Autistic Gender, Physical Sex, and sexuality Differences

Autistic Gender, Physical Sex, and sexuality Differences
by Lisa Macafee

​This article inquires as to differences in autistic physical sex, sexuality, and gender, and explores the connections and implications of identity development with specific attention to physical and biological markers associated with sex and gender. Nine of the thirty articles reviewed discussed biological markers of autistic transgender identities and four of the articles were specifically focused on biological components of gender diversity among autistics. Autism is currently diagnosed at a ratio of one female to four males and many autistic people have an atypical gender presentation (Allely, 2018). The first theme concentrates on differences in gender identity and sexuality development among autistic people. Autistic people are 2.46 times more likely than a neurotypical person to wish they were the opposite gender (Kallitsounaki & Williams, 2022). The second theme addresses the biological component of gender diversity of physical sex differences in autistic people. Researchers posited the “extreme male brain” theory of autism linking elevated rates of androgens in both AMAB and AFAB with autism development (Gasser et al. 2021; Jones et al., 2011), while other researchers prefer defining autism as a “gender defiant disorder” (Kirkovski et al., 2013).

Theme One: Autistic Development of Gender Identity and Sexuality
Seven articles discussed divergent autistic patterns gender identity and sexuality development, and one article focused specifically on sexuality, with three more discussing autistic sexuality. Autistic people are more resistant to social conditioning, do not intuitively pick up social norms, and hence do not feel as much need to conform to norms of society, which may enable them to explore gender identities more fully without feeling the same social pressure to conform as a neurotypical person (Cooper et al., 2022; Ehrensaft, 2018; Walker, 2021). For some autistic people, this has made understanding of gender identity easier, but for others, they may experience rigidity around established routines and internal conflicts with desired gender expression, which can increase gender dysphoria (Cooper et al., 2022). Some autistic people do not internalize the norms of gender going along with the idea of being “a boy” or “a girl” in youth, as one person stated, “[w]hen I was little, I didn’t think about gender at all. It was a category that had no meaning to me. I was just a person" (Ehrensaft, 2018).

Autistic people describe being able to think more critically about gender than neurotypical people because the gender norms are not intuitively internalized. but note this can be an alienating experience when others are not asking the same questions about gender (Maroney & Horne, 2022). Autistic AFAB people expressed internal conflict between their autistic traits and a feminine identity (Davies, 2023), which may contribute to higher representation of non-binary gender identity among autistic AFAB people (Nobili et al., 2018). It is unclear if autistic people follow the same neural developmental pathways as neurotypical people in their development of gender identity (Kallitsounaki & Williams, 2022) and many autistic adults identify outside the gender binary of male or female (Strang et al., 2023).

Autistic people are more likely to identify as lesbian, gay, bisexual, and asexual, between 35% (Strang et al., 2023) to 54% identifying as non-heterosexual (Attanasio et al., 2021). Higher levels of androgen exposure in the womb are associated with both gay orientations and autism (Tankersley, 2021). Asexuality rates vary study to study, approximately 13% to 36% of autistic people state a lower-than-average sex drive or asexual identity, citing difficulty defining their identities due to their autism diagnosis as a contributing factor to asexuality, “but it is not clear whether asexuality in ASD is determined by a lack of sexual attraction or by the interpersonal and social difficulties typical of autism” (Attanasio et al., 2021) while others state autism helped them understand their identities (Cooper et al., 2022). AFAB autistics especially report uncertainty in their sexual attraction, with 21% stating confusion around sexuality, and demisexual identities (being attracted to a personality instead of sex or gender) highlighted in this group (Attanasio et al., 2021). It has been suggested autistic adults may identify as lesbian, gay, bisexual, or asexual while exploring their gender identity (Tankersley, 2021) and may define their sexuality around their gender non-conformity, for example, if someone does not have strong feelings about their own gender, they may find they similarly are more flexible about the gender of their partner (George & Stokes, 2018).

Theme Two: Autistic Physical Sex Differences
Six articles discussed autism and physical sex variation and correlations and five of these focused solely on differences in physical sex characteristics in autistic people. The extreme male brain theory states autism is “due to elevated fetal testosterone which are positively co-related with a no. of autistic trails and inversely correlated with social development [and] empathy” and the gender defiant disorder theory (Gasser et al. 2021; Jones et al., 2011; Kirkovski et al., 2013) draws attention to the “clear associations between changes in androgen levels and autism [which] have been observed” (Gasser et al. 2021). Increased androgen exposure can lead to sexual differentiation processes possibly resulting in autistic people being neither fully masculinized or feminized as typical peers, with gender atypical patterns of males being less masculine and females being less feminine apparent in autistic populations (Attanasio et al., 2021). Both AMAB and AFAB autistics have higher levels of androgenous features than neurotypical people (Kirkovski et al., 2013; McKenna et al., 2021).

AFAB autistics have more masculine faces and digit ratios than neurotypical AFAB while AMAB autistics have more feminine faces and digit ratios than neurotypical AMAB people (McKenna et al., 2021). AFAB autistic androgen exposure in the womb (Jones et al., 2011) have implications in intersex traits such as masculinized facial features as compared to typically developing females, and higher androgen-effects such as poly-cystic ovarian syndrome (PCOS) and delayed menarche (Gasser et al. 2021; Jones et al., 2011). Additionally, genetic and hormonal factors may have as great an influence on social function of gender as the chromosomal sex at birth (McKenna et al., 2021). Mothers of autistic children also have higher rates of PCOS (Jones et al., 2011), and babies with high birth weight are associated with both higher autistic traits and higher rates of gender nonconformity (Heylens et al., 2018; Tankersley, 2021).

Transmen and AFAB non-binary people have higher than average autistic traits, while autistic AFAB people report higher levels of gender non-conformity, comfort around boys instead of girls, and handedness patterns more common among males (Jones et al., 2011). AFAB autistics have higher bioactive testosterone as compared to neurotypical AFAB people and may be more vulnerable to androgen impact than their AMAB autistic peers, who have similar testosterone to other neurotypical AMAB people (Kirkovski et al., 2013). Indeed, “the autosomal genetic factors (i.e., the [polygenic risk scores]) that predict testosterone and [sex hormone binding globulin] levels may exert effects on social functioning that are comparable in magnitude to the effect of binary (i.e., chromosomal) sex itself” and AFAB increased facial masculinity and masculine digit ratios are associated with autism diagnosis (McKenna et al., 2021).

Discussion
AFAB autistics exhibit more masculinized tendencies, which fits with the extreme male brain theory, but does not explain AMAB autistics having higher rates of transgender identities and feminized facial features as compared to typically developing males (Kirkovski et al., 2013; McKenna et al., 2021). AFAB gender diverse clients had significant autistic traits present 45% of the time, but transgender AMAB only at 30%, which was not found to be significant (Nobili et al., 2018). Further research is needed to determine if autistic people are biologically more inclined towards asexuality, bisexuality, and gender expansiveness due to hormones and secondary sex characteristic development or if autistic people fall into these patterns due to trauma, stigma, or lack of understanding (Attanasio et al., 2021).

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