,” and gave participants the opportunity to respond to
questions in an unlimited manner (thesis, unpublished).
Providing fixed options or norm-setting may limit indi-
viduals with an ASD from freely describing what some
may consider atypical in this domain. A free-format ques-
tionnaire to learn about sexuality and gender in this group
might thus be more instructive and respectful of the indi-
vidual’s unique journey.
Conclusion
Aside from the limitations, the study yielded some impor-
tant findings. It supports assertions that autistic individu-
als are more diverse in their gender identities than the
wider population. Moreover, autistic individuals experi-
ence more GD traits than the wider population and this is
more pronounced among autistic females. These differ-
ences might be an outcome of sociocultural gendered
norms, which highlight any deficits in social functioning
in ASD more conspicuously among females than males.
Paradoxically, the same sociocultural system that penal-
izes social deficits among autistic females more harshly
than it does in males may provide some respite to gender
non-conforming females more than it does to gender non-
conforming males, due to society’s increased tolerance
toward female but not male gender-deviations (Kite and
Whitley, 1996).
Biological explanations for the increased prevalence of
GDT in ASD present a stronger case for females than it
does for males. However, social reasons provide an expla-
nation for GDT in both sexes adequately and might be the
better explanation at this stage. Tensions between an “ASD
personality” with a “neurotypical personality” could be
misguidedly attributed to gender identity as being the rea-
son for discord across different contexts. It is however
equally tenable that in some cases, feelings of dissatisfac-
tion with one’s gender identity could progress to a clinical
GD. The levels of complexity in terms of clinical manage-
ment of clients with ASD presenting with gender-related
issues would be higher, as the convergence of ASD-related
social difficulties and gender-related issues would afford
unique challenges for disentangling the relative contribu-
tions of each factor and for developing effective interven-
tions. This study also found that autistic individuals
demonstrated gender-fluid attitudes in endorsing a large
number of non-conforming gender identities and noncha-
lance toward the gender of their romantic or sexual part-
ner. It is known that autistic individuals overall are less
concerned with social rules and may not always adhere to
social etiquette (Attwood, 1998). Perhaps examining gen-
der from the perspective of someone with ASD licenses a
denaturalization of gendered norms and expectations. At
this stage, there is sufficient evidence to consider gender-
dysphoric expressions in ASD as one of the presenting
George and Stokes
issues requiring clinical management. Whether a diagnosis
of GD is warranted in clients presenting with gender-dys-
phoric issues is a matter of prudent clinical discernment in
unravelling displaced feelings of social discontentment
from a true clinical GD.
In a society where gender has been decisively defined,
individuals who exist outside its norms become likely tar-
gets of disapproval (Meyer, 2003). There is evidence of
increased psychiatric comorbidity in populations with dis-
contentment with their gender identity (Hepp et al., 2005)
as well as among autistic individuals (Ghaziuddin et al.,
2002). Possibly autistic individuals who also have gender-
dissatisfaction bear a significant burden of distress.
Investigation into the mental health outcomes of individu-
als who belong to sexual and gender minorities within the
ASD population should be informative. Designing special-
ized psycho-sexual programs targeting any gender-related
confusion tailored to each birth-sex, to provide com-
prehensive support to the autistic individual with the goal
of reducing frustration and increasing acceptance, is
recommended.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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